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64,337
| 163,058
|
50395+50396
|
Discharge summary
|
report+report
|
Admission Date: [**2118-6-26**] Discharge Date: [**2118-6-30**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 32729**] is a [**Age over 90 **] year old woman with rheumatoid arthritis
on chronic prednisone, HTN, recurrent pneumonias, asthma/COPD,
who presents from home acutely dyspneic, found with 90% sat at
home. She was recently admitted to [**Hospital1 18**] for pneumonia, where
she was treated for community-acquired pneumonia with
CTX/azithromycin transitioned to cefpodoxime, as well as a COPD
exacerbation for which she was given pulse steroid dosing with
taper. She was placed on standing albuterol and ipratropium nebs
on discharge. There has been noted worsening in the patient's
respiratory status over the last few months, including episodes
of lethargy and decreased responsiveness as reported to her PCP,
[**Name10 (NameIs) **] patient's steroid dose was increased recently out of concern
for COPD exacerbation. She presents from home with dyspnea
increasing over the past 2 days and increased sputum production
for the last week, as well as rhonchi and wheezing throughout
per EMS. She received combivent en route to [**Hospital1 18**] with
improvement of O2 sat. There have been no fevers or chills.
Patient has been eating and drinking. There has been no noted
confusion.
.
In the ED, initial vs were: 98.7 110 184/83 30 100% on NRB.
Patient was struggling to breathe, but reported feeling fine.
Patient triggered for hypoxia and dyspnea when the NRB was taken
off and patient desaturated to 85% on RA. Portable CXR showed
signs of fluid overload. ECG showed NSR at a rate of 80, with
leftward axis, normal intervals, and evidence of LVH, with no ST
deviations. She was given a dose of ceftriaxone and levofloxacin
in the ED. She was also given combivent and solumedrol 125 mg IV
x 1. Vitals in ED prior to transfer to MICU are as follows: HR
78 BP 151/77 RR 15 O2sat 100% on CPAP.
.
On the floor, patient reports feeling well, and that her
breathing is near her baseline. She reports no pain or
discomfort.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
-Generalized tonic-clonic seizure with left arm weakness in the
setting of a right frontal meningioma last [**Month (only) 404**], with mass
effect and edema. Managed non-surgically and managed on
levetiracetam previously. Followed by Dr. [**Last Name (STitle) **], as above.
-Right thalamic infarct
-Hypertension
-Dyslipidemia
-Benign essential tremor
-Hypothyroidism
-Rheumatoid arthritis
-Depression
Social History:
She lives at home with 24 hour care. Per home health aide, she
is bed/wheelchairbound. Reportedly, she used to smoke for about
20 pack years in the past, not currently smoking.
Family History:
Noncontributory
Physical Exam:
Vitals: T: BP: 164/83 P: 87 R: 20 O2: 100% CPAP
General: Alert, oriented x3, no acute distress, appears
comfortable, cooperative
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear with
no lesions noted
Neck: supple, JVP not easily assessed, no LAD
Lungs: Harsh wheezes diffusely bilaterally, coarse rhonchi
bilaterally, not using accessory muscles, noted coarse upper
airway sounds
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops audible but difficult to appreciate given coarse breath
sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 1+ DP pulses bilaterally, 2+ LE edema
bilaterally, no leg size discrepancy.
.
Pertinent Results:
[**2118-6-26**] 01:13PM BLOOD WBC-15.7* RBC-4.55 Hgb-13.3 Hct-39.4
MCV-87 MCH-29.1 MCHC-33.6 RDW-15.8* Plt Ct-220
[**2118-6-28**] 04:59AM BLOOD WBC-9.2 RBC-3.84* Hgb-11.1* Hct-32.6*
MCV-85 MCH-28.8 MCHC-34.0 RDW-15.5 Plt Ct-212
[**2118-6-26**] 01:13PM BLOOD Neuts-82* Bands-2 Lymphs-8* Monos-3 Eos-2
Baso-0 Atyps-0 Metas-1* Myelos-2*
[**2118-6-26**] 01:13PM BLOOD PT-11.6 PTT-20.7* INR(PT)-1.0
[**2118-6-26**] 01:13PM BLOOD Glucose-150* UreaN-19 Creat-0.6 Na-140
K-4.1 Cl-101 HCO3-27 AnGap-16
[**2118-6-28**] 04:59AM BLOOD Glucose-135* UreaN-26* Creat-0.8 Na-141
K-3.8 Cl-103 HCO3-26 AnGap-16
[**2118-6-27**] 06:00AM BLOOD LD(LDH)-311*
[**2118-6-26**] 01:13PM BLOOD proBNP-939*
[**2118-6-27**] 06:00AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1
.
Blood culture [**2118-6-26**]: No growth to date.
Sputum culture [**2118-6-26**]: Contaminated.
.
EKG: Sinus at 68. Normal axis and intervals. LVH. No clear acute
changes.
.
CXR: Low lung volumes. LLL atelectasis, can't exclude
infiltrate. Mild edema.
.
TTE: Mild AV stenosis, mild LVH with preserved biventricular and
regional function. Increased PCWP.
Brief Hospital Course:
Ms. [**Known lastname 32729**] is a [**Age over 90 **] year old woman with rheumatoid arthritis
on chronic prednisone, HTN, recurrent pneumonias, asthma/COPD,
who presented with acute respiratory failure due to a COPD
exacerbation and pulmonary edema.
.
The patient presented in respiratory distress. She was started
on standing ipratropium/albuterol nebs and pulse dose steroids.
She had signs on exam of end expiratory wheezes consistent with
a COPD exacerbation. In addition, she had an elevated BNP with
CXR findings of mild edema. She was therefore diuresed for a
component of pulmonary edema. TTE and EKG showed LVH without any
acute changes concerning for ischemia. She does have probable
pulmonary hypertension which may contribute to her pulmonary
problems. She received steroids, nebs, diuresis and chest PT
with good effect. She returned to her 2L NC home oxygen
requirement. She continued to have mild labored breathing with
some audible wheezing and intermittent cough with sputum
production but by the report of the patient's family and home
health aides, this was consistent with her baseline status over
the past several weeks to months. Though she presented with a
leukocytosis, this resolved and she was not felt to have a
pneumonia. The patient's respiratory status overall is poor and
she has a life expectancy of less than 6 months. The family
understands and agrees with this assessment. They are interested
in hospice care and indeed attempted to enroll the patient in
hospice recently however they were refused care because she did
not meet criteria based upon the hospice assessment of life
expectancy and severity of illness. The [**Hospital 228**] health care
proxy will follow-up with her primary care doctor to [**Hospital 71540**]
hospice referral. For now she will have a home nurse as a bridge
to hospice. She continues to be DNR/DNI, readdressed with her
HCP while in the ICU. Given her chronic steroid use, she was
started on bactrim prophylaxis.
.
The patient had a swallow evaluation and it is recommended that
she take a modified PO diet of nectar thick liquids and pureed
solids. She should have 1:1 supervision for feeding: no straws-
single cup sips only, slow rate of intake, sit up fully to 90
degrees for all PO intake, no mixed consistencies with liquids
and solids, check for pocketing before lying her down after
meals.
.
The patient had poorly controlled hypertension and her home
metoprolol was uptitrated. The remainder of her medical issues
including RA on chronic prednisone, seizures, hyperlipidemia,
hypothyroidism and depression were stable and the patient was
continued on her home med regimen.
.
Code: DNR/DNI, confirmed with HCP
.
Communication: patient, POA [**Name (NI) 4648**] [**Name (NI) 105030**] [**Telephone/Fax (1) 105031**]
.
Medications on Admission:
Prednisone 30 mg PO daily
Metoprolol tartrate 50 mg PO BID
Atorvastatin 10 mg PO daily
Albuterol sulfate 2.5 mg/3 mL nebs IH q4h PRN SOB/wheezing
Alendronate 70 mg PO qweekly
Bupropion HCl 75 mg PO daily
Celecoxib 200 mg PO daily
Cephalexin 500 mg PO TID
Fluticasone 110 mcg/actuation aerosol 1 puff IH [**Hospital1 **]
Ipratropium-albuterol 0.5 mg-3 mg/3 mL nebs 1 inhalation q8h
Levetiracetam 1000 mg PO BID
Levothyroxine 25 mcg PO daily
Osteo Biflex 2 tabs PO daily
Discharge Medications:
1. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
3. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
Disp:*120 doses* Refills:*3*
6. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours.
Disp:*120 doses* Refills:*4*
7. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
8. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Inhalation twice a day.
Disp:*1 inhaler* Refills:*3*
10. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute respiratory failure due to COPD exacerbation and pulmonary
edema
Pulmonary hypertension
Rheumatoid arthritis
Seizures
Hypertension
Hyperlipidemia
Hypothyroidism
Depression
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 with worsening of your chronic shortness of
breath. This was due to an exacerbation of COPD and pulmonary
edema or fluid in the fluids. Please continue to take the
prescribed inhalers, nebulizers, steroids with bactrim
prophylaxis and lasix to continue to treat this problem. [**Name (NI) **]
will have a home nurse assist you and you should further explore
hospice options with your primary care doctor.
Followup Instructions:
Follow-up with your primary care doctor within 1 week for
ongoing care including hospice referral.
.
Name: [**Last Name (LF) **],[**First Name3 (LF) 2946**] S.
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 2205**]
*Dr. [**Last Name (STitle) 2204**] will contact you with appointment information.
You should see the doctor within one week.
Admission Date: [**2118-6-26**] Discharge Date: [**2118-6-30**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
See other discharge summary
Major Surgical or Invasive Procedure:
None
Social History:
Brief Hospital Course:
See other discharge summary
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
See other discharge summary
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
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[
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11418, 11418
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,409
| 195,936
|
43299
|
Discharge summary
|
report
|
Admission Date: [**2173-1-20**] Discharge Date: [**2173-1-24**]
Date of Birth: [**2112-7-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
critical aortic stenosis
Major Surgical or Invasive Procedure:
s/p Aortic valve replacement (23mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic tissue) [**2173-1-19**]
History of Present Illness:
This is a 60 year old female with known aortic stenosis,
followed with serial echocardiograms, who complains of
progressive dyspnea and chest pressure. Previously she underwent
cardiac catheterization ([**2172-12-18**]) which revealed normal
coronary arteries. Her most recent cardiac echocardiogram from
[**2172-7-18**] showed an LVEF of a 80%, bicuspid aortic valve, and
severe aortic stenosis with trace aortic insufficiency. Peak
aortic gradient was 74mm Hg, and her ascending aorta was
moderately dilated at 4.0cm. There was only trace mitral
regurgitation.
She was admitted for same day surgery.
Past Medical History:
-Hyperlipidemia
-History of Rheumatic Fever
-Dilated Ascending Aorta
-Seizure disorder- last seizure [**9-21**]
-Right breast- "borderline" melanoma [**2142**]
-Left breast needle biopsy for benign mass [**2166**]
-?TIA-reports dysarthria x several minutes in restaurant, which
resolved spontaneously. (Following this event had headaches for
one month and was told that she had encephalitis.)
-Right ankle fracture x 2
-s/p bilateral breast implants 20 years ago
-s/p tonsillectomy
Social History:
Race:Caucasian
Last Dental Exam:going to dentist next week
Lives with:Alone, no children
Occupation:Real Estate [**Doctor Last Name **]
Tobacco:denies
ETOH:[**12-19**] glasses of wine per night
Family History:
Paternal uncle died of aortic stenosis
Physical Exam:
Admission:
Pulse:79 Resp:18 O2 sat:99%RA
B/P Right:124/74 Left:116/71
Height:5'9" Weight:173lbs
General: Elderly female in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] - full dentures
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - 3/6 systolic murmur which
radiated to carotids and precordium. soft diastolic murmur alos
noted at left lower sternal border.
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema - trace
Varicosities: superficial varicosities noted, did not stand
Neuro: Grossly intact
Pulses:
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit transmitted murmur, +thrill
Pertinent Results:
[**2173-1-24**] 06:30AM BLOOD Hct-26.9*
[**2173-1-23**] 07:15AM BLOOD WBC-6.5 RBC-2.48* Hgb-8.1* Hct-23.9*
MCV-97 MCH-32.6* MCHC-33.8 RDW-13.1 Plt Ct-148*
[**2173-1-20**] 11:48AM BLOOD WBC-12.3*# RBC-2.74*# Hgb-9.0*#
Hct-26.5*# MCV-97 MCH-32.9* MCHC-34.0 RDW-12.8 Plt Ct-165
[**2173-1-24**] 06:30AM BLOOD UreaN-10 Creat-0.7 K-4.3
[**2173-1-23**] 07:15AM BLOOD Glucose-105* UreaN-11 Creat-0.7 Na-139
K-4.0 Cl-105 HCO3-29 AnGap-9
[**2173-1-21**] 03:46AM BLOOD Glucose-127* UreaN-13 Creat-0.6 Na-136
K-4.4 Cl-106 HCO3-23 AnGap-11
[**2173-1-24**] 06:30AM BLOOD Mg-2.0
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted and underwent an aortic valve
replacement by Dr. [**Last Name (STitle) **]. For surgical details, please see
operative note. She weaned from bypass in sinus rhythm on
Propofol and Neo-Synephrine infusions. Following the operation,
she was brought to the CVICU for invasive monitoring. She
remained stable, weaned from pressors and was extubated the day
of her surgery. CTs and temporary pacing wires were removed
according to protocols and she transferred to the floor on POD
1.
Beta blockade was begun and titrated as tolerated and she was
diuresed towards her preoperative weight. Lasix was continued
at discharge to facilitate this. On POD 3 her hematocrit was
found to be 23.9%, she was easily fatigued and had a soft blood
pressure. A unit of PRBCs were transfused, the following day her
hematocrit was 25% and she felt well.
Physical Therapy worked with her for mobility and strength.
Wounds were clean and healing well at discharge. Her pain was
well controlled with oral analgesics.
Discharge precautions and instructions as well as follow up were
discussed with her prior to discharge.
Medications on Admission:
Simvastatin 20mg po daily
Vitamin C 1000mg po daily
ASA 81 mg po daily
MVI 1 tab [**Hospital1 **]
Fish Oil 1000mg po daily
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
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).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 1 months.
Disp:*50 Tablet(s)* Refills:*0*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Ascorbic Acid 1,000 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p aortic valve replacement
hyperlipdemia
h/o rheumatic fever
critical aortic stenosis
dilated ascending aorta
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge of incision
Danger Signs:
When to Call 911
You should call 911 or your local emergency number to be taken
to the nearest emergency room for any emergency situation, such
as:
* Chest pain not related to your incision or angina pain,
similar to the pain you had prior to surgery
* Extreme shortness or breath or difficulty breathing
* Severe bleeding, especially if you are on warfarin (Coumadin)
* Fainting, severe lightheadedness or changes in mental status
When to Call Your Surgeon
Call your surgeon ([**Telephone/Fax (1) 1504**] (24 hours a day, seven days a
week) if any of the following occur:
* Your incision is warm, red or swollen or there is increased
tenderness or pain
* Any of your incisions have ANY fluid or drainage coming out
* You have a fever of 100.5 degrees Fahrenheit or higher
* Your weight has gone up more than two pounds in one day or
five pounds in a week
* You have severe pain or increased swelling in either leg
* You have palpitations
* You feel dizzy or weak (if severe, call 911)
* You notice any of the following, especially if you are on
warfarin (Coumadin)
o A lot of dark, large bruises
o Black or dark bowel movements
o Pain, discomfort or swelling in any area, especially after an
injury
o Severe or unusual headache (if symptoms are severe, please
call 911)
Discharge Condition: Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Medications/Orders:
No Saved Discharge Medications/Orders
Followup Instructions:
Please call to schedule appointments:
Surgeon: Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 7477**]in [**12-19**] weeks
Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] in [**12-19**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2173-1-24**]
|
[
"345.90",
"458.29",
"441.9",
"746.4",
"395.2",
"272.0",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
5884, 5942
|
3321, 4462
|
345, 476
|
8118, 8283
|
2733, 3298
|
8306, 8809
|
1843, 1884
|
4636, 5861
|
5963, 6077
|
4488, 4613
|
6219, 8097
|
1899, 2714
|
281, 307
|
504, 1109
|
1131, 1615
|
1631, 1827
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,905
| 111,003
|
19724
|
Discharge summary
|
report
|
Admission Date: [**2102-1-4**] Discharge Date: [**2102-1-10**]
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 79 year old with
multiple medical problems including AFib on Coumadin status
post AICD, CRI, type 2 diabetes mellitus, CHF, who presents
from outside hospital following discovery of subarachnoid
hemorrhage after a fall. Yesterday the patient had a
mechanical fall at home, specifics unclear. EMS was called,
but the patient refused to go to the hospital. There was
loss of consciousness for unclear duration and head trauma.
In the morning the patient did not feel well and went to
[**Hospital **] [**Hospital 1459**] Hospital. A head CT showed three separate
areas of hemorrhage in the midline above ventricle, two above
the falx, and surrounding edema left greater than right mass
effect, no shift or fluid collections. Chest x-ray at
outside hospital also showed a patchy right upper lobe
infiltrate and elevated right diaphragm with mild vascular
congestion.
Patient denied cough, shortness of breath, fevers, chills,
sweats, chest pain, abdominal pain.
PAST MEDICAL HISTORY:
1. AFib on Coumadin status post ICD.
2. CRI.
3. Type 2 diabetes.
4. CHF.
5. Hypertension.
ALLERGIES: Penicillin.
MEDICATIONS:
1. Lisinopril.
2. Digoxin.
3. Allopurinol.
4. Lasix.
5. Sotalol.
6. Detrol.
7. Paxil.
8. Coumadin.
9. Kayexalate.
10. Colchicine.
11. Glyburide.
PHYSICAL EXAM: Temperature 96.7, pulse 79, blood pressure
113/96, respirations 16, and O2 saturation 93% on room air,
and 97% on 3 liters. In general, in neck brace. Oriented to
person, not place or year. Neurologic: Pupils 4 mm to 2 mm
reactive to light and accommodation. EOMI. Face with right
droop at rest, symmetric with smile. Tongue symmetric.
Sensation intact. Normal palatal elevation. No pronator
drift, but difficult to assess. Hand grips [**3-22**] and
symmetric. Able to wiggle toes. Bilateral Babinski. Neck:
Unable to assess JVP in collar. Lungs clear anteriorly and
laterally. Cardiovascular: Irregularly, irregular, 3/6
systolic ejection murmur at the left sternal border and left
upper sternal border. Abdomen: Bowel sounds present, mild
right upper quadrant tenderness. Liver edge palpable 3 cm
below costal margin with no guarding or rebound.
LABORATORIES: Were significant for a white count of 7.3 with
76 polys, hematocrit of 44.5, and platelets of 116,
creatinine is 2.1, INR of 2.4.
HOSPITAL COURSE: After admission, patient underwent q1h
neuro checks. Initially was started on Levaquin for right
upper lobe pneumonia that was seen at the outside hospital,
but this was stopped after there was no infiltrates seen.
Patient was given FFP and vitamin K. A right upper quadrant
ultrasound which was evaluated secondary to
hyperbilirubinemia and thrombocytopenia was normal. However,
there was a 7 cm AAA. Neurosurgery was consulted, and took
patient to angiogram to rule out a sinus thrombosis. This
was not seen, but patient developed acute renal failure post
angiogram. Patient also spiked a temperature while in the
ICU with gram-positive cocci in clusters in the sputum.
The patient also continued with the C spine as Neurosurgery
did not clear it secondary to ossified fracture of
longitudinal ligament at C2, C3 with grade I anterolisthesis.
Patient continued to do poorly, and there was no plan to take
the patient to the operating room. He was planning to be
called out to the floor, but instead of transferred from the
West MICU to the East MICU.
When he arrived to the East MICU, patient was noted to have
paradoxical breathing with bloody sputum production, and was
mostly unresponsive. An ABG was done, which demonstrated
7.43, 44, 117. Family was notified that the patient was
doing poorly.
At 2 a.m. on [**2102-1-10**], the patient acutely became tachypneic
and tachycardic, and then hypotensive. He was suctioned for
a very large amount of secretions. It was thought he may
have aspirated. IV fluid bolus was given without effect, and
the patient quickly became pulseless, and then apneic with
only occasional agonal breathing. This quickly decreased to
a respiratory rate of 0. Patient had an AICD and pacer, and
this continued to discharge even after patient became
pulseless. A magnet was obtained so that the AICD would not
fire.
Patient on exam was without pulse. On auscultation, no heart
or lung sounds were heard for two minutes. Pupils were fixed
and dilated. Time of death was 2:20 a.m. on [**2102-1-10**]. Family and attending were notified.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-ACV
Dictated By:[**Last Name (NamePattern1) 8141**]
MEDQUIST36
D: [**2102-3-21**] 14:53
T: [**2102-3-23**] 08:09
JOB#: [**Job Number 53333**]
|
[
"287.5",
"584.9",
"518.82",
"E884.2",
"507.0",
"428.0",
"852.06",
"427.31",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.05",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
2437, 4750
|
1405, 2419
|
116, 1092
|
1114, 1389
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,760
| 187,564
|
45567
|
Discharge summary
|
report
|
Admission Date: [**2121-7-30**] Discharge Date: [**2121-8-3**]
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Nsaids / Codeine / Percocet
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered mental status, fever
Major Surgical or Invasive Procedure:
Central Venous Line Removal
History of Present Illness:
(History obtained from charts, son, and telephone discussion
with transferring physician). Ms. [**Known lastname **] is an 82-year-old
woman with MMP including CAD ( s/p 4V CABG [**6-/2112**], s/p PCI [**2114**]),
CHF EF 25%, PVD who intiially presented to an OSH on [**2121-7-26**]
with chest tightness and shortness of breath that began earlier
that day. Patient ruled out with 3 sets cardiac enzymes, no EKG
changes, and stress test revealed cardiomyopathy with EF 30%, no
reversible defects. 2 nights prior to transfer, patient felt
unwell and experienced a low-grade fever, chills with T 99.5.
Patient with recent history of urinary retention with recurrent
UTIs, had been on Macrobid as outpatient which was held on
admission, and this was re-started at treatment dose by the
covering MD. The following morning ~6AM, patient was found
unresponsive. Moonlighter noted patient's eyes to be "rolling
around" and patient appeared "rigid" on examination, and was
concerned about seizure, so administered 2mg Ativan and
Phenobarbital 500mg IV. Around this time, patient had
temperature spike to 103, other VSS (had pulse, BP, and was
breathing during unresponsive episode). Patient had an emergent
CT scan which did not reveal bleed, but showed evidence of prior
infarctions. She was admitted to the ICU, where she was found to
have labored breathing and was intubated. She received an LP
which showed 1 WBC, 0 RBC, Glu 75, TP 32. She was started
empirically on Vanc/Ceftriaxone. ID was consulted, and
doxycycline was added for possible [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**] Spotted Fever.
Patient continued to spike temperatures, but no localizing
source of infection could be found - no rashes, no diarrhea, no
cough, no sputum, LP negative. She received a neck, chest,
abdomen, and pelvis CT which were reportedly unremarkable. Given
persistence of fever this morning (101), patient is being
transferred to [**Hospital1 18**] ED for further evaluation and management;
specifically, team at OSH felt that patient may benefit from
MRI, which they are unable to do with intubated patients.
Patient has not received any sedation while intubated after
initial Propofol.
Past Medical History:
1. CAD s/p 4V CABG [**2111**] s/p PCI [**2114**]
2. CHF EF 25%
3. PVD
4. Mitral Valve Prolapse
5. GERD
6. Arthritis
7. IBS
8. s/p CCY
Social History:
Fully functional prior to recent events - cooks, drives, shops
independently. Lives alone in [**Location (un) 5110**]. Former tobacco user. No
recent travel, no pets.
Family History:
(per OSH records): Mother died of ? metastatic rectal CA. Sister
with AAA.
Physical Exam:
VS: T 98.2 Ax, BP 126/46; HR 62; RR 16; O2 99% AC FI02 0.5 TV
550 PEEP 5
GEN: intubated, unresponsive, no posturing
HEENT: PRRL. MMM. ET tube in place without surroundng erythema.
CV: RRR. No MRG
LUNGS: CTA B/L anterior lung field
ABD: soft, NT/ND. +BS
EXT: Symmetric DPs. No edema. Deviated toes
NEURO: PRRL. + gag reflex, + cough. Withdraws to noxious
stimuli. No response to verbal stimuli. Upgoing toes
bilaterally. Patellar reflexes asymmetric L > R, hyperreflexive.
Pertinent Results:
[**2121-7-30**] 07:37PM PT-11.3 PTT-24.7 INR(PT)-1.0
[**2121-7-30**] 07:37PM NEUTS-92.1* LYMPHS-5.0* MONOS-2.8 EOS-0.1
BASOS-0.1
[**2121-7-30**] 07:37PM WBC-12.4*# RBC-3.09* HGB-9.9* HCT-28.5*
MCV-92 MCH-31.9 MCHC-34.6 RDW-13.4
[**2121-7-30**] 07:37PM T3-43* FREE T4-1.0
[**2121-7-30**] 07:37PM TSH-1.4
[**2121-7-30**] 07:37PM calTIBC-199* FERRITIN-784* TRF-153*
[**2121-7-30**] 07:37PM ALBUMIN-3.0* CALCIUM-8.1* PHOSPHATE-4.1
MAGNESIUM-1.9 IRON-11*
[**2121-7-30**] 07:37PM CK-MB-22* MB INDX-0.9 cTropnT-0.87*
[**2121-7-30**] 07:37PM CK(CPK)-2458*
[**2121-7-30**] 07:37PM estGFR-Using this
[**2121-7-30**] 07:37PM GLUCOSE-129* UREA N-47* CREAT-1.8* SODIUM-142
POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-21* ANION GAP-16
[**2121-7-30**] 08:27PM TYPE-ART TEMP-37.9 TIDAL VOL-550 PEEP-5 O2-50
PO2-149* PCO2-35 PH-7.41 TOTAL CO2-23 BASE XS--1 -ASSIST/CON
INTUBATED-INTUBATED
[**2121-7-30**] 09:22PM URINE RBC-[**3-3**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**3-3**]
[**2121-7-30**] 09:22PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2121-7-30**] 09:22PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2121-7-30**] 09:22PM URINE OSMOLAL-357
[**2121-7-30**] 09:22PM URINE HOURS-RANDOM SODIUM-11
.
MRI BRAIn: 1. Extensive acute innumerable infarcts involving
bilateral cerebral and cerebellar hemispheres and a single focus
of acute infarct in the right side of the pons. This could most
likely represent embolic or septic in origin and needs clinical
correlation. The largest acute infarct noted is located in the
left MCA territory, involving most of the left MCA territory. 2.
Faint visualization of the left MCA-M1 segment and the
bifurcation. The M2, M3, and M4 segments are not definitely
visualized. This could most likely represent thromboembolic
occlusion. 3. Tiny foci of susceptibility, scattered in the
brain parenchyma could represent foci of hemorrhage versus
calcification.
.
EEG: Abnormal portable EEG due to the voltage asymmetry and
background slowing and disorganization described above. The
lower
voltage background over the left hemisphere suggests material
interposed
between the recording electrodes and cortical surface (e.g.
subdural
fluid), or a widespread cortical dysfunction. The background
suggests a
widespread encephalopathy. Medications, metabolic disturbances,
and
infection are among the most common causes. There were no
epileptiform
features.
.
ECHO: No vegetations or abscess seen. Dilated left ventricle
with severe regional systolic dysfunction. Mild right
ventricular systolic dysfunction. Moderate aortic regurgitation.
Moderate mitral regurgitation. Mild pulmonary hypertension.
Brief Hospital Course:
[**Known firstname 1258**] [**Known lastname **] is an 82-year-old woman with CAD s/p 4V
CABG, CHF (EF 25%), PVD, who was intubated at OSH for
respiratory distress, transferred here for further work-up and
management of persistent mental status changes and fever. The
following issues were addressed during her MICU course:
.
# AMS
Patient with new acute decompensation in mental status, arrived
in comatose state without need for sedation. Toes were upgoing
bilaterally on Babinski, and patient withdrew only to deep
noxious stimuli. LP negative at OSH. Head CT negative for acute
changes at OSH. Given concern for central process, emergent head
MRI was obtained which showed large MCA stroke with several
small bilateral acute CVAs, likely embolic. SBP was maintained >
120 with intermittent use of pressors to maintain cerebral
perfusion. Neurology stroke service was consulted, prognosis was
poor given territory of involvement. Patient was not
anti-coagulated given risk for hemorrhagic conversion. To
evaluate etiology of embolic CVA, LENIs were done and returned
negative for DVT. TTE was done which showed no vegetations or
abscess. Given depressed LOC, EEG was done to rule out
non-convulsive status, which showed widespread encephalopathy.
In light of these findings, discussion was held between ICU and
family regarding goals of care, and it was decided to pursue
comfort care. Patient was extubated.
.
# RESPIRATORY DISTRESS
Patient with altered level of consciousness requiring mechanical
ventilation, unable to generate spontaneous breaths. CXR
unremarkable for infiltrate or effusion on admission. As above,
given prognosis, decision was made for comfort care, and patient
was extubated.
.
# FEVER
Patient received full fever work-up including CXR, UA, Blood Cx.
Patient with leukocytosis and left shift. Patient was continued
empirically on Vancomycin for gram + coverage given embolic
source of CVAs. 2/2 Blood cultures at OSH returned positive for
Staph aurues, and Vancomycin was continued. Surveillance
cultures were obtained. TTE was obtained to assess for
endocarditis, and no vegetations were seen. TEE was deferred
given goals of care.
.
# CARDIAC/NSTEMI
Patient with significant cardiac history, CAD and ischemic
cardiomyopathy, reduced EF 25%. Patient began to rule in for MI
at OSH, enzymes and EKG revealed NSTEMI here. Patient was
medically managed. Anti-coagulation was contra-indicated given
large territory infarct. She was given ASA, high-dose Lipitor.
HR was well controlled in 60s without pharmacotherapy. BB were
held to maintain MAP > 60 for cerebral perfusion.
.
# COMMUNICATION
HCP, [**Name (NI) **], [**Name (NI) **] [**Name (NI) **]
Medications on Admission:
MEDICATIONS AT HOME
1. Prilosec 40mg PO qd
2. Coreg 12.5 mg PO BID
3. Spironolactone 12.5mg PO qd
4. Lasix 40mg PO qd
5. Ecotrin 162mg PO qd
6. Vytorin 10mg PO qd
7. Tylenol
8. CoQ10 50mg PO BID
9. Diovan 40mg PO qd
10. Macrobid 50mg PO qd started [**2121-7-13**]
.
MEDICATIONS ON TRANSFER
1. Dilantin 100mg q8h NG
2. NaCL @ 125 c/hr
3. ASA 162mg NG
4. Albuterol q4h: PRN
5. Colace 100 [**Hospital1 **]
6. Lasix 40mg IV qd
7. Diovan 160mg NG qd
8. Levaquin qPM
9. Coreg 12.5 mg [**Hospital1 **]
10. Ceftriaxone 2g IV q12h
11. Vancomycin 1g IV q12h
12. Zovirax 800mg IV q12h
13. Flagyl q8h
14. Protonix 40mg NG qd
Discharge Disposition:
Expired
Discharge Diagnosis:
Stroke
Discharge Condition:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2121-11-18**]
|
[
"421.0",
"995.92",
"428.0",
"V09.0",
"038.11",
"V45.81",
"276.52",
"530.81",
"410.71",
"414.8",
"434.11",
"443.9",
"276.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9590, 9599
|
6251, 8926
|
299, 328
|
9649, 9824
|
3501, 6228
|
2915, 2991
|
9620, 9628
|
8952, 9567
|
3006, 3482
|
231, 261
|
356, 2557
|
2579, 2715
|
2731, 2899
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,866
| 163,326
|
52534
|
Discharge summary
|
report
|
Admission Date: [**2116-3-8**] Discharge Date: [**2116-3-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
suprapubic catheter replacement
strangulated right inguinal hernia repair
History of Present Illness:
86yo M with h/o CAD s/p MI [**2097**], atrial fibrillation,
osteoporosis, Parkinson's, gout, BPH s/p TURP (, h/o neurogenic
bladder with suprapubic catheter, admitted [**3-8**] with N/V and
malaise. He was found to have a strangulated R inguinal hernia
and taken for repair. He also had ARF on admission with a
creatinine of 4.1, which improved to normal with IVF. His
suprapubic catheter was found to be obstructed, and was replaced
by Urology. He received 5d vanc/levo/flagyl postop. His postop
course was complicated by episodic shortness of breath, improved
with gentle diuresis, and atrial fibrillation with episodes of
HR to 120s. He is being transferred to the Medicine service for
further management of his dyspnea.
.
Currently, he states he feels well. He reports improvement in
his dyspnea. He denies chest pain, palpitations,
lightheadedness, N/V, abdominal pain.
Past Medical History:
1. CAD- s/p MI in [**2097**], stress echo in [**5-5**] with inferobasal
wall akinesis
2. Osteoporosis- on Actonel
3. Parkinson's disease- diagnosed [**9-7**], on Sinemet, neurogenic
bladder s/p suprapubic catheter placement
4. gout- on allopurinol
5. BPH
6. bladder diverticula- hematuria
Social History:
lives with wife in [**Name (NI) **], housekeeper qd, daughter states she
thinks they need home health aide; +tob- 1ppd x 5y, occasional
EtOH, denies drugs.
Family History:
Non-contributory
Physical Exam:
vitals- T98.5, HR 108, BP 136/80, RR 24, O2sat 99% 3LNC
General- elderly man lying in bed, tachypneic but appears
comfortable, no accessory muscle use
HEENT- sclerae anicteric, dry MM
Neck- supple, no carotid bruit, no LAD, JVP ~9cm
Lungs- decreased breath sounds 1/3 up b/l, increased expiratory
phase, no wheeze/rales
Heart- irregularly irregular
Abd- NABS, soft, nontender, ND, RLQ surgical incision with mild
erythema but no d/c and staples in place, suprapubic catheter in
place with serous discharge on drain sponge
Ext- trace/1+ LE edema b/l, no calf pain, negative [**Last Name (un) 5813**] sign,
feet appear well-perfused
Skin- dry erythematous/hyperpigmented macules coalescing into
patches on anterior thighs and upper arms b/l
Neuro- A&Ox3, some word finding difficulty, CN III-XII intact,
strength grossly intact and symmetric, no pronator drift
Pertinent Results:
[**2116-3-8**] 04:56PM WBC-27.1*# RBC-4.82# HGB-14.6# HCT-45.2#
MCV-94 MCH-30.2 MCHC-32.2 RDW-15.8*
[**2116-3-8**] 04:56PM NEUTS-50 BANDS-45* LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2116-3-8**] 04:56PM PLT SMR-UNABLE TO PLT COUNT-594*#
[**2116-3-8**] 04:56PM PT-12.3 PTT-26.3 INR(PT)-1.1
[**2116-3-8**] 04:56PM CK(CPK)-40
[**2116-3-8**] 04:56PM CK-MB-NotDone cTropnT-0.02*
[**2116-3-8**] 04:56PM GLUCOSE-318* UREA N-66* CREAT-4.1*#
SODIUM-137 POTASSIUM-6.1* CHLORIDE-99 TOTAL CO2-17* ANION
GAP-27*
[**2116-3-8**] 05:03PM LACTATE-10.3*
[**2116-3-8**] 05:13PM URINE RBC-21-50* WBC-0-2 BACTERIA-MANY
YEAST-NONE EPI-0
[**2116-3-8**] 05:13PM URINE BLOOD-LGE NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-MOD
.
CXR ([**3-12**]): b/l pleural effusions, RLL infiltrate- atelectasis
vs. pna
.
ECG: atrial fibrillation, no ischemic changes
.
TTE ([**9-8**]): suboptimal quality, cannot evaluate LV function
.
Stress TTE ([**5-5**]): evidence of prior MI with inferobasal
akinesis
Brief Hospital Course:
# Dyspnea: His episodes of dyspnea were thought likely
secondary to pulmonary edema and pneumonia. His CXR showed a
RLL opacity and bilateral small pleural effusions. His TTE
showed diastolic heart dysfunction, which was thought to be
contributing to his pulmonary edema in the setting of poorly
controlled atrial fibrillation, as well as with the IV fluids he
received perioperatively. He was diuresed with prn Lasix. He
was maintained on levofloxacin to treat a suspected aspiration
pneumonia. He defervesced and his white count trended down. As
he had been on DVT prophylaxis with both SC heparin and
pneumaboots, and his dyspnea improved with diuresis and
antibiotics, we did feel a CTA to rule out PE was necessary at
this time. He was symptom free upon discharge. As he has a
normal EF and his heart rate was well-controlled, he was not
discharged on oral furosemide.
.
# Leukocytosis/Fever: He had a leukocytosis on admission,
presumably secondary to his strangulated hernia. He received 5
days of IV vancomycin, levofloxacin, and metronidazole. He was
then maintained on po levofloxacin by the Surgery team,
presumably to treat a suspected UTI. His urine culture came
back with <10,000 organisms. However, he did have a RLL
infiltrate on CXR, suspicious for an aspiration pneumonia. A
bedside swallow evaluation revealed aspiration on a regular
diet, so he was switched to a ground diet with thin liquids. A
video swallow showed severe dysphagia but no evidence of
aspiration on his ground diet. A urine culture was repeated to
rule out UTI with his indwelling suprapubic catheter, and came
back with >100,000 Proteus mirabilis, resistant to
fluoroquinolones but sensitive to ceftriaxone. Surgery reported
he is recovering well s/p his strangulated hernia repair. He
was afebrile for 36 hours upon discharge. His WBC count had
trended down to 14. He was discharged on cefpodoxime for 7 days
to treat his UTI and also to complete his treatment for
pneumonia.
.
# Atrial fibrillation: On admission, his metoprolol dose had
been halved, presumably in the setting of infection. On
transfer to the Medicine service, he was having occasional
episodes of HR in the 120s, during which he was asymptomatic.
His metoprolol dose was increased back to his outpatient dose,
and was then titrated up for better rate control. Per OMR
notes, he is not an anticoagulation candidate secondary to fall
risk.
.
# Strangulated hernia: In the OR, his hernia sac was found to
be hemorrhagic, but he had normal bowel. After the surgery, his
RLQ incision was slightly erythematous but nontender and without
discharge. He should have his staples removed on postop day 14,
which will be [**3-22**].
.
# Hypernatremia: Upon transfer to the medicine service, he was
hypernatremic with a sodium of 149. His free water deficit was
calculated to be ~2.5L. He was hydrated gently D5W, and his
hypernatremia resolved.
.
# Anemia: His hematocrit was not far off baseline last year. It
was stable throughout his admission. His stools were guaiac
negative.
.
# ARF: His creatinine was markedly elevated on admission in the
setting of vomiting and decreased oral intake. It improved to
normal with IVF and was stable for the rest of his admission.
.
# Parkinson's: He was maintained on his Sinemet at his
outpatient dose.
.
# CAD: He is s/p MI in [**2097**]. He had a lipid panel in [**10-7**]
with total cholesterol 160, LDL 95, and HDL 52. He was
maintained on aspirin. His metoprolol was titrated up for his
atrial fibrillation as above.
.
# FEN: He was found to be aspirating on his regular diet, so he
was switched to a ground diet with meds crushed in applesauce.
Nutrition consult was concerned for poor nutritional status that
may result in poor wound healing. He was put on Boost to
supplement his nutrition. His video swallow eval showed severe
dysphagia but no aspiration on the ground diet.
.
# Ppx: PPI. SC heparin + pneumaboots.
.
# Code status: FULL CODE.
.
Medications on Admission:
Outpatient meds:
Actonel 35mg qwk
[**Doctor First Name **] 60mg [**Hospital1 **]
Allopurinol 100mg qd
Atrovent tid prn
Metoprolol 50mg [**Hospital1 **]
Sinemet 25-100mg tid
Triamcinolone 0.025% cream tid prn
Aspirin 325mg qd
.
Meds on transfer:
Metoprolol 25mg [**Hospital1 **]
Pioglitazone 15mg qd
Levofloxacin 250mg qd
Protonix 40mg IV qd
SSI
SC heparin
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) nab
Inhalation Q6H (every 6 hours) as needed.
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl
Topical DAILY (Daily).
10. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100)
mg PO BID (2 times a day).
11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO once a day.
12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
13. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Primary:
Aspiration pneumonia
Diastolic heart failure
Atrial fibrillation
Strangulated right inguinal hernia
Obstructed suprapubic catheter
Urinary tract infection
Secondary:
Parkinson's disease
Discharge Condition:
good, good sats on room air, symptoms improved
Discharge Instructions:
Please take your medications as prescribed.
If you experience worsening shortness of breath, chest pain,
fever>101, or other concerning symptoms, please call your doctor
or go to the ER.
Followup Instructions:
You have an appointment scheduled with [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP on
[**2116-3-27**] at 10:20am, ([**Telephone/Fax (1) 1921**]. Please discuss follow up
with Dr. [**Last Name (STitle) 665**] at that appointment.
Completed by:[**2116-3-19**]
|
[
"427.31",
"428.30",
"276.0",
"550.10",
"428.0",
"997.3",
"507.0",
"997.5",
"584.9",
"599.0",
"596.54",
"332.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.00",
"59.94"
] |
icd9pcs
|
[
[
[]
]
] |
9326, 9399
|
3754, 7740
|
276, 352
|
9639, 9687
|
2678, 3731
|
9924, 10245
|
1766, 1784
|
8147, 9303
|
9420, 9618
|
7766, 7993
|
9711, 9901
|
1799, 2659
|
222, 238
|
380, 1265
|
1287, 1577
|
1593, 1750
|
8011, 8124
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,406
| 163,838
|
52246
|
Discharge summary
|
report
|
Admission Date: [**2140-7-23**] Discharge Date: [**2140-7-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
Central line
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **]yo male with PMH significant for CAD, CHF, and
ESRD on HD. Per patient, he went to dialysis on Friday morning.
At dialysis he admits to feeling cold. On his drive home he
admits to "shaking like a leaf". He turned up the heat in his
car; but when he arrive home he felt so weak that he could not
get out of the car on his own. He leaned against the [**Doctor Last Name 534**] and
his neighbor called 911 and he was brought to [**Hospital1 **].
His vitals were T 103 BP 89/44 AR 69 RR 20 O2 sat 100% on 2L. At
the OSH he received Vancomycin 1gm IV and Gentamycin 150mg IV.
He was then transferred to [**Hospital1 18**] for further work-up.
.
In the [**Hospital1 18**] ED his initial vitals were T 101 BP 71/34 AR 70 RR
16 O2 sat 93% on 2L. He received Levaquiin 500mg IV, Flagyl
500mg IV, and Tylenol. He received 3L NS and a RIJ central line
was placed and he was started on Levophed.
.
Of note, he was recently discharged from [**Hospital1 18**] after he
presented with an absent bruit/thrill in his dialysis access. He
underwent a thrombectomy with patch graft revision of the venous
anastomosis.
.
Past Medical History:
1) CAD s/p CABG
-Cardiac catheterization [**5-3**] w/L main and 3 vessel dz w/
patent LIMA to LAD w/ 70% stenosis in distal LAD, patent SVG to
diagnoal ramus w/ 50% stenosis in native diagonal branch, patent
SVG to OM1/OM2 but occluded OM1 at touchdown. s/p unsuccessful
PTCA of LM, Moderate right and left ventricular diastolic
dysfunction
-5-vessel CABG [**2124**] (LIMA-LAD, SVG-D1, SVG-RI,
SVG-OM1, SVG-OM2)
2) CHF: Echo ([**6-3**]) EF 30-35%, [**12-1**]+ MR, 2+ TR, moderate
pulmonary artery systolic HTN. Reportedly small ASD on a TEE
3) S/p pacemaker placement Tachy-Brady syndrome [**3-/2128**],
w/replacement
[**11-1**]
4) HTN
5) Hypercholesterolemia
6) ESRD, on HD (since [**2134**]) MWF evenings via left arm AV graft
(evening shift at [**Location (un) 4265**], [**Location (un) **])
7) Chronic anemia associated w/ renal failure
8) Renal cell carcinoma, s/p left nephrectomy
9) Gout w/flairs 1-2x/mo
10) s/p TURP for BPH
11) Bilateral cataracts
12) Left hydrocele w/ hydrocelectomy [**12/2130**]
#. Multiple episodes of SOB
.
PSHx:
#. Right common femoral artery thrombus s/p cath in [**5-3**]
#. Left CEA [**2127**] (s/p TIA)
#. Thrombectomy and revision of LUE AV graft [**2-1**] w/multiple
interventions to graft in the past.
Social History:
He lives alone in [**Location (un) 745**]. Recently retired fully from selling
furniture, pt had reduced from full time work to part time work
over the past year.
+ tob: cigar/pipe smoking, daily x20-25 years w/cessation 20yrs
prior
- EtOH
- Illicit/Recreational drug use
Family History:
Daughter with MI in mid-40s, had Type 1 DM, deceased 56y/o
Brother w/heart disease, ?MI. + hypertension, + diabetes
mellitus, Brother w/lymphoma, ? question liver ca
Physical Exam:
.
vitals T 98.1 BP 106/60 AR 71 RR 16 O2 sat 98% on 2L
Gen: Pleasant male, lying in bed
HEENT: MMM
Heart: nl s1/s2, no s3/s4, +systolic murmur
Lungs: +crackles posteriorly @ lung bases
Abdomen: soft, NT/ND, +BS
Extremities: No edema, 2+ DP/PT Pulses bilaterally
.
Pertinent Results:
[**2140-7-23**] 12:55AM WBC-12.6*# RBC-2.80* HGB-10.1* HCT-30.2*
MCV-108* MCH-36.2* MCHC-33.5 RDW-15.4
[**2140-7-23**] 12:55AM NEUTS-83.0* BANDS-0 LYMPHS-9.1* MONOS-6.8
EOS-0.9 BASOS-0.1
[**2140-7-23**] 12:55AM GLUCOSE-116* UREA N-17 CREAT-3.7*# SODIUM-139
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-30 ANION GAP-17
.
Relevant Imaging:
1)Cxray ([**7-23**]): No infiltrate
.
[**7-23**] AV fistulogram - No abscess or hematoma identified within
the left upper extremity.
.
[**2140-7-25**] 06:30AM INR 1.6*
Brief Hospital Course:
Mr. [**Known lastname **] is a [**Age over 90 **]yo male with CAD, ESRD who presented with
fevers, hypotension, and leukocytosis. His hospital course is
described by problems below:
# Fever - Patient presented with fevers, hypotension, and
leukocytosis. The source of underlying infection is unclear on
admission. Initially treated for presumed sepsis. Given
vanc/gent at OSH, atbidmc central line placed and briefly placed
on levophed. After more information about his baseline BP
obtained, levophed discontinued. He remained afebrile. Was
treated with vanc/levo/flagyl. Cultures remained negative for
48 hours. Abx discontinued and patient discharged home after
uneventful dialysis.
.
#) ESRD on HD: followed by renal in house. dialysed monday
before discharged.
# Hypertension: Held all pressure medications secondary to
hypotension initially, resumed atenelol on discharge.
.
# CAD: continued asa, and resumed atenelol.
# h/o thrmbosed av fistula - initially coumadin held for
procedure and pt placed on heparin gtt. At discharge INR 1.6,
advised to take 3 mg of coumadin and have a repeat INR checked
on wednesday at dialysis.
Medications on Admission:
Allergies: NKDA
.
Atenolol 25mg PO daily
Cinacalcet 30mg PO daily
Pravastatin 10mg PO daily
Aspirin 81mg PO daily
B Complex-Vitamin C-Folic Acid 1mg PO daily
Folic Acid 1mg PO daily
Pyridoxine 100mg PO daily
Sevelamer 800mg PO TID
Digoxin 50 mcg PO daily
Docusate Sodium 100mg PO BID
Warfarin 2mg PO QHS
Cyanocobalamin 500mcg PO daily
Discharge Medications:
1. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
6. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Digoxin 50 mcg/mL Solution Sig: One (1) PO DAILY (Daily).
8. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
9. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Topical Q6H (every 6 hours) as needed.
10. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
12. Vitamin B Complex Capsule Sig: One (1) Capsule PO once a
day.
13. Outpatient Lab Work
Please check PT/PTT/INR at dialysis on Wedensday [**2140-7-27**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Fever
ESRD on hemodialysis
Secondary:
CAD
HTN
Hypercholesterolemia
Chronic anemia associated w/ renal failure
h/o Renal cell carcinoma, s/p left nephrectomy
Discharge Condition:
Good
Discharge Instructions:
You were admitted with fevers after dialysis and were treated
with antibiotics and fluids. All the cultures showed no active
infection.
We incresed your coumadin dose to 3 mg, please have your INR
checked at next dialysis as the dosing might need to be
readjusted.
If you have fevers, chills, nausea, vomiting, lightheadedness,
dizziness or any bleeding please contact your PCP or return to
the emergency room.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 311**] [**Telephone/Fax (1) 1713**] to setup a follow
up appointment in [**12-1**] weeks.
You have a sheduled follow up appointment with surgery as below:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2140-7-28**]
10:40
Completed by:[**2140-7-26**]
|
[
"V45.01",
"780.6",
"458.21",
"V10.52",
"414.01",
"428.0",
"585.6",
"V45.1",
"272.0",
"403.91",
"285.21",
"288.60",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6575, 6581
|
4034, 5176
|
268, 283
|
6792, 6799
|
3503, 3820
|
7381, 7799
|
3036, 3204
|
5561, 6552
|
6602, 6771
|
5202, 5538
|
6823, 7358
|
3219, 3484
|
222, 230
|
3838, 4011
|
311, 1463
|
1485, 2730
|
2746, 3020
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,531
| 187,061
|
40858
|
Discharge summary
|
report
|
Admission Date: [**2156-9-3**] Discharge Date: [**2156-9-7**]
Date of Birth: [**2109-4-21**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
urinary retention, constipation, and LLE weakness
Major Surgical or Invasive Procedure:
T4-T5 laminectomy and resection of spine mass
History of Present Illness:
The pt is a 47 year-old right handed woman with a past
medical history significant for HTN, HLD, DMII who presents
today
as a direct admission from rehab for complaints of urinary
retention, constipation, and worsening LLE weakness. She was
previously admitted for placement of a VP shunt which was placed
on [**8-23**]. this was done after a workup that was initiated as she
began having frequent falls and gait difficulty. At that time
she
had no retention of urine however she had occasional
constipation
that was felt to be related to opiod pain medications, also she
was having episodes of confusion. Following this hospitalization
was was discharged to rehab. She states that the urinary
retention and constipation have been almost constant since
discharge and that her weakness has progressively worsened. Of
note, her discharge summary stated that she had no urinary or
fecal issues and that her LLE was 5-/5 throughout in regards to
her motor strength examination. Today she reports urinary
retention and constipation as above as well as sensation deficit
of the LLE. She denies saddle anesthesia and states she knows
when she has to urinate or defecate but simply can not produce
either. She denies headaches, nausea, vomiting, dizziness, or
changes in vision, hearing, or speech. Of note is a T4-5
intradural, extramedullary mass that was found on MRI scan of
the
thoracic spine which was obtained during her prior admission and
plan for intervention was tentatively scheduled for [**2156-9-28**].
Past Medical History:
- HTN
- HLD
- DMII
Social History:
She lives with her 3 children. She works as a
housekeeper in a hotel. She denies tob, etoh, drug use.
Family History:
Multiple family members with DM, no history of stroke
known.
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
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.
Motor: [**6-3**] RUE and LUE, [**6-3**] RLE, 4+ L IP, 5 Q, 4+ H, 5 AT, [**Last Name (un) 938**],
GS
Toes downgoing bilaterally
Pertinent Results:
[**2156-9-4**] MRI THORACIC SPINE W/O CONTRAST
IMPRESSION: The previously noted intradural extramedullary mass
in the
thoracic spine at T4-T5 level is again identified. The edema
identified
within the spinal cord superior to the level of the mass appears
to have
slightly more prominent compared to the prior study. It is
unclear whether
this is secondary to increasing edema or differences in
technique.
[**2156-9-4**] CT HEAD W/O CONTRAST
IMPRESSION: Ventriculomegaly, which has decreased since the
previous study of [**2155-8-24**]. The previously seen pneumocephalus
has resolved. It is unclear whether this is patient's baseline
or there remains dilatation of both the baseline. If the patient
has prior outside studies, comparison would be helpful as there
are no studies earlier than [**2156-8-18**] at [**Hospital1 18**].
Brief Hospital Course:
On [**2156-9-4**] Ms. [**Known lastname 89244**] was admitted to [**Hospital1 18**] from rehab fascility
due to increased left lower extremity weakness, urinary
retention and constipation. She was taken to the OR on that
date for laminectomies of T4-T5 and resection of her intradural,
extramedullary mass that was found on MRI scan of the thoracic
spine which was obtained during her prior admission. The
original plan had been to remove this mass at the end of the
month after she had made some recovery from her hydrocephalus
and VP shunt placement. However, given her new neurological
deficit it was necessary to remove this lesion before the mass
could cause further neurological damage. The patient tolerated
the procedure well. The decision was made intraoperatively to
sacrifice the exiting posterior nerve root at the T4-T5 level to
achieve complete tumor resection. In the end of the operation,
we saw improvement of SSEPs to almost normal stage on the left
and the motor potentials were unchanged compared to
preoperative.
On [**9-4**] Ms. [**Known lastname 89244**] was transferred to the SICU after surgery and
on [**9-5**] was stable enough to be transferred to the floor. On
that date her shunt was reprogrammed to 1.0. She continued to do
well on the floor and was kept on flat bed rest until the
morning of [**9-6**]. She was mobilized with the physical therapy
team. Her dressing remained dry and she had no headaches. She
was cleared for discharge back to her rehab facility [**9-7**].
Medications on Admission:
amlodopine, ciprofloxicin,
docusate, enalapril, hctz, heparin, lantus, humolog, metformin,
metoclopromide, rozerem, senna, simethicone, zocoro, tylenol,
labetalol, lactulose, zofran.
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
7. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
8. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for SBP>140.
9. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back pain.
Disp:*90 Tablet(s)* Refills:*2*
10. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever/pain.
12. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO three
times a day: before meals.
13. lactulose 10 gram Packet Sig: One (1) PO every six (6)
hours as needed for constipation.
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
15. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day.
16. Lantus 100 unit/mL Solution Sig: One (1) 32 Subcutaneous at
bedtime.
17. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
18. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
19. Rozerem 8 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
20. insulin lispro 100 unit/mL Solution Sig: One (1) 2
Subcutaneous three times a day: per sliding scale protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
T4-5 intradural extramedullary spine mass
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:
?????? Do not smoke.
?????? Keep your wound clean and dry / No tub baths or pool swimming
for two weeks from your date of surgery.
?????? If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
?????? Fever greater than or equal to 101?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in [**8-8**] days (from date of surgery)
for removal of your staples/sutures and/or a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in one month.
??????You will a CT head without contrast prior to your appointment.
No spine imaging will be required
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
|
[
"V53.01",
"237.9",
"564.00",
"336.3",
"788.29",
"250.00",
"401.9",
"V12.54",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.4",
"00.94"
] |
icd9pcs
|
[
[
[]
]
] |
7102, 7174
|
3533, 5045
|
357, 404
|
7260, 7260
|
2677, 3510
|
9114, 9850
|
2125, 2188
|
5279, 7079
|
7195, 7239
|
5071, 5256
|
7443, 9091
|
2203, 2408
|
267, 319
|
432, 1944
|
7275, 7419
|
1966, 1987
|
2003, 2109
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,629
| 106,031
|
36472
|
Discharge summary
|
report
|
Admission Date: [**2149-8-10**] Discharge Date: [**2149-9-13**]
Date of Birth: [**2080-6-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Shellfish Derived / Latex
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Transferred from OSH for transplant evaluation
Major Surgical or Invasive Procedure:
placement of temporary hemodialysis catheter
continuous [**Last Name (un) **]-venous hemodialysis
endotracheal intubation
placement of central venous catheter
placement of arterial line
History of Present Illness:
69F c h/o EtOH-cirrhosis admitted to OSH with vomiting and
weight loss on [**2149-8-7**] now transferred for transplant
evaluation/ Patient had hip surgery [**6-1**] wks prior to
presentation to [**Doctor Last Name **]-[**Last Name (un) 45902**]. Since then her husband noted
that she has been increasingly confused, trying to dial a
telephone number on the VCR remote. He called her
gastroenterologist who increased her lactulose from 3 tbsp to
4tbsp four times daily and placed her on reglan for chronic
vomiting. One day prior to admission to OSH she had diarrhea all
day, was incontinent and had lost 5-8lbs over the week secondary
to nausea and decreased PO intake so her husband brought her
into the [**Name (NI) **].
In the ED at the osh she was noted to be dehydrated and
encephalopathic. She was hydrated and then had a significant
drop in her hematocrit (from 21 to 26) with hydration over the
next few days. She had guaiac positive stools without overt GIB.
She was transfused to a hct of 24.5 on the day of discharge. She
was also treated for a positive UA (although denied sx) with
cephtriaxone. A culture was not perofrmed.
On presentation to [**Hospital1 18**] patient notes she has been feeling
better and is able to hold down meals as long as she eats
slowly. She has had no dysuria or abdominal pain and no urinary
frequency. She denies h/o GIB, melena, BRBPR. She denies sick
contacts or travel recently. She denies SOB, edema, chest pain.
She does feel a little dehydrated but thinks she can keep up
with it with her meals.
Rest of ROS is negative including no chest pain, palpitations,
syncope or presyncope, falls, fevers, chills, night sweats, SOB,
rash.
Past Medical History:
ESLD from ETOH cirrhosis
Gastric Ulcer in [**2145**]
Hepatic encephalopathy
Transfusion dependend anemia
EGD [**3-3**] with gastral antral vascular ectasia (GAVE) syndrome
and portal hypertensive gastropathy
Depression
Chronic headaches
Valvular heart disease: on recent evaluation with TTE normal LV
size and function with some evidence of diastolic dysfunction,
mod MR [**First Name (Titles) 151**] [**Last Name (Titles) **], mild ao stenosis and trace PR
Social History:
Per OMR, married with 5 children. She had 1 miscarriage during a
pregnancy. She is a retired bookkeeper. She has never smoked
cigarettes nor used recreational drugs. Per OMR initial
hepatology note, "She has a history of alcohol excess with 4
glasses of wine per night over a prolonged period. She has not
consumed any alcohol since she was given her diagnosis of
cirrhosis back in [**2145**]."
Family History:
Negative for liver disease. Brother with prostate CA. Father had
emphysema. Mother died of heart disease in her 80s.
Physical Exam:
VS: 65 103/58 12 98%2L nc
Gen: Responsive to verbal stimuli
HEENT: Scleral icterus. PERRL. Neck supple
CV: Nl S1+S2, II/VI systolic murmur at the base
Pulm: Bibasilar rales
Abd: Distended, NT. +bs
Ext: 2+ pitting edema. 1+ dp bilaterally.
Neuro: Responsive to verbal stimuli. Not oriented. +asterixis.
Pertinent Results:
LABS ON ADMISSION:
[**2149-8-11**] 05:25AM BLOOD WBC-4.8 RBC-2.48* Hgb-8.2* Hct-24.7*
MCV-100* MCH-32.9* MCHC-33.0 RDW-18.8* Plt Ct-51*
[**2149-8-11**] 05:25AM BLOOD PT-20.4* PTT-44.2* INR(PT)-1.9*
[**2149-8-11**] 05:25AM BLOOD Glucose-110* UreaN-15 Creat-1.1 Na-141
K-4.6 Cl-115* HCO3-21* AnGap-10
[**2149-8-11**] 05:25AM BLOOD ALT-51* AST-96* LD(LDH)-318* AlkPhos-79
TotBili-5.7*
[**2149-8-11**] 05:25AM BLOOD Albumin-2.6* Calcium-7.6* Phos-2.1*
Mg-1.1* Iron-140
.
LABS ON [**9-12**]:
[**2149-9-12**] 01:55AM BLOOD WBC-10.1 RBC-2.02* Hgb-6.9* Hct-21.1*
MCV-104* MCH-34.4* MCHC-33.0 RDW-24.1* Plt Ct-30*
[**2149-9-12**] 01:55AM BLOOD Plt Ct-30*
[**2149-9-12**] 01:55AM BLOOD PT-27.6* PTT-49.0* INR(PT)-2.7*
[**2149-9-12**] 01:55AM BLOOD Fibrino-109*
[**2149-9-12**] 01:55AM BLOOD Glucose-157* UreaN-28* Creat-1.9* Na-136
K-3.9 Cl-100 HCO3-22 AnGap-18
[**2149-9-12**] 01:55AM BLOOD Calcium-10.8* Phos-3.4 Mg-2.1
.
CTH ([**8-21**]): No evidence of acute intracranial abnormality.
.
Hip ([**8-21**]): There is no evidence for fracture or dislocation.
Pelvic calcifications likely represent phleboliths.
.
Abd U/S ([**8-18**]): 1. Patent hepatic vasculature but with slow flow
in the main portal vein with possible new non-occlusive thrombus
in the main portal vein wall.
2. Diffuse coarsened echogenic liver consistent with stated
history of cirrhosis.
3. Cholelithiasis, without evidence of acute cholecystitis.
4. Mild-to-moderate ascites around the liver capsule.
.
CXR ([**8-11**]): No previous images. The cardiac silhouette is at the
upper limits of normal in size, with the lungs clear and no
evidence of vascular congestion or pleural effusion. Mild
eventration of the central aspect of the right hemidiaphragm,
with no clinical significance.
.
ECG ([**8-19**]): Sinus rhythm with atrial premature beats including a
four beat run of probable atrial tachycardia. Non-specific ST-T
wave changes. Since the previous tracing of [**2149-8-18**] further T
wave changes are suggested but there may be no significant
change.
.
ECG ([**8-24**]): Sinus with 1:1 conduction. NA-NI. LAA. Non-specific
ST-T wave changes anteriorly present on prior ECGs.
.
TTE ([**8-12**]): The left atrium is moderately dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
EGD ([**8-22**]):
- Varices at the lower third of the esophagus.
- Erythema, congestion, abnormal petechial vascularity and
mosaic appearance in the whole stomach compatible with portal
hypertensive gastropathy
- Linear erythematous streaks in the antrum compatible with
gastric antral vascular ectasia
- Schatzki's ring
.
Flex sig ([**2149-8-18**]):
- Large internal hemorrhoids
- Small non bleeding rectal varices.
Brief Hospital Course:
Ms. [**Known lastname **] is a 69 year old female with MELD ~32 EtOH
cirrhosis c/b encephalopathy, ascites, portal hypertensive
gastropathy, and grade II varices transferred to the MICU for
encephalopathy and renal failure after admission to the floor
for GIB and evaluation for transplant. Pt was admitted to the
MICU where pt underwent flexible sigmoidoxcopy on [**8-18**]
demonstrating internal hemorrhoids and non-bleeding rectal
varices. Pt remained stable and was transferred to the floor.
The pt underwent EGD on [**8-22**] that demonstrated 5 cords of grade
II varices, a Schatzki's ring, GAVE and portal hypertensive
gastropathy. Over the following days pt developed progressive
renal failure and encephalopathy. Pt was started on rifaxamin
and lactulose and transferred back to the MICU. Renal failure
was initially thought to be [**1-27**] hepatorenal and pt was treated
with midodrine, albumin and octreotide, however, renal was
consulted and thought that the renal failure was [**1-27**] ATN and so
these medicines were discontinued. Pt deteriorated further
clinically and started on pressors and intubated for airway
protection. She continued to deteriorate on pressors and renal
function did not recover and so CVVH was initiated. Pt had
recurrent atrial fibrillation and was put on hold on the
transplant list because she was felt to be too sick. Ultimately,
a family mtg was held as it was felt that her ultimate prognosis
was very poor. The decision was made to terminally extubate her
and pressors were discontinued.
Contact: [**Name (NI) **] [**Name (NI) **] (husband) [**Telephone/Fax (1) 82615**]
Medications on Admission:
HOME MEDICATIONS:
neomycin 500mg QID
Omperazole 20mg daily
Aldactone 50mg daily
Lasix 20mg [**Hospital1 **]
Lactulose 4 tbspn 4 times daily
reglan 5mg/5mL 2 tspns QID
.
Medications (on transfer):
Albumin 25% (12.5g / 50mL) 50 g IV DAILY
CeftriaXONE 1 gm IV Q24H
Citalopram Hydrobromide 10 mg PO DAILY
Hemorrhoidal Suppository 1 SUPP PR DAILY
Lactulose 30 mL PO Q2H
Metoclopramide 10 mg PO QIDACHS
Miconazole Powder 2% 1 Appl TP TID:PRN rash
Midodrine 7.5 mg PO TID
Levothyroxine Sodium 37.5 mcg IV DAILY
Metoprolol Tartrate 2.5 mg IV Q6H
Pantoprazole 40 mg IV Q12H
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Discharge Condition:
Discharge Instructions:
Followup Instructions:
Completed by:[**2149-9-13**]
|
[
"287.5",
"284.1",
"789.59",
"427.31",
"112.1",
"569.3",
"303.93",
"V49.83",
"784.0",
"572.3",
"750.3",
"572.2",
"785.50",
"599.0",
"276.2",
"456.21",
"584.5",
"311",
"280.0",
"997.31",
"286.6",
"397.0",
"276.51",
"571.2",
"536.3",
"396.2",
"518.81",
"537.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"38.91",
"38.93",
"54.91",
"39.95",
"45.13",
"45.24",
"96.6",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9131, 9150
|
6894, 8516
|
367, 554
|
9196, 9196
|
3626, 3631
|
9248, 9276
|
3170, 3288
|
9173, 9173
|
8542, 8542
|
9222, 9222
|
3303, 3607
|
8560, 9108
|
281, 329
|
582, 2261
|
3645, 6871
|
2283, 2742
|
2758, 3154
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,089
| 180,612
|
3444
|
Discharge summary
|
report
|
Admission Date: [**2156-5-15**] Discharge Date: [**2156-5-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4071**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2156-5-17**] Pericardiocentesis with placement of pericardial drain;
[**2156-5-19**] removal of pericardial drain
History of Present Illness:
88 year-old female with a history of HTN, Hyperlipidemia who was
recently admitted for pericarditis [**2156-5-4**] and discharged home
readmitted with recurrent chest pain. Completed 10 day course of
ibuprofen [**5-14**], pain less severe this time (formerly [**7-11**] now
[**2-9**]). No nausea, diaphoresis, or shortness of breath. Patient
mild symptoms at rest, no change with exertion. There is no
history of exertional dyspnea, PND, orthopnea, presyncope,
syncope, or palpitations.
In the ED, initial vitals were stable. Cardiac enzymes were
negative x 1. EKG unchanged. Given ASA 325 mg. Bedside
ultrasound showed ? pericardial effusion. She was initially
admitted to the [**Hospital1 **] service. Given 20 mg of prednisone for
pericarditis for planned 3 days.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Arthritis
4. C Diff diarrhea (currently on chronic PO vanc)
5. Zoster
6. Pseudogout
7. Recurrent UTIs
8. h/o dental abscess
Social History:
denies tob/etoh/illicits, lives with husband.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - 99.2 BP 149/72 HR 99 RR 24 O2 95% 3L.
Gen: WDWN elderly female lying in bed, nad, A&O X 3. Mild
distress with speaking full sentences.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No rub.
Chest: No chest wall deformities. bilateral wheezing, no
crackles.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABORATORIES
[**2156-5-15**] 04:30PM PLT COUNT-392
[**2156-5-15**] 04:30PM NEUTS-82.5* LYMPHS-10.6* MONOS-5.7 EOS-0.9
BASOS-0.3
[**2156-5-15**] 04:30PM CK-MB-NotDone
[**2156-5-15**] 04:30PM WBC-8.4 RBC-3.44* HGB-10.8* HCT-31.8* MCV-92
MCH-31.4 MCHC-34.1 RDW-13.1
[**2156-5-15**] 04:30PM cTropnT-<0.01
[**2156-5-15**] 04:30PM CK(CPK)-34
[**2156-5-15**] 04:30PM estGFR-Using this
[**2156-5-15**] 04:30PM GLUCOSE-127* UREA N-38* CREAT-1.2* SODIUM-137
POTASSIUM-5.0 CHLORIDE-104 TOTAL CO2-22 ANION GAP-16
[**2156-5-15**] 06:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2156-5-15**] 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2156-5-15**] 06:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
TSH 11 (elevated)
Free T4 1.3 (normal)
Pericardial Fluid Culture: Positive for strep viridans
(pan-sensitive)
STUDIES
ECG [**2156-5-15**]: Normal sinus rhythm. Non-specific ST-T wave
abnormalities. Since the previous tracing of [**2156-5-4**] there is no
diagnostic interval change.
CXR [**5-15**]: Low lung volumes, without an acute cardiopulmonary
process.
b/l LE dopplers [**2156-5-16**]: No evidence of DVT
CTA Chest [**2156-5-16**]:
1. No evidence of pulmonary embolus.
2. Moderate to large pericardial effusion, a new finding since
[**2156-5-3**].
3. Bilateral basal pulmonary atelectasis and pleural effusions,
which have
also increased since the previous CT.
4. Bilateral upper pole renal cysts.
TTE [**2156-5-17**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-3**]+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is a moderate sized (1-1.5cm) circumferential pericardial
effusion with sparing along the inferior and inferolateral
walls. There is mild right ventricular diastolic collapse,
consistent with impaired filling/tamponade physiology.
Compared with the prior study (images reviewed) of [**2156-5-4**], the
pericardial effusion new and early tamponade physiology is
suggested.
Clinical correlation and serial evaluation is suggested.
TTE [**2156-5-18**]:
The estimated right atrial pressure is 10-20mmHg. 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. There is no aortic
valve stenosis. No aortic regurgitation is seen. Mild to
moderate ([**12-3**]+) mitral regurgitation is seen. There is a
moderate sized pericardial effusion. The effusion appears
circumferential with a layer of echo dense material, consistent
with blood, inflammation or other cellular elements anterior to
the RV. There is right ventricular diastolic collapse,
consistent with impaired fillling/tamponade physiology.
Compared with the prior study (images reviewed) of [**2156-5-17**],
the findings are similar.
Cardiac Cath [**2156-5-18**]:
1. Pericardial effusion with tamponade physiology.
2. Successful pericardiocentesis of 220 cc bloody fluid.
HEMODYNAMICS: RV 42/8, PCW 16, PA 43/18, mean 28, RA 16. Post
procedure RA pressure went drom 15->10 pericardial pressure from
15->3.
Pericardial Fluid Cytology [**2156-5-18**]: NEGATIVE FOR MALIGNANT
CELLS.
TTE #2 [**2156-5-18**]:
Overall left ventricular systolic function is normal (LVEF>55%).
There is a small echo dense pericardial effusion, consistent
with blood, inflammation or other cellular elements.
Compared with the prior study (images reviewed) of [**2156-5-18**],
the echo lucent pericardial effusion is no longer appreciated.
There is residue echo dense material mostly anterior to the RV.
TTE [**2156-5-19**]:
The estimated right atrial pressure is 0-10mmHg. Overall left
ventricular systolic function is normal (LVEF>55%). There is a
very small pericardial effusion. There are no echocardiographic
signs of tamponade.
Compared with the prior study (images reviewed) of [**2156-5-18**],
the effusion appears smaller.
Brief Hospital Course:
88 yo F w/ htn, hyperlipidemia, chronic c.diff, recent admission
for pericarditis presents with recurrent pleuritic chest pain
after discontinuing her NSAIDS admitted with recurrent
pericarditis.
Upon admission to cardiology, patient was noted to have
pleuritic chest pain with poor oxygen saturation. The team
worked her up for possible PE. LE dopplers were negative and
CTA chest did not show PE but was significant for new
pericardial effusion.
Echocardiogram on [**2156-5-17**] showed large pericardial effusion with
some RV collapse. She was given IV fluid and her pulsus was
monitored and was stable at 12.
Repeat echocardiogram [**5-18**] showed continued evidence of
tamponade and she underwent pericardiocentesis. 220 cc of
bloody pericardial fluid was drained. Post procedure RA
pressure went drom 15->10 pericardial pressure from 15->3. Post
procedure echo showed resolution of the effusion and residual
fibrinous material.
She was monitored in the CCU after pericardiocentesis and repeat
Echocardiograms showed no further reaccumulation of fluid.
Pericardial fluid was sent and based on her laboratories, the
effusion appeared possibly hemorrhagic, likely from
pericarditis. Cytology was negative for malignancy. Of note,
her pericardial fluid grew Strep viridans but all of her blood
cultures were negative. ID was consulted and left the following
impression:
"The appearance of Strep viridans in broth only is highly
suspicious of a contaminant; this possibility is enforced by the
failure of blood culture bottles innoculated at drainage to grow
at all. Strep viridans pericarditis is highly unlikely
clinically in the absence of endocarditis, and the patient has
had negative blood cultures and no clear evidence of valvular
disease. Given these observations, we would recommend no
antibiotic therapy at this time."
The patient was discharged home with PCP [**Last Name (NamePattern4) 702**].
# Pericarditis:
She was initially given steroids, which were discontinued in the
CCU. She was discharged on a course of ibuprofen.
# Acute diastolic heart failure:
Patient showed clinical evidence of volume overload, most likely
from the fluids she received in the hospital. She received some
diuretics post procedure but did not require additional lasix.
Her ECHO showed EF>55%.
# Chronic c. difficile: Pt was continued on her course of PO
vancomycin per outpatient medications.
# Hypertension: Continued home metoprolol.
# Hyperlipidemia: Continue zocor.
# Arthritis: Held mobic while on ibuprofen.
# Subclinical Hypothyroidism:
The patient was noted to have sinus tachycardia around 100 even
after her pericardiocentesis. TSH was sent and was found to be
high with a normal free T4. It is recommended that her PCP
recheck thyroid function tests in the future.
Medications on Admission:
1. Protonix 40 mg Daily
2. Simvastatin 10 mg daily
3. Cholecalciferol (Vitamin D3) 400 unit Daily
4. Calcium Carbonate 500 mg TID
5. Multivitamin Daily
6. Vancomycin HCl 250 mg PO daily
7. Metoprolol Tartrate 25 mg PO BID
8. Acidophillus
Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Acidophilus Capsule Sig: One (1) Capsule PO daily ().
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. Pericarditis
2. Pericardial effusion with tamponade physiology
.
Secondary:
1. Hypertension
2. Hyperlipidemia
3. Arthritis
4. Chronic Clostridium Difficle diarrhea
5. Zoster
Discharge Condition:
Hemodynamically stable, afebrile
Discharge Instructions:
You were admitted to the hospital with chest pain after a recent
admission with similar pain. Echocardiogram showed accumulation
of fluid around the heart that was not present on your previous
admission. You had a procedure to remove this fluid. Following
this procedure your chest pain improved. You should take
ibuprofen 400 mg twice a day for 7 days following discharge.
This will help the pericardium to heel and decrease the chances
of resccumulation of fluid.
Followup Instructions:
An appointment has been scheduled with your PCP: [**Name10 (NameIs) 2946**] [**Name8 (MD) 15898**], MD. Date/Time: [**6-8**], Tuesday, 2:15 PM. Phone:
[**Telephone/Fax (1) 2205**]. Location: [**State **], [**Location (un) **], MA
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**]
Completed by:[**2156-6-30**]
|
[
"008.45",
"403.90",
"423.3",
"423.9",
"276.6",
"599.0",
"585.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"37.0",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
10425, 10483
|
6595, 9394
|
273, 392
|
10713, 10748
|
2223, 6572
|
11266, 11620
|
1453, 1536
|
9683, 10402
|
10504, 10692
|
9420, 9660
|
10772, 11243
|
1551, 2204
|
223, 235
|
420, 1189
|
1211, 1374
|
1390, 1437
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,840
| 185,578
|
20298
|
Discharge summary
|
report
|
Admission Date: [**2137-11-27**] Discharge Date: [**2137-12-7**]
Date of Birth: [**2091-6-15**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This 46-year-old female with
diabetes mellitus and known coronary artery disease status
post renal transplant in [**2129**]. She also had a history of
peripheral vascular disease and end-stage renal disease.
Earlier in the day on the 17th, she developed back pain that
radiated down her right arm. She called her primary care
physician, [**Name10 (NameIs) 1023**] sent her to the Emergency Room. The pain was
relieved with sublingual nitroglycerin. Today she was also
found to be in diabetic ketoacidosis. She was transferred in
for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction.
2. End-stage renal disease status post renal transplant in
[**2129**].
3. Peripheral vascular disease status post aorto to right
femoral bypass graft.
4. Insulin dependent-diabetes mellitus.
5. Right cataract.
ALLERGIES:
1. Penicillin.
2. Lasix.
MEDICATIONS AT TIME OF CATH LAB EMERGENCY CONSULT:
1. CellCept.
2. Isordil.
3. Aspirin.
4. Insulin.
5. Plavix.
6. Neoral.
7. Toprol XL.
8. Prednisone.
9. Hydrochlorothiazide.
10. Folate.
11. Zantac.
12. Accupril.
13. Nifedipine.
LABORATORIES: White count 13.1, hematocrit 31.6, platelet
count 371,000. Blood gas was as follows: 7.23/45/87/20/-8
base access.
PREOPERATIVE LABORATORY WORK: BUN 15, creatinine 0.8, sodium
137, K 4.6, chloride 108, bicarb 17, anion gap 17, glucose at
210, also repeated in that evening at 9 p.m. was also 409.
CK at 9 in the evening was 135. ALT 26, AST 34, alkaline
phosphatase 42, amylase 29, total bilirubin 0.3. CK MB
fraction was 15 with an index of 11.1%. Her magnesium also
that evening was 2.0.
Preoperative chest x-ray for checking her Swan placement
showed the femoral access Swan-Ganz catheter in normal
position, intra-aortic balloon pump was in position. There
was no cardiomegaly. Lungs were clear. There were no
pleural effusions or pneumothoraces and no evidence of acute
cardiopulmonary disease.
Preoperative EKG showed sinus rhythm at 81 with a right
bundle branch block and no significant change from her prior
EKGs at admission.
Preoperative laboratory work was as follows: White count
13.1, hematocrit 31.6. PT 12.5, PTT 31.5, platelet count
371,000. INR 1.0.
In the Cath Laboratory, results showed significant coronary
disease with a 90% mid LAD lesion and 90% proximal circumflex
lesion. Her systolic blood pressure is approximately 170.
Nipride was started for afterload reduction and Cardiology
inserted an intra-aortic balloon pump. Carotid duplex was
requested and patient was seen by Dr. [**First Name4 (NamePattern1) 18078**] [**Last Name (NamePattern1) 14968**] with
Cardiothoracic Surgery at that time for evaluation of
imminent coronary artery bypass grafting. In addition, there
was a 99% lesion of the LAD at the takeoff of a major
diagonal. The RCA had a patent stent with 40% distal lesion.
Patient was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] of Cardiothoracic
Surgery service. Patient was followed by her attending
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Additional preoperative
laboratory work showed a sodium 137, potassium 4.6, chloride
108, bicarb 17, BUN 15, creatinine 0.8. Patient received
some stress dosed steroids and remained on Lasix as well as
IV nitroglycerin with a wedge goal of 14-18. Nipride was
stopped and kept in reserve if needed. Patient was given
BiPAP as needed, and was admitted to the CCU from the
Catheterization Laboratory.
MEDICATIONS AT HOME: Were listed by the patient as the
following:
1. Plavix 75 mg p.o. q.d.
2. Aspirin 81 mg p.o. q.d.
3. Nifedipine XL 90 mg p.o. q.d.
4. Zantac unknown dose.
5. Folate unknown dose.
6. Lopressor 75 mg p.o. b.i.d.
7. CellCept [**Pager number **] mg p.o. b.i.d.
8. Neoral 75 mg p.o. b.i.d.
9. Levoxyl 112 mcg p.o. q.d.
10. Accupril 20 mg p.o. q.d.
11. Prednisone 5 mg p.o. q.d.
12. Isordil 40 mg p.o. b.i.d.
ALLERGIES: Were previously noted as penicillin and question
of Lasix.
Patient was followed by the CCU team and remained
hemodynamically stable through the 18th. She was on an
Integrilin drip as well as Heparin drip. Her metoprolol was
increased to 50 b.i.d. She was started on captopril 12.5
t.i.d. and also remained on nitroglycerin drip. She was also
receiving her renal dosing of cyclosporin for post
transplant.
The single episode of flash pulmonary edema was successfully
treated in the Catheterization Laboratory. Her diabetic
ketoacidosis resolved. Her CHF was all managed by the CCU
team. She was seen by Social Work. The preliminary
noninvasive carotid studies showed an occluded left ICA and a
right ICA narrowing of less than 40%. Patient was seen by
Vascular Surgery to evaluate the role of whether or not the
patient would need a left carotid endarterectomy prior to
CABG. Dr. [**Last Name (STitle) 48367**] of Vascular Surgery determined there is
no role for vascular surgery at this particular time.
On [**11-29**], the patient underwent coronary artery bypass
grafting x2 by Dr. [**Last Name (STitle) 70**] with a LIMA to the LAD and a
vein graft to the OM. The patient still had her preoperative
intra-aortic balloon pump in place. She was transferred to
Cardiothoracic ICU in stable condition A-paced on a
Neo-Synephrine drip on 1 mcg/kg/minute, insulin at 6
units/hour, and a propofol titrated to 10 mcg/kg/minute.
On postoperative day one, she remained on CPAP with pressure
support in the low 90s in sinus rhythm with a pressure of
144/70. Her heart was regular rate and rhythm. She had
scattered rhonchi throughout her lungs. Her extremities were
warm with 1+ edema. Sedation was minimized with a plan to
wean extubate her and D/C her chest tubes. Captopril was
started 6.25 t.i.d. Lasix diuresis was begun. She remained
NPO at that time given her intubation, and she received 1 amp
of bicarb to balance her. Her white count was 18.1 with a
hematocrit of 31.6, platelet count of 110,000
postoperatively. PT was 13.0 with an INR of 1.1. Her K was
4.7 with a BUN of 25 and a creatinine of 0.9.
Her intra-aortic balloon pump remained in place. Her
nitroglycerin was being titrated to help maintain a good
blood pressure. She was seen by the Cardiology fellow for
pulling her balloon pump on the 20th, which was done without
any complications.
On postoperative day two, she was extubated. Her balloon
pump was out. Her Neo-Synephrine was off as well as her
nitroglycerin IV drip. She remained on captopril and Lasix.
Plavix was restarted. She was in sinus rhythm in the 80s
with a pressure of 114/52. She was saturating 100% on 3
liters nasal cannula and was making good progress. Her white
count rose slightly to 18. Hematocrit remained stable at
26.4, but her platelets dropped again to 76,000. Patient's
prednisone 5 mg p.o. q.d. was restarted.
On postoperative day three, she remained in sinus rhythm in
the 60s as her beta blockade began. Her incisions were
clean, dry, and intact. Her captopril was stopped. She was
maintained with good blood pressure. She continued to
receive Lasix, and her CellCept was restarted as well as the
cyclosporin A. She was seen by the Renal fellow. Her
creatinine rose slightly to 1.2. She remained on her
immunosuppressive drugs. They recommended gentle diuresis.
She was also seen by the clinical nutrition team for
screening followed by the social worker as well as the case
manager.
On postoperative day four, heart was regular rate and rhythm.
Her lungs were clear bilaterally. Her thyroid medicine had
also been restarted the day prior. Cyclosporin level was
sent off. Her creatinine rose slightly to 1.4 with a K of
4.2. Her hematocrit remained at 25.6. White count was at
13.2. Recommendations were made and evaluated daily by the
CT Surgery team. She was also seen by the physical therapist
and the patient's blood sugar did drop during the day to 56.
It was up to 434 in the afternoon. Patient was treated and
decision was made that the patient would need an insulin drip
overnight so that the team decided to transfer the patient
back to CSRU as a CCU bed was needed for closer monitoring of
her blood sugar and regular insulin drip.
On postoperative day five, she continued to be followed in
CSRU. Her creatinine dropped again slightly to 1.1. Her
white count also dropped to 11.0 with a potassium of 4.1.
Her blood sugar continued to be up and down. She received
Levaquin for a UTI, and the decision was made to transfer her
back to [**Hospital Ward Name 121**] 2. She was seen by the [**Last Name (un) **] attending as well
as the Renal fellow again, and the patient began her
ambulation back out on [**Hospital Ward Name 121**] 2.
On postoperative day six, patient was maintaining a good
blood pressure 143/69 in sinus rhythm at 85 and was
hemodynamically stable. She was alert and oriented in no
distress. Her wounds were clean, dry, and intact. Her lungs
were clear bilaterally. Her extremities had 2+ pedal edema.
She had palpable DPs. Her belly was soft, nontender,
nondistended. She was doing well. Her temporary pacing
wires were discontinued. Diuresis was restarted. The
cyclosporin range came back 100-150. Levels were to be
checked daily, and [**Last Name (un) **] continued to follow the patient for
blood sugar control.
Patient continued to progress well with ambulation with
slight desatting, but recovered significantly. She was
asymptomatic when she walked with Physical Therapy and was
almost back to her baseline level.
On postoperative day seven, she had no complaints. Was
hemodynamically stable with a good blood pressure. Her lungs
were clear bilaterally with the exception of some diminished
sounds at her right base. Heart was regular rate and rhythm.
Sternum was stable. Her incisions were clean, dry, and
intact. Her chest x-ray showed a right basilar pneumothorax
with a left pleural effusion. She was stable hemodynamically
and continued on her current medications. The plan was to
repeat her chest x-ray in the morning. She had good urine
output. Was taking p.o. and was tolerating them well.
Creatinine was stable. She continued her immunosuppressive
medicines, and remained on the insulin protocol that had been
setup [**First Name8 (NamePattern2) **] [**Last Name (un) **] team.
On postoperative day eight, the day of discharge, she had no
complaints. Had a blood pressure of 120/55 with a T max of
98.4, heart rate was 75 in sinus rhythm, satting 98% on room
air. On the day of discharge, her white count is 10.2,
hematocrit 27.7, sodium 143, K 4.4, chloride 106, bicarb 30,
BUN 20, creatinine 1.2 with a blood sugar of 147. Her
cyclosporin A level was 307. Her repeat chest x-ray was
pending at that time. The follow-up chest x-ray showed no
pneumothorax. She remained on all of her medications and was
ambulating well, and was discharged to home on [**12-7**].
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x2.
2. Severe three vessel coronary artery disease with acute
myocardial infarction and cardiogenic shock.
3. Insulin dependent-diabetes mellitus.
4. Status post diabetic ketoacidosis.
5. Diabetic nephropathy with end-stage renal disease status
post renal transplant in [**2129**].
6. Diabetic retinopathy.
7. Right eye cataract.
8. Status post right aorto to right femoral bypass.
9. Occluded left carotid artery.
10. Hypothyroidism.
FOLLOW-UP INSTRUCTIONS: Patient was instructed to followup
with Dr. [**First Name (STitle) **] in [**12-13**] weeks, and to followup with the [**Last Name (un) **]
physician to discuss blood sugars and to require Humalog
doses. Patient was also instructed to followup with the
cardiologist in [**1-14**] weeks and see her Transplant physicians
in the next month. An appointment was made for her to return
to the [**Hospital 54486**] Clinic in [**1-14**] weeks and to see Dr. [**Last Name (STitle) 70**]
for postoperative visit in the office at one month.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d.
3. Metoprolol 50 mg p.o. b.i.d.
4. Amlodipine 5 mg p.o. b.i.d.
5. Lasix 20 mg p.o. b.i.d. for 14 days.
6. Potassium chloride 20 mEq p.o. b.i.d. for two weeks while
on Lasix.
7. Cyclosporin modified 75 mg p.o. q.12h.
8. Prednisone 5 mg p.o. q.d.
9. Mycophenolate mofetil 750 mg p.o. b.i.d.
10. Levothyroxine sodium 112 mcg p.o. q.d.
11. Percocet 30/300 1-2 tablets p.o. prn q.4h. for pain.
12. Colace 100 mg p.o. b.i.d. as needed for constipation.
13. Zantac 75 mg p.o. b.i.d.
14. Insulin both glargine and Lispro Human as directed by
sliding scale with patient to follow her protocol with
checking sugars before meals and at bedtime, and following up
with her [**Last Name (un) **] physicians immediately for correct protocol
dosing.
15. Levofloxacin 500 mg p.o. q.24h. for three more days with
last dose being [**12-9**].
16. Fluticasone propionate 110 mcg ......... aerosol two
puffs inhalation b.i.d.
CONDITION ON DISCHARGE: The patient was discharged to home
in stable condition on [**2137-12-7**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2138-1-2**] 14:34
T: [**2138-1-3**] 04:56
JOB#: [**Job Number 54487**]
|
[
"250.11",
"V45.82",
"785.51",
"428.0",
"250.51",
"443.9",
"V42.0",
"410.71",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"36.15",
"36.11",
"97.44",
"39.61",
"37.21",
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11122, 11605
|
12187, 13146
|
3739, 11101
|
181, 745
|
11630, 12164
|
767, 3717
|
13171, 13545
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,209
| 174,717
|
29330
|
Discharge summary
|
report
|
Admission Date: [**2156-1-23**] Discharge Date: [**2156-1-28**]
Date of Birth: [**2086-6-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillin G / Keflex
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
CABG X 4 (LIMA>LAD, SVG>Diag>OM, SVG>RCA [**1-23**]
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 4460**] is a 69 year old female who recently was
catheterized secondary to a complaint of angina. The
catheterization revealed sever three vessel disease and was
referred to [**Hospital3 **] Medical Center for surgical evaluation.
Past Medical History:
HTN
Bronchiectasis
Chronic back pain due to injury
Social History:
Smoked 1ppd x 50yrs. Negative EtOH use or IVDU.
Family History:
Father had MI at age 62.
Physical Exam:
At the time of discharge, Ms. [**Known lastname 4460**] was found to be in no acute
distress. She was awake, alert, and oriented. Upon ausculation
of her chest, her lungs were clear bilaterally and her heart was
of regular rate and rhythm. No sternal drainage or erythema was
noted. Her abdomen was soft, non-tender, and non-distended.
Ms. [**Known lastname 70450**] extremities were warm with trace edema. Her leg
incisions were clean and dry.
Pertinent Results:
[**2156-1-27**] 07:40AM BLOOD WBC-14.2*
[**2156-1-27**] 07:40AM BLOOD UreaN-19 Creat-0.9 K-5.3*
[**2156-1-26**] 06:00AM BLOOD WBC-15.6* RBC-3.63* Hgb-10.9* Hct-32.1*
MCV-88 MCH-29.9 MCHC-34.0 RDW-15.1 Plt Ct-238
Brief Hospital Course:
On [**2156-1-23**] Ms. [**Known lastname 4460**] [**Last Name (Titles) 1834**] a Coronary Artery Bypass times
four vessels (LIMA to LAD, SVG to Diag, SVG to distal RCA).
This procedure was performed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**], M.D. The
patient tolerated the procedure well and was transferred in
stable condition to the surgical intensive care unit.
In the surgical intensive care unit she was seen in consultation
by the pulmonary service for her multiple pulmonary issues
including bronchiectasis, emphysema, lung nodules, sinusitis,
and recent pneumonia. She was successfully extubated by
post-operative day one. Her pressors were weaned and oral blood
pressure regimen was mazimized. She was gently diuresed. By
post-operative day 2 seh was ready for transfer to the surgical
step down floor.
On the surgical step down floor Ms. [**Known lastname 70450**] chest tubes and
epicardial wires were removed. She was seen in consultation by
the physical therapy service. By post-operative day five she
was ready for discharge to home.
Medications on Admission:
lopressor 75 ", omeprazole 20, lisinopril 5, lipitor 80, HCTZ
25, tazadone 50 , hydrocodone APAP, Aspirin 325
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 mdi* Refills:*2*
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
13. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day) as needed.
Disp:*120 Troche(s)* Refills:*0*
14. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
15. Zithromax 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] [**Location (un) 5503**]
Discharge Diagnosis:
CAD
COPD
HTN
Chronic back pain
OA
Hiatal Hernia
L adrenal adenoma
Discharge Condition:
good
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] if any change in respiratory status (sputum
production, shortness of breath, wheezing...etc.)
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no driving for 1 month
no lifting > 10# for 10 weeks
Followup Instructions:
with Dr. [**Last Name (STitle) 47403**] in [**2-14**] weeks
with Dr. [**Last Name (STitle) 914**] in [**4-15**] weeks
with Dr. [**Last Name (STitle) 5310**] in [**2-14**] weeks
with Dr. [**Last Name (STitle) **] in [**4-15**] weeks (can be when you come in to see
Dr. [**Last Name (STitle) 914**]
Make an appointment with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] for 6 months for follow
up of carotid stenosis
Completed by:[**2156-1-28**]
|
[
"401.9",
"494.0",
"492.8",
"414.01",
"411.1",
"553.3",
"724.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"39.56",
"99.04",
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
4849, 4921
|
1558, 2647
|
294, 348
|
5031, 5038
|
1322, 1535
|
5362, 5838
|
811, 837
|
2807, 4826
|
4942, 5010
|
2673, 2784
|
5062, 5339
|
852, 1303
|
248, 256
|
376, 654
|
676, 729
|
745, 795
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,090
| 101,726
|
45188
|
Discharge summary
|
report
|
Admission Date: [**2117-9-14**] Discharge Date: [**2117-9-15**]
Date of Birth: [**2043-8-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Bactrim / Vancomycin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Reason for MICU admission: Drug reaction
Major Surgical or Invasive Procedure:
Placement of Central Line
History of Present Illness:
hpi: 74 yo female presents to ED from [**Hospital 100**] Rehab with
pruritic, painful rash over trunk, chest, back, arms, and
proximal legs. Patient had been recently admitted to [**Hospital1 18**] for
COPD flare requiring brief stay in the ICU, during that
admission she was found to have [**3-7**] blood cultures positive for
MRSA. She was started on Vancomycin and Gent at that time, Gent
later discontinued but Vancomycin continued to complete a two
week course after TTE was negative for vegetation. Per report
from [**Hospital 100**] Rehab, rash developed on [**2117-9-9**]. Vancomycin was
stopped on [**2117-9-10**], but rash continued getting worse with
exfoliation and bullae concerning for [**Doctor First Name **]-[**Location (un) **]. In
addition, per ED report she had positive blood cultures (GPC in
clusters) from [**2117-9-12**] at [**Hospital 100**] Rehab, although the
documentation from the HR stated the repeat blood cultures were
negative. She was transferred to [**Hospital1 18**] for further management
and dermatologic evaluation.
.
In the ED, she denied fevers, chills, CP, SOB, palpitations,
headache, swelling in tongue, throat or wheezing. Vital signs
were 96.2 111 125/74 18 100%3L. She was given Sarna lotion,
Benadryl, and changed to Linezolid.
.
Currently she complains of prurutis and pain.
Past Medical History:
pmhx:
1.COPD - GOLD Stage III with FEV1 32% predicted on PFTs in [**2115**],
on home O2
2.Moderate-to-severe aortic stenosis - valve area 0.9 cm, Mean
gradient 29mmHg, peak velocity 3.4 on echo in [**8-/2117**]
3.Diastolic CHF
4.Obstructive sleep apnea - No formal sleep study and not on
CPAP
5.Achalasia, s/p pneumatic dilatation and botulinum toxin
injection of LES
6.Morbid obesity
7.Chronic lower extremity edema
8.S/P cholecystectomy: [**2102**]
9.Chronic low-back pain
Social History:
4 children. One adult daughter is deceased at age 47, [**2-5**] to
cancer, the remaining daughers are alive. Currently at [**Hospital 100**]
Rehab, previously lived alone. remote history of tobacco use for
"few years" after she was married, no ETOH. No drug use.
Family History:
Mother deceased at age 72, [**2-5**] to trauma. Daughter died at age
47 of cancer.
Physical Exam:
PE:
vitals: 97.1 101-120 117/24 29 100%RA
GEN: In discomfort, speaking comfortably
HEENT: Sclera anicteric, erythematous rash not sparing the
nasolabial folds, no stridor or OP swelling, OP clear without
lesions
NECK: Supple
CV: RRR, [**3-9**] sys cres-descres murmur RUSB -> carotids
LUNGS: Decreased air movement anteriorally
ABDOMEN: Obese, soft, NTND, no HSM
EXT: 3+ BL edema
SKIN: Exfoliating erythematous rash with evidence of ruptured
bullae over chest with dry base, back, anterior thigh, no rash
on palms/soles
NEURO: AAOx3, CN II-XII intact
Pertinent Results:
[**2117-9-14**] 06:30AM WBC-26.1* RBC-3.69* HGB-10.5* HCT-32.4*
MCV-88 MCH-28.3 MCHC-32.2 RDW-16.1*
[**2117-9-14**] 06:30AM NEUTS-92.3* BANDS-0 LYMPHS-4.9* MONOS-2.0
EOS-0.7 BASOS-0.1
[**2117-9-14**] 06:30AM PLT SMR-NORMAL PLT COUNT-292
.
[**2117-9-13**] 06:55PM GLUCOSE-114* UREA N-24* CREAT-0.8 SODIUM-134
POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-36* ANION GAP-10
.
Pertinent results:
CXR: Bedside AP and lateral views labeled "upright, stretcher at
10:00 p.m." are compared with PA and lateral views dated
[**2117-8-29**]. Allowing for differences in radiographic technique,
motion-blurring and patient positioning, the overall appearance
is essentially unchanged. There is evidence of pulmonary
hyperinflation with diaphragm flattening, suggestive of
underlying obstructive lung disease, but no focal airspace
process is seen. The cardiomediastinal silhouette and pulmonary
vessels are unchanged with no evidence of CHF. DISH involving
the thoracic spine is redemonstrated.
.
ECHO [**8-/2117**]: Mild LAE, mild LVH, normal function (EF>55%). RV
size and free wall motion normal. Mod to severe AS, no AR.
trivial MR.
.
EKG:
.
UA: small leuks, neg nit, occ bacteria, 0-2 WBC
Brief Hospital Course:
A/P: 74F Vancomycin for MRSA bacteremia, transferred from [**Hospital 100**]
Rehab for worsening rash and persistent bacteremia.
.
# Rash: On presentation, dermatology was consulted. They
believe that it is most consistent with AGEP (acute generalized
exanthematous pustulosis), which is a drug hypersensitivity
recation. Fever and leukocytosis can acompany this reaction.
They recommened supportive care. A biopsy was taken and should
be follow up after the patient is discharged. Petrolatum can be
applied to entire body surface [**Hospital1 **]-TID to help with healing.
Also, ABD pads or other cushioning in intertriginous areas to
prevent trauma as well as viscous lidocaine prn oral comfort.
She will need suture removal in [**10-17**] days and should follow up
at dermatology clinic. ([**Telephone/Fax (1) 1971**] to schedule a follow-up
appointment.) The patient was also aggressively hydrated
because of the large volume of fluids that she is losing from
her skin.
.
# Bacteremia: Unclear etiology but likely pulmonary; from
previous admission. The patient remained afebrile despite
growing [**3-7**] blood cultures for gram positive cocci in clusters
during that admission. TTE was performed at that time revealing
knwon stable AS with a thickened valve but no evidence of
vegetation. The patient's vancomycin was stopped on admission
and she was started on Linezolid. Repeat blood cultures are
pending at the time of discharge. She will need a total of a 14
day course starting from [**9-7**] (ending on [**9-21**]).
Medications on Admission:
Meds(per last dc summary, needs to be confirmed)
Aspirin 325 mg PO DAILY
Furosemide 40 mg Tablet PO DAILY
Ipratropium Bromide neb Inhalation Q6H
Albuterol Sulfate neb Inhalation Q6H
Aluminum-Magnesium Hydroxide QID as needed.
Miconazole Nitrate Topical [**Hospital1 **]
Pantoprazole 40 mg PO Q24H
Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q4-6H
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: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q8H
(every 8 hours) as needed for pruritis.
5. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB, wheeze.
8. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1)
Inhalation Q2H (every 2 hours) as needed for SOB, wheeze.
9. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
[**1-5**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed.
12. Petrolatum Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
13. Linezolid 600 mg IV Q12H
14. Morphine Sulfate 2-4 mg IV Q3-4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Rash secondary to vancomycin
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a rash secondary to an antibiotic that
you had taken. During your stay, your antibiotics were changed
and you were treated with fluids and aquaphor cream. You will
need to continue taking the Linezolid medication to complete a
14 day course (to be completed on [**9-21**])
Followup Instructions:
You will be discharged to the MACU at [**Hospital 100**] Rehab for ongoing
care.
--Please arrange for suture removal in [**10-17**] days.
--Please call the dermatology clinic at [**Telephone/Fax (1) 1971**] to schedule
a follow-up appointment.
|
[
"424.1",
"327.23",
"E930.8",
"V09.0",
"782.3",
"428.30",
"693.0",
"790.7",
"278.01",
"428.0",
"496",
"724.2",
"041.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7618, 7684
|
4418, 5959
|
351, 378
|
7757, 7766
|
3598, 4395
|
8111, 8358
|
2537, 2621
|
6360, 7595
|
7705, 7736
|
5985, 6337
|
7790, 8088
|
2636, 3188
|
271, 313
|
406, 1741
|
1763, 2241
|
2257, 2521
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,243
| 193,840
|
13738
|
Discharge summary
|
report
|
Admission Date: [**2134-5-9**] Discharge Date: [**2134-6-11**]
Date of Birth: [**2080-7-4**] Sex: M
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: The patient is an unfortunate 52
year old gentleman who was an unrestrained driver on a high
speed motor vehicle accident versus a utility pole. There
was significant damage of the vehicle and the utility pole
was broken in half. The patient was found to have a possible
alcohol level upon arrival. Question of loss of
consciousness prior to the encounter with the paramedics. He
was found awake and alert, bleeding from facial lacerations
and the windshield was noticed to be spidered. Significant
damage to the steering wheel. He was nevertheless
hemodynamically stable at the scene and upon transfer to the
[**Hospital1 69**]. His main complaint was
facial pain and right chest pain.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease,
2. Asthma.
3. Hypertension.
4. Status post splenectomy as a child apparently related to
trauma.
5. Status post colectomy in the distant past for colon
cancer.
MEDICATIONS ON ADMISSION: Unclear but the patient referred
that he took medications for hypertension.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs upon arrival to the [**Hospital1 1444**], the patient had a
temperature of 98.6, heart rate 78, blood pressure
140/palpable, respiratory rate 20, oxygen saturation 95% in
room air. The patient was awake, alert and followed
commands. He had multiple facial lacerations. He had a deep
laceration on the right side of the nose. There was a
hematoma on the right upper eyelid and laceration of the
right eyebrow. There was an abrasion of the scalp on top of
the head. The pupils are equal, round, and reactive to light
and accommodation, 3.0 to 2.0 millimeters. The neck had a
cervical collar in place. Trachea was midline. Chest -
There was a bruise over the xiphoid, good inspiratory and
expiratory effort, bilateral breath sounds, no crepitus to
palpation. He was tender over the right lateral chest wall.
He was regular rate and rhythm. The abdomen had a midline
scar well healed. He was nontender to palpation. Pelvis was
stable, nontender to palpation. The back showed no bruises
and no step-off and no tenderness. He had good rectal tone.
He was occult blood positive. Extremities had some abrasions
on both knees. No obvious bony deformity. Motor strength
was [**4-25**]. He had bilateral palpable pulses. He had a
laceration on the left forehead that appeared to be
superficial.
LABORATORY DATA: Hematocrit on arrival was 27.7, white blood
cell count 14.0, platelets 250,000. Prothrombin time 13.2,
partial thromboplastin time 28.0 and INR 1.2. His gas
obtained in the Trauma Bay was a pH of 7.32, pCO2 of 48, pO2
of 136, bicarbonate 26 and base excess of -1. ETOH level
435. Amylase was 101.
His initial trauma evaluation showed a chest x-ray with
widened mediastinum that raised the question of aortic
injury. Pelvis and cervical spine were negative. CT of the
head showed no evidence of intracranial hemorrhage. The
chest CT showed a transection of the proximal descending
thoracic aorta and very important juxta-aortic hematoma. CT
of the abdomen was unremarkable.
An emergent consultation with the thoracic surgery service
was obtained and he was taken to the operating room for an
urgent left posterolateral thoracotomy with repair of the
proximal descending thoracic aorta using a 20 millimeter gel
weave tube graft using also left atrial femoral bypass. The
patient tolerated the procedure well and he was transferred
in stable condition to the Trauma Intensive Care Unit.
Due to the mechanism of the accident and the nature of this
injury once in the SICU, he was found to have an important
pulmonary contusions requiring full ventilatory support.
Over the first 48 hours, he was maintained on pressors and
his ventilatory status was critical.
On postoperative day number one, he was noted to have an
important right pleural effusion and a large chest tube was
placed. The patient developed acute respiratory distress
syndrome and continued to require full ventilatory support.
Within a week after his operation, he was noted to have
bilateral pneumonia and needed to be bronchoscoped several
times. One of the bronchoalveolar lavages came positive for
Methicillin resistant Staphylococcus aureus and he was
started on Vancomycin.
In order to provide nutrition for this patient, a NJ was
placed and he was started on tube feeds. Around this time,
he was noticed to have significantly and consistently
elevated blood sugar. He required to be placed on an
aggressive regular insulin sliding scale to control his blood
sugar.
Over the course of the next couple weeks, the patient had
several trials of weaning off the ventilator but all of them
failed. Finally, it was decided to trach him and in a last
attempt and effort, the patient was extubated on [**2134-6-1**], by
the SICU staff. He remained extubated keeping good oxygen
saturation and decent blood arterial gases through that day.
By [**2134-6-6**], he was in good condition in order to be
transferred to the floor on TC6 where he was immediately
evaluated by physical therapy and started exercising with the
nursing staff. At this time, he was awake, alert and most of
the time oriented times two. Reviewing his prior trauma
films, we were able to clinically clear his cervical spine.
Despite his significant clinical improvement, he presented
with impaired mobility, impaired endurance and significant
knowledge deficit associated probably with decondition
secondary to prolonged hospitalization and Intensive Care
Unit stay. He continued to work daily with physical therapy
and on [**2134-6-10**], he completed successfully a second course of
fourteen days of intravenous Vancomycin.
We reviewed his case with infectious disease and the final
recommendation was to continue the Vancomycin for a total of
21 days. The last week that the patient was on the floor he
repeatedly expressed strong desire of being discharged. At
that time, that was not an option since the patient was
getting intravenous antibiotic and he had no insurance. Case
manager and social worker worked very hard trying to find VNA
to provide outside hospital antibiotics but this was
impossible at that time.
Two options were presented to the patient. One was to stay
for another seven days and complete his 21 days of
intravenous Vancomycin or be discharged on p.o. Nasalide that
the patient had to pay on his own. He rejected both of the
possibilities and agreed to stay until [**2134-6-12**]. He was
supposed to get his usual dose of Vancomycin twice a day.
Unfortunately around 9:00 o'clock on Friday, [**2134-6-11**], while
we had a covering resident for the trauma team, the patient
signed out against medical advice. He was explained in
detail all the implications about his decision and he was
given prescriptions for Percocet 5/325 one to two tablets
p.o. q4-6hours to control his pain, Flovent inhaler 110 mcg
two puffs b.i.d. He was instructed in part to use insulin
and he was provided with a glucometer. He was given a
prescription for insulin subcutaneous. He was given a
prescription for Lopressor 75 mg p.o. b.i.d. He was
encouraged to follow-up on Trauma Clinic next week so we
could assess his progress.
Social Work also scheduled a VNA to follow him up in regards
to his diabetic training. He was instructed to make a
follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] from the
Cardiothoracic Surgical Service in two to three weeks after
the time he was discharged and also to make a follow-up
appointment in the Trauma Clinic as stated above.
CONDITION ON DISCHARGE: At the time of discharge was good,
but once again please note that the patient left the hospital
against medical advice without completing his 21 day course
of intravenous Vancomycin for Methicillin resistant
Staphylococcus aureus pneumonia.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], M.D. [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern4) 26544**]
MEDQUIST36
D: [**2134-6-16**] 11:27
T: [**2134-6-16**] 19:02
JOB#: [**Job Number 41349**]
|
[
"482.41",
"861.21",
"518.5",
"V10.05",
"901.0",
"873.49",
"E815.0",
"807.06",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"88.72",
"38.93",
"34.04",
"39.61",
"96.04",
"33.23",
"39.57"
] |
icd9pcs
|
[
[
[]
]
] |
1120, 1235
|
1258, 7794
|
170, 864
|
886, 1093
|
7819, 8340
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,134
| 110,613
|
30519
|
Discharge summary
|
report
|
Admission Date: [**2141-2-10**] Discharge Date: [**2141-2-27**]
Date of Birth: [**2075-12-22**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
intubation
paracentesis
exploratory laparotomy, supracervical hysterectomy, bilateral
salpingo-oophorectomy, partial omentectomy, pelvic mass
resection for large mass from R ovary.
History of Present Illness:
This is a 65 y/o woman with no known past medical history (she
has not had medical care in about 20 years), who presented to
the ED at an OSH complaining of abdominal pain. She says she
was getting out of the shower when she all of a sudden developed
a [**9-27**] pressure like abdominal pain. She denies any nausea,
vomiting associated with the pain, was not eating at the time.
The pain was so severe she became diaphoretic. She has never
had this abdominal pain before. She denies any chest pain,
shortness of breath, lower extremity edema, fevers. She states
that she feels that her abdomen has been growing slowly over the
last 6 months, and had attributed it to weight gain, although
she had only gained three pounds over this period of time. She
denies any family history of breast or ovarian cancer.
.
The only other time she had been in the hospital was when she
gave birth. Of note, she was recently treated at a walk in
clinic for a UTI with nitrofurantoin. Because she still wasnt
feeling well after the course of nitrofurantoin, she returned to
clinic where they gave her two days of ciprofloxacin.
.
In the ED at the OSH, she had an abdominal ultrasound which
showed a ascites. This prompted a CT scan which was notable for
a complex cystic low abdominal and pelvic mass, measuring 16 x
16.5 x 11.5 cm, positioned superior to the uterus.
.
She was admitted to the OSH, and overnight, she developed a
leukocytosis to 23,600, up from 11,000 on admission with a
bandemia of 25%. She was started on levo/vanco/flagyl. Her
creatinine was noted to increase from baseline of 0.8 on
admission to 2.8 ([**2-10**] at 6:45). Bicarbonate decreased from 24
--> 16. Her blood pressures transiently decreased to SBP of the
70s, and she was started on a dopamine gtt (1 mcg/min). She
received one dose of mucomyst at 1700. Was started on NS with 2
amps of bicarb at 250cc/hr for 800cc.
.
On arrival, the patient denied shortness of breath. She denied
nausea, vomiting, abdominal pain. She denied fevers, chills,
sweats. She denied diarrhea, constipation, BRBPR, melena. Her
last episode of hematuria was ~1-2 weeks ago.
.
ROS: She denies lightheadedness, palpitations. She denies chest
pain. She denies weakness, blurry vision.
Past Medical History:
None - except for recent presumed UTI (although pt has not seen
a physician [**Last Name (NamePattern4) **] 20 years)
Social History:
Smoked 1 pack per day for 50 years, she quit smoking 15 years
ago. She drinks socially and has never had a problem with
alcohol abuse. She lives with her husband at home. Has one
child who is alive and well. She used to work as a telephone
operator.
.
Family History:
She has a father who died of lung disease at 59 and a mother who
died of "[**Last Name **] problem" at 70s. She has no FH of breast or
ovarian cancer.
.
Physical Exam:
Temp 100.3 BP 110/70 Pulse 120 Resp 22 O2 sat 87% FM UO 0 cc.
Pulsus 5
Gen - sleepy, arousable, accessory muscle use
HEENT - PERRL, extraocular motions intact, sclera anicteric,
mucous membranes moist, no OP lesions
Neck - no JVD, no thyromegaly
Nodes - no cervical, supraclavicular, axillary lymphadenopathy
Chest - distant breath sounds throughout, no w/c/r.
CV - Normal S1/S2, tachy, regular, no murmurs, rubs, or gallops
Abd - Distended, (+) fluid wave, no HSM, normoactive bowel
sounds
Back - No spinal, costovertebral angle tenderness
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses
bilaterally. No calf pain, erythema or cords palpable.
Neuro - Alert and oriented x 3, cranial nerves [**1-30**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact.
Skin - No rashes
Pertinent Results:
.
OSH:
2/22 [**2-10**] 7am 9am 1815
Cr 0.9 2.8 3.2 3.8
BUN 8 22 8 32
.
[**2141-2-9**]: CXR: LLL atelectasis
.
[**2141-2-9**]: Abd US: Multiple shadowing gallstones. GB wall not
thickened. IH ducts not dilated. Common hepatic duct 4mm.
Ascites
.
[**2141-2-9**]: 1301: CT abd/pelvis with contrast - complex cystic and
solid irregular mass - midline low abdomen and pelvis -
16x16.5x11.5cm. Irregularly enhancing mural components and
several low attenuation areas within the complex fluid
commponents. Extensive ascites. Midline uterus. Mild small bowel
dilatation. Kidneys normal without hydro/masses
.
ECG: HR 101, sinus tachycardia, normal intervals, no ST
depressions, normal axis, no q waves. No ECG available for
comparison.
ECG: here - sinus tach 111, nl axis, interval, sl peaked T waves
in V2, otherwise no acute ST T wave changes
.
CXR: left sided pleural effusion. mild vascular congestion
.
[**2141-2-11**] CT head
1.9 x 1.7 cm hyperdense, likely extra-axial lesion seen to the
right of the cerebellum, most likely representing meningioma.
Comparison with prior studies if available would be helpful. If
none are available, MRI would be recommended for further
evaluation. MRI would also be more sensitive in the evaluation
for potential metastases.
*
[**2141-2-22**] EKG
Sinus rhythm
Poor R wave progression - possible old anteroseptal myocardial
infarction
Low QRS voltage in limb leads Nonspecific T wave changes
Since previous tracing of [**2141-2-10**], sinus tachycardia absent, and
further T
waves changes seen
*
[**2141-2-23**] LENI
No evidence of right or left lower extremity deep vein
thrombosis.
*
[**2141-2-26**] CXR
Large right pleural effusion has increased slightly since [**2-22**] with
worsening of right basilar atelectasis. Smaller left pleural
effusion is
unchanged. Upper lungs show vascular redistribution but no
indication of
pneumonia. Heart size is slightly larger today, but difficult
to assess and the presence of adjacent pleural effusion. There
is no mediastinal vascular engorgement to suggest elevated
central venous pressure. No pneumothorax.
*
[**2141-2-10**] 08:43PM BLOOD WBC-25.3* RBC-4.94 Hgb-14.6 Hct-45.7
MCV-93 MCH-29.5 MCHC-31.9 RDW-13.8 Plt Ct-487*
[**2141-2-16**] 02:25AM BLOOD WBC-17.0* RBC-2.45* Hgb-7.1* Hct-21.8*
MCV-89 MCH-29.1 MCHC-32.6 RDW-14.3 Plt Ct-219
[**2141-2-18**] 05:31AM BLOOD WBC-23.9* RBC-3.90* Hgb-11.7* Hct-33.2*
MCV-85 MCH-29.9 MCHC-35.1* RDW-15.1 Plt Ct-295
[**2141-2-26**] 07:05AM BLOOD WBC-11.4* RBC-3.31* Hgb-9.8* Hct-28.7*
MCV-87 MCH-29.7 MCHC-34.2 RDW-15.3 Plt Ct-572*
[**2141-2-10**] 08:43PM BLOOD PT-14.0* PTT-36.7* INR(PT)-1.2*
[**2141-2-10**] 08:43PM BLOOD Fibrino-916* D-Dimer-8124*
[**2141-2-23**] 07:20AM BLOOD D-Dimer-3722*
[**2141-2-14**] 03:30AM BLOOD Ret Aut-1.4
[**2141-2-10**] 08:43PM BLOOD Glucose-140* UreaN-35* Creat-3.4* Na-138
K-5.5* Cl-108 HCO3-15* AnGap-21*
[**2141-2-17**] 05:06AM BLOOD Glucose-134* UreaN-42* Creat-0.9 Na-146*
K-4.2 Cl-112* HCO3-24 AnGap-14
[**2141-2-22**] 11:35AM BLOOD Glucose-95 UreaN-18 Creat-0.5 Na-139
K-3.3 Cl-106 HCO3-26 AnGap-10
[**2141-2-10**] 08:43PM BLOOD ALT-20 AST-51* LD(LDH)-487* CK(CPK)-1081*
AlkPhos-53 Amylase-78 TotBili-0.3
[**2141-2-13**] 04:01AM BLOOD ALT-17 AST-35 LD(LDH)-329* AlkPhos-41
Amylase-86 TotBili-0.3
[**2141-2-12**] 03:30PM BLOOD Lipase-12
[**2141-2-10**] 08:43PM BLOOD CK-MB-22* MB Indx-2.0
[**2141-2-10**] 08:43PM BLOOD cTropnT-<0.01
[**2141-2-11**] 05:54AM BLOOD CK-MB-22* MB Indx-1.8 cTropnT-0.01
[**2141-2-14**] 08:26AM BLOOD Hapto-212*
[**2141-2-16**] 02:25AM BLOOD Hapto-247*
[**2141-2-17**] 04:53PM BLOOD TSH-13*
[**2141-2-17**] 04:53PM BLOOD T4-5.3 T3-87
[**2141-2-10**] 08:43PM BLOOD Cortsol-107.4*
[**2141-2-11**] 05:54AM BLOOD Cortsol-136.8*
[**2141-2-10**] 08:43PM BLOOD CEA-10* CA125-96*
[**2141-2-11**] 06:15PM BLOOD AFP-8.4
[**2141-2-17**] 04:53PM BLOOD Anti-Tg-LESS THAN Thyrogl-22
[**2141-2-10**] 09:04PM BLOOD CA [**52**]-9 -Test
[**2141-2-11**] 02:00AM BLOOD ACTH - FROZEN-Test
Brief Hospital Course:
This patient is a 65yo G3P2 with no known PMH presenting to OSH
with several weeks of abdominal bloating and a 16x16 pelvic mass
and ascites, transferred with hypoxia and ARF following CT with
contrast. The patient was transferred to the MICU. In the MICU,
her main issues were as follows:
*
1. Respiratory failure
In the MICU, she underwent evaluation to r/o pulmonary embolus
given her rapid decompensation. She was started on empiric
therapy with heparin. Given the likelihood of acute renal
failure from CT contrast, she could not be evaluated with CTA.
As a result, she had LENIs that were neg and an echo that showed
good ejection fraction with no RV strain. In consultation with
Pulmonary Medicine, the decision was made not to treat her for
pulmonary embolus. Her respiratory failure was thought to be
secondonary to mod/large bilat effusions seen on chest CT and
large ascites, as well as volume overload from acute renal
failure. She was intubated and remained on ventilatory support
for 8 days. A left subclavian line was placed for hemodynamic
monitoring. Her first attempt at extubation was not successful
due to pt drowsiness. A CT of the head was performed to r/o
neurological injury. No hemorrhage was seen. She was eventually
extubated the following day without complications.
*
2. Acute Renal failure:
On presentation to the MICU, the patient was anuric and her
creatinine was significantly higher than at the OSH. This rapid
rise was thought to be secondary to contrast induced
nephropathy. A CT of the abdomen on [**2-9**] showed no evidence of
obstruction. The Renal service was consulted and they
recommended CVVHD dialysis which she underwent over the
following 7 days with improvement in her urine output and
creatinine measurement.
*
3. Fevers - On arrival, the patient was noted to have a fever
with leukocytosis. Blood, urine, sputum cultures were obtained
that did not reveal any signs of infection. The CXR had no
evidence of infiltrates. The abdominal ultrasound showed some
cholelithiasis but no evidence of cholecystitis. She was treated
empirically with vancomycin, ciprofloxacin and flagyl. Her
fevers improved after her second day in the MICU, and her
antibiotics were discontinued after surgery.
*
4. Altered mental status: On presentation, the patient had
altered mental status that was thought to be secondary to taking
dilaudid and benzodiazepine at OSH. Her neuro exam was
non-focal. Once stable from her respiratory status, she
underwent CT Head that revealed a small hyperdense mass in right
cerebellum c/w meningioma. She was recommended for further
imaging with MRI.
*
5. Elevated cortisol: On arrival, the patient was found to have
elevated cortisol levels. This was thought to be due to acute
stress reaction and leukomoid reaction. As rare forms of ovarian
cancer can also cause ectopic ACTH production, ACTH was also
measured and found to be mildly elevated at 52. No further
work-up was done.
*
6. Hypothyroidism:
The patient was found to have an elevated TSH of 13 during her
ICU stay. This likely represents a stress response. She should
have this retested 4-6 weeks after discharge to determine
whether she has hypothyroidism.
*
7. Pelvic mass: CT of the abdomen from OSH suggested a large
pelvic mass. This was associated with ascites. On her second
day, she underwent paracentesis under ultrasound guidance to
improve her respiratory status and to R/O bacterial peritonitis.
Four liters were drained. Although the fluid seemed suggestive
of peritonitis, this was not associated with bacteria on gram
stain. No malignant cells were seen. A second paracentesis was
performed under ulstrasound guidance with 1l fuild drained. An
attempt to further chracterise this mass, the patient underwent
testing for a number of tumour markers. Her CA-125 was mildly
elevated at 96, CEA as measured at 10, a 19-9 was significantly
elevated at >[**Numeric Identifier 38500**] and her HCG was negative. Given the elevation
in CA [**52**]-9, she was seen by the surgical oncology who did not
feel that this was consistent with pancreatic cancer despite
such an abnormally elevated CA [**52**]-9. Dr [**Last Name (STitle) 2028**] from
gynecology-oncology recommended exploratory laparotomy for
likely ovarian cancer once stabilised. She was taken to the OR
on [**2-18**], eight days following her initial presentation.
*
The patient was taken to the operating room where she underwent
exploratory laparotomy, supracervical hysterectomy, bilateral
salpingo-oophorectomy, partial omentectomy, pelvic mass
resection for large mass from R ovary. Please see operative
note for full details.
*
Her post-op course was complicated by:
1. wound infection
2. tachypnea likely secondary to atelectasis and pneumonia and
presumed pulmonary embolus
*
1. Wound: On post-op day #2, the patient was found to have a
wound infection for which she completed a 5 day course with
vancomycin with complete resolution.
*
2. Tachypnea: On post-op day #4, the patient was found to be
tachypneic with considerable shortness of breath at rest. This
was a change from her baseline. A chest X-ray revealed worsening
collapse of her RLL and her RML. An infiltrate could not be
ruled out. An ABG was performed that did not show evidence of
hypoxemia. There was concern for pulmonary embolus given that
the patient had initially developed respiratory failure and had
not been treated for embolus. Pulmonary medicine was consulted
and they felt strongly that this was likely secondary to
atelectasis and mucus plugings but could not rule out pneumonia
or pulmonary embolus. Given her renal failure from CT contrast,
she was not recommended for CTA. Moreover, given her ventilatory
defects, a VQ scan was not recommended either. US of the LE was
performed that did not show evidence of DVT. D-Dimer was
measured and was elevated. As pulmonary embolus could not be
definitively ruled out, they recommended empiric therapy with
lovenox. She was started on lovenox and will continue this for 6
months. She also received chest PT, nebuliser and Advair and
improved significantly. She was weaned off of oxygen on post-op
day #7. She has a follow-up with Pulmonary medicine after
discharge.
*
Otherwise, the patient's post-op course was uneventful. At the
time of discharge, she was evaluated by PT who recommended some
PT services at home. Otherwise, her pain was well controlled,
she was tolerating a regular diet and urinating without
difficulty.
*
Medications on Admission:
MEDS outpatient:
Nitrofurantoin
Cipro x 2 days
.
MEDS on transfer:
Levo
Vanco
Flagyl
colace
MOM
Maalox
Tylenol
Reglan prn
protonix
xanax 0.25 prn
dilaudid prn
mucomyst
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: 70mg Subcutaneous [**Hospital1 **]
(2 times a day) for 6 months: This dose may need to be
readjusted in case your weight changes over the next 6 months.
Disp:*QS * Refills:*0*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO every [**3-24**]
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Likely ovarian cancer
Post-op wound infection
Pneumonia
Presumed pulmonary embolus
Discharge Condition:
Good
Discharge Instructions:
vomiting, worsening abdominal pain, difficulty with urinating,
vaginal bleeding, worsening shortness of breath or any other
worrisome symtom.
*
No driving while taking narcotics.
*
Nothing in your vagina for 4 weeks (this includes intercourse)
*
No heavy lifting for 4 weeks.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 5777**] Date/Time: [**3-6**], 11:45, [**Hospital Ward Name 23**] [**Location (un) **].
*
The following appts are on [**Hospital Ward Name **] 7 (medical specialties)
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2141-3-16**] 1:10
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2141-3-16**] 1:30
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] /DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2141-3-16**] 1:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
Completed by:[**2141-3-3**]
|
[
"183.0",
"682.2",
"415.19",
"998.59",
"997.3",
"518.81",
"584.9",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.4",
"54.91",
"65.61",
"99.15",
"38.91",
"68.39",
"96.72",
"96.04",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
15798, 15849
|
8226, 10471
|
302, 485
|
15976, 15983
|
4192, 8203
|
16307, 17131
|
3189, 3345
|
14894, 15775
|
15870, 15955
|
14701, 14750
|
16007, 16284
|
3360, 4173
|
247, 264
|
513, 2756
|
10486, 14675
|
2778, 2898
|
2914, 3173
|
14768, 14871
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,684
| 123,576
|
5546
|
Discharge summary
|
report
|
Admission Date: [**2139-2-23**] Discharge Date: [**2139-3-8**]
Date of Birth: [**2068-4-8**] Sex: M
Service: CARDIOTHORACIC SURGERY
TENTATIVE DATE OF DISCHARGE: [**2139-3-8**].
PRIMARY DIAGNOSES:
1. Type A ascending aortic aneurysm.
PRIMARY PROCEDURE:
1. Supra-coronary ascending aortic graft / resuspension of
aortic valve, with a 30 millimeter Gelweave graft. Surgeon
was Dr. [**Last Name (STitle) **].
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 5749**] is a 70 year old
gentleman who presents with an asymptomatic Type AA ascending
aortic aneurysm. The patient was found to have a new split
heart sound on a work-up for pituitary adenoma in the past
six months. As well, he had electrocardiographic changes.
An echocardiogram and a CT scan of the chest revealed an
ascending aorta which was dilated. An echocardiogram on
[**2138-12-4**], revealed an ejection fraction of greater than
55%. His ascending aorta was 5.2 centimeters, with a one to
two plus aortic insufficiency. He has a normal left
ventricular function.
PAST MEDICAL HISTORY:
1. Significant for left Horner's syndrome.
2. Transient ischemic attack with amaurosis fugax in [**2131**].
3. Bilateral cataracts.
4. Pituitary adenoma.
5. Liver cysts.
6. Colon polyps.
PAST SURGICAL HISTORY:
1. Right shoulder repair.
2. Right Achilles tendon repair.
3. Tonsillectomy.
MEDICATIONS: Upon admission were:
1. Aspirin 325 mg p.o. q. day.
2. Vitamin C.
3. Multivitamin.
4. Glucosamine chondroitin.
5. Vitamin E.
LABORATORY: Upon admission white blood cell count of 6.2,
hematocrit of 39.5 and platelet count of 237. His INR was
1.0.
Also significant for a sodium of 137, potassium of 3.9,
chloride of 106, bicarbonate of 26, BUN of 14 and a
creatinine of 0.7 with a glucose of 89.
His liver function tests were within normal limits.
In [**Month (only) 956**] of this year, he had a CT scan of the chest and
abdomen which revealed liver cysts, an ascending aorta of 5.3
by 5 centimeters, and an abdominal aorta of normal caliber.
In [**2138-5-13**], he had an MRI of his head which revealed a
pituitary adenoma and no carotid vertebral disease. He had a
carotid ultrasound which revealed widely patent carotids on
[**2139-2-10**].
ALLERGIES: He has an allergy to penicillin which gives him
hives.
REVIEW OF SYSTEMS: On review of systems, he revealed HEENT
significant for a right hearing aid. He has no chronic
obstructive pulmonary disease or asthma. He has heart
palpitations without syncope. He has hemorrhoids and colonic
polyps. He has no history of renal disease. He has no
history of claudication. He has no history of diabetes
mellitus.
PHYSICAL EXAMINATION: On physical examination, he is 5'[**44**]"
with a blood pressure of 118/66, a weight of 178 pounds. His
heart rate is 72 with occasional irregularities, but
otherwise in sinus. HEENT: Pupils are equal, round and
reactive to light. Extraocular movements intact. He is
nonicteric. Neck with no bruits heard. No jugular venous
distention. Chest is clear to auscultation bilaterally.
Heart: Occasionally irregular with normal S1 and S2. He has
a faint I/VI systolic ejection murmur. His abdomen was soft,
nontender, nondistended with an enlarged liver and no
splenomegaly. Extremities were warm and well perfused. He
had palpable pulses bilaterally in upper and lower
extremities.
Significantly, he had a catheterization preoperatively which
revealed clean coronary arteries without coronary artery
disease.
HOSPITAL COURSE: On [**2139-2-23**], the patient was seen in the
Operating Room and underwent a supra-coronary extending
aortic graft with a 30 millimeter Gelweave graft. He has had
a recent suspension of his aortic valve. This was completed
by Dr. [**Last Name (STitle) **] and assisted by Dr. [**Last Name (STitle) 22350**] and [**Doctor Last Name **].
He did well and on postoperative day one was on
Neo-Synephrine at 1.25. He had a central venous pressure of
5 and a pulmonary artery pressure of 20/7 with an index of
2.5. His chest tubes were left in and Neo-Synephrine was
weaned off.
On postoperative day two, the patient was in atrial
fibrillation with a heart rate of 71 and a blood pressure of
122/39. He was started on amiodarone drip and Neo-Synephrine
was continued at 2.15. His chest tubes were discontinued
later on [**2139-2-25**]. On postoperative day three, he
continued to have a Neo-Synephrine requirement at 0.75. He
was on oral amiodarone at that time. He remained in atrial
fibrillation with a pulse of 90 and a blood pressure of
108/37.
From a respiratory standpoint he was doing fine. At this
point, it was decided to begin heparinization in light of his
atrial fibrillation. On this day, his white blood cell count
was 14.0 and hematocrit of 26.9 and sodium and 146.
He was evaluated by the Physical Therapist on [**2139-2-25**], and
found to need continued endurance training, balance and
mobility.
On [**2139-2-27**], which was postoperative day four, he remained
in atrial fibrillation but had O2 and hemodynamically stable.
At this point, he was not on any drips.
He was seen in consultation by the Cardiology Service on
[**2139-2-27**], and upon being asked to evaluate the patient for
possible cardioversion. At this time, he was on amiodarone
400 mg p.o. twice a day and was on a heparin drip.
Recommendations by the Cardiology Service at that point were
the start Coumadin therapy, decrease his amiodarone to 400
p.o. q. day and to do [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts as an outpatient.
The plan would be for him to follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] two weeks after his discharge with cardioversion to
follow four weeks later; however, consideration was given to
cardioverting the patient prior to after his discharge, but
this was not done at this time.
The patient remained in stable condition on [**2139-2-28**], when
he was transferred to the floor. He was on amiodarone,
aspirin and was continued on a heparin drip of 1100. He was
given 3 mg of Coumadin and he had a white blood count on that
day of 8.0, hematocrit of 27.3 and a platelet count of 180.
His PTT was 34.3. He had a mg of Coumadin on [**2139-2-27**]. He
remained stable on postoperative day six, [**3-1**], on a heparin
drip which was at 1400. He was also on Lasix, Coumadin,
aspirin and amiodarone at that time. He was given 3 mg of
Coumadin that day and his Lasix was increased to 20 twice a
day.
On the morning of [**2139-3-2**], at approximately 03:00 a.m.,
the patient had an episode of hypotension on the floor which
was persistent. At that time, he did not respond to fluid
resuscitation although he continued to make urine. A chest
x-ray was obtained which revealed an increase in the cardiac
silhouette which was worrisome for a pericardial effusion.
There was also attenuation of the pulmonary arterial
vasculature concerning for tamponade. As well, there was an
interval increase in the left pleural effusion and
progression of the left lower lobe atelectasis and
consolidation. There was no pneumothorax at the time of this
study.
Given these findings and the patient's persistent hypotension
as well as an electrocardiogram which revealed ST depressions
in the anterior leads, the patient was transferred
immediately back to the Intensive Care Unit. A chest tube
was placed into the left chest which affected a drainage in
the left pleural effusion. This yielded over one liter in
fluid. The following examination, given continued concern
with regard to the patient's respiratory status, a CT
angiogram was completed. The impression of that CT angiogram
which was done at approximately 08:20 in the morning of [**3-2**]. [**2138**], revealed a large hemopericardium. It also revealed
a small left pneumothorax with the placement of a left chest
tube. There was also a small degree of pneumomediastinum.
There were also small bilateral pleural effusions. There was
no evidence of pulmonary embolism at the time of that scan.
Subsequent chest films showed steady improvement in his
cardiac status and on [**2139-3-5**], there was near complete
resolution of his left pneumothorax. The Swan which had been
in place during his acute event of [**3-2**], had been
removed. His atelectasis was slightly better.
His chest x-ray continued to improve, including a film done
on [**2139-3-7**], which revealed no pneumothorax and near
complete resolution of the atelectasis with only some
residual changes in the right lower lung base. His cardiac
silhouette was also decreased in size, indicating an
improvement in the size of his cardiac silhouette. His
cardiac scheelite on [**2139-3-7**] was much improved and there
was no evidence of pneumopericardium at that time.
Also of note, during his acute event on [**3-2**], due to
the patient's instability and the nature of his repair, the
patient was taken to the Cardiac Catheterization Laboratory
by Dr. [**Last Name (STitle) 911**] to evaluate his coronaries and repair in light
of his electrocardiographic changes. At that time, his right
coronary system was found to be normal with no stenosis as
well as his left coronary system. His resting hemodynamics
revealed an elevated right and left sided filling pressures.
Supra-valvular aortography showed no evidence of a
dissection.
Another aspect of the work-up on the 19th was an
echocardiogram which revealed suboptimal image quality. The
results were significant for a left pleural effusion. The
left ventricle was a normal size. The overall systolic
function was well preserved. His right ventricular size was
also normal. His aortic valve leaflets appeared normal. He
had one plus aortic regurgitation. His mitral valve was
within normal limits. There was a question of a pericardial
effusion at that time.
An echocardiogram was repeated on [**2139-3-5**] which revealed a
moderate sized pericardial effusion. The effusion was
echo-dense and filled with blood, inflammation or other
cellular elements. It did appear loculated. There was
significant attenuated respiratory variation of the mitral
tricuspid valve consistent with impaired ventricular filling.
The conclusion at the time of that echocardiogram was left
ventricle with normal wall thickness, cavity size and
systolic function. His right ventricular chamber size and
free wall motion were normal. There was a small loculated
collection of fluid obtained in the right atrial free wall
without chamber collapse. There was a 3 centimeter thick
layer of echo-dense material suspended in the diaphragmatic
surface of the right ventricle, most likely representing
clotted blood.
In summary, this hemopericardium and left sided effusion is
most likely as a result of his pacing wires being
discontinued. This was unusual in light of the fact that his
wires were discontinued after his heparin had been held for
an appropriate amount of time.
The patient remained in the Intensive Care Unit on the 19th
after this extensive work-up. The clinical suspicion in
light of all his examinations was that there was no obvious
tamponade which would require intervention; therefore, no
other interventions were carried out. However, the patient
did continue in atrial fibrillation and on [**2139-3-3**] was
stable hemodynamically with a pulse of 98, in atrial
fibrillation with a blood pressure of 115/49.
He was planned for cardioversion on the morning of
[**2139-3-4**]. Also on [**3-4**], he remained on the amiodarone
drip in atrial fibrillation with stable hemodynamics. The
Swan-Ganz catheter was discontinued. At this time, the
Electrophysiology attending physician left [**Name Initial (PRE) **] note delineating
the patient's circumstances given the bleeding from his chest
wall secondary to discontinuation of the wires versus the
benefit of anti-coagulation in light of his atrial
fibrillation.
His recommendation which has been followed was that he would
hold off on anti-coagulation. He also recommended
continuation of the amiodarone. Just prior to cardioversion,
the patient converted into a normal sinus rhythm; therefore,
the cardioversion was not done at that time.
The patient has remained in normal sinus rhythm on [**3-5**]
and 23rd. He was transferred back to the floor on the
afternoon of the 22nd and has remained stable since that
time.
His labs on [**2139-3-7**], were significant for a white blood
cell count of 11.9, a hematocrit of 28.1, a platelet count of
342, Sodium of 136, potassium of 4.5, chloride of 104,
bicarbonate of 23, BUN of 17, creatinine of 0.7 and a glucose
of 88.
The patient had an extensive discussion with Dr. [**Last Name (STitle) **]
with regard to the risks and benefits of not restarting
anti-coagulation. The patient was in agreement with the
treatment plan of amiodarone. The patient's chest tube was
discontinued on the afternoon of [**2139-3-7**] and the patient
tolerated this well.
Preliminarily the plan will be for the patient to be
discharged to home on the 25th with Physical Therapy
following.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Type A extending aortic aneurysm.
2. Osteoarthritis.
3. Left Horner's syndrome.
4. History of transient ischemic attack.
5. Bilateral cataracts.
6. Pituitary adenoma.
7. Liver cyst.
8. Colonic polyps.
9. Left hemothorax.
10. Hypotension.
11. Anemia.
12. Atrial fibrillation.
13. Pericardial effusion.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q. day.
2. Indomethacin 25 mg p.o. three times a day.
3. Amiodarone 400 mg p.o. twice a day through [**2139-3-10**]. Starting on [**2139-3-11**], the patient will take
400 mg p.o. q. day of amiodarone.
4. Percocet, one to two tablets p.o. q. four hours p.r.n.
pain.
5. Tylenol 650 mg p.o. q. four hours p.r.n. pain.
6. Enteric-coated aspirin 325 mg p.o. q. day.
7. Colace 100 mg p.o. twice a day.
8. KayCiel 20 mEq p.o. q. day times two weeks.
9. Lasix 20 mg p.o. q. day times two weeks.
DISCHARGE INSTRUCTIONS:
1. The patient will follow-up with Dr. [**Last Name (STitle) **] in one
month.
2. The patient will follow-up with his primary care
physician in one to two weeks.
3. He should see [**First Name8 (NamePattern2) **] [**Doctor Last Name **], his Cardiologist, in one to
two weeks as well.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**2139-3-7**]
|
[
"512.1",
"441.2",
"997.3",
"511.9",
"427.31",
"998.2",
"423.0",
"518.0",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"99.04",
"34.04",
"89.64",
"88.42",
"35.39",
"37.23",
"88.56",
"38.45",
"86.3",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
13190, 13504
|
13527, 14049
|
3541, 13104
|
14073, 14507
|
1303, 2323
|
2703, 3522
|
2343, 2679
|
463, 1064
|
1086, 1280
|
13130, 13169
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,800
| 145,745
|
27603
|
Discharge summary
|
report
|
Admission Date: [**2154-2-5**] Discharge Date: [**2154-2-14**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
shortness of breath, fever, chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85yo M w/ CAD s/p CABG and RCA stents, AS, COPD on home O2 and
NSCLC was admitted to cardiology [**Date range (1) 18727**] (AM of admission).
Details of admission not available as DC summary not yet
started, but initial CMI note documents cath performed to
evaluate for possible AVR for AS. Cath report shows diagnostic
cath [**2-4**] with 3VD, patent grafts as below, LVEDP of 27, and
15mm Hg gradient across the aortic valve (calculated valve area
.9cm2). The patient had three bare metal stents placed to his
RCA.
.
His family notes that he had increasing DOE prior to admission
to the point that he could not walk across his room on the day
of discharge. Two hours after arriving home, he spiked a fever
to 102. This was associated with chest tightness, SOB,
diaphoresis, nausea and increased work of breathing. His
neighbor, a pediatrician, brought over a sat machine which read
63% and so 911 was called. ED VS: 98.7 105 166/94 25 70%3L.
Patient placed on BIPAP and given vanco, levaquin, aspirin,
ntg, ntg gtt, soludemdrol 125mg, albuterol neb, lasix 50mg. ED
discussed case with cardiology fellow who requested admission to
MICU.
Past Medical History:
CAD
[**2140**] CABG x 3
[**2149**] RCA stenting x 3
Aortic stenosis
RUL non-small cell cancer, s/p cyber knife ablation [**2153-8-7**]
at [**Hospital1 18**]
Hypertension
Hyperlipidemia
O2 dependent COPD- 2 liters at rest, 4 liters with activity
Sleep apnea (CPAP w/ oxygen)
Osteoarthritis of knees
BPH
Hernia repair
Tonsillectomy
Hard of hearing, bilateral hearing aids
Social History:
Patient is married with one daughter. [**Name (NI) **] had a
son who died of leukemia.
Family History:
Father with an enlarged heart, passing away at
age 52. Brother had a small MI in his late 40's- early 50's
Physical Exam:
97.2 128/57 79 24 98% on [**10-11**] w/FIO2 50%
Tolerating BIPAP, appearing comfortable
JVD at least to level of BIPAP mask straps
Suble crackles at bil bases
Tachy, irregular
Soft, nt, nd, +BS
WWP X 4 w/bil edema and LCV rash distal to RLE
Groin site c/d/i w/o bruit or thrill
Pertinent Results:
Selected Labs:
[**2154-2-5**] 09:00PM BLOOD WBC-11.4* RBC-3.52* Hgb-11.1* Hct-33.5*
MCV-95# MCH-31.5 MCHC-33.1 RDW-16.4* Plt Ct-215
[**2154-2-14**] 05:20AM BLOOD WBC-9.2 RBC-3.57* Hgb-11.1* Hct-34.2*
MCV-96 MCH-31.1 MCHC-32.5 RDW-15.9* Plt Ct-313
[**2154-2-10**] 06:45AM BLOOD Glucose-180* UreaN-43* Creat-1.1 Na-138
K-4.9 Cl-102 HCO3-26 AnGap-15
[**2154-2-14**] 05:20AM BLOOD UreaN-38* Creat-1.1 K-4.8
[**2154-2-5**] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.09* proBNP-9173*
[**2154-2-11**] 12:45PM BLOOD proBNP-5470*
[**2154-2-6**] 07:59AM BLOOD Type-ART PEEP-5 pO2-67* pCO2-38 pH-7.48*
calTCO2-29 Base XS-4 Intubat-NOT INTUBA
[**2154-2-7**] 11:21PM BLOOD Type-ART FiO2-50 pO2-53* pCO2-37 pH-7.48*
calTCO2-28 Base XS-3 Intubat-NOT INTUBA Comment-NASAL
BIPA01/30/07 09:00PM CK-MB-NotDone cTropnT-0.09* proBNP-9173*
CT CHEST W/O CONTRAST [**2154-2-9**] 4:44 PM
.
There are extensive coronary artery and aortic calcifications.
Patient is status post CABG. The central airways are patent to
the segmental levels bilaterally.
There are pathologically enlarged mediastinal lymphatic nodes,
including right paratracheal and left paratracheal, that are not
overtly changed from previous examination by size criteria.
There has been interval increase in soft tissue surrounding
CyberKnife marker, now measuring 19 mm versus 9 mm previously,
suggestive of progression of the disease. Again noted is
interstitial fibrosing pattern associated with ground-glass
opacities, affecting predominantly right lung in peripheral
distribution. This is more prominent compared to previous
examinations, and may represent interstitial fibrosing process
versus radiation pneumonitis. Imaged portion of the liver is
unremarkable. There are several gallstones in the gallbladder,
without evidence of acute cholecystitis. There is a cyst arising
from the upper pole of the right kidney. There is a
hypoattenuating lesion in the upper pole of the left kidney,
likely representing angiomyolipoma. There are extensive vascular
calcifications.
BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic
lesions.
IMPRESSION:
1. Interval increase in size of soft tissue surrounding
CyberKnife marker, worrisome for progression of the disease.
2. More prominent appearance of right lung interstitial
fibrosing pattern that may represent interstitial fibrosing
process versus radiation pneumonitis. There is no evidence of
edema.
.
ECHOCARDIOGRAM [**2154-2-6**]
The left atrium is elongated. The right atrium is markedly
dilated. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy
with normal cavity size and systolic function (LVEF>55%).
Regional left ventricular wall motion is normal. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated athe sinus level. The ascending aorta is moderately
dilated. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (area 0.8-1.19cm2) Mild
to moderate ([**1-8**]+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Moderate, calcific aortic stenosis. LVH. Normal
LVEF.
Brief Hospital Course:
Mr. [**Known lastname **] is a charming 85 year old gentleman with CAD s/p CABG,
COPD on home O2, and NSCLC who was admitted for elective heart
catheterization, found to have patent grafts, AS, and elevated
LVEDP. He received three bare metal stents to his RCA and was
discharged home. He returned the same evening of discharge with
fever, chest tightness, SOB, and hypoxia. He was brought to the
MICU and diuresed, placed on antibiotics, and transferred to the
cardiology-medicine service the following day. He was diuresed,
underwent multiple consultations by cardiology, pulmonary, and
Heme-onc. He was discharged to home with VNA with potential
bridge to hospice pending follow up appt in the
multidisciplinary lung cancer clinic.
1) Hypoxia
On admission CXR, patient appeared to be volume overloaded;
given lasix in ED and his hypoxia improved with continued
diuresis. Elevated LVEDP in cath lab the day prior supports
this diagnosis (although could be [**2-8**] pulm htn and AS) and
patient received 2L IVF in the prior two days for
catheterization. Of note the patient has severe COPD at baseline
with 2L resting and 4-5L ambulatory O2 requirement. Serial ABG's
on transfer to the floor revealed well compensated chronic
respiratory alkalosis with marked A-a gradient with pO2 in the
50's.
- Pulmonary consultation was obtained and formulated a likely
multifactorial etiology, but could not rule out radiation
pneumonitis s/p XRT and possibley cardiac catheterization as a
possible etiology. Aspiration pneumonitis surrounding cardiac
cath was also considered
- Lasix diuresis improved oxygenzation
- Prednisone was started, but later discontinued per pulmonary
given lack of clear benefit in pneumonitis and possibility that
it may worsen pt's fluid balance.
- Levo/Flagyl for aspiration PNA.
- BiPAP at night improved oxygenation.
.
2) Fever-
Blood, urine, sputum cultures were unrevealing. CXR without
evidence of focal consolidation, but given evidence for Lung CA
progression. Patient was treated with Levofloxacin/Flagyl for
possible aspiration vs. post-obstructive pneumonia.
.
3) [**Name (NI) **]
Pt was s/p stent to RCA the evening of re-admission. Despite
evidence for AS by valve area, the gradient across the valve was
not considered significant in impairing the pt's hemodynamics.
- Pt was continued on ASA, Plavix
- He was titrated on metoprolol for rate control
- We continued Isosorbide Dinitrate.
4) afib/flutter/[**Name (NI) 67437**]
Pt had a number of cardiac dysrhythmias present during his
admission. Anticoagulation was not pursued given prognosis of
pt's co-morbidities risks of life threatening bleeding.
- rate controlled with metoprolol
- continued ASA and Clopidogrel
5) Non Small Cell Lung Cancer:
Repeat PET CT scan from [**2154-1-7**] revealed evidence for
progression of disease s/p XRT. Inpatient hematology oncology
consultation was obtained and did not recommend a role for
chemotherapy given the patient's multiple co-morbidities that
would preclude adequate dosing of chemotherapy to derive
survival benefit.
- Palliative care consultation was obtained and discussed
non-curative options for treatment.
- The patient was discharged to home with VNA with possible
bridge to hospice following outpatient consultation the
multidisciplinary lung cancer clinic at [**Hospital1 18**].
Medications on Admission:
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. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day.
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day.
7. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
12. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
14. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
15. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
17. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
18. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. 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*
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*1 month supply* Refills:*2*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Tylenol 325 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for pain.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
12. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day: Weigh
yourself each day. Call your docter if weight increases more
than three pounds.
Disp:*60 Tablet(s)* Refills:*6*
14. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
15. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day: take with 200mg
tablet for a total dose of 225mg daily.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA/Hospice
Discharge Diagnosis:
Non Small Cell Lung Cancer
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a fever following stents placed to your
right coronary artery. You had significant trouble breathing and
were taken care of in the ICU. You had an element of congestive
heart failure, and possible obstructive pneumonia. Most
significantly your chest CT and recent PET scans show evidence
for progression of lung cancer.
.
Please follow up with the Lung Cancer clinic for further
consultation regarding further comprehensive care for your lung
cancer.
.
Please take all of your medications as prescribed.
.
Call your doctor or 911 if you experience any worsening
shortness of breath, chest pain, dizziness, headaches,
difficulty urinating or any other concerning symptoms.
Followup Instructions:
Please call [**0-0-**] for an appointment with the Lung Cancer
Clinic at [**Hospital1 18**] for comprehensive evaluation of your lung
cancer, this will allow you to meet with Dr. [**Last Name (STitle) **] and a
medical oncologist to further discuss your care.
|
[
"276.3",
"507.0",
"401.9",
"424.1",
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"600.00",
"414.01",
"162.8",
"428.0",
"492.8",
"V45.82",
"397.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12704, 12771
|
5846, 9174
|
248, 255
|
12904, 12913
|
2375, 5823
|
13656, 13919
|
1948, 2057
|
10704, 12681
|
12792, 12883
|
9200, 10681
|
12937, 13633
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2072, 2356
|
174, 210
|
283, 1435
|
1457, 1828
|
1844, 1932
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,004
| 180,993
|
53109+53110
|
Discharge summary
|
report+report
|
Admission Date: [**2144-11-18**] Discharge Date: [**2144-11-19**]
Date of Birth: [**2096-7-14**] Sex: F
Service: Fenard ICU
CHIEF COMPLAINT: Melena.
HISTORY OF PRESENT ILLNESS: Forty-eight year old with a
history of occasional stress headaches who presents with four
episodes of melena. She states that this has not occurred
previously also with abdominal cramping. States that melena
has large volumes and is complaining of dizziness.
She went to her [**Hospital **] Care Center and had another episode of
melena at the [**Hospital **] Care Center. Vital signs at the [**Hospital **]
Care Center: Blood pressure 118/50 with a heart rate of 88
sitting, blood pressure 90/50 with a heart rate of 112
standing. A OG lavage was performed with coffee grounds,
that were mostly cleared after 500 cc of flushing and the
lavage was terminated due to patient's discomfort. She notes
that she has been ingesting Advil periodically within the
past two weeks. She states that she has been taking 600 mg
about 4x over the last 10 days due to tension headaches. She
denies any vomiting, but with occasional retching. She was
admitted to the Fenard ICU for further monitoring.
PAST MEDICAL HISTORY:
1. Osteoporosis.
2. Tension headaches.
3. Depression.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Multivitamin.
2. Fosamax q week.
3. Celexa 40 mg p.o. q.d.
4. Hormone replacement therapy.
SOCIAL HISTORY: The patient lives in [**Location (un) 538**]. Has
four children and has a boyfriend. She is currently
unemployed and lives with her mother. She was a former
banking employee. She smoked a [**2-1**] pack a day for the past
38 years and occasional wine.
FAMILY HISTORY: Significant for breast cancer and CAD in her
mother. There is no history of GI malignancy.
REVIEW OF SYSTEMS: A 10 pound weight loss over the past
month, poor energy level over the past two weeks, as well as
poor appetite. She denies any constipation. Denies any
fever or chills, but notes that she has been having night
sweats that have been common since her menopause.
PHYSICAL EXAM ON ADMISSION: Temperature 98.3, blood pressure
100/52, heart rate of 86, breathing at 20, and 100% on room
air. In general, the patient is a pale appearing female in
no acute distress. HEENT: Pupils are equal, round, and
reactive to light. Extraocular muscles are intact. Pale
conjunctiva. Oropharynx is clear. Neck is supple with no
lymphadenopathy and no bruits. Neck veins are flat. Lungs
are clear to auscultation bilaterally, no wheezes, rales, or
rhonchi. Cardiovascular examination: S1, S2, regular rate
with no murmurs, rubs, or gallops. Abdominal examination:
bowel sounds present, soft, nontender, nondistended. C
section midline scar well-healed, no guarding, tenderness, or
rebound. Guaiac positive on Emergency Department
examination. Extremities: No edema, warm, 2+ posterior
tibial pulses bilaterally. Neurological examination: Alert
and oriented times three.
PERTINENT LABORATORY DATA: White count 10.5, hematocrit
26.9, platelets 315. Sodium 140, potassium 3.4, chloride
106, CO2 26, BUN 23, creatinine 0.7, glucose 112, calcium
9.3, PT 12.9, PTT 22.5, INR 1.1, ALT 4, AST 14, alkaline
phosphatase 43, amylase 120, total bilirubin 0.2, CK 64,
troponin-T less than 0.01.
HOSPITAL COURSE:
1. Upper GI bleed: Patient was admitted to the [**Hospital Ward Name 516**]
Intensive Care Unit for hemodynamic monitoring. She was
given IV fluid hydration and a repeat hematocrit was drawn
revealing a value of 18.9. Patient was consented for blood
transfusion at this time and was given 2 units of packed red
blood cells without incident. A GI consult was obtained and
subsequent EGD was performed on hospital day #2, which
revealed a normal esophagus, several erosions of the mucosa
in the stomach with no active bleeding noted in the fundus
and cardia compatible with NSAID associated gastropathy.
The rest of the EGD was unremarkable.
She was started on Protonix 40 mg p.o. daily and will
continue this medication for a six week course. H. pylori
antibodies were checked in the serum which were negative.
She was instructed to continue taking her Fosamax as
instructed once a week and to followup with her primary care
physician in the next 2-4 weeks or sooner if further episodes
of melena persisted. She was followed on a clear diet, and
was advanced rapidly. A repeat hematocrit post EGD revealed
a value of 30.5, and was deemed stable for discharge to home.
Incidentally, cardiac enzymes were also drawn with her low
hematocrit, but were unremarkable.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Home with followup with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8488**].
DISCHARGE MEDICATIONS:
1. Multivitamins.
2. Fosamax q week.
3. Celexa 40 mg p.o. q.d.
4. Hormone replacement therapy.
5. Protonix 40 mg p.o. q.d. x6 weeks.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed secondary to nonsteroidal
anti-inflammatory gastropathy.
2. Osteoporosis.
3. Tension headaches.
4. Depression.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D. [**MD Number(2) 8038**]
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2144-11-27**] 18:31
T: [**2144-11-30**] 07:00
JOB#: [**Job Number 109405**]
Admission Date: [**2144-11-18**] Discharge Date: [**2144-11-19**]
Date of Birth: [**2096-7-14**] Sex: F
Service:
NO DICTATION
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D. [**MD Number(2) 8038**]
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2144-11-27**] 18:18
T: [**2144-11-30**] 06:57
JOB#: [**Job Number 109406**]
|
[
"305.1",
"307.81",
"535.41",
"285.9",
"E935.9",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"96.34"
] |
icd9pcs
|
[
[
[]
]
] |
1737, 1830
|
4974, 5794
|
4819, 4953
|
1351, 1446
|
3355, 4626
|
1850, 2128
|
159, 168
|
197, 1194
|
2143, 3338
|
1216, 1325
|
1463, 1720
|
4651, 4796
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,203
| 175,375
|
5598
|
Discharge summary
|
report
|
Admission Date: [**2161-3-10**] Discharge Date: [**2161-3-14**]
Date of Birth: [**2107-5-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
E-Mycin / Amoxicillin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest discomfort
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x 3 [**2161-3-10**]
closed thoracostomy right [**2161-3-10**]
History of Present Illness:
This 53 year old white male with known coronary artery disease,
s/p multiple stents to RCA and LAD. Developed chest discomfort
described as a "warmth" over the past 1-2 weeks, the worst
episode occurring when he carried bags through the
airport. He underwent cardiac catheterization which revealed
severe
triple vessel disease.
Past Medical History:
coronary artery disease
NSTEMI- [**2148**], s/p stent of PDA
[**2153**] Coronary PCI
[**2154**] Coronary PCI
Hyperlipidemia
benign prostatic hyperplasia
Social History:
Lives with: [**Doctor First Name 22483**] girlfriend
Occupation:District manager for a retail company
Tobacco: 1 [**11-22**] ppd x 30yrs
ETOH: socially
Family History:
mother/father with CAD in their 40s
Physical Exam:
Admission:
Pulse: 66SR Resp: 13 O2 sat: 97%RA
B/P Right: 129/91 Left:
Height: Weight:
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] no Edema or
Varicosities
Neuro: Grossly intact x
Pulses:
Femoral Right: cath Left: 1+
DP Right: doppler Left: doppler
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits appreciated
Pertinent Results:
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. 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 regional left ventricular
systolic dysfunction with moderate anterior and antero-septal
hypokinesis. Overall left ventricular systolic function is
mildly depressed (LVEF= 40-45 %). The right ventricular cavity
is mildly dilated with mild global free wall hypokinesis. There
are simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Torn mitral chordae are present. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
POST CPB:
1. Improved global and focal LV and RV function with inotropic
support (Epinephrine)
2. N o change in valve structure and function.
3. Intact aorta
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2161-3-10**] 15:44
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
Operating Room on [**2161-3-10**] where he underwent coronary artery
bypass. Overall the patient tolerated the procedure well
weaning from bypass on low dose Epinephrine transiently.
Post-operatively he was transferred to the CVICU in stable
condition for recovery and invasive monitoring. The immedaite
postoperative CXR revealed a small right pneumothorax which
enlarged on a subsequent film off the ventilator. A right CT
was placed uneventfully. Cefazolin was used for surgical
antibiotic prophylaxis. POD 1 found the patient extubated,
alert and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility.
By the time of discharge on POD #4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged in good condition with
appropriate follow up instructions and VNA.
Medications on Admission:
atenolol 25', diltiazem SR 120', prasugrel 10' (60mg on [**2161-2-27**]),
crestor 20', flomax 0.4', Vit C 500', asa 325', zinc 50',
cranberry
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain for 1 months.
Disp:*90 Tablet(s)* Refills:*0*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
NSTEMI- [**2148**], s/p stent of PDA
[**2153**] and [**2154**] Coronary angioplasty
postoperative pneumothorax
Hyperlipidemia
benign prostatic hyperplasia
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
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:
Surgeon Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2161-4-15**], 1pm
Please call to schedule appointments
Primary Care: Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 275**] ([**Telephone/Fax (1) 6699**]) in [**11-22**]
weeks
Cardiologist: Dr. [**Last Name (STitle) 7047**] ([**Telephone/Fax (1) 8725**]) in [**11-22**] weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2161-3-14**]
|
[
"V45.82",
"272.4",
"412",
"512.1",
"E878.2",
"414.01",
"600.00",
"414.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5913, 5969
|
3133, 4466
|
304, 398
|
6226, 6623
|
1839, 2777
|
7163, 7703
|
1120, 1158
|
4659, 5890
|
5990, 6205
|
4492, 4636
|
6647, 7140
|
1173, 1820
|
248, 266
|
426, 758
|
780, 935
|
951, 1104
|
2788, 3110
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,394
| 186,138
|
2207+2208
|
Discharge summary
|
report+report
|
Admission Date: [**2195-10-23**] Discharge Date: [**2195-10-27**]
Date of Birth: [**2129-4-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
Diffuse large B cell lymphoma, final cycle 6 [**Hospital1 **]-R
Major Surgical or Invasive Procedure:
Right PICC
History of Present Illness:
66 year old male symptoms began in [**2195-5-26**] with a sore throat
and some left ear pain. He then began to have a sensation of
something stuck in his throat and reported a weight loss of
[**11-9**] pounds over several weeks. He was evaluated by Dr.
[**Last Name (STitle) **] in the ENT and a flexible fiberoptic
nasopharyngolaryngoscopy was unremarkable. He underwent an
endoscopy on [**6-24**] which revealed lesions in the stomach and
esophagus. Biopsies were consistent with diffuse large B-cell
lymphoma (see below). He denies any drenching night sweats. He
did have low grade fevers initially which have resolved. He
reports a weight loss of [**11-9**] pounds over the past several
weeks. He does note that he has loose stools intermittently
since [**Month (only) 116**].
*
ROS: +decreased appetite, chills, numbness fingers and toes, occ
headache, fatigue, has lost 40lbs since tx began has been stable
last few weeks
Denies chest pain, dyspnea, palpitations, diarrhea, fever,
chills, nausea, emesis
Past Medical History:
ONC History
[**6-1**] gastric and GE junstion bx c/w NHL-DLBCL type
[**7-2**] negative cytogenetics and flow cytometry for marrow
involvement
[**7-2**] s/p first cycle of R-[**Hospital1 **]-[**Hospital1 **] wasgiven rather than CHOP
due to a significant cardiac history and a decrease risk of
cardiotoxicity with anthracycline that is given as continuous
infusion
[**2195-7-21**] admitted for fever/neutropenia-no documented source of
infection and his fevers resolved with recovery of his counts
He did not have disease outside the esophagus or stomach by CT
scan or PET scan
[**2195-7-30**] rituxan
[**Date range (1) 11745**] cycle 2 r-[**Hospital1 **]
[**8-18**] rituxan
[**8-19**] cycle 3 [**Hospital1 **]
[**2195-9-11**] for cycle 4 of
[**Hospital1 **].
[**9-11**] rituxan
[**9-11**] cycle 4 [**Hospital1 **]
[**9-30**] cycle 5 [**Hospital1 **]
[**10-1**] PET- resolution FDG uptake in distal esophagus and prox.
stomach
[**10-20**] rituxan
[**10-23**] to start cycle 6!
hep b and c VL negative on [**10-20**], completed augmentin regimen
*
PAST MEDICAL HISTORY:
Atrial fibrillation- currently in sinus rhythm
Coronary artery disease:LAD stent in [**5-30**], PTCA drug
eluting stent in circumflex in [**3-31**]
CHF-[**9-10**] Overall normal LVEF>55%, Grade II (moderate) LV
diastolic dysfunction
COPD
Trigeminal neuralgia
Pulmonary artery hypertension- moderate by echo
Hepatitis B and C-([**Name6 (MD) 11746**] when MD [**First Name (Titles) **] [**Last Name (Titles) **] stick injury-
untreated)- viral loads have been negative
Dyslipidemia
Social History:
SH: married for 42 years and has one
son. [**Name (NI) **] has two brothers and one sister, both brothers passed
away from MI. He smoked 1ppd for 47 years, quit 3 years ago.
Drinks a glass of wine at night.
Family History:
FH: two brothers passed away from an MI. He had a
sister with question of lung CA. Mother died of "stomach
cancer", father died of lung CA. Father with also significant
cardiac history
Physical Exam:
Physical Exam
Vitals: 98.9, hr 85, rr 16, 121/68, 97%RA
General- nad, alert and oriented times 3, pleasant
HEENT- OP clear, MMM, no lesions or exudates
Neck-no bruits, no LAD or thyromegaly, supple
Cardiac- RRR, no m/r/g, S1 and S2 normal
Lungs- clear bilaterally
Abdomen- soft, nt/nd, bs+, no organomegaly, no rt or guarding
Ext- no edema, cyanosis, or cords
Neuro- cn 2-12 intact, sensation intact, reflexes 2+ throughout,
cerebellar function intact, no nystagmus, muscle strength 5/5
upper and lower extremities
Pertinent Results:
[**2195-10-27**] 12:33AM BLOOD WBC-9.7 RBC-2.45* Hgb-8.5* Hct-25.3*
MCV-104* MCH-34.7* MCHC-33.5 RDW-19.3* Plt Ct-357
[**2195-10-25**] 12:00AM BLOOD Neuts-96.0* Bands-0 Lymphs-2.6*
Monos-1.3* Eos-0.1 Baso-0
[**2195-10-27**] 12:33AM BLOOD Plt Ct-357
[**2195-10-23**] 11:19AM BLOOD Fibrino-609*
[**2195-10-27**] 12:33AM BLOOD Gran Ct-9350*
[**2195-10-27**] 12:33AM BLOOD Glucose-115* UreaN-18 Creat-0.9 Na-141
K-3.6 Cl-103 HCO3-28 AnGap-14
[**2195-10-27**] 12:33AM BLOOD Albumin-3.4 Calcium-7.9* Phos-3.4 Mg-2.4
[**2195-10-27**] 12:33AM BLOOD ALT-24 AST-28 LD(LDH)-243 AlkPhos-57
TotBili-0.6
[**2195-10-23**] 11:19AM BLOOD TSH-1.2
CHEST PORT. LINE PLACEMENT
Reason: Please read for right PICC, 48cm.Thanks! [**Doctor First Name **] #[**Numeric Identifier 11747**]
[**Hospital 93**] MEDICAL CONDITION:
64 year old req. chemo with new PICC
REASON FOR THIS EXAMINATION:
Please read for right PICC, 48cm.Thanks! [**Doctor First Name **] #[**Numeric Identifier 11747**]
HISTORY: Check PICC line placement.
FINDINGS: In comparison with study of [**10-2**], there is little
change in the appearance of the heart and lungs. There has been
placement of a right PICC line that extends to the mid superior
vena cava at the level of the carina. No evidence of
pneumothorax.
This information has been telephoned to the venous access nurse.
Brief Hospital Course:
66 y/o male with newly diagnosed [**6-1**] NHL-DLBCL with primary
involvement of the distal esophagus and proximal stomach,
negative PET otherwise here for cycle 6 [**Hospital1 **]
# NHL diffuse large B cell lymphoma type
Patient started cycle 6 of [**Hospital1 **]. Has tolerated the chemotherapy
well. Chemotherapy was given per protocol. IV fluids were
monitored carefully given his cardiac history. He underwent
right PICC placement with no complications. Tolerated the
chemotherapy with no issues. Was diuresed with good response to
lasix secondary 9lb weight gain. Was discharged after completing
chemotherapy at patient's request. He will follow up on thursday
[**2195-10-29**] to receive Neulasta and see Dr. [**Last Name (STitle) **].
# Atrial fibrillation
Continue on amiodarone, stopped coumadin per discussion with
cardiology on previous admissions, was in NSR throughout
hospitalization.
# CAD
s/p 2 stents placed, stopped plavix long time ago per
cards,continued simvastatin and ASA.
# COPD
Continued serevent diskus
# Hep B and C
Negative VL on [**2195-10-20**], continued lamivudine prophylaxis
# Dyslipidemia
Continued simvastatin
# Iron deficiency anemia
On ferrous sulfate, held during hospitalization
Medications on Admission:
AMIODARONE 200 mg--1 tablet(s) by mouth once a day afib
ASPIRIN 325 mg--1 tablet(s) by mouth once a day prevention
ATIVAN 0.5 mg--[**1-27**] tablet(s) by mouth q4-6 hours as needed for
nausea, anxiety, insomnia
FERROUS SULFATE 325 mg (65 mg)--1 tablet(s) by mouth once a day
LAMIVUDINE 100 mg--1 tablet(s) by mouth
METOPROLOL SUCCINATE 50 mg--1 tablet(s) by mouth once a day
OMEPRAZOLE 20 mg--2 capsule(s) by mouth once a day
SEREVENT DISKUS 50 mcg--1 puff inhaled twice a day for shortness
of breath
SIMVASTATIN 20 mg--1 tablet(s) by mouth once a day chol
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet 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. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*20 Tablet(s)* Refills:*0*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Diffuse large B cell lymphoma
Secondary:
CAD
Atrial fibrillation
COPD
Hep B
Hep C
Dyslipidemia
Discharge Condition:
Good, stable, ambulating well
Discharge Instructions:
You were admitted to receive your 6th and final cycle of
[**Hospital1 **]-R. You tolerated the chemotherapy with no complications.
You will be scheduled to receive a Neulasta dose on Thursday
[**2195-10-29**] as well as see Dr. [**Last Name (STitle) **]. If you develop any fever,
chills, nausea, emesis, or any worrisome symptoms please call
Dr.[**Name (NI) 11748**] office or go to the emergency room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2195-10-29**] 11:30
Provider: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2195-10-29**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2196-2-11**] 1:00
Admission Date: [**2195-11-2**] Discharge Date: [**2195-12-3**]
Date of Birth: [**2129-4-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
fever, shortness of breath
Major Surgical or Invasive Procedure:
bronchoscopy
endotracheal intubation
History of Present Illness:
66 yo M w/ h/o NHL-DLBCL type, s/p last cycle of chemo [**10-27**],
presented to ED on [**2195-11-2**] with fever, lethargy, and diarrhea x
few days with fevers to 103F at home. Diarrhea resolved by the
time of admission, but still with decreased po's. No N/V, Abd
pain, bloody stools, CP, SOB, cough, skin lesions. No sick
contacts.
.
Overnight on [**11-3**], received Cefepime for broad spectrum coverage
of neutropenic fever. At 11:30a.m. on [**11-4**], pt was patient felt
lightheaded with palpitations. Telemetry revealed narrow-complex
tachycardia HR 170's with decrease in blood pressure from 90's
to 70's systolic. EKG done. Cardiology and [**Hospital Unit Name 153**] teams were
consulted. On arrival, patient had already reconverted to sinus
tachycardia.
.
In the [**Hospital Unit Name 153**], BP stable, sinus tachycardia to 107. No complaint
of chest pain or palpitations.
Past Medical History:
NHL (s/p 6 cycles [**Hospital1 **]-rituxan)
Paroxysmal atrial fibrillation
Coronary artery disease: LAD stent in [**5-30**], DES to LCx in [**3-31**]
CHF: [**9-10**] Overall normal LVEF>55%, Grade II (moderate) LV
diastolic dysfunction
COPD
Trigeminal neuralgia
Pulmonary artery hypertension- moderate by echo
Hepatitis C-([**Name6 (MD) 11746**] when MD [**First Name (Titles) **] [**Last Name (Titles) **] stick
injury-untreated)- viral loads have been negative
Dyslipidemia
.
ONC History
[**6-1**] gastric and GE junstion bx c/w NHL-DLBCL type
[**7-2**] negative cytogenetics and flow cytometry for marrow
involvement
[**7-2**] s/p first cycle of R-[**Hospital1 **]- [**Hospital1 **] was given rather than
CHOP due to a significant cardiac history and a decrease risk of
cardiotoxicity with anthracycline that is given as continuous
infusion
[**2195-7-21**] admitted for fever/neutropenia-no documented source of
infection and his fevers resolved with recovery of his counts
He did not have disease outside the esophagus or stomach by CT
scan or PET scan
[**10-1**] PET- resolution FDG uptake in distal esophagus and prox.
stomach
[**10-20**] hep b and cVL negative on [**10-20**]
Meds: ECASA 325 daily, amio 200 daily, lamivudine 50 mg daily,
metoprolol XL 50 mg daily, salmeterol, simvastatin 20 daily,
pantoprazole 40 mg daily, ativan 1 mg hs prn, FeSO4 325 daily
Social History:
SH: married for 42 years and has one
son. [**Name (NI) **] has two brothers and one sister, both brothers passed
away from MI. He smoked 1ppd for 47 years, quit 3 years ago.
Drinks a glass of wine at night.
Family History:
FH: two brothers passed away from an MI. He had a
sister with question of lung CA. Mother died of "stomach
cancer", father died of lung CA. Father with also significant
cardiac history
Physical Exam:
V: Tc 99.6F Tm 102.1F HR 92-170's BP 112/76 (76/54-124/67) 21
96%RA
General: NAD, AAOx3, pleasant male laying in bed
HEENT: OP clear, MMM, no lesions or exudates
Neck: No bruits, no LAD or thyromegaly, supple, JVP approx 10 cm
Cardiac: RRR, tachy, nl S1 and S2, no m/r/g
Lungs: Crackles at bases bilaterally. no wheezes rales or ronchi
Abdomen: Soft, nt/nd, NABS, no organomegaly
Ext: No c/c/e, 2+ DP and PT pulses
Pertinent Results:
[**2195-11-2**] 07:45PM WBC-0.1*# RBC-2.73* HGB-9.2* HCT-27.5*
MCV-101* MCH-33.9* MCHC-33.6 RDW-17.6*
[**2195-11-2**] 07:45PM NEUTS-25* BANDS-0 LYMPHS-47* MONOS-20* EOS-5*
BASOS-3* ATYPS-0 METAS-0 MYELOS-0
[**2195-11-2**] 07:45PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
SCHISTOCY-OCCASIONAL TEARDROP-1+
[**2195-11-2**] 07:46PM LACTATE-0.8
[**2195-11-2**] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2195-12-2**] 05:29AM BLOOD WBC-2.5* RBC-2.31* Hgb-7.9* Hct-24.6*
MCV-106* MCH-34.0* MCHC-32.1 RDW-20.1* Plt Ct-68*
[**2195-12-1**] 03:56AM BLOOD Neuts-94* Bands-0 Lymphs-1* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2195-11-21**] 08:38AM BLOOD FDP-10-40
[**2195-12-2**] 05:29AM BLOOD Glucose-107* UreaN-41* Creat-1.2 Na-113*
K-6.7* Cl-85* HCO3-25 AnGap-10
[**2195-11-30**] 02:42AM BLOOD LD(LDH)-796*
[**2195-11-21**] 08:38AM BLOOD Hapto-226*
[**2195-11-23**] 03:20PM BLOOD IgG-379* IgA-74 IgM-13*
[**2195-12-2**] 06:41AM BLOOD Type-ART Temp-36.3 pO2-75* pCO2-47*
pH-7.30* calTCO2-24 Base XS--3
.
Bronchoscopy: Stain POSITIVE for PCP. +Atypical cells, unknown
etiology - could not exclude lymphoid origin
.
CXR: [**11-5**] -
Cardiac silhouette is mildly enlarged and pulmonary vascularity
remains
engorged. Diffuse hazy opacities have progressed bilaterally
accompanied by underlying interstitial opacities. Additionally,
a more confluent asymmetric area of airspace opacification has
developed in the left perihilar region. Although at least
partially due to pulmonary edema, coexisting infection should be
considered, particularly in the left upper lobe.
.
CTA chest [**11-13**]
CONCLUSION:
1. Extensive ground-glass change along with subpleural
reticulation, airtrapping and traction bronchiectasis most
likely representing the known PCP infective change.
2. Renal hypodensities are incompletely assessed and may
represent cysts. The left kidney is atrophic.
3. No pulmonary embolism or aortic dissection.
.
[**Last Name (un) **] pathology [**2195-11-19**]
INTERPRETATION
Non-specific T-cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by B-cell lymphoma are
not seen in specimen. Correlation with clinical findings and
morphology is recommended. Flow cytometry immunotherapy may not
detect all lymphomas due to topography, sampling or artifacts of
sample preparation.
.
cytometry: Atypical cell present, favor reactive pneumocytes.
Pulmonary macrophages, inflammatory cells and blood. No viral
cytopathic effects seen.
.
ECHO [**11-19**]:
No atrial septal defect or patent foramen ovale is seen by 2D or
saline contrast. Images were suboptimal - a patent foramen ovale
or secundum ASD cannot be definitively excluded on the basis of
this study
Brief Hospital Course:
A/P: 66 y/o M w/ NHL-DLBCL with primary involvement of the
distal esophagus and proximal stomach, s/p R-[**Hospital1 **] p/w
neutropenic fever with episode of symptomatic SVT with
hypotension now in NSR without intervention.
.
# PCP [**Name Initial (PRE) 1064**]: Upon admission - CXR c/w multi-focal pneumonia.
Pt with tachypnea and respiratory alkalosis. Fever as high as
103.3. Previously started on cefepime and levofloxacin for
neutropenic fever (ANC 240 on admission). Gran ct quickly rose
to normal levels. Initial sputum cx showed 1+ GPC in pairs but
negative for PCP, [**Name10 (NameIs) **] maintained high suspicion due to
bilateral infiltrate on CXR, rising LDH and hypoxia.
Bronchoscopy [**11-6**] --> Positive for PCP. [**Name10 (NameIs) **] with a component
of heart failure requiring diuresis. Pt. required intubation
soon after bronchoscopy but tolerated a slow wean and was
extubated on [**11-9**]. He continued to remain respiratorily
tenuous though was gradually improving until he was reintubated
again a couple weeks later for desaturations. He the had a
protracted course with pulmonary microatelectasis complicated by
barotrauma, pneumothoraces, and oxygen toxicity from ventilation
with high O2 and pressure/volume requirements. He underwent 2
BALs with no addititive information, and he has continued to
decline despite antibiotic therapy, steroids, and a trial of
proning. After everything within reason was done, he was
declared CMO by his family and allowed to expire on the morning
of [**2195-12-3**].
.
# Hyperkalemia: his course was also complicated by elevated
potassium. It was probably exacerbated by the bactrim. He was
given multiple rounds of insulin with D50 and calcium carbonate
to maintain his K below 6 until he was made CMO.
.
#Hyponatremia: he had persistent and worsening hyponatremia
during the last few weeks of his stay. His free water was
limited when possible.
.
# CHF: He required diuresis throughout much of his
hospitalization. He responded well to low doses of IV Lasix. Pt
had normal EF with some diastolic dysfunction and a negative
bubble study by ECHO.
- Lasix IV - Plan as above to diurese as above.
.
# SVT: Regular narrow complex tachycardia. Per EP/ Cardiology
appears to be atrial tachycardia given p-waves. Hx of
lightheadedness and palpitations in the past. BB had been
stopped on admission given fever. Has seen Dr. [**Last Name (STitle) **] for
paroxysmal SVT in the past, treated with atenolol. Likely [**2-27**]
inflammation, stress, infection. New event [**11-10**] with rates to
180s, no conversion with Valsalva or carotid massage. Rec'd 5mg
IV metoprolol with conversion within 10 minutes. He was covered
with beta blockage and amiodarone and had no further episodes
throughout his stay.
.
# Elevated LFTs: Mildly elevated, will cont. to follow in
setting of mult. medications that may cause hepatotoxicity
including statin and Bactrim. They resolved and remained
stable.
.
# Constipation: he did not have a bowel movement for over a week
before his death despite aggressive bowel regimen. A abdominal
film showed now obvious impaction or dilation of his colon or
small bowel.
.
# CAD: S/p 2 stents in the past. No chest pain w/ SVT. He was
continued on ASA, B-blocker, and statin.
.
# NHL: S/p neulasta, initially neutropenic given recently
completed final cycle of chemotherapy. Neutrophil count quickly
rebounded to normal. BAL revealed atypical cells - could not r/o
lymphoid origin. Onc followed throughout his stay.
.
# Hep C: Negative VL on [**2195-10-20**], cont lamivudine prophylaxis
.
# Iron deficiency anemia: Hct at baseline. Cont FeSO4. He did
require pRBCs during his stay.
.
# FEN: he was given tube feeds for the last couple weeks of his
stay. This was complicated by high residuals which limited his
feeding.
.
# PPX: PPI, pneumoboots, acyclovir
.
# Communication: Son [**Name (NI) **]: [**Telephone/Fax (1) 11749**], CELL: [**Telephone/Fax (1) 11750**]. 2.
wife [**Name (NI) **] work [**Telephone/Fax (1) 11751**]
Medications on Admission:
ECASA 325 daily
amio 200 daily
lamivudine 50 mg daily
metoprolol XL 50 mg daily
salmeterol
simvastatin 20 daily
pantoprazole 40 mg daily
ativan 1 mg hs prn
FeSO4 325 daily
Discharge Disposition:
Expired
Discharge Diagnosis:
cardiac asystole resulting from protracted respiratory failure
Discharge Condition:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"070.54",
"496",
"350.1",
"428.0",
"276.1",
"414.01",
"136.3",
"428.32",
"070.32",
"427.31",
"V45.82",
"512.8",
"584.9",
"202.80",
"288.00",
"284.1",
"427.32",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"96.72",
"33.24",
"96.04",
"38.93",
"33.27",
"96.6",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
19800, 19809
|
15555, 19577
|
9474, 9512
|
19915, 20061
|
12701, 15532
|
8642, 9391
|
12061, 12248
|
7180, 7980
|
4786, 4823
|
19830, 19894
|
19603, 19777
|
8214, 8619
|
12263, 12682
|
9408, 9436
|
4852, 5316
|
9540, 10427
|
10449, 11820
|
11836, 12045
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,007
| 115,451
|
6587
|
Discharge summary
|
report
|
Admission Date: [**2182-11-4**] Discharge Date: [**2182-11-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo M w/ CAD s/p CABG, AF s/p ppm on coumadin, presents with
fevers, productive cough (brown sputum) and worsening SOB over
[**12-29**] day. In the ED: he presented in respitory distress with
initial vitals: T 102.2, BP 140/70, HR 72, RR 40's 02sat
78RA->93% on NRB. A CXR showed evidence of a LLL infiltrate. His
labs were significant for a WBC count of 11.6 (16 bands),
bun/crt 50/2. BNP 7359. lactate 2.9. Negative CE. He was started
on BIPAP with good effect (PS 12, PEEP 8, 100%, 99% 02sats with
RR of 20's), he was given fluids 1L NS, azithro, ceftrioxone,
tylenol. Admited to the ICU for BIPAP and treatment of his PNA.
ROS: significant for productive cough, SOB, decreased appetite
over past 2 days. Denies any dietary indescretions.
Past Medical History:
1. Coronary artery disease.
(a) Status post acute myocardial infarction in [**2149**].
(b) Status post coronary artery bypass graft in [**2165**].
2. Prostate cancer; status post radiation therapy.
3. Status post permanent pacemaker placement.
4. Status post left total hip replacement surgery.
5. History of melanoma.
6. History of atrial fibrillation.
7. Hypercholesterolemia.
Social History:
accountant and retired lawyer, [**Name (NI) 25190**] [**Name2 (NI) **]. no smoking,
minimal etoh. no drugs. lives with his wife.
Family History:
Family History: A daughter died of unknown CA at the age of 54.
No other family history of cancer, diabetes, HTN, stroke, or
heart disease.
Physical Exam:
VS: Temp: 97.3 BP: / HR: 63 RR: O2sat
GEN: venti mask in place, NAD, pleasant elderly M
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: JVD approx 8-10cm
RESP: rales throughout
CV: heart sounds obscured by rales.
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3.
Pertinent Results:
[**2182-11-3**] 11:48PM WBC-11.6* RBC-4.22* HGB-12.8* HCT-36.6*
MCV-87 MCH-30.3 MCHC-35.0 RDW-14.0
[**2182-11-3**] 11:48PM NEUTS-69 BANDS-16* LYMPHS-13* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2182-11-3**] 11:48PM PLT COUNT-213
[**2182-11-3**] 11:48PM CK-MB-2 cTropnT-<0.01 proBNP-7359*
[**2182-11-3**] 11:48PM GLUCOSE-165* UREA N-50* CREAT-2.0* SODIUM-139
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-24 ANION GAP-17
[**2182-11-3**] 11:54PM LACTATE-2.9*
[**2182-11-4**] 12:07AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2182-11-4**] 05:58AM CK-MB-3 cTropnT-<0.01
.
CXR: LLL infiltrate, mild CHF
Brief Hospital Course:
Pneumonia: Pt admitted to ICU and respiratory distress resolved
with BIPAP. LLL infiltrate on CXR, prominent vasculature.
Improved with coverage with ceftrioxone/azithro for CAP.
A.fib: Stable, h/o afib, followed closely by cardiology.
Therapeutic on coumadin.
Bacteremia: Patient was admitted to ICU on presentation. Blood
cultures with strep pneumonia, thought secondary to pneumonia,
sensitive to levofloxacin.
On hospital day 3, pt had normal O2 sat, looked and felt well.
WBC count normalized and pt was afebrile. He asked to be
discharged home, and was discharged to complete a 10 day course
of levofloxacin.
Medications on Admission:
Amlodipine 2.5mg qdaily
simvastatin 80mg qdaily
toprol XL 50mg qdaily
coumadin 2mg/1mg/1mg
triamterene 37.5 qdaily
ocutabs qdaily
Discharge Medications:
1. Continue all home medications
2. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 6 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please take your antiobiotic every other day until the pills are
completed.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 14069**] within 2 weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2182-11-27**]
|
[
"427.31",
"V45.01",
"584.9",
"585.9",
"272.0",
"V45.81",
"486",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3803, 3809
|
2822, 3446
|
266, 273
|
3863, 3872
|
2172, 2799
|
3996, 4223
|
1653, 1778
|
3627, 3780
|
3830, 3842
|
3472, 3604
|
3896, 3973
|
1793, 2153
|
223, 228
|
301, 1064
|
1086, 1475
|
1491, 1621
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,587
| 144,575
|
47072
|
Discharge summary
|
report
|
Admission Date: [**2191-11-18**] Discharge Date: [**2191-11-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
Fall, bilateral humeral fractures
Major Surgical or Invasive Procedure:
intramedullary rodding of right proximal humerus fracture
open repair of right rotator cuff
intramedullary rodding of left proximal humerus fracture
Central venous line placement
History of Present Illness:
85 yo female with past medical history significant for CVA,
Afib, Dementia, dCHF, temporal arteritis, PMR, presents s/p
unwitnessed fall at [**Hospital 100**] Rehab with c/o bilateral shoulder
pain. Pt found to have bilateral proximal humeral fractures and
nasal fracture in ED and admitted to trauma.
Per nursing notes, pt found on floor at 3:15 AM [**2191-11-18**] lying
face down. She was not noted to be in respiratory or cardiac
distress. Pt recalls being hurt but cannot say what happened
prior.
Past Medical History:
Dementia - amyloid angiopathy
s/p CVA
Atrial fibrillation (not anticoagulated due to
amyloid/angiopathy)
Diastolic Congestive Heart Failure ([**6-18**] ECHO EF 60%)
Chronic Urinary Retention
Periperal edema: likely venous stasis
Osteoporosis
Temporal Arteritis, on prednisone
Polymyalgia Rheumatica
Depression w/ catatonia and confusion assoc w/ dementia
Atrophic vaginitis
Vitamin D deficiency: [**2191-9-22**] 25-OH total 20 ng/mL
Fe deficiency anemia
hx L pleural effusion
hx UTIs, inc ESBL
hx PNA
hx compression fractures
hx central retinal vein thrombosis
hx melenoma - removed
s/p cataract surgery
s/p kyphoplasty L2-L4
Social History:
Lives at [**Hospital 100**] Rehab. Non-smoker, no ETOH.
Family History:
NC
Physical Exam:
VITAL SIGNS: T=98.1 BP=158/105 HR=86 (with bursts to 140s)
RR=20 O2= 98% 3LNC
GENERAL: Pleasant, with facial bruising and echymoccyes under
eyes. Calls for daughter to c/o pain.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. MMM. OP clear. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: Irregular, normal rate. Normal S1, S2. II/VI SEM. No
rubs or [**Last Name (un) 549**]. JVP= 8cm
LUNGS: anterior CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 1+ dorsalis pedis.
SKIN: No rashes/lesions.
NEURO: A&Ox1.
Pertinent Results:
Admission labs:
[**2191-11-18**] 04:45AM WBC-11.7* RBC-3.60* HGB-10.3* HCT-31.8*
MCV-88 MCH-28.6 MCHC-32.4 RDW-15.8*
[**2191-11-18**] 04:45AM NEUTS-68.0 LYMPHS-24.9 MONOS-5.2 EOS-1.3
BASOS-0.5
[**2191-11-18**] 04:45AM PLT COUNT-393
[**2191-11-18**] 04:45AM GLUCOSE-121* UREA N-35* CREAT-0.7 SODIUM-142
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-29 ANION GAP-14
[**2191-11-18**] 04:45AM PT-11.3 PTT-22.1 INR(PT)-0.9
Imaging:
CT head: IMPRESSION:
1. No acute intracranial hemorrhage.
2. Chronic small vessel ischemic changes.
3. Sinusitis changes.
4. Displaced left nasal bone fracture.
5. Periorbital swelling and hematoma anterior to the left
zygoma. Orbital
globes are intact.
CT Cspine
IMPRESSION:
1. No evidence of acute fracture.
2. Diffuse osteopenia and degenerative changes.
3. Small left pleural effusion.
CT sinus
IMPRESSION:
1. Displaced left nasal bone fracture.
2. Opacification of the sinuses. The left OMU is occluded.
3. Left periorbital swelling and hematoma.
Echo:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Overall left
ventricular systolic function is normal (LVEF>55%). There is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
The estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate aortic regurgitation. Mild to moderate mitral
regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2191-6-28**],
the severity of aortic regurgitation has increased. The severity
of pulmonary hypertension has increased. The rhythm now appears
to be atrial fibrillation with beat-to-beat variation in left
ventricular ejection fraction.
Carotic US
IMPRESSION: Limited left-sided study but less than 40% carotid
stenosis.
Right side was not evaluated as described above.
CXR
Impression: Stable appearances with slight improvement in
pulmonary edema
which is mild. Persistent moderate-to-large left pleural
effusion and smaller right pleural effusion.
KUB
There is less fecal material in the colon. The bowel loops of
the colon and gas-filled small bowel loops in the abdomen are
not distended. Maximum
diameter of the colon is 4.1 cm.
Degenerative changes of bilateral hip joints, vertebroplasty at
several of the lumbar vertebral bodies are unchanged.
Brief Hospital Course:
85 yo female with dementia who fell and sustained nasal fracture
and bilateral humeral fractures, s/p intramedullary rodding of
right proximal humerus fracture, open repair of right rotator
cuff, and intramedullary rodding of left proximal humerus
fracture. She was transferred to the TSICU for Afib with RVR
and subsequently transferred to MICU for volume overload.
.
# Bilateral UE humeral fractures: She underwent intramedullary
rodding of right proximal humerus fracture, open repair of right
rotator cuff, and intramedullary rodding of left proximal
humerus fracture. As per orthopedics, her activity level should
be weight bearing in upper extremities as tolerated.
.
# Afib/Aflutter: This was likely worsened by diuresis, systemic
infection and increased adrenergic tone. She required a
diltizem drip and was successfully transitioned to diltiazem
extended release 360mg daily after her other acute issues had
resolved. Her heart rate has been maintained in the 80's. She
was anticoagulated with ASA alone given fall risk.
.
# Pulm edema/Chronic left pleural effusion: Patient was
diuresed with IV Lasix as needed. Her goal urine output should
be 1L daily. She is on lasix 20mg IV BID, and she should receive
PRN IV lasix to achieve her goal urine output as her BP
tolerates.
.
# ?UTI: Infectious diseases service felt that her urine
cultures were consistent with contamination, as she has had ESBL
UTI's in the past. She received a three day course of meropenem,
until it was stopped for this reason. She is continued on
premarin cream for prevention of UTI.
.
# C. diff: Patient developed leukocytosis and abdominal pain, as
well as diarrhea. She was found to have C.difficile and was
started on flagyl in the ICU on [**2191-11-25**]. Because her white
blood cell count continued to increase, she was also started on
PO vancomycin on [**2191-11-27**]. If the patient's abdominal exam shows
evidence of rebound/guarding or stool output stops quickly and
in the setting of continued abdominal tenderness, KUB to assess
for toxic megacolon should be performed. KUB on [**2191-11-26**] showed
no evidence of toxic megacolon.
.
# Acute on Chronic Diastolic Congestive Heart Failure: Patient
with acute on chronic diastolic CHF exacerbation upon transfer
to the ICU. She was placed on lasix 20mg IV BID, as well as PRN
lasix IV to achieve goal UOP of 1L per day. Because of variable
BP's with Afib on RVR, beta blocker was held. If blood pressure
will tolerate, and HR remains stable in the 60's to 80's, low
dose coreg should be started. Patient also would require that
ACEi started, given CHF. KCl was held during hospitalization as
daily labs were being drawn. If labs are not obtained frequently
at rehab, she will require resumption of home dose 20meq KCl
daily.
.
# Nasal fracture: Patient was seen by plastics who recommended
dressing changes and surgical correction concurrent with humerus
fix. However, risks/benefits or reduction of nose was discussed
with family, who opted for non-operative management due to risk
of complications. She was managed with xeroform and DSD to
forehead daily x1 week, then bacitracin [**Hospital1 **].
.
#. Osteoporosis - Calcium continued and Vitamin D infusions as
below.
.
#. Temporal Arteritis/Polymyalgia Rheumatica - Continued
prednisone, home dose, on discharge. She was on stress dose
steroids briefly while in the TSICU.
.
#. Depression w/ catatonia and confusion assoc w/ dementia -
Continued seroquel, remeron, and cymbalta
.
#. Vitamin D deficiency: Pt gets weekly infusion and will
resume at rehab when discharged. Vitamin D infusion was held
while inhouse.
#. Chronic pain: Pt was on cymbalta at goal and continued on
seroquel 50 mg qhs. Pain service followed, and recommended
oxycodone Q3 hours while she still has pain from b/l humeral
fractures.
#. Anemia: Niferex was held during hospitalization given her
acute infection with C. Difficile. It should be resumed after
course of antibiotics finished.
Medications on Admission:
cymbalta 20 mg daily
omeprazole 20 mg daily
seroquel 50 mg [**Hospital1 **]
remeron 15 mg QHS
ASA 81 mg enteric coated daily
toprol XL 50 mg daily
lasix 80 mg daily
KCL 20 mEQ [**Hospital1 **]
premarin cream 1 application MOTH@20
prednisone 5mg daily
niferex 150 mg daily
artificial tears 1 drop OU [**Hospital1 **]
tylenol 650 mg QID
vitamin D2 50,000 units PO weekly
anusol 1% per rectum QHS
amoxicillin 2gm prior to dental procedures
skin creams: aveeno [**Hospital1 **], bengay [**Hospital1 **]
fleets enema daily:prn
hot pack to lower back QID:prn
Discharge Medications:
1. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO Q4H (every 4
hours) as needed for pain: please continue as long as having
pain from upper extremity fractures.
2. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg Injection
[**Hospital1 **] (2 times a day): Hold for sbp<100.
3. Diltiazem HCl 360 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
4. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 13 days: Continue until [**2191-12-11**].
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 11 days: please continue until [**2191-12-9**].
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
17. Premarin 0.625 mg/g Cream Sig: One (1) application Vaginal
as dir: Please continue at dosing prior to arrival at hospital.
18. Anusol 1-12.5 % Ointment Sig: One (1) application Rectal
once a day.
19. Tears Naturale Forte 0.1-0.3-0.2 % Drops Sig: One (1) drop
Ophthalmic twice a day.
20. FLEETS ENEMA
Please administer daily PRN
21. Other
Please apply Aveeno cream and Bengay cream [**Hospital1 **]
22. Hot Packs
Please apply to lower back QID PRN
23. Bacitracin 500 unit/g Ointment Sig: One (1) application
Topical twice a day: please apply until nasal fracture healed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Bilateral humeral fractures s/p ORIF
2. Nasal fracture
3. Acute on Chronic Diastolic Congestive Heart Failure
4. Atrial fibrillation and Atrial flutter with rapid ventricular
response
5. Clostridium Difficile Colitis
Discharge Condition:
stable vital signs, HR 80's. Oriented only to person.
Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2191-11-18**] after falling. You broke
your nose and both of your arms. You had surgery for your arm
bone fractures. You will need to continue physical therapy when
you are in rehab, and you can take oxycodone for pain.
You also had a fast and abnormal heart rate. You will start
taking a medication called diltiazem for this. You also had some
symptoms of heart failure, and will require intravenous lasix to
get some of the excess fluid off. You should have daily weights
and your doctor should be notified for any weight gain >3lbs in
3days. Follow a diet with less than 2 grams sodium and restrict
your fluid intake to 2L per day.
You also had a stool infection while you were hospitalized. You
will need to complete a 2 week course of flagyl and vancomycin.
The following changes have been made to your medications:
STOP taking toprol XL.
STOP taking Potassium supplements.
STOP taking niferex
START taking oxycodone every four hours
START taking Flagyl until [**2191-12-9**]
START taking vancomycin until [**2191-12-11**]
START bacitracin cream until nasal fracture healed.
STOP taking lasix 80mg by mouth daily and START taking lasix
20mg IV twice a day
INCREASE cymbalta 20mg daily to 30 mg daily
INCREASE aspirin 81mg daily to 325 mg daily
RESUME your Vitamin D infusions as determined by your PCP
Please return to the hospital if you have chest pain, shortness
of breath, fever>100.4, worsening profuse diarrhea, bloody/black
stool, or any other symptoms concerning to you.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 34720**], [**2-11**]
weeks after your discharge from rehab.
Please follow up with Dr. [**Last Name (STitle) **] on [**2191-12-7**] at 2:30pm on
[**Hospital Ward Name 23**] [**Location (un) **]. The phone number is [**Telephone/Fax (1) 1228**].
|
[
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"008.45",
"427.31",
"428.0",
"E885.9",
"427.32",
"280.9",
"428.33",
"446.5",
"290.40",
"812.00",
"788.20",
"277.39",
"311",
"802.0",
"840.4",
"733.00",
"819.0",
"924.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.63",
"79.31"
] |
icd9pcs
|
[
[
[]
]
] |
12076, 12142
|
5325, 9307
|
298, 478
|
12425, 12481
|
2385, 2385
|
14063, 14423
|
1749, 1753
|
9911, 12053
|
12163, 12404
|
9333, 9888
|
12505, 14040
|
1768, 2366
|
225, 260
|
506, 1010
|
2823, 5302
|
2401, 2814
|
1032, 1660
|
1676, 1733
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,407
| 195,442
|
46602
|
Discharge summary
|
report
|
Admission Date: [**2156-12-27**] Discharge Date: [**2157-1-4**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year-old
female with a history of aortic stenosis status post
valvuloplasty times three complaining of increased
chest/epigastric pain with radiation to her arms. She was
taken to the Emergency Room at [**Hospital1 188**]. She was admitted to the Medical Service.
PAST MEDICAL HISTORY: Aortic stenosis status post
valvuloplasty times three. Coronary artery disease status
post myocardial infarction. Congestive heart failure,
chronic obstructive pulmonary disease, breast cancer,
hypercholesterolemia, right groin pseudoaneurysm.
MEDICATIONS: Cardizem, Toprol, aspirin, Persantine, Zantac,
Albuterol, Lasix.
ALLERGIES: Penicillin and sulfa.
PHYSICAL EXAMINATION: Afebrile. Vital signs stable. Cor
respiratory rate. +3/6 systolic ejection murmur. Chest
clear to auscultation. Abdomen soft, nontender,
nondistended.
HOSPITAL COURSE: It was decided that the patient would have
an aortic valve replacement. This was performed [**2156-12-29**]. She had a aortic valve replacement with CE #19 valve
placed. Postoperatively, she was on Levo and Epi, which were
appropriately weaned. The patient remained sedated
postoperative one, two and three. A neurology consult was
obtained and they recommended a head CT, which revealed
multiple infarcts. The patient was also noted to be in a
decerebrate posture. On [**1-4**], the patient was noted to
have acute right lower ischemia. A vascular surgery consult
was obtained and it was decided to start the patient on
heparin. A lactate level was obtained, which was 10.1. A
general surgery consult was obtained to rule out mesenteric
ischemia. They elected to treat the patient conservatively.
A repeat head CT at the request of neurology was obtained on
[**1-2**], which continued to show multiple infarcts. The
patient continued to remain decerebrate posture. On [**1-4**], the patient remained in a deep coma and neurology
declared the patient as an extremely poor prognosis. A
lengthy conversation was obtained between Dr. [**Last Name (STitle) 1537**] and the
patient's family. It was decided at that time to make the
patient comfort measures only and DNR. The patient expired
[**2157-1-4**] at 5:30 p.m.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2157-1-5**] 08:06
T: [**2157-1-5**] 08:10
JOB#: [**Job Number 98963**]
|
[
"728.89",
"276.2",
"427.31",
"285.9",
"496",
"396.2",
"434.91",
"997.02",
"398.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.72",
"39.61",
"35.22",
"89.64",
"42.23"
] |
icd9pcs
|
[
[
[]
]
] |
1015, 2614
|
840, 997
|
129, 432
|
455, 817
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,147
| 113,522
|
29387
|
Discharge summary
|
report
|
Admission Date: [**2175-1-30**] Discharge Date: [**2175-2-9**]
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 6994**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
-Triple lumen placed on [**2175-1-31**].
-Intubation.
History of Present Illness:
Patient is an 82 year old female with ESRD on hemodialysis MWF,
mild dementia, hypertension, CAD statsu post CABG in [**2162**], who
presented with two days of confusion and mental status changes
at her nursing home. [**Name (NI) **] son reports that he saw her [**2-4**]
days prior to admission and she was her usual
self--conversational, alert, oriented, and with mild memory
difficulties. [**Name (NI) **] son went to see her on the morning of
[**1-30**] and noted that she was writhing, lying in the fetal
position and noticed shallow breathing. He could not elicit more
detailed complaints out of her as she was not verbal on the day
of admission.
.
Per the nursing home reports, she was hypoxic to the 70s on the
morning of admission. It increased to the 90s% on 2-4L NC.
Vomited x1 on morning of admission. Emesis was nonbilious and
nonbloody. She was incontinent of stool x4, when she is
typically continent. Last hemodialysis was on Friday (is on MWF
schedule). Has had increasing confusion over the last few days.
.
In the ED, she was febrile to 101.4 and was cultured. She was
hypertensive to 160s-190s systolic. CXR demonstrated fluid
overload, with a question of pneumonia. A blood gas revealed an
ABG 7.46/27/183. Initial lactate was 2.6. She was placed on
BiPAP and as she could not be weaned from BiPAP, was admitted to
MICU. She initially received one gram of vanco, 1g of ceftaz,
80mg of gentamicin. He received one dose of ASA 600mg PR.
.
In the MICU, patient was getting dialyzed and was found to be
more unresponsive, cyanotic, not at all moaning or responding to
sternal rub. She was intubated for airway protection,
tachypneic, appeared moribund. L subclavian triple lumen placed,
as well. HD was discontinued and 1L NS was run in through the HD
catheter wide open. At that point, patient appeared somewhat
more responsive.
Past Medical History:
-ESRD on HD (m/w/f)
-Status post right hip repair in [**2174-8-2**] which has prompted
prolonged nursing home stay
-Hypertension
-CABG x3 in [**2172**] at [**Hospital1 2025**] (found to have 3VD on cath)
-Arthritis
-Neuropathy
-Laparscopic cholecystectomy in summer [**2174**]
-Left temporal CVA [**11-7**]
-Pneumothorax after line placement in [**2174-12-2**] status post
chest tube
-Herpes zoster right t3/t4 in [**2174-11-2**]
Social History:
Widowed, resides at [**Location (un) **] [**Hospital1 **] NH, four children, no
tobacco, no ETOH. Generally pleasant but tends to isolate. Her
four children visit her but she does not speak with them very
often.
Family History:
Mother had coronary artery disease.
Physical Exam:
Physical Exam (on admission to MICU):
VS: 101.8 165/82 99 28 88% (bad pleth) on BiPAP 10/5
Gen: moaning, does not respond verbally to questions, not
responding to commands
HEENT: mask interfering with exam
Neck: JVD to 10cm
CV: RRR, nl S1/S2, no m/r/g
Chest: R tunneled s/c dialysis catheter - no surrounding
erythema
Pulm: CTAB anteriorly
Abd: soft, NT/ND, +BS, no masses
Ext: no c/c/e; onychomycosis
Neuro: delirium, cannot answer questions
.
Physical Exam on admission to floor:
T:97.9 BP:140/80 HR:80 RR:20 O2saturation: 100% on room air,
blood sugar 41.
Gen: Laying in bed. Minimally responding. Knew year and city,
but assumed in nursing home. Elderly woman, in no apparent
distress.
HEENT: Slight conjunctival pallor. No icterus. Slightly dry
mucous membranes. NGT in place.
NECK: No cervical or supraclavicular lymphadenopathy. No JVD. No
thyromegaly. Hemodialysis catheter in left upper chest.
CV: RRR. Normal S1 and S2. No murmurs, rubs or [**Last Name (un) 549**]
appreciated.
LUNGS: Clear to auscultation bilaterally. Decreased breath
sounds in lower lung fields, bilaterally. Slight crackles
appreciated, bilaterally.
ABD: Normal active bowel sounds in all four quadrants. Soft.
Nontender and nondistended. No guarding or rebound. Liver edge
not palpated. No splenomegaly appreciated. No abdominal aortic
bruit.
EXT: Distal extremities cool and cyanotic. No lower extremity
edema, bilaterally. 2+ radial pulses, bilaterally.
SKIN: Several ecchymoses.
Pertinent Results:
Images:
AV fistulogram ([**2175-2-8**]): Left AV fistulogram demonstrates good
flow in the anterior side of the fistula to the cephalic vein.
Also there is patent subclavian, and SVC veins.
.
EKG ([**2175-1-30**]): 97bpm, NSR, LAFB, TWI in V2 (old)
.
Chest Xray Portable ([**2175-2-3**]): Perhaps slight improvement in
pulmonary edema. Persistent left lower lobe atelectasis or
consolidation.
.
Chest xray ([**2175-2-2**]): Left subclavian vein catheter tip is in
the lower SVC. Right subclavian catheter tip is in the right
atrium. Left lower lobe collapse is persistent. Small right
pleural effusion is stable. NG tube tip is in the stomach.
There is no pneumothorax. Mild cardiomegaly is stable.
.
CXR ([**2175-1-30**]): 1. Pulmonary edema with bilateral pleural
effusions, new since the [**2174-12-15**] plain radiograph. 2.
Confluent opacity in the right mid-lung zone and base likely
represents alveolar edema, though pneumonic consolidation is a
consideration. 3. No supine evidence of pneumothorax.
.
Cardiac ([**2175-1-31**]): The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with mid to apical
anteroseptal/anterior hypokinesis. Overall left ventricular
systolic function is mildly depressed. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+) 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 mild pulmonary artery systolic hypertension.
There is a small pericardial effusion.
No vegetation seen.
.
Abdominal U/S ([**2175-1-31**]): 1. Unremarkable liver and no biliary
dilatation. 2. Status post cholecystectomy. 3. Bilateral
pleural effusions, loculated on the right. 4. Atrophic kidneys.
.
TTE ([**2174-11-25**]): [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, RV mildly dilated, EF 60-70%,
1+ MR, mild pulmonary HTN.
.
Micro:
Blood ([**1-30**]): Staph aureus coag +.
.
Endotracheal ([**2-1**]): Yeast. Staph aureus coag +.
.
Stool ([**1-31**], [**2-2**]): C. dificile negative.
.
Labs:
[**2175-2-8**]: WBC 8.1, Hgb 9.4, Hct 29.6, Plt 248, PT 15.6, PTT 33.5,
INR 1.4
[**2175-2-6**]: WBC 10.0, Hgb 9.6, Hct 29.8, Plt 235, PT 14.9, PTT
61.5, INR 1.3
[**2175-2-8**]: Na 139, K 4.3, Cl 106, HCO3 23, BUN 16, Cr 3.5, Glu 83
[**2175-2-6**]: Na 138, K 4.2, Cl 104, HCO3 23, BUN 25, Cr 4.1, Glu 100
[**2175-2-8**]: Ca 7.7, Mg 2.4, PO4 3.4
[**2175-2-6**]: Ca 8.0, Mg 2.6, PO4 3.4
[**2175-2-4**] 06:59AM BLOOD WBC-12.7* RBC-3.20* Hgb-9.7* Hct-30.7*
MCV-96 MCH-30.3 MCHC-31.6 RDW-18.8* Plt Ct-189
[**2175-2-2**] 05:30AM BLOOD WBC-11.5* RBC-3.13* Hgb-9.3* Hct-29.8*
MCV-95 MCH-29.9 MCHC-31.4 RDW-18.9* Plt Ct-126*
[**2175-1-30**] 06:39PM BLOOD WBC-15.3*# RBC-3.82*# Hgb-12.2# Hct-36.9#
MCV-97 MCH-31.9 MCHC-33.0 RDW-18.7* Plt Ct-229
[**2175-2-4**] 06:59AM BLOOD Plt Ct-189
[**2175-2-4**] 06:59AM BLOOD PT-13.9* PTT-31.4 INR(PT)-1.2*
[**2175-1-30**] 06:39PM BLOOD PT-13.6* PTT-26.8 INR(PT)-1.2*
[**2175-1-30**] 06:39PM BLOOD Plt Smr-NORMAL Plt Ct-229
[**2175-2-4**] 06:59AM BLOOD Glucose-225* UreaN-16 Creat-2.6* Na-141
K-3.9 Cl-104 HCO3-25 AnGap-16
[**2175-2-1**] 05:15AM BLOOD Glucose-89 UreaN-59* Creat-4.7*# Na-144
K-2.5* Cl-104 HCO3-22 AnGap-21*
[**2175-1-31**] 03:33AM BLOOD Glucose-294* UreaN-44* Creat-3.5*# Na-137
K-3.9 Cl-98 HCO3-19* AnGap-24*
[**2175-1-30**] 04:45PM BLOOD Glucose-206* UreaN-76* Creat-5.4*# Na-143
K-5.5* Cl-97 HCO3-19* AnGap-33*
[**2175-2-3**] 04:30AM BLOOD ALT-175* AST-37 AlkPhos-97 Amylase-66
TotBili-0.4
[**2175-1-30**] 05:10PM BLOOD ALT-355* AST-269* LD(LDH)-598*
CK(CPK)-143* AlkPhos-142* Amylase-356* TotBili-0.4
[**2175-2-3**] 04:30AM BLOOD Lipase-33
[**2175-1-30**] 05:10PM BLOOD Lipase-17
[**2175-2-2**] 09:02AM BLOOD CK-MB-NotDone cTropnT-0.67*
[**2175-1-31**] 06:34PM BLOOD CK-MB-9 cTropnT-0.83*
[**2175-1-31**] 02:08PM BLOOD CK-MB-8 cTropnT-0.81*
[**2175-1-31**] 03:33AM BLOOD CK-MB-11* MB Indx-8.7* cTropnT-0.60*
[**2175-1-30**] 05:10PM BLOOD CK-MB-8 cTropnT-0.59*
[**2175-2-4**] 06:59AM BLOOD Calcium-8.3* Phos-2.5* Mg-3.1*
[**2175-1-31**] 03:33AM BLOOD Albumin-3.2* Calcium-8.6 Phos-5.4*#
Mg-2.2
[**2175-2-3**] 04:30AM BLOOD Genta-3.6* Vanco-28.2*
[**2175-1-31**] 03:33AM BLOOD Genta-0.8* Vanco-16.1
[**2175-2-3**] 05:08PM BLOOD pO2-73* pCO2-37 pH-7.48* calTCO2-28 Base
XS-3
[**2175-1-30**] 07:50PM BLOOD pO2-183* pCO2-27* pH-7.46* calTCO2-20*
Base XS--2
[**2175-2-3**] 05:08PM BLOOD Lactate-1.4
Brief Hospital Course:
Hospital Course/Assessment/Plan:
Patient is an 82 year old female with a history of CAD status
post CABG, ESRD on hemodialysis, CVA with dementia who presents
with worsening mental status who was admitted to the ICU for
hypoxic respiratory failure.
.
.
1) Hypoxic respiratory failure:
On admission, most likely related to excess fluid, despite
stable hemodialysis schedule. Pleural effusions and pulmonary
edema on chest xray. No history of COPD. Appears to have
underlying PNA, as well.
- Continue hemodialysis for fluid removal. Blood culture on
[**1-30**] revealed staph aureus, coag positive blood. Initial
antibiotic was ceftazidime, but discontinued [**1-31**], as infection
thought to be related to HD line. Decision made to treat
through with vancomycin and gentamycin for potential line
sepsis. Flagyl continued for two weeks, despite stool that was
negative for C. difficile. Will be discharged on vancomycin and
flagyl.
By [**2-4**], patient maintaining 100% oxygen saturation on 2
liters nasal canula. On [**2-8**], patient oxygen saturation
95% on room air.
.
2) Fever and leukocytosis:
Multiple sources of infection. Sputum on [**2-1**] revealed some
yeast. Stool on [**2-2**] was C. dificile negative and negative for
salmonella, shigella, and campylobacter.
Treated presumed HD line infection with gentamicin and
vancomycin. AV fistulogram revealed AV fistula in left arm
functioning. Removed tunneled left catheter line on [**2175-2-9**], so
will continue only vancomycin for two weeks (until [**2175-2-24**]).
Dosing of antibiotics after hemodialysis sessions for vancomycin
trough less than 15. Will continue metronidazole for two weeks.
-On [**2-6**], left triple lumen (placed on [**2175-1-31**]) appeared
infected. Line removed.
.
3) Abnormal LFTs:
Most likely due to shock liver. Right upper quadrant ultrasound
did not reveal any obstructive picture.
.
4) Urinary Tract infection:
Patient had positive urine analysis on admission.
As above, treated with broad spectrum antibiotics.
.
5) Mental status changes:
Presented to hospital and unresponsive. Most likely due to
multiple conditions. Initially, had fluid overload and hypoxia.
In days prior to discharge, patient's mental status improved.
Much more lucid and requesting to eat on own. Consulted speech
and swallow to assist. Continued with thickened pureed liquids,
with aspiration precautions.
.
6) Diarrhea:
Patient presented with recent vomiting and diarrhea. Most
likely due to viral gastroenteritis. Rectal tube in place.
- C. dificile culture from [**2175-2-2**] negative. Despite this, will
continue on PO flagyl, as previous C. dificile infection and
patient has been hospitalized for extended period.
.
7) CAD status post CABG:
Elevated troponin compared with previous troponins with similar
degree of renal failure, but EKG shows no changes. Most likely
due to demand ischemia, in setting of hypoxia and respiratory
distress. factors.
- Continued aspirin. Initially held beta blocker and ACE I as
hypotensive. Trended cardiac enzymes. Did not start heparin.
.
8) Tight glycemic control:
Initiated for tight glycemic control in ICU setting. No history
of diabetes. Blood sugars remained in good control.
.
9) ESRD on HD:
Patient with right HD line, with L fistula not being used.
Initially, held nephrocaps and fosrenal as couldn't take PO
medications.
- Continued with HD on M,W,F schedule. Restarted nephro caps.
.
10) Dementia:
- Mild at baseline per son. Avoided ativan.
.
11) Depression:
Initially held effexor.
.
12) FEN/GI:
Initially NPO, with NGT placed secondary to altered mental
status.
-Consulted speech and swallow. With altered mental status,
concern for aspiration. Tolerated thickened liquids. NGT
removed, per patient on [**2-5**].
.
13) Prophylaxis:
Placed on SC heparin and PPI.
.
14) Access:
R tunneled line for HD pulled on [**2175-2-9**]. L subclavian triple
lumen catheter pulled on [**2-7**]. Right AV fistula with good flow.
.
15) Code:
DNR/DNI.
Ok to be intubated for a short period of time. Family said that
no heroic measures or long-term intubation or feeding tubes.
Would not want a trach, but ok to intubate if we project that it
would be a temporizing measure (for example, while we remove
fluid)
.
16) [**Name (NI) **] - son [**Name (NI) **] [**Name (NI) 7860**] is HCP - [**Telephone/Fax (1) 70582**]
Medications on Admission:
lisinopril 30mg daily
marinol 2.5mg daily
prednisone 7.5mg daily
prilosec 20mg daily
pravachol 20mg qHS
calcium carbonate 500mg [**Hospital1 **]
senna 1 tab qHS
lopressor 50mg tid
nephrocaps 1 tab qAM
asa 81mg daily
effexor 75mg daily
ativan 0.25mg daily, 0.5mg qPM prn
norvasc 10mg daily
fosrenal 500mg tid
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Continue for 2 weeks. Stop on [**2175-2-24**].
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous QHD (each hemodialysis): Give after dialysis
treatments, if trough<15.
Give until [**2175-2-24**].
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed: for fever>100.5.
12. Pravachol 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary:
-Hypoxic episode requiring intubation
-ESRD (dialysis treatments M,W,F)
.
Secondary:
-Status post right hip repair in [**2174-8-2**] which has prompted
prolonged nursing home stay
-Hypertension
-CABG x3 in [**2172**] at [**Hospital1 2025**] (found to have 3VD on cath)
-Arthritis
-Neuropathy
-Laparscopic cholecystectomy in summer [**2174**]
-Left temporal CVA [**11-7**]
-Pneumothorax after line placement in [**2174-12-2**] status post
chest tube
-Herpes zoster right t3/t4 in [**2174-11-2**]
Discharge Condition:
Stable.
Discharge Instructions:
-You were admitted for depressed oxygenation levels. Initially,
you needed to be intubated.
-You were found to have an infection in your blood. Several
antibiotics, vancomycin, gentamicin, and metronidazole, were
started.
One of these medications, vancomycin, can be administered after
dialysis sessions and should be administered for two more weeks,
until [**2175-2-24**].
-An AV fistulogram demonstrated patent flow. Your right
tunneled catheter line was pulled on [**2175-2-9**].
-If you experience any more increased shortness of breath, chest
pain, fever, or any other concerning symptoms, call your PCP or
come to the ED immediately.
Followup Instructions:
-You are scheduled to continue to receive vancomycin until
[**2175-2-24**]. This medication should be administered
following dialysis sessions. Dose for vancomycin troughs less
than 15.
-Your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) **]), will continue to
follow your progress.
|
[
"403.91",
"V45.81",
"785.52",
"570",
"428.0",
"995.92",
"038.11",
"518.81",
"294.8",
"585.6",
"486",
"410.71",
"599.0",
"008.45",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.71",
"39.95",
"88.49"
] |
icd9pcs
|
[
[
[]
]
] |
15077, 15171
|
9150, 13513
|
236, 292
|
15719, 15729
|
4404, 9127
|
16420, 16788
|
2868, 2905
|
13872, 15054
|
15192, 15698
|
13539, 13849
|
15753, 16397
|
2920, 4385
|
174, 198
|
320, 2169
|
2191, 2622
|
2638, 2852
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,891
| 189,389
|
37454
|
Discharge summary
|
report
|
Admission Date: [**2166-1-13**] Discharge Date: [**2166-1-21**]
Date of Birth: [**2086-3-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ambien
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2166-1-13**] cardiac catheterization
[**2166-1-14**] 1. Mitral valve replacement with the 25-mm Mosaic tissue
valve.
2. Coronary artery bypass grafting x2: Left internal mammary
artery graft to left anterior descending, reverse saphenous vein
graft to the right coronary artery.
History of Present Illness:
79 year old male with known severe mitral regurgitation,
moderate mitral valve prolapse and progressive shortness of
breath referred for cardiac catheterization and surgery.
Past Medical History:
Mitral Regurgitation
Coronary Artery Disease
Hypertension
bradycardia s/p pacemaker
Prostate cancer s/p hormonal therapy - due for next treatment
[**3-31**] - (resultant urinary incontinence
Chronic renal insufficiency
Chronic obstructive pulmonary disease
Hiatal hernia
Gastric esophageal reflux disease
Depression
Central tremors
Social History:
Lives with: spouse
Occupation: retired engineering manager
Tobacco: denies
ETOH: rare
Family History:
Family History: sister MV prolapse, MI
Brother CAD
Physical Exam:
Pulse: 72 Resp: 18 O2 sat:
B/P Right: 134/66 Left: 133/77
Height: 5'5" Weight: 68kg
General: no acute distress
Skin: Dry [x] intact [x] ecchymotic area right hip flank around
to posterior down posterior right leg (fell at home few days
ago,
left calf area ecchymosis with discoloration - area warm to
touch
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [] Murmur 3/6 systolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] healed incision midline lower healed, right and left flank
with surgical scars healed
Extremities: Warm []Cool , well-perfused [] Edema left +1 right
trace Varicosities: superficial None []
Neuro: Alert and oriented x3 nonfocal with bedrest exam with
tremors bilateral upper extremities
Pulses:
Femoral Right: cath site Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right: no bruit Left: murmur
Pertinent Results:
[**2166-1-13**] Cardiac Catheterization
1. Selective coronary angiography in this right dominant system
demonstrated two vessel disease. The LMCA had non-obstructive
coronary
disease. The LAD had a 70% stenosis mid-vessel. The LCx was
diffusely
diseased. The RCA had an 80% mid-vessel stenosis.
2. Resting hemodynamics revealed normal right and left sided
filling
pressures with v waves to 25mm Hg.
[**2166-1-19**] CXR
The patient is status post sternotomy. Allowing for differences
in
positioning, the cardiomediastinal silhouette is likely stable.
A right-sided pacemaker is present, with lead tips over right
atrium and right ventricle. There is some patchy increased
retrocardiac density and atelectasis at the left base. There is
minimal blunting of left greater than right costophrenic angles,
consistent with minimal pleural fluid. Upper zone
redistribution, without other evidence of CHF.
Compared with [**2166-1-16**], there has been partial interval clearing
of opacity at the right base and of the right effusion.
Atelectasis at the left base is slightly worse.
[**2166-1-14**] ECHO
PRE-BYPASS:
The left atrium is dilated. 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.
The left ventricular cavity is mildly dilated. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size is normal. with borderline normal free
wall function.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are myxomatous. There is
moderate/severe mitral valve prolapse. Moderate to severe (3+)
mitral regurgitation is seen.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on [**Known firstname **] [**Known lastname **]
prior to surgical incision.
Post-bypass:
The patient is not receiving inotropic support post-CPB.
There is a bioprosthetic valve well-seated in the mitral
position with good leaflet excursion. There is no transvalvular
regurgitation . The [**Location (un) **] transvalvular gradient is approximately
7 mm Hg with the valve area approximately 2.3 cm2.
Biventricular systolic function is preserved and similar to
pre-bypass function. All other findings consistent with
pre-bypass findings.
The aorta is intact post-decannulation.
Brief Hospital Course:
Presented for cardiac catheterization as preoperative workup and
was admitted post procedure. He completed preoperative
evaluation and on hospital day two he was brought to the
operating room for coronary artery bypass grafting and mitral
valve replacement surgery. Please see operative note for
details. He received vancomycin for perioperative antibiotics.
Post operatively he was transferred to the intensive care unit
for management. Electrophysiology interrogated his pacemaker
that evening. In the first twenty four hours he was weaned from
sedation, awoke, and was extubated without complications. He
remained in the intensive care unit for pulmonary and
hemodynamic management. Physical therapy worked with him on
strength and mobility. He was gently diuresed towards his
preoperative weight. He had a brief episode of atrial
fibrillation which converted with beta blockade. He had loose
stools which resolved when discontinuing his Colace. He
continued to make steady progress and was discharged to Life
care rehab in [**Location 15289**]. He will follow-up with Dr.
[**Last Name (STitle) **], his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
CARVEDILOL - (Prescribed by Other Provider) - 6.25 mg Tablet -
1
Tablet(s) by mouth twice a day
ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth every morning
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 2
Tablet(s) by mouth every morning, one tablet every evening
IMIPRAMINE HCL - (Prescribed by Other Provider) - 10 mg Tablet
-
2 Tablet(s) by mouth three times a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth every morning
ASCORBIC ACID - (Prescribed by Other Provider) - 1,000 mg
Tablet
- 1 Tablet(s) by mouth every morning
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1
Tablet(s) by mouth every morning
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (Prescribed
by Other Provider) - 600 mg (1,500 mg)-200 unit Tablet - 1
Tablet(s) by mouth twice a day
LACTOBACILLUS ACIDOPHILUS [ACIDOPHILUS] - (Prescribed by Other
Provider) - Capsule - 1 Capsule(s) by mouth every morning
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- 1,200 mg-144 mg Capsule - 1 Capsule(s) by mouth twice a day
Discharge Medications:
1. Imipramine HCl 10 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO QAM for 10 days.
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO QAM for 10 days.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Ascorbic Acid 1,000 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM.
10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for pain.
12. Polyethylene Glycol 3350 17 gram/dose Powder Sig: 17 Grams
PO DAILY (Daily) as needed for constipation .
13. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) mdi
Inhalation four times a day for 1 months.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Mitral Regurgitation s/p MVR
Coronary Artery Disease s/p cabg
Hypertension
bradycardia s/p pacemaker
Prostate cancer s/p hormonal therapy - due for next treatment
[**3-31**] - (resultant urinary incontinence
Chronic renal insufficiency
Chronic obstructive pulmonary disease
Hiatal hernia
Gastric esophageal reflux disease
Depression
Central tremors
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with darvocet 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:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2166-2-20**] 1:30
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) 37742**] in [**12-7**] weeks
Cardiologist Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 8725**] in [**12-7**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2166-1-21**]
|
[
"285.9",
"530.81",
"414.01",
"427.31",
"496",
"553.3",
"333.1",
"311",
"185",
"424.0",
"V45.01",
"788.30",
"518.0",
"585.9",
"287.5",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"88.72",
"36.11",
"36.15",
"37.23",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8732, 8799
|
5063, 6239
|
326, 610
|
9192, 9288
|
2413, 5040
|
9827, 10295
|
1305, 1342
|
7514, 8709
|
8820, 9171
|
6265, 7491
|
9312, 9804
|
1357, 2394
|
267, 288
|
638, 814
|
836, 1170
|
1186, 1273
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,462
| 195,192
|
10912
|
Discharge summary
|
report
|
Admission Date: [**2160-1-15**] Discharge Date: [**2160-1-24**]
Date of Birth: [**2099-11-27**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Skin Biopsy
History of Present Illness:
The patient is a 59 yo M with h/o multiple myeloma s/p allo
transplant 95 days ago now with fevers x 1 day. Was feeling
well until approximately 24 hours prior to admission when he
developed increasing fatigue and malaise. Temp at home was 103.
He took 1g of tylenol. + headaches while febrile. Pain
relieved with tylenol. No acute vision changes/phtophobia.
Some nausea when hungry. Denies abdominal pain or vomiting. 1
episode of diarrhea per day x 1 week. No blood in stool.
Slightly decreased PO intake over last few days.
Denies chest pain, shortness of breath, abdominal pain, urinary
complaints, bowel complaints, LE swelling.
In the ED, inital vitals were T100.8, HR79, BP144/77, RR20,
O297%RA. Spiked to 102 while in the ED. He received 1L NS.
Blood and urine cultures were sent. CXR was within normal
limits. A CT Chest was performed but not read at the time of
admission to BMT (received 1L NS pre-treatment). His case was
discussed with the on-call oncology fellow who wanted him
started on levo/vanco and admitted to the BMT service for futher
workup. He received 1gm vanco and levofloxacin 750mg x 1 in the
ED. Nasal washing were sent for viral cultures.
Past Medical History:
-- CAD s/p non-ST elevation
-- Myocardial infarction and stent placement on [**2157**]
-- Hx of DVT, no longer on anticioagulation
-- HPT
-- Gastroseophagel reflux disease
-- Depression
-- Rhinnorrhea week prior to transplant hospitalization
-- Multiple myeloma s/p 4 cycles of VAD, auto SCT in [**2156**],
dendritic cell fusion vaccine in [**2157**]. Cytoxin and Velcade in
[**2158**] and Revlimid started in [**7-20**]. Mini-Allo transplant in
[**10-21**].
Oncology History: Diagnosed in [**2155**], treated with 3 cycles of
VAD and then underwent an autologous stem cell transplant in
03/[**2156**]. He was enrolled in the dendritic cell vaccine study;
however, in [**3-/2157**], he had a cardiac event that resulted in the
stem placement and has been followed closely by cardiology. In
[**10/2157**], the patient was noted to have a rise in his Bence [**Doctor Last Name **]
protein, in his urine, and was started on thalidomide, then
treated with 2 cycles of Velcade and Decadron withpout response.
Then was given one cycle of Cytoxan at 1 gm per meter square on
[**2158-5-29**] and was noted to have reduction in excretion of Bence
[**Doctor Last Name **] protein to 2200 mg per day. He also received XRT in the
low-back area in 06/[**2158**]. He was then started on Revlimid and
Decadron back in [**6-/2158**] for approximately 2 cycles. He remained
on this medication for about a year. He eventually underwent
reduced intensity allogeneic transplant with Campath
conditioning in [**10-21**].
Social History:
Married, has 2 children. No tobacco or alcohol use.
Family History:
Maternal grandfather died of lung cancer in his 70s (was a
smoker). Maternal grandmother had breast cancer in her 40s. His
mother had coronary artery disease.
Physical Exam:
VITALS: T103 HR81 RR20 BP 159/94 O298%RA
GENERAL: well appearing male, NAD, lying comfortably in bed
HEENT: Oropharynx clear, without any erythema, lesions, or
thrush.
NECK: Supple, without adenopathy.
LYMPHATICS: No lymphadenopathy
CHEST: Clear to auscultation.
HEART: RRR, S1, S2. No clicks, murmurs, or rubs.
ABDOMEN: Soft, NT/ND, without hepatosplenomegaly.
EXTREMITIES: Without edema.
Pertinent Results:
[**1-17**] Skin biopsy:
Skin, right flank; punch biopsy (A):
Spongiotic dermatitis with focal mononuclear cell exocytosis and
superficial dermal mononuclear cell infiltrate with eosinophils
(see comment).
Comment: The histologic appearances favor a drug reaction,
however, given the findings of focal "tagging" of lymphocytes at
the [**Last Name (un) **]-epidermal junction and rare dyskeratotic
keratinocytes, graft versus host disease (spongiotic type)
cannot be entirely excluded. Correlation with the clinical
findings is suggested. Case findings phoned to Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] by Dr. [**Last Name (STitle) **] on [**2160-1-18**]. Case reviewed with concurrence by
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **].
CT Chest w/o contrast [**1-15**]:
1. No interstitial or alveolar opacity is noted to suggest
infection.
2. Unchanged diffuse myelomatous changes of the bone and stable
mid thoracic compression fractures.
Chest CT w/o Contrast [**1-18**]:
1. 9-mm subpleural ground glass opacity in the right upper lobe
which may
represent an evolving fungal/infectious or inflammatory process.
2. Left anterior descending coronary artery stent.
3. Diffuse myelomatous changes throughout the bones with stable
mid thoracic compression fractures.
KUB X ray [**1-18**]:
IMPRESSION: Mild diffuse distention of small and large bowel.
These findings represent a nonspecific bowel gas pattern. Close
clinical followup is recommended.
No evidence of pneumoperitoneum.
V/Q scan:
Normal perfusion of the lungs. No evidence of pulmonary embolus.
Micro DATA:
C diff toxin A +
Influenza A +
[**1-15**] CMV Viral load negative
[**1-23**] CMV viral load pending upon discharge
Beta Glucan negative
Galactomannan negative
Blastomycosis pending upon discharge
Histoplasmosis pending upon discharge
Coccidiomycosis negative
Cryptococcus negative
[**2160-1-15**] 09:48PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2160-1-15**] 09:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2160-1-15**] 09:48PM URINE RBC-0-2 WBC-[**3-19**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2160-1-15**] 09:48PM URINE GRANULAR-0-2 HYALINE-[**3-19**]*
[**2160-1-15**] 09:48PM URINE AMORPH-FEW
[**2160-1-15**] 08:51PM LACTATE-1.3
[**2160-1-15**] 08:20PM GLUCOSE-112* UREA N-24* CREAT-1.8* SODIUM-137
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-22 ANION GAP-15
[**2160-1-15**] 08:20PM CALCIUM-8.8 PHOSPHATE-4.1 MAGNESIUM-1.4*
[**2160-1-15**] 08:20PM WBC-4.5 RBC-2.73* HGB-9.2* HCT-26.4* MCV-97
MCH-33.7* MCHC-34.9 RDW-18.4*
[**2160-1-15**] 08:20PM NEUTS-43.0* BANDS-0 LYMPHS-50.1* MONOS-6.5
EOS-0.2 BASOS-0.2
[**2160-1-15**] 08:20PM PLT COUNT-196
[**2160-1-14**] 08:40AM UREA N-22* CREAT-1.7* SODIUM-138
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
[**2160-1-14**] 08:40AM ALT(SGPT)-8 AST(SGOT)-20 LD(LDH)-312* ALK
PHOS-102 TOT BILI-0.9 DIR BILI-0.3 INDIR BIL-0.6
[**2160-1-14**] 08:40AM CALCIUM-9.7 PHOSPHATE-3.4 MAGNESIUM-1.5* URIC
ACID-6.9 CHOLEST-201*
[**2160-1-14**] 08:40AM WBC-5.5 RBC-3.06* HGB-10.2* HCT-30.8*
MCV-101* MCH-33.2* MCHC-33.0 RDW-18.9*
[**2160-1-14**] 08:40AM NEUTS-40* BANDS-0 LYMPHS-48* MONOS-10 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2160-1-14**] 08:40AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
TEARDROP-OCCASIONAL
[**2160-1-14**] 08:40AM PLT SMR-NORMAL PLT COUNT-259
[**2160-1-14**] 08:40AM GRAN CT-2530
Brief Hospital Course:
Influenza A: Stable for first few initial days of
hospitalization; then developed high fevers despite treatment of
C diff colitis as well as a rapid respiratory rate up to 50. He
had a respiratory alkylosis and metabolic acidosis. He was not
hypoxic. Transferred to ICU for respiratory distress, nasal
aspirate returned w/ Influenza A positive. Treated w/ Tamiflu.
Should continue for additional 4 days of thearpy.
Clostridium Dificile Diarrhea: Febrile w/ diarrhea, found to
have C diff, great improvement w/ Flagyl. Has an additional 5
days in his course of flagyl.
Lung nodule: patient should have repeat CT scan in 2 weeks to
re-evaluate lung nodule and monitor for increase in size or
number. The etiology of the lung nodule was unclear, ?fungal
versus inflammatory. He was on voriconazole initially upon
transfer to the ICU, his galactomannan and Beta glucan had
returned negative and this medication was stopped. He did have
an LFT rise due to the vori; but this began to decrease when his
vori was stopped. Pending upon discharge was a repeat CMV viral
load (negative on [**2160-1-15**]) as well as a histoplasmosis and
blastomycosis antigen.
Prophylaxis: Patient was initially on pentamadine for PCP
[**Name Initial (PRE) 1102**]. He was started on atovaquone 1500mg po daily
empirically when he began to display respiratory distress prior
to influenza A returning positive. He was left on Atovaqone for
PCP prophylaxis as it was thought this would provide better
protection.
Multiple Myeloma: Day 100+ labs were drawn. Patient is day +103
upon discharge for mini transplant for multiple myeloma. His
counts had begun to trend downward prior to discharge. It was
thought this could be due to suppression as a result of his
viral illness. He will have his counts checked on the day after
discharged.
Medications on Admission:
Acyclovir 400mg TID
Amlodipine 2.5mg TID
Fluconazole 200mg daily
Folic Acid 1mg daily
Lorazepam 0.5 mg q4hrs PRN
Mag Oxide 400 mg qAM/800mg QPM
Metoprolol Tartrate 50mg [**Hospital1 **]
Neoral 75mg [**Hospital1 **]
Protonix 40mg daily
Pentamidine 300 mg month
Discharge Medications:
1. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)). Tablet(s)
2. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO QPM
(once a day (in the evening)).
3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO once a day.
6. Oseltamivir Phosphate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day) for 4 days.
Disp:*8 Capsule(s)* Refills:*0*
7. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*2*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
11. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
Disp:*60 * Refills:*5*
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Disp:*1 month supply* Refills:*0*
13. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
14. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day.
16. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Five
(5) ML Intravenous DAILY (Daily) as needed: flush each port
daily.
Disp:*90 prefilled syringes (5mL)* Refills:*2*
17. Outpatient Lab Work
LABS: CBC / DIFF, GRANULOCYTE COUNT, CHEM 10.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**]
Discharge Diagnosis:
Primary Diagnosis:
Influenza A
C diff colitis
Secondary Diagnosis:
Multiple myeloma
Hypertension
Discharge Condition:
Stable, no diarrhea, sating well on room air
Discharge Instructions:
You were admitted for a fever and found to have two infections.
C diff colitis which is a diarrheal illness, you will need to
take the antibiotic Flagyl 3 times per day for an additional 5
days. Also, you will have to take tamiflu for an additional 4
days.
In addition you had a rash and were started on prednisone, it is
possible that this was graft versus host disease of the skin but
more likely it was a drug reaction to either levofloxacin or
vancomycin. You should continue taking prednisone 20mg daily
until instructed to decrease this dose.
Please call your doctor or return to the emergency room if you
have a fever, an increase in your diarrhea, shortness of breath
or any other symptoms that concern you.
Followup Instructions:
Please follow up on [**1-25**] on the [**Location (un) 436**] of the [**Hospital Ward Name 1826**]
Building on the [**Hospital Ward Name 516**] of [**Hospital1 18**]- your appointment is at
9:30 a.m.
You will have labs drawn at this appiontment.
|
[
"V45.82",
"412",
"530.81",
"599.0",
"041.04",
"584.9",
"414.01",
"996.85",
"008.45",
"288.00",
"487.1",
"203.00",
"E878.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11083, 11139
|
7294, 9122
|
283, 297
|
11281, 11328
|
3714, 7271
|
12096, 12346
|
3129, 3289
|
9432, 11060
|
11160, 11160
|
9148, 9409
|
11352, 12073
|
3304, 3695
|
238, 245
|
325, 1514
|
11228, 11260
|
11179, 11207
|
1536, 3044
|
3060, 3113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,144
| 102,351
|
21819
|
Discharge summary
|
report
|
Admission Date: [**2195-7-27**] Discharge Date: [**2195-8-7**]
Date of Birth: [**2141-8-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
OLT on [**2195-7-28**] for Hep C and alcoholic cirrhosis
Major Surgical or Invasive Procedure:
liver transplant [**2195-7-28**]
clot evacuation and biliary reconstruction [**2195-7-29**]
History of Present Illness:
Patient in his usual state of health on liver transplant waiting
list for HCV and ETOH cirrhosis when he was called in for OLT.
Pt denies fever/chills or any recent illnesses.
Past Medical History:
DM on PO meds
HCV
ETOH cirrhosis
Social History:
Lives in single family home with 2 floors.
Has a female friend who will be helping post transplant, not
currently residing with him.
One child
Denies recent ETOH use
Still smoking
Family History:
Non-Contrib
Physical Exam:
A+Ox3 in NAD
eyes anicteric, no jaundice of skin
Card: RRR, no M/R/G
Resp: Lungs CTA bilaterally
Abd: Distended, soft, NT, no scars
Extremeties: [**2-6**]+ bilateral pitting edema of LE
+ pedal pulses
Pertinent Results:
[**2195-7-27**] 02:00PM GLUCOSE-156* UREA N-24* CREAT-1.2 SODIUM-137
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
[**2195-7-27**] 02:00PM ALT(SGPT)-96* AST(SGOT)-104* ALK PHOS-123*
TOT BILI-3.0*
[**2195-7-27**] 02:00PM CALCIUM-8.3* PHOSPHATE-2.3* MAGNESIUM-1.9
[**2195-7-27**] 02:00PM WBC-3.7* RBC-3.35* HGB-11.7* HCT-32.8* MCV-98
MCH-34.9* MCHC-35.7* RDW-16.2*
[**2195-7-27**] 02:00PM PLT COUNT-51*
[**2195-7-27**] 02:00PM PT-17.2* PTT-28.2 INR(PT)-1.6*
[**2195-7-27**] 02:00PM FIBRINOGE-212
Brief Hospital Course:
Pt admitted on [**7-27**] for OLT for ETOH cirrhosis and HCV. There
was concern pre-op that the patient might have a thrombosed
portal Vein. During the procedure, when the liver was excised,
the patient had a period of instability, with his blood pressure
dropping to the high 70s low 80s systolic range, with some
arrhythmias.
This responded to fluid resuscitation. There was some clot and
thickening in the lateral wall on the left side of the recipient
portal vein, and this was removed. There was excellent portal
flow upon release of clamp. The caval
anastomosis was hemostatic. This was quickly followed by release
of the portal clamp. There was excellent flow through the
portal vein, and the liver perfused nicely. Patient had a
diffuse coagulopathy, and required aggressive resuscitation
with both packed RBCs and clotting factors. Once hemostasis was
achieved, the artery was reperfused and there was excellent flow
and thrill in the hepatic artery.
Again, the patient had diffuse ooze from several areas,
including the raw surface on the right diaphragm, an area around
the portal vein, and several measures were taken to achieve
hemostasis, including direct cautery with both [**Last Name (un) 4161**] and Argon
beam and topical application of hemostatic agents, such as
Surgicel and Surginette. He also continued to receive
aggressive blood product resuscitation. He did remain
hemodynamically stable during this period.
Both ducts were of equal and good caliber.
After the completion of all the anastomoses, at least an hour
was spent securing hemostasis. During course of the case,
the patient received 9 liters of crystalloid, 23 units of
FFP, 15 units of packed RBCs, and 7 units of platelets, and 4
units of cryoprecipitate. He received 3800 cc by cell [**Doctor Last Name 10105**].
He remained hemodynamically stable. The patient was transferred,
still intubated, in stable condition to the intensive care unit.
Post op, coagulopathy complicated the immediate post op course
and the patient was taken back to the OR. There was no
hemorrhage from the gallbladder fossa or hilar area. Near the
hilum, ongoing bile staining was noted that presumably was
coming from the common duct anastomosis. The hematoma was
evacuated in the pelvis and the abdomen was irrigated thoroughly
with crystalloid solution. Active hemorrhage was not identified.
A moderate amount of blood was also identified behind the spleen
but
there was no active bleeding. Once hemostatis was established,
the patient underwent a takedown choledochocholedochostomy,
conversion to a Roux-en-Y and hepaticojejunostomy.
On [**7-29**], an US was done and the main, right and left portal
veins are patent and demonstrate normal hepatopetal flow with
normal arterial waveforms, including extensive diastolic flow.
The hepatic veins are patent. The common bile duct was not
dilated, measuring 4 mm.
LFTs were initially elevated with AST and ALT peaking on POD1
and trending to normal by POD 9. Alk phos was always less than
200 and T bili peaked at 4.7 on POD 5. Patient remained afebrile
throughout the post op period.
Patient was extubated on POD 2 and remained in ICU until POD 5.
Cholangiogram performed on POD 6 was negative with no evidence
of leak, stricture or biliary duct dilatation.
Fluid volume status in the form of edema was an issue throughout
the hospitalization and lasix was initiated on POD 5 with very
good results. Weight on D/C was 3 kg above admission weight.
Patient was to acquire [**Last Name (un) 10289**] stockings on D/C and was encouraged
to use TEDS and ACE wraps while hospitalized.
Immunosuppresion was per protocol, however there was a mild
elevation of the Prograf level and adjustments were implemented
to a final discharge dose of [**1-4**]. Creatinine slightly above
baseline at 1.5 on discharge.
[**Doctor Last Name 406**] drain was still having high output, so it was left in at
discharge. Pt remained afebrile throughout, BP stable and well
controlled. Blood sugar well controlled on home dose Glipizide.
SS Insulin used in hospital but not required for home as usage
minimal to none while hospitalized.
Pt discharged to home with VNA services and hospital bed for
[**Location (un) 448**] while in the post op period. This was per patient
request as home has narrow stairways.
Pt to follow up in clinic and blood draws per routine.
Medications on Admission:
Lasix 40", Aldactone 25', Glipizide 5'
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
tab PO DAILY (Daily).
3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Valcyte 450 mg Tablet Sig: One (1) Tablet PO once a day.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*28 Patch 24HR(s)* Refills:*0*
8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
9. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed: Continue as long as you are on pain
medications.
11. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
14. Miconazole Nitrate-Zinc Oxide 0.25 % Ointment Sig: One (1)
tube Topical twice a day for 14 days: Wash area and pat dry
gently. Apply twice a day.
Disp:*1 tube* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
liver transplant [**2195-7-28**] for HCV
DMII
Discharge Condition:
stable
Discharge Instructions:
Call[**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, increased
leg swelling, abdominal pain, jaundice or
redness/bleeding/drainage from incision or capped bile tube.
Empty JP drain when half full, record output from JP. bring
Labs every Monday & Thursday for cbc, chem 10, ast, alt, alk
phos, tbili, albumin and trough prograf level. Results fax'd to
[**Telephone/Fax (1) 697**]
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2195-8-13**] 9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2195-8-13**]
10:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2195-8-20**]
7:45
Completed by:[**2195-8-17**]
|
[
"997.4",
"250.00",
"782.3",
"574.10",
"287.5",
"070.54",
"305.1",
"452",
"998.11",
"286.7",
"571.2",
"570",
"584.5",
"572.3",
"303.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.43",
"33.24",
"51.22",
"45.91",
"50.59",
"99.05",
"99.06",
"00.93",
"87.54",
"51.37",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7619, 7663
|
1726, 6085
|
370, 464
|
7753, 7762
|
1187, 1703
|
8205, 8645
|
938, 951
|
6174, 7596
|
7684, 7732
|
6111, 6151
|
7786, 8182
|
966, 1168
|
274, 332
|
492, 669
|
691, 725
|
741, 922
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,077
| 114,019
|
18401
|
Discharge summary
|
report
|
Admission Date: [**2152-12-4**] Discharge Date: [**2152-12-14**]
Date of Birth: [**2101-1-11**] Sex: F
Service: MEDICINE
HISTORY OF THE PRESENT ILLNESS: This is a 51-year-old woman
with a history of asthma, chronic steroid use found to have
bronchotracheal malacia, status post two bronchial and one
tracheal stentings by pulmonologist in [**State 12000**] which was
complicated by a polymicrobial infection of the stent with
Staphylococcus and Pseudomonas. The patient was admitted for
a stent removal.
PAST MEDICAL HISTORY:
1. Asthma.
2. Tracheomalacia, status post two bronchial stents and one
tracheal stent.
3. Status post Staphylococcus and pseudomonal infection.
4. Depression.
5. Migraines.
6. Obstructive sleep apnea.
7. Diabetes.
8. Hypercholesterolemia.
ALLERGIES: The patient is allergic to penicillin, sulfa
which caused throat swelling and morphine which caused
headache and nausea and vomiting and Lactulose.
SOCIAL HISTORY: No tobacco, no alcohol, lives in [**Location **]. Works
with a company associated with RT.
FAMILY HISTORY: Mother has severe asthma.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: On
admission to the MICU, the patient was afebrile, temperature
96.6, heart rate 77, blood pressure 150/87, 100% on assisted
ventilation, respiratory rate 12, tidal volume of 600, FI02
1, PEEP 5. General: The patient was lying in bed,
intubated, sedated. HEENT: Pupils were equal, round, and
reactive to light. Heart: Regular rate, no murmur. Chest:
Coarse breath sounds anteriorly. Abdomen: Soft,
nondistended, positive bowel sounds. Extremities: Warm with
good pulses bilaterally. Neurologic: The patient was
intubated, sedated, grimaces to pain.
LABORATORY/RADIOLOGIC DATA: White cell count 10.0,
hematocrit 33.4, platelets 311,000. Electrolytes were all
within normal limits.
HOSPITAL COURSE: 1. TRACHEOMALACIA: After removal of her
stent, the patient required intubation as her lung collapsed
post stent removal. The patient was successfully extubated
on postoperative day number two, transferred to the general
medical floor. However, she developed another respiratory
failure the following day and then was transferred back to
the MICU for Heliox 80/20%. The patient was also started on
Solu-Medrol IV and BIPAP.
The patient was then able to stabilize and her respiratory
distress was resolved and then transferred back to the floor
awaiting her tracheoplasty after he infection has been
successfully treated. The patient had a bronch done on
[**2152-12-12**] that showed no organisms or PMNs seen on
Gram's stain. The patient continued to do very well, was
able to have good 02 saturations in room air.
2. INFECTIOUS DISEASE: Status post stent infection and
stent removal. The patient was on Levo for ten days and did
very well, afebrile, no signs of infection except the patient
still had an elevated white blood cell count without
bandemia.
3. HYPERTENSION: The patient's blood pressure was well
controlled on Losartan 100 mg q.d.
4. DIABETES: The patient was placed on oral hypoglycemic,
Metformin, and covered by a regular insulin sliding scale.
The patient did very well. Her sugar was well controlled.
5. DEPRESSION: The patient's mood seems to be stable on
Prozac. No signs of depression at the present time.
CONDITION ON DISCHARGE: The patient was stable, able to have
good 02 saturations on room air, no signs of respiratory
distress or failure on discharge, afebrile.
DISCHARGE STATUS: The patient was discharged to a hotel,
awaiting to be returned to a hospital for tracheoplasty next
Tuesday. The patient's contact information is that the
patient is staying at Crown Plaza and ....................,
phone number [**Telephone/Fax (1) 50660**], room under the name [**Known lastname 5514**] or
Ciener. Her cell number is [**Telephone/Fax (1) 50661**].
DISCHARGE DIAGNOSIS:
1. Bacterial pneumonia.
2. Tracheal stenosis.
3. Tracheomalacia.
4. Hypoxemia.
DISCHARGE MEDICATIONS:
1. Zolpidem 5 mg, one to two tablets p.o. q.h.s. p.r.n.
insomnia.
2. Albuterol/Ipratropium two puffs inhalation every four
hours.
3. Lansoprazole 30 mg p.o. b.i.d.
4. Metformin 500 mg p.o. at dinnertime.
5. Fluticasone propionate two puffs inhalation b.i.d.
6. Losartan 100 mg p.o. q.d.
7. Fluoxetine 40 mg p.o. q.d.
8. Levofloxacin 500 mg p.o. q.d. for six days.
FOLLOW-UP PLANS: The patient will be contact[**Name (NI) **]. She will
come back to the hospital for her tracheoplasty procedure
next Tuesday, [**2152-12-19**].
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 18513**]
MEDQUIST36
D: [**2152-12-15**] 11:28
T: [**2152-12-15**] 11:38
JOB#: [**Job Number 50662**]
|
[
"996.59",
"486",
"518.0",
"519.1",
"518.81",
"E878.1",
"250.00",
"996.69",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.22",
"99.15",
"98.15",
"96.04",
"96.05",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
1087, 1135
|
4010, 4383
|
3903, 3987
|
1879, 3330
|
4401, 4803
|
1150, 1861
|
550, 960
|
977, 1070
|
3355, 3882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,201
| 113,257
|
5193
|
Discharge summary
|
report
|
Admission Date: [**2187-9-30**] Discharge Date: [**2187-10-8**]
Date of Birth: [**2119-12-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
UGIB, ?infection
Major Surgical or Invasive Procedure:
ERCP
Messenteric catheterization +/- embolization
History of Present Illness:
This is a 67 y.o male with h.o metastatic RCC to the pancreas,
recent ICU course for UGIB (12units pRBCs) who reports sudden
intermittent chills since wednesday for which he took tylenol.
Pt also reports R.side gnawing rib pain, while lying in bed
before the onset of chills. In addition, pt reports dark stools
for the last few days which started after taking "iron pills".
Pt states he went to [**Hospital1 2436**] ED because of a fever of 101.3,
however he felt better and did not want to wait to be seen. He
returned to [**Hospital1 2436**] today and was transferred to [**Hospital1 18**] after
a dose of zosyn, HCT 25. Pt denies headache/dizziness/blurred
vision, URI/cough, sick contacts, CP, +palp when anxious, -abd
pain/n/v/d/brbpr, dysuria/hematuria, joint pain, rash,
paresthesias.
.
At [**Hospital1 18**], pt found to be hypotensive to 75/40, asymptomatic. He
was given 3L IVF, lactate 6.8. HCT 22.8 from a baseline of 35 a
few weeks ago. He was found to have black, guaiac +stool. GI saw
pt, pt s/p stent to pancreatic ampulla, ?blocked from blood.
Plan is to transfuse, ERCP tomorrow. ED also treated for
possible cholangitis/sepsis and pt was given dose of vanco.
Vitals 99.2, BP 99/66 HR 88 sat 98% on RA. Access 3PIV's 2,
20's, 18. Pt also found to be in ARF.
.
Currently, pt reports that he is anxious.
.
Past Medical History:
# GIB [**2184**], EGD revealed duodenal ulcer c/w malignancy
# Hypertension.
.
1. Status post left nephrectomy followed by high-dose IL-2
[**2166**].
2. LAK therapy in [**2167**].
3. st. post resection of residual renal bed mass in [**2168**]
4. Recurrence in the left renal fossa and pancreas in [**4-/2182**]
5. Low-dose interleukin-2 in 12/[**2181**].
6. Atrasentan medication trial 11/[**2181**].
7. initiated on Nexavar 400 mg twice daily, dose reduced on
10/1005 in the setting of hypertension. His course has been
complicated by a GI bleed with possible small bowel obstruction,
and an admission to [**Hospital3 **] in [**8-/2185**] for anemia
and acute renal failure while on full dose Nexavar 400 mg given
twice daily.
8. Nexavar dose reduced to 400 mg q.a.m., 200 mg q.p.m.
9. Nexavar dose increased to 400 mg b.i.d. following CT in
[**9-/2186**], which showed progression of pancreatic metastases.
10. Enrolled in perifosine trial 06-408 on [**2187-2-28**].
11. Perifosine held since [**2187-6-13**] due to GI bleed.
12. ERCP on [**2187-6-20**] showed a malignant appearing mass in
duodenum, pathology consistent with metastatic renal cell Ca.
13. Perifosine restarted [**2187-6-27**] for one week, held on [**7-4**] due
toSBO requiring hospital admission in [**Hospital3 2783**], and
restarted again on [**7-11**].
14. Perifosine held due to elevated LFTs on [**2187-7-25**].
15. ERCP on [**2187-8-3**] - biliary stent placed to proximal CBD.
.
Social History:
He is married and has two children. He is retired from GM.
Reports quit smoking [**2186-11-21**], former 1/2ppd, quit ETOH as well in
[**Month (only) **], no drug use
Family History:
Non-contributory
Physical Exam:
Per admission note:
vitals:T. 96.9, BP 102/65, HR 92, RR 27, sat 96% on RA
gen-nad, lying in bed, appears stated age, cooperative, anxious
HEENT-perrla, eomi, anicteric, mmm, poor dentition
neck-no lad, no JVD, supple
chest-b/l ae no w/c/r
heart-s1s2 +2/6 systolic flow murmur, no r/g
abd-+bs,soft, NT, ND, +irregular hepatomegaly, ~2cm below costal
margin, +abdominal masses
ext-no c/c/e 2+pulses
neuro-aaox3, CN2-12 intact, non-focal.
.
Pertinent Results:
[**2187-9-30**] 07:36PM WBC-5.1 RBC-2.82*# HGB-7.5*# HCT-22.8*#
MCV-81* MCH-26.6* MCHC-32.8 RDW-18.1*
[**2187-9-30**] 07:36PM NEUTS-73* BANDS-14* LYMPHS-9* MONOS-2 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2187-9-30**] 07:36PM PLT SMR-NORMAL PLT COUNT-142*
.
[**2187-9-30**] 07:36PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-OCCASIONAL POLYCHROM-1+ BURR-1+
.
[**2187-9-30**] 07:36PM PT-15.6* PTT-35.0 INR(PT)-1.4*
.
[**2187-9-30**] 07:36PM GLUCOSE-78 UREA N-28* CREAT-1.6* SODIUM-141
POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-13* ANION GAP-22*
[**2187-9-30**] 07:36PM ALT(SGPT)-59* AST(SGOT)-59* LD(LDH)-181
CK(CPK)-14* ALK PHOS-513* TOT BILI-2.5*
[**2187-9-30**] 07:36PM LIPASE-12
.
[**2187-9-30**] 07:36PM cTropnT-<0.01
[**2187-9-30**] 07:36PM CK-MB-NotDone
.
TRENDS:
HCT: Admit -> 23, 27, 22, 25, 27, 34, 28, 27, 26, 22, 28
.
Bands on Diff: Admit -> 14, 10, 7, 0
.
[**2187-9-30**] 07:42PM BLOOD Lactate-6.8*
[**2187-10-1**] 02:52AM BLOOD Lactate-4.8*
[**2187-10-1**] 05:30AM BLOOD Lactate-3.3*
[**2187-10-1**] 02:22PM BLOOD Lactate-1.8
.
ECG:sinus, poor baseline, similar morphology to [**2187-8-21**] EKG.
.
Imaging:
CXR: [**2187-9-30**]:
Added density behind the left heart border in the left lower
lobe may
represent a focus of pneumonic consolidation; alternatively
metastases from the known metastatic renal cell cancer cannot be
entirely excluded. CT would be of benefit for further
evaluation.
A CBD stent is seen in the upper abdomen.
.
Liver U/S [**2187-9-30**]:
Increase in size and number of hepatic mets. CBD or stent not
seen. Small perihepatic ascites. Portal vein remains occluded
with numerous collaterals. Gallladder wall thickening and edema
but no focal tenderness during scanning. Large hypoechoic mass
in the region of the pancreatic head not well assessed due to
overlying bowel gas.
"findings equivocal for cholecystitis, stones"
.
[**2187-10-1**] ERCP/Biliary:
IMPRESSION:
1. No filling defects within previously placed metallic common
bile duct
stent.
2. Smooth impression on the common bile duct, proximal to stent,
suggests
extrinsic compression. Correlate with real-time findings.
Please refer to GI procedural note for further details.
.
[**2187-10-3**] MESSENTERIC CATHETERIZAION +/- EMBOLIZATION:
***Prelim Report***
Gastrointestinal arteriograms demonstrated massive tumor
staining from
multiple feeding arteries originating from celiac artery,
superior mesenteric artery, and isolated pancreatic artery
without active ______.
Brief Hospital Course:
67 y.o male with metastatic RCC who presents with HCT drop,
melena, recent fever, hypotension.
.
#melena/HCT drop - Pt has h.o GIB in past that were secondary to
bleeding metastasis. Pt had recent admit to MICU course [**7-30**]
where angiography was performed to stop bleeding. Hct on admit
was 22.8, down from 35 on discharge. Patient underwent ERCP in
which showed ulcerated mass at duodenum, able to temporarily
stem blood flow. On day 3 of ICU stay he had more melena and was
taken by IR for messenteric catheterization +/- embolization,
but were unable to isolate source of bleeding. Melena continued
and ERCP, IR and surgery say pt is not eligible for further
interventions to stop the bleeding.
.
Pt continued to be transfused units of PRBC while H/H was being
followed. This was consistent with patient's stated goals of
living long enough to make it to hospice care, where he can be
closer to family.
.
# Infection - Pt with fever, normal white count but with
bandemia, recent RUQ/rib pain. Slightly elevated LFT's, elevated
bili -> RUQ u/s finding gallbladder wall thickening and edema,
"possible cholecystitis". Potentially transient cholangitis. Pt
completed a total of 7 days of Vancomycin and Pip/Tazo.
.
# Metastatic RCC - Pain controlled. Heme met with family offered
chemo for one final round but with the caution that this could
make the duodenal met bleed faster. The patient and family did
not want to pursue this.
.
# Lactic acidosis - likely from poor perfusion secondary to
recent hypotension and infection. Could also be secondary to
metastatic disease. Resolved within 2 days.
.
#ARF - baseline 0.9-1.0, admitted at 1.6. Likely prerenal in the
setting of hypotension, hypovolemia. Resolved with hydration.
.
#HTN-currently normotensive, hold home anti-HTN medications.
.
# Anxiety
- receiving scheduled ativan per pt request.
.
# Thrombocytopenia:
- PLT count now improving
- no heparin d/t bleed
- HIT Ab negative
- Transfused prn for bleeding
.
CODE: DNR/DNI
DISPO: discharged to hospice care:
[**Last Name (un) 1502**] Family Hospice House - [**Location (un) **]. [**Telephone/Fax (1) 21227**]
Medications on Admission:
allopurinol 100mg,2 tabs daily
atenolol 50mg daily
diltiazem 180mg, 2 capsules daily
nexium 40mg daily
lisinopril 40mg daily
lorazepam 0.5mg 1-2tabs q6h prn anxiety
compazine 5mg 1-2tab [**Hospital1 **] nausea
acetaminophen 500mg [**11-22**] Q6h prn
ferrous sulfate 325mg 1 daily.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
4. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
8. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1502**] Family Hospice House [**Location (un) **]
Discharge Diagnosis:
# Gastrointestinal bleed; ongoing
# Cholecystitis/Cholangitis
# Metastatic renal cell carcinoma
# Acute renal failure; resolved
# Thrombocytopenia
Discharge Condition:
poor; dying.
Discharge Instructions:
Patient is being discharged to hospice.
Please take medications as necessary for patient comfort.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-10-17**] 3:30
Provider: [**Name10 (NameIs) 11021**] [**Name11 (NameIs) 11022**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2187-10-17**] 3:30
|
[
"287.5",
"V64.3",
"V10.52",
"197.8",
"578.1",
"401.1",
"584.9",
"280.0",
"285.1",
"578.9",
"197.7",
"574.00",
"276.2",
"197.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"99.04",
"51.10",
"88.76"
] |
icd9pcs
|
[
[
[]
]
] |
9694, 9788
|
6445, 8570
|
332, 383
|
9979, 9994
|
3922, 6422
|
10140, 10429
|
3428, 3447
|
8902, 9671
|
9809, 9958
|
8596, 8879
|
10018, 10117
|
3462, 3903
|
276, 294
|
411, 1736
|
1758, 3228
|
3244, 3412
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,152
| 141,288
|
7365
|
Discharge summary
|
report
|
Admission Date: [**2170-5-15**] Discharge Date: [**2170-5-26**]
Date of Birth: [**2089-7-9**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Atenolol / Shellfish / Percocet
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
syncopy, nausea, vomiting, left lower extremity cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80F who suffered a syncopal fall at her house with mild
confusion while walking after 2-3 days of nausea, vomiting, and
diearrhea. Recovered quickly to a GCS of 15, interactive and
telling jokes. The patient presented to the [**Hospital1 18**] ED, where she
was found to have a SBP in the 60's, but fluid resuscitation
with
two liters of crystalloid returned her to a BP of 120's.
Additionally, the patient is febrile with cellulitis over ther L
incision and a nidus that appears to be the left foot. No
evidence of graft compromise or infection, although it appears
to
track right over the incision. The patient has a palpable
dorsalis pedis pulse, and the graft was recently studied and
deemed to be patient.
Of note, the patient is status-post
bilateral femoropopliteal bypasses, the right one in [**2157**] and
the second one in [**2166**]. A vein graft angioplasty was done on
the left resulting in a vein graft rupture, which required a
covered stent. She experiences pain in her feet at night, this
is improved by walking.
Currently, she has a fever, has no abdominal pain without any
evidence of ischemic compromise, but she continues to have
intermittent dropping BP's.
Past Medical History:
Coronary artery disease, s/p diagonal stent
Hypertension
Hyperlidiemia
Peripheral [**Year (4 digits) **] Disease: [**2157**] right fem-[**Doctor Last Name **] bypass, Prior L
iliac stent, 3/06 L SFA stent, RAS, s/p right renal stent,
Embolic CVA- L eye (lost periph vision), Carotid disease
Severe asthma/COPD
Cutaneous T cell lymphoma, tx'd w/ photophersis, c/b
vasodepressive syncope
Cataract surgery
Diverticulosis/Colitis
hx C. Diff [**9-11**]
GERD
Osteoporosis
Chronic anemia
OSA (CPAP)
Bilateral Total Hip Arthroplasty
R inguinal hernia repair
Left knee fracture
Compression fractures
[**5-13**] admit NEBH pseudo-obstr of R colon --> massive distension
c/b hepatic compression
Colon polypectomy
Glaucoma/ macular degeneration
Psoriasis
Social History:
Patient is widowed. Her daughter lives upstairs from her.
Patient smoked 1.5 packs a day x 40 years, quitting seven years
ago.
Family History:
Noncontributory
Physical Exam:
Discharge Physical Exam:
Gen: NAD, AAOx3
CV: RRR
Pulm: CTAB throughout
Abd: soft, NT/ND
Ext: LLE with erythema to knee, minor tracking up medial thigh,
1+ edema, wwp; RLE wwp, no edema
Pulse exam:
F P DP PT G
R p p d d d
L p p p d d
Pertinent Results:
Blood Culture, Routine (Final [**2170-5-18**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
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.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final [**2170-5-16**]):
GRAM POSITIVE COCCI IN CLUSTERS.
REPORTED BY PHONE TO [**Doctor Last Name **] [**Doctor Last Name **] #[**Numeric Identifier 27133**] [**2170-5-16**] 09:10AM.
Anaerobic Bottle Gram Stain (Final [**2170-5-16**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2170-5-17**]):
Feces negative for C.difficile toxin A & B by EIA.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2170-5-21**]):
Feces negative for C.difficile toxin A & B by EIA.
Brief Hospital Course:
The patient was originally admitted to the medicine service for
evaluation of falls, nausea, and vomiting. CT head on [**2170-5-15**]
showed no acute intracranial process. Sequelae of chronic small
vessel ischemic disease. Minimal ethmoid sinus disease, likely
due to inflammation. She also underwent a CT abd/pelvis, which
showed the following:
1. Dilated pancreatic duct particularly distally within the
head. Recommend
MRCP for further evaluation on a non-emergent basis.
2. Extensive atherosclerotic disease within the abdominal aorta
and its
branches, but no evidence of aneurysm.
3. Diverticulosis of the sigmoid colon, but no evidence of
diverticulitis.
4. Compression fractures of T12 and T8 are unchanged compared to
priors.
5. Small hiatal hernia.
She underwent an ECHO, which showed no substantial change from
her prior, essentially normal. EF > 55%. Further details can
be seen in the ECHO report. She also underwent carotid duplex,
which showed bilateral 60 to 69% carotid stenosis.
After other workup was negative for infectious sources, she was
transferred to the [**Date Range 1106**] service for treatment of left lower
extremity cellulitis. She underwent a duplex of the lower
extremity, which showed no evidence of DVT or fluid collections
in the left lower extremity. She was placed on broad spectrum
antibiotics, vanc/cipro/flagyl. She was pan-cultured, and one
bottle of blood on [**2170-5-15**] returned as MSSA. Infectious disease
was consulted and recommended stopping cipro and flagyl in light
of her history of c. difficile. Vancomycin was continued, given
the patient's allergy to PCN. The patient's leg did not show
dramatic improvement over the next few days; therefore, she
underwent a CT of the LLE on [**2170-5-21**]. This showed Extensive left
lower extremity subcutaneous edema without focal fluid
collection. Limited evaluation of left femoropopliteal bypass
graft without evidence of fluid collection along the graft. WIll
continue a total course of Vanco X 4 weeks.
During this stay she required Lasix of LE edema. On [**5-24**], BP
80's. Lasix discontinued and plan for Lasix 20mg prn for
swelling ordered per Dr. [**Last Name (STitle) **]. Will also start Regular Diet
without salt restriction. INR 3.0, drifting [**Last Name (STitle) **]. Will decrease
to 2mg daily with goal 2, given history of GI bleed (Coumadin is
her home medication).
Medications on Admission:
ALENDRONATE [FOSAMAX] - (Prescribed by Other Provider) - 35 mg
Tablet - 1 Tablet(s) by mouth weekly
ARANESP SURECLICK -POLYSORBATE - (Prescribed by Other Provider)
once a month
BETAXOLOL [BETOPTIC S] - (Prescribed by Other Provider) - 0.25
%
Drops, Suspension - 1 gtt OU [**Hospital1 **]
CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth daily at bedtime
FLUTICASONE [FLOVENT DISKUS] - (Prescribed by Other Provider) -
50 mcg Disk with Device - 3 puff INH four times daily
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth daily
FORMOTEROL FUMARATE [FORADIL AEROLIZER] - (Prescribed by Other
Provider) - 12 mcg Capsule, w/Inhalation Device - 1 puff IH
twice
a day
FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth daily
HYDRALAZINE - (Prescribed by Other Provider) - 10 mg Tablet - 2
Tablet(s) by mouth in a.m., 10 mg in p.m.if BP over 130 as
needed
IPRATROPIUM-ALBUTEROL [COMBIVENT] - (Prescribed by Other
Provider) - 18 mcg-103 mcg (90 mcg)/Actuation Aerosol - 2 puffs
INH four times a day
METHOTREXATE SODIUM - (Prescribed by Other Provider) - 7.5 mg
Tablet - 1 Tablet(s) by mouth weekly on Fridays
WARFARIN - (Prescribed by Other Provider) - 4 mg Tablet - 1.5
Tablet(s) by mouth daily per INR 6mg once daily per pt
ASPIRIN [BABY ASPIRIN] - (Prescribed by Other Provider) - 81 mg
Tablet, Chewable - one Tablet(s) by mouth once daily skip dose
on
Friday when taking methotrexate
CALCIUM + VITAMIN D - (Prescribed by Other Provider) - 600 mg
(1,500 mg)-200 unit Tablet - 1 tablet [**Hospital1 **]
DIPHENHYDRAMINE HCL [BENADRYL] - (Prescribed by Other Provider)
- 25 mg Capsule - 1 Capsule(s) by mouth qpm
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
Capsule(s) by mouth daily
Discharge Medications:
1. Vancomycin 1,000 mg Recon Soln Sig: 1 gram Intravenous once
a day for 3 weeks: [**Date range (1) 27134**].
Disp:*qs qs* Refills:*0*
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Three (3) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Brimonidine 0.15 % Drops Sig: One (1) Ophthalmic qd ().
9. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] ().
10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Formoterol Fumarate 12 mcg Capsule, w/Inhalation Device Sig:
One (1) Capsule, w/Inhalation Device Inhalation [**Hospital1 **] ().
14. Alendronate 70 mg Tablet Sig: 0.5 Tablet PO QTUES (every
Tuesday).
15. Methotrexate Sodium 2.5 mg Tablet Sig: Three (3) Tablet PO
QFRI (every Friday).
16. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
17. Travoprost 0.004 % Drops Sig: One (1) Ophthalmic hs ().
18. Theophylline 100 mg Tablet Sustained Release 12 hr Sig:
Three (3) Tablet Sustained Release 12 hr PO DAILY (Daily).
19. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day) as needed for thrush.
21. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
22. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
23. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
24. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO daily prn (with
Lasix or low K) as needed for with Lasix.
25. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
26. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for itching.
27. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
28. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA): Home medication, continue management by
PCP after discharge from rehab. Keep INR equal or <2 (h/o GI
bleed).
29. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO bid ().
30. Icaps MV 100-1.66-0.83 mcg-mg-mg Tablet, Delayed Release
(E.C.) Sig: One (1) Cap PO bid ().
31. Outpatient Lab Work
Vanco through, Cr, WBC weekly
INR 2-3x per week (keep INR less than or equal to 2 per Dr. [**Last Name (STitle) **],
history of GI bleeds)
32. Lasix 20 mg Tablet Sig: One (1) Tablet PO prn swelling as
needed for swelling, LE edema: Per Cardiologist, Dr. [**Last Name (STitle) 27135**] pleas
monitor swelling/edema and give prn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare of [**Location (un) 1439**]
Discharge Diagnosis:
left lower extremity cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Heart healthy diet.
Activity as tolerated.
Resume all home medications unless specifically instructed not
to. Please take all new medications as prescribed.
Call the office or come to the emergency room if you experience
any of the following:
Increased swelling of leg, spread of redness, pain not
controlled by pain medications, cold, painful leg, fever >
101.5, nausea/vomiting/diarrhea, dizziness, fainting.
Followup Instructions:
Provider: [**Name10 (NameIs) 1412**] [**Name Initial (NameIs) **] [**Name12 (NameIs) 1413**], M.D. Date/Time:[**2170-6-7**] 2:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2170-6-28**] 10:25
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3628**] (NHB) Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2170-10-22**] 9:00
Completed by:[**2170-5-25**]
|
[
"443.9",
"038.11",
"995.91",
"202.10",
"272.4",
"733.00",
"682.6",
"276.8",
"530.81",
"327.23",
"682.7",
"401.9",
"414.01",
"493.20",
"V43.64"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11867, 11956
|
4402, 6799
|
363, 370
|
12032, 12032
|
2836, 4379
|
12619, 13063
|
2515, 2532
|
8672, 11844
|
11977, 12011
|
6825, 8649
|
12183, 12596
|
2547, 2547
|
265, 325
|
398, 1586
|
12047, 12159
|
1608, 2353
|
2369, 2499
|
2572, 2816
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,857
| 124,407
|
40605
|
Discharge summary
|
report
|
Admission Date: [**2151-4-16**] Discharge Date: [**2151-4-22**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Aphasia and right hemiplegia.
Major Surgical or Invasive Procedure:
Administration of intravenous t-PA.
History of Present Illness:
Mrs. [**Known lastname **] is a 70-year-old woman (per initial report, later
found to be 87) with a history of atrial fibrillation, presently
subtherapeutic on coumadin (INR 1.4) arriving via EMS with
aphasia and right hemiplegia in afib with RVR.
Per ED team (in discussion with EMS) she was at home and last
seen normal at 1800 and then developed sudden onset aphasia and
right-sided weakness. Patient was supposed to go to [**Hospital1 2025**] but
reportedly showed up here by accident. No further history was
known at time of arrival and family unavailable despite numerous
attempts to contact (as they were en route to hospital).
Later, her daughter, [**Name (NI) **] [**Name (NI) 88863**] arrived who provided additional
history; she was actually last seen normal around 5:30 PM when
she left the house. When she returned around 9:30 PM she called
her name and she did not respond and was not moving the right
side of her body.
ROS unobtainable.
Past Medical History:
- Atrial Fibrillation
- Colostomy, unclear reason (has had for years per daughter)
Social History:
Lives independently and does all ADLs.
Family History:
Unknown.
Physical Exam:
On Admission:
VS; BP 151/100 P 150 RR 14
Gen; lying in bed, NAD
HEENT; NC/AT, nonrebreather in place
CV; tachycardic, regular rate
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; 1+ edema at ankles
Neuro;
MS; eyes open, does not speak or follow any commands.
CN; PERRL 3mm-->2mm, eyes deviated to the left and do not cross
midline. Does not appear to blink to threat on the right. Face
obscured by nonrebreather but appears to have R NLF flattening.
Motor; Spontaneously moves RUE and RLE antigravity. Flacid
paralysis of LUE and LLE.
Sensory; withdrawl to noxious in RUE and RLE, no grimace or
withdrawl to noxious in LUE and LLE
Pertinent Results:
[**2151-4-21**] 05:20AM BLOOD WBC-6.5 RBC-4.01* Hgb-12.3 Hct-36.1
MCV-90 MCH-30.6 MCHC-33.9 RDW-13.7 Plt Ct-171
[**2151-4-19**] 02:49AM BLOOD WBC-6.8 RBC-3.96* Hgb-12.3 Hct-35.5*
MCV-90 MCH-31.0 MCHC-34.6 RDW-13.7 Plt Ct-160
[**2151-4-18**] 01:23AM BLOOD WBC-5.9 RBC-4.13* Hgb-12.7 Hct-37.9
MCV-92 MCH-30.7 MCHC-33.4 RDW-14.1 Plt Ct-181
[**2151-4-17**] 02:10AM BLOOD WBC-11.1*# RBC-4.48 Hgb-13.7 Hct-40.9
MCV-91 MCH-30.6 MCHC-33.5 RDW-14.1 Plt Ct-198
[**2151-4-16**] 10:00PM BLOOD WBC-6.0 RBC-4.82 Hgb-14.6 Hct-44.1 MCV-92
MCH-30.3 MCHC-33.1 RDW-14.2 Plt Ct-205
[**2151-4-16**] 10:00PM BLOOD Neuts-67.6 Lymphs-23.7 Monos-5.5 Eos-1.8
Baso-1.5
[**2151-4-22**] 05:25AM BLOOD PT-19.3* PTT-29.4 INR(PT)-1.7*
[**2151-4-21**] 05:20AM BLOOD PT-17.3* INR(PT)-1.5*
[**2151-4-19**] 02:49AM BLOOD PT-15.7* PTT-31.1 INR(PT)-1.4*
[**2151-4-18**] 01:23AM BLOOD PT-14.9* PTT-23.4 INR(PT)-1.3*
[**2151-4-17**] 02:10AM BLOOD PT-16.8* PTT-24.8 INR(PT)-1.5*
[**2151-4-16**] 10:00PM BLOOD PT-16.1* PTT-25.4 INR(PT)-1.4*
[**2151-4-21**] 05:20AM BLOOD Glucose-102* UreaN-23* Creat-0.9 Na-139
K-3.8 Cl-100 HCO3-31 AnGap-12
[**2151-4-19**] 02:49AM BLOOD Glucose-99 UreaN-13 Creat-0.9 Na-138
K-4.8 Cl-105 HCO3-26 AnGap-12
[**2151-4-18**] 01:23AM BLOOD Glucose-130* UreaN-16 Creat-0.9 Na-139
K-4.3 Cl-106 HCO3-27 AnGap-10
[**2151-4-17**] 02:10AM BLOOD Glucose-146* UreaN-32* Creat-0.9 Na-138
K-5.0 Cl-101 HCO3-27 AnGap-15
[**2151-4-16**] 10:00PM BLOOD Glucose-123* UreaN-33* Creat-1.0 Na-140
K-4.7 Cl-98 HCO3-26 AnGap-21*
[**2151-4-18**] 01:23AM BLOOD CK(CPK)-68
[**2151-4-17**] 02:10AM BLOOD CK(CPK)-157
[**2151-4-18**] 01:23AM BLOOD CK-MB-2 cTropnT-<0.01
[**2151-4-17**] 02:10AM BLOOD CK-MB-3 cTropnT-<0.01
[**2151-4-16**] 10:00PM BLOOD cTropnT-<0.01
[**2151-4-21**] 05:20AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.0
[**2151-4-19**] 02:49AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.3
[**2151-4-18**] 01:23AM BLOOD Calcium-8.6 Phos-2.7# Mg-2.2 Cholest-179
[**2151-4-18**] 01:23AM BLOOD Triglyc-130 HDL-49 CHOL/HD-3.7
LDLcalc-104
[**2151-4-18**] 01:23AM BLOOD %HbA1c-6.0* eAG-126*
[**2151-4-17**] 11:13AM BLOOD Digoxin-0.3*
[**2151-4-16**] 10:00PM BLOOD Digoxin-0.4*
[**2151-4-18**] 09:17PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2151-4-18**] 09:17PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2151-4-16**] 10:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.011
[**2151-4-16**] 10:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
EKG [**2151-4-16**]:
Atrial fibrillation with a rapid ventricular response.
Inferolateral
ST-T wave changes may be due to myocardial ischemia. Clinical
correlation is
suggested. No previous tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
154 0 80 276/440 0 46 -31
NCHCT [**2151-4-16**]:
FINDINGS: There is subtle obscuration of [**Doctor Last Name 352**]-white matter
differentiation in
the left parieto-occipital region. There is no acute
intracranial hemorrhage.
The ventricles and sulci are prominent, consistent with
age-related
involutional changes. Periventricular and subcortical white
matter
hypodensities are consistent with small vessel ischemic disease.
More focal
hypodensities in the right corona radiata and right occipital
lobe likely
represent chronic lacunes. There is no shift of normally midline
structures.
Dense calcifications are noted in the bilateral cavernous and
supraclinoid
portions of the internal carotid arteries, as well as the left
vertebral
artery. The paranasal sinuses and mastoid air cells are clear.
Note is made
of bilateral lens prostheses.
IMPRESSION:
1. Subtle hypodensity in left MCA territory, corresponding to
infarct seen on
subsequent CTA/CTP.
2. Chronic involutional changes.
CTA Head and Neck/CT Perfusion [**2151-4-16**]:
FINDINGS:
CT PERFUSION: There is area of increased transit time and
slightly decreased
cerebral blood flow and volume identified in the left frontal
watershed and
left parietal watershed regions as well as in the deep watershed
region of the
left cerebral hemisphere. These findings indicate areas of
watershed ischemia
with likely evolving infarcts.
CT ANGIOGRAPHY NECK: The CT angiography of the neck demonstrates
tortuous
arteries without evidence of high-grade stenosis or occlusion in
the neck.
Vascular calcifications are seen at the aorta. Linear opacities
are seen at
the right lung apex, otherwise less prominent at the left lung
apex. This
could be related to patient's congestive heart failure, but
clinical
correlation recommended.
CT ANGIOGRAPHY HEAD: CT angiography of the head demonstrates
tortuous
intracranial arteries, but no evidence of vascular occlusion is
identified.
IMPRESSION:
1. Findings indicative of watershed ischemia with probable
evolving infarcts
in the left cerebral hemisphere. MRI can help for further
assessment.
2. CT angiography of the neck demonstrates tortuous arterial
structures with
calcification without stenosis or occlusion.
3. CT angiography of the head demonstrates tortuous intracranial
arteries
without evidence of stenosis or occlusion.
MRI Brain [**2151-4-17**]:
FINDINGS: There are small areas of restricted diffusion in the
left posterior
temporal watershed region. There are no other acute infarcts
identified.
Mild-to-moderate changes of small vessel disease are seen in the
subcortical
white matter and the periventricular white matter. There is no
midline shift
or hydrocephalus. Moderate brain atrophy is seen.
IMPRESSION: Small areas of restricted diffusion in the left
posterior
temporal lobe indicate areas of evolving infarcts in the left
posterior
watershed distribution. No other infarcts are seen. Moderate
brain atrophy
and small vessel disease. The infarcts demonstrated are much
less extensive than the perfusion abnormality seen on the
previous CT perfusion study.
NCHCT [**2151-4-17**]:
FINDINGS: The small acute infarcts in the left posterior
temporal cortex,
left parietal white matter, and possibly in the left parietal
cortex, which
were seen on the prior MRI, are barely detectable on this CT.
Foci of low
density in the periventricular, deep and subcortical white
matter of the
cerebral hemispheres, including the left temporal and parietal
lobes, do not
demonstrate any progression since [**2151-4-16**], and they appeared
consistent with
chronic microvascular infarcts on the [**2151-4-17**] MRI. There is no
acute
intracranial hemorrhage, edema or mass effect. The ventricles
and sulci are
prominent due to age-related involutional changes.
There is fluid in the sphenoid sinuses.
IMPRESSION:
1. The small acute infarcts in the left temporal and parietal
lobes are
barely detectable by CT.
2. Unchanged supratentorial white matter hypodensities, likely
chronic
microvascular infarcts.
3. Fluid in the sphenoid sinuses, possibly related to prolonged
supine
positioning. Please correlate with symptoms.
EKG [**2151-4-18**]:
Atrial fibrillation. Diffuse ST-T wave abnormalities. The QTc
interval
appears prolonged but it is difficult to measure. Cannot exclude
ischemia.
Clinical correlation is suggested. Since the previous tracing of
[**2151-4-16**] the
ventricular rate is slower and further ST-T wave abnormalities
are now present.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
91 0 86 398/452 0 48 -141
TTE [**2151-4-19**]:
The left atrium is moderately dilated. No thrombus/mass is seen
in the body of the left atrium. The right atrium is moderately
dilated. 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%). No masses or thrombi
are seen in 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. 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 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. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
Brief Hospital Course:
Time Code Stroke called: 2156
Time Neurology at bedside for evaluation: 2159
Upon arrival to the Emergency Room, Code Stroke was called:
Time (and date) the patient was last known well: 1800
NIH Stroke Scale Score: 22
t-[**MD Number(3) 6360**]: Yes
Time t-PA was given: 10:40
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
NIH Stroke Scale score was 22
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 2
2. Best gaze: 1
3. Visual fields: 2
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 4
6a. Motor leg, left: 0
6b. Motor leg, right: 4
7. Limb Ataxia: unable to assess
8. Sensory: 2
9. Language: 3
10. Dysarthria: unable to assess
11. Extinction and Neglect: 1
Given the absemce of hemorrhage or other contraindications, t-PA
was given in the Emergency Room under the direction and
supervision of neurology. As per protocol, she was then
transferred to the NeuroICU for close monitoring. On examination
after arriving in the NeuroICU, she continued to demonstrate a
mild upper motor neuron pattern of weakness, most evident in the
hand, along with aphasia, most notable for anomia and difficulty
repeating. This was, however, a marked improvement from her
admission examination. While in the ICU she continued to
demonstrate atrial fibrillation with a rapid ventricular rate.
Diltiazem drip was initiated then weaned with increased dosing
of metoprolol and initiation of digoxin. Coumadin was restarted
and aspirin started, with the intent of continuing this until
her INR was above 2.0, at which point, aspirin can be
discontinued.
The etiology of her stroke was felt to be cardioembolic given
her AF and subtherapeutic INR. Her TTE was negative for
thrombus, atheroma, or PFO, and EF was normal. While on the
floor, she had some intermittent, self-limited episodes of rapid
heart rate, which were responsive to bolus doses of IV
metoprolol. Fasting lipid panel was normal, and HgbA1C is 6.0.
INR on day of discharge was 1.7.
On day of discharge, pt's language is fluent, but she cannot
repeat, and she has an anomia for low-frequency words. Her CN
are normal. Strength shows some cortical slowness to right sided
UE movements, but generally preserved strength. She can bear
weight, but had difficulty walking independently.
Medications on Admission:
-coumadin
-others unknown
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): Please discontinue once INR > 2.0 .
2. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
3. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please check INR daily with goal [**1-28**]. .
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for pain or fever.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. insulin regular human 100 unit/mL Solution Sig: 2-10 Units
Injection QAC and QHS: per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Acute stroke
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 with an acute stroke that affected your
language and strength. You were given a medicine in the
emergency room to break up the blood clot in your brain, and
after this, your symptoms improved markedly, though not
completely. As you have atrial fibrillation, it will be
important for you to continue on coumadin and have your INR
monitored regularly, with a
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & SIDOROV Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2151-6-2**] 4:00
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2151-4-22**]
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"719.7",
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"V55.3",
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"V58.61",
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"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
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|
10778, 13110
|
282, 319
|
14442, 14442
|
2161, 10755
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1428, 1468
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,667
| 105,534
|
21161
|
Discharge summary
|
report
|
Admission Date: [**2144-10-14**] Discharge Date: [**2144-10-29**]
Date of Birth: [**2072-12-18**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p PEA arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
71F with hx of COPD (on home O2 with cor pulmonale), DM2,
history of NSTEMI, diabetes, hyperlipidemia, diastolic
dysfunction, and pulmonary hypertension presents s/p PEA arrest
during hip fracture surgery. 2 weeks prior to admission,
patient had 2 falls, daughter spoke with witness of fall who
reported patient "blacked out". On [**10-8**], patient had MVA, hit a
tree but refused to go to the ER, no major injuries. On [**10-11**],
she had to lower herself to the floor to become comfortable
because of "swollen legs", but lost balance and fell on her
buttocks, causing a left hip fracture, which brought her to the
hospital the day after falling. Minimal PO intake in days prior
to admission.
Upon admission to OSH ED, found to have K+ 6.7, given calcium
gluconate, D50 with insulin, repeat K was 5.2. CK 66, Trop
0.04. CXR showed hyperinflation and left costophrenic angle
blunting. ECG in complete heart block with peaked T waves.
Dual chamber atrial sensing pacer placed [**2144-10-13**], then had hip
fracture surgery [**2144-10-14**]. Also received 1 unit PRBC transfusion
for dropping Hct ? GI bleed per family, they were told she would
need outpt colonscopy.
Towards closing of surgery, her BP suddenly dropped, she went
into PEA arrest, was given epi and atropine and CPR was
completed for 2-3 minutes with restoration of pulse. Echo was
completed that showed ? new anterior wall motion abnormality,
but hard to assess because she was paced. [**Hospital 56108**]
transferred to [**Hospital1 18**] for cath and CCU management.
Update before arriving to floor: Clean coronaries found during
catheterization, fighting tube, mean PCWP 38, biventricular
failure, mean RA 20, RV 55/20, PA mean 47, CI 4.2, latest ABG
7.19/67/349/27 Vent 420mL, 26, 100% FiO2, 5 PEEP, K 3.6, Lactate
1.0, H/H 9.8/29, no central line access, on 5mcg dopamine
peripherally, urine cloudy 100cc, received 300mL NS bolus, on
heparin for possible PE
On review of systems, she is intubated and sedated, not
responding to stimuli. Upon arrival to the floor patient no
longer on dopamine drip, BP dropped to 50s/30s with MAPs 40s, HR
120s ventricular paced regular p waves, faint carotid pulses
felt, started phenylephrine drip with rapid increase in MAPs to
70s and greater palpable pulses.
Per family, cardiac review of systems is notable for absence
TIA, stroke, palpitations, dysphagia, odynophagia, moves bowels
1/day, occasionally BRBPR [**3-17**] hemorrhoids, no melena, has
diarrhea occasionally, + ankle edema, no orthopnea, no PND, no
chest pain, baseline is 0.5-1 flight of stairs then needs to
stop secondary to SOB no CP.
Past Medical History:
severe COPD, on home O2 1.5L (per family), [**2138**] PFTS: FEV1 0.42,
FEVI/FVC 31, low DLCO,
DM2 - non-insulin dependent, no
retinopathy/neuropathy/nephropathy
HTN since [**2139**]
CAD s/p NSTEMI in [**2138**] - @[**Hospital1 18**] cath EF 55% normal coronaries
hypercholesterolemia
pulmonary hypertension
PAST SURGICAL/GYN HISTORY
G5P5
s/p tonsillectomy
s/p hysterectomy
Social History:
Has supportive family; one son and four daughters. Previously
worked as a bookkeeper, currently volunteers in an office.
-Tobacco history: reportedly 100+ pk-years, continues to smoke
1ppd, had bad dreams on nicotine patch in past, would not want
nicotine patch to be placed (per family)
-ETOH: 1 drink/year
-Illicit drugs: none
- caffeine use: [**7-22**] cups caffeine/day
Baseline - completes all IADLs and ADLs, drives, ambulates
independently, active volunteer
Family History:
father with liver CA died at 76, brother died of liver CA as
well, mother died at 80 had osteoporosis, 2 sisters with HTN, 1
son with HTN, 4 healthy daughters, no history of sudden death or
known arrythmias
Physical Exam:
Admission Exam:
T 95 HR 125 BP 118/57 (off dopa) sats 100% on AC Tv 400ml RR 28
FiO2 50%, PEEP 5, elevated Peak pressures
GENERAL: Intubated, not sedated, not agitated, not responding to
stimuli; withraws to nailbed pressure on toes but not on fingers
HEENT: NCAT. Sclera anicteric. PERRL. 1+ carotid pulses
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. + diffuse wheezing
anterior and posteriorly, no crackles or rhonchi.
ABDOMEN: Soft, NT, mildly distended, does not grimace to
palpation. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
EXTREMITIES: 2+ LE pitting edema, 1+ chest wall edeam, no
cyanosis, feet slightly cool, unappreciable PT/DP and radial
pulses, no femoral bruits, femoral venous and arterial lines
c/d/i.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Discharge Exam:
Pertinent Results:
(from OSH)
UA small leuk esterase, neg nitrates, 2-5WBCs.
BUN/Cr 42/0.8
Na 142
K 6.7 repeat after intervention 5.2
Ca 8.4
albumin 3.2
alk po4 98
AST 32
ALT 74
CK 66
trop 0.04
INR 1.0
PTT 27.5
WBC 8.6
Hct 27.9
Plt 216
ABG 7.33/50/62/26.2 89% (unknown settings)
.
[**2144-10-14**] 11:20PM BLOOD WBC-12.0* RBC-3.69* Hgb-11.2* Hct-35.3*
MCV-96 MCH-30.3 MCHC-31.7 RDW-16.4* Plt Ct-234#
[**2144-10-16**] 03:13PM BLOOD WBC-8.5 RBC-2.65* Hgb-8.2* Hct-23.2*
MCV-88 MCH-30.8 MCHC-35.1* RDW-17.5* Plt Ct-135*
[**2144-10-18**] 03:56AM BLOOD WBC-10.7 RBC-3.24*# Hgb-9.4* Hct-27.8*
MCV-86 MCH-29.1 MCHC-33.8 RDW-18.8* Plt Ct-175
[**2144-10-14**] 11:20PM BLOOD Neuts-92.1* Lymphs-3.6* Monos-3.9 Eos-0.2
Baso-0.3
[**2144-10-15**] 10:13PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-3+ Polychr-2+ Ovalocy-OCCASIONAL Target-1+
Burr-1+ Stipple-1+
[**2144-10-14**] 11:20PM BLOOD PT-12.1 PTT-30.2 INR(PT)-1.0
[**2144-10-14**] 11:20PM BLOOD Glucose-232* UreaN-12 Creat-0.6 Na-137
K-3.8 Cl-108 HCO3-23 AnGap-10
[**2144-10-18**] 03:56AM BLOOD Glucose-160* UreaN-23* Creat-0.8 Na-141
K-4.5 Cl-102 HCO3-32 AnGap-12
[**2144-10-14**] 11:20PM BLOOD ALT-52* AST-41* LD(LDH)-440* AlkPhos-123*
TotBili-0.4
[**2144-10-15**] 06:11PM BLOOD Hapto-148
[**2144-10-15**] 01:57AM BLOOD TSH-1.3
[**2144-10-17**] 09:00AM BLOOD Vanco-31.9*
[**2144-10-18**] 10:48AM BLOOD Vanco-20.1*
[**2144-10-14**] 09:48PM BLOOD Type-ART pO2-349* pCO2-67* pH-7.19*
calTCO2-27 Base XS--3
[**2144-10-18**] 11:33AM BLOOD Type-ART pO2-110* pCO2-47* pH-7.49*
calTCO2-37* Base XS-10
[**2144-10-14**] 09:48PM BLOOD Glucose-216* Lactate-1.0 Na-135 K-3.6
Cl-105
[**2144-10-15**] 01:17AM BLOOD freeCa-0.77*
[**2144-10-16**] 04:19AM BLOOD freeCa-1.12
.
Cardiac Cath Study Date of [**2144-10-14**]
COMMENTS:
1. Selective coronary angiography in this left dominant system
revealed
no angiographically significant disease.
2. Limited resting hemodynamics revealed elevated right
(RVEDP=20mmHg)
and left (PCW=38mmHg) sided filling pressures. There was
moderate
pulmonary arterial hypertension (SBP=56mmHg). Systemic pressures
were
normal while on 5mcg/kg/min of dopamine. The cardiac index was
normal
(CI=3.1l/min/m2).
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal ventricular function.
3. Moderate pulmonary hypertension.
4. Elevated right and left sided filling pressures
.
ECG Study Date of [**2144-10-14**]
The patient is atrial sensed and ventricular paced at a rate of
111. There is an intraventricular conduction delay with
secondary ST-T wave changes. On the prior tracing of [**2138-8-12**],
the patient was in normal sinus rhythm. Therefore, comparisons
are not valid.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
111 0 158 358/447 0 -85 95
.
CHEST (PORTABLE AP) Study Date of [**2144-10-14**]
FINDINGS: No pneumothorax. The patient is newly intubated, the
tip of the
ETT projects 4.5 cm above the carina. Expected course of the
nasogastric
tube. Newly inserted right pectoral pacemaker with expected
course of the
leads. Slight costophrenic angle blunting due to old pleural
scar, no
evidence of recent pleural effusions. Moderate interstitial
edema could be
present. Viral pneumonia would be an alternative explanation for
the slight increase in visibility of the interstitial
structures. Normal size of the cardiac silhouette.
.
Portable TTE (Focused views) Done [**2144-10-15**]
Conclusions
There is moderate regional left ventricular systolic dysfunction
with mid to apical severe hypokinesis. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %). The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The aortic valve leaflets are mildly thickened (?#).
Mitral regurgitation is present but cannot be quantified. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is
trivial/physiologic pericardial effusion.
IMPRESSION: Limited views in an emergency study. Regional left
ventricular systolic dysfunction is consistent with stress
cardiomyopathy (Takotsubo) or coronary artery disease. Right
ventricular dilation, hypokinesis, and moderate pulmonary artery
systolic hypertension are consistent with pulmonary emobli or
other chronic lung diseases.
.
ECG Study Date of [**2144-10-15**]
Marked baseline artifact. Patient remains in an atrial sensed,
ventricular
paced rhythm at a rate of 126. Otherwise, compared to tracing #1
there is no diagnostic interval change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
126 0 152 340/455 0 -85 92
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2144-10-15**]
IMPRESSION:
1. No pulmonary embolism. Mild pulmonary edema.
2. Severe centrilobular and paraseptal emphysema.
3. Extensive anasarca.
4. Left upper lobe spiculated lesion, malignancy cannot be
excluded, if
clinically appropriate, a short interval followup CT is
suggested in three
months' time.
.
BILAT LOWER EXT VEINS Study Date of [**2144-10-15**]
IMPRESSION: No evidence of right or left lower extremity DVT.
.
CAROTID SERIES COMPLETE PORT Study Date of [**2144-10-15**]
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On the right there is moderate heterogeneous plaque in
the ICA. On the left there is mild heterogeneous plaque in the
ICA, ECA and CCA. On the right systolic/end diastolic velocities
of the ICA proximal, mid and
distal respectively are 110/35, 133/36, 108/23 cm/sec. CCA peak
systolic
velocity is 52 cm/sec. ECA peak systolic velocity is 66 cm/sec.
The ICA/CCA ratio is 2.3. These findings are consistent with
40-59% stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and
distal respectively are 68/26, 85/28, 97/32, cm/sec. CCA peak
systolic
velocity is 52 cm/sec. ECA peak systolic velocity is 66 cm/sec.
The ICA/CCA ratio is 2.3. These findings are consistent with
<40% stenosis.
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Impression: Right ICA stenosis 40-59%.
Left ICA stenosis <40% .
.
HIP 1 VIEW Study Date of [**2144-10-15**]
FINDINGS: No previous images. Hemiarthroplasty is seen on the
left without
evidence of hardware-related complication. Soft tissue changes
of recent
surgery are noted.
.
CT HEAD W/O CONTRAST Study Date of [**2144-10-17**]
FINDINGS: There is no acute intracranial hemorrhage, major
vascular
territorial infarction, mass effect or edema. [**Doctor Last Name **]-white matter
differentiation is preserved. There is periventricular and
subcortical white matter hypodensity which is similar to prior
and most likely related to chronic small vessel ischemic
disease. Age-appropriate prominence of
ventricles and sulci is consistent with diffuse parenchymal
volume loss. Basal cisterns are preserved. Globes and lenses are
intact. Visualized paranasal sinuses and mastoid air cells are
well aerated. No osseous abnormality is identified.
IMPRESSION:
1. No acute intracranial abnormality. If there is concern for
acute
ischemia, MRI is recommended for further evaluation if not
contraindicated.
2. Findings compatible with chronic small vessel ischemic
disease.
.
CT PELVIS W/O CONTRAST Study Date of [**2144-10-17**]
CT ABDOMEN WITHOUT IV CONTRAST: There is septal thickening and
small bilateral pleural effusions at the lung bases, compatible
with mild edema, but slightly improved compared to the prior
study. Emphysematous changes are again noted. Enteric tube is
noted in situ.
Evaluation of the abdominal organs is limited without IV
contrast. Within
this limitation, the liver, gallbladder, pancreas, spleen, and
bilateral
adrenal glands are normal. There is delayed nephrogram of the
bilateral
kidneys suggestive of impaired renal function. No evidence of
hydronephrosis or hydroureter. There is mild intra-abdominal
ascites. The stomach and intra-abdominal loops of small and
large bowel are unremarkable. No free air in the abdomen. There
is dense atherosclerotic calcification of the abdominal aorta
through its bifurcation. Evaluation for mesenteric and
retroperitoneal lymphadenopathy is limited; however, no large
lymphadenopathy is noted.
CT PELVIS WITHOUT IV CONTRAST: Evaluation is limited by streak
artifact from the hip prosthesis. Within this limitation, the
urinary bladder is collapsed around a Foley catheter. The distal
ureters and rectum are unremarkable. There is sigmoid
diverticulosis without evidence of acute diverticulitis. Small
amount of simple free fluid in the dependent portion of the
pelvis. No pelvic or inguinal lymphadenopathy is noted.
BONE WINDOWS: The patient is status post left THR. T12
compression deformity is again noted. Multilevel degenerative
change in the lumbar spine is present with endplate osteophyte
formation. In addition, there is vacuum disc phenomenon with
loss of disc height at L5-S1.
IMPRESSION:
1. Within limitations above, no evidence of intra-abdominal or
pelvic
hematoma.
2. Small intra-abdominal ascites and free fluid in the dependent
portion of the pelvis.
3. Delayed persistent nephrogram suggestive of impaired renal
function.
4. Mild pulmonary edema, slightly improved from prior.
5. Sigmoid diverticulosis without evidence of acute
diverticulitis.
.
Brief Hospital Course:
71F with history of severe COPD, DM2, HLD, HTN, pulmonary HTN,
presents with recent diagnosis of complete heart block, s/p
pacer, followed by hip fracture repair during which time she
became acutely hypotensive and had PEA arrest, CPR and ACLS
protocol achieved restoration of pulse, now s/p cath clean
coronaries, biventricular failure and persistent tachycardia.
.
# s/p PEA arrest: Etiology unclear, initial differential
included hypotension, PE, sepsis, or given recent hip fracture
repair, bone cemement implantation syndrome. Pt required
levophed for pressor support. Empiric antibiotics for possible
sepsis (most likely source was pneumonia) were begun (cefepime
and vancomycin). Pancultures were sent which showed sputum with
gram positive rods and cocci and gram neg rods and sputum
cultures grew ACINETOBACTER BAUMANNII COMPLEX sensitive to
cipro. Pt was placed initially started on cefepime then placed
on 8 day course of Cipro. Urine cultures and blood cultures
showed no growth.
.
Cardiac catheterization was completed to evaluate for possible
ischemic causes of her PEA arrest, however catheterization
showed normal coronary arteries. It also showed moderate
pulmonary hypertension and markedly elevated right and left
sided filling pressures. Due to elevated filling pressures and
initially high suspicion for a PE, a CT-A chest was completed
which excluded PE, but showed mild pulmonary edema, severe
centrilobular and paraseptal emphysema, extensive anasarca and a
left upper lobe spiculated lesion, (malignancy could not be
excluded). She was actively diuresed with improvement of her
oxygenation and was able to be successfully extubated. An ECHO
was also completed that showed LV basal hyperkinesis and
relative apical [**Name2 (NI) 56109**], RV not adequately visualized.
.
#. Respiratory failure: Pt was known to have severe COPD, on
home O2, with pulmonary hypertension, biventricular failure and
possible fluid overload. She had significant anasarca and was
agressively diuresed as her blood pressure would allow. High
peak pressures on vent were likely secondary to COPD, retaining
CO2 on gas. Combivent q4hr, flovent [**Hospital1 **] and empiric antibiotics
(cefepime and vancomycin) as above were initiated; pt vanco and
cefepime d/c'ed and pt placed on cipro for sensitive
acinetobacter. Attempts to wean oxygen saturation and monitor
ventilation status towards goal of extubation were challenging
given pt's neurologic status. However, gradually respiratory
status improved. Pt was able to be extubated but mental status
did not improve significantly.
.
#. Mental Status/non-responsive: Pt remained relatively
non-responsive. She was not on sedation. Neurology was consulted
as patient was no longer requiring sedation and was not
responding to stimuli. EEG was performed which showed limited
brain activity at that time. CT of head showed no acute
abnormality only chronic vessel ischemic disease. MRI of the
head could not be performed due to pacemaker. Pt's mental status
marginally improved but waxed and waned. At times responded to
questions w/simple [**2-15**] word answers and could follow simple
commands but at other times was lethargic. Initially it was
hoped that temporary NG tube for tube feeds during the pt's
early recovery would help aid improved mental status and
recovery; however, it became clear that improvement in
neurologic function and clinical status was unlikely. After
several family meetings and discussions with the team and
neurology, the decision was made to make the patient CMO in
[**Location (un) **] with what her family believed to be her previously stated
wishes (she did not want to live in a debilitated state in a
nursing home).
.
#. Biventricular diastolic dysfunction (normal CI). CXR did not
show impressive pulmonary edema. Diastolic dysfunction was
likely due to combination of COPD, pulmonary hypertension and
HTN.
.
#. Tachycardia: Pt had dual chamber atrial sensed pacemaker,
regular tachycardic p waves. Etiology for sinus tachycardia
included PE, verses sepsis. It was felt that it was unlikely
re-entrant pacer tachycardia as pacer adequately firing at
120bpm and we can see regular p waves. Some of tachcardia was
attributed to possible pain as tachycardia would improve when
patient was repositioned off of hip but would increase with
manipulation. Fentanyl was started to treat possible pain and
pt's tachycardia improved. Fentanyl was switched to tramadol to
decrease any possible sedation. Pain appeared well managed;
tachycardia improved. When pt was made CMO, morphine was
provided to ease any discomfort on the part of the pt.
.
#. Elevated Trop 0.04: Pt had h/o NSTEMI [**2141**] but clean
coronaries on cath. Concern for stress induced cardiomyopathy.
Aspirin was condinued and CE trended down.
.
# L Hip Fracture. Ortho was consulted; hip films showed no
misalignment or acute process related to fixation. One proposed
hypothesis for pt's condition given lack of evidence for PE was
the possiblilty of bone cement implantation syndrome which
procudes similar symptoms.
.
#. Metabolic acidosis: new development of metabolic acidosis a
few hours after being on floor was of unclear etiology.
Possibilities included lactic acidosis (patient was on metformin
at home) although lactate normal 1.0, DKA although BS 200s, RTA
less likely considering normal renal function. No toxins
suspected. Blood glucose was monitored. With eventual addition
of tube feeds, blood glucose levels where moderately challenging
to control so basal insulin of 4 units glargine was started in
addition to ISS.
.
#DM2: ISS was started. Home metformin was held given risk of
lactic acidosis.
.
#Hyperlipidemia: statin was continued
.
# CODE: Initial pt was full but after several lenghty
conversations w/team and neuro, family felt the pt would not
want to be reintubated or want any extreme measures. Family
members also felt that pt would not want to have a feeding
tube/PEG or live incapacitated in a nursing home. Pt was made
DNR/DNI/CMO w/ no feeding tube. All unnecessary medications were
stopped with the exception of medications deemed necessary for
comfort. This decision was confirmed with the patients children
and family members. [**Name (NI) **]: [**Name (NI) 41417**] [**Telephone/Fax (1) 56110**] ([**Name2 (NI) **]er),
[**Name (NI) **] [**Telephone/Fax (1) 56111**] (daughter), [**Name (NI) **] [**Name (NI) **] (son and primary
health proxy lives in NJ) [**Telephone/Fax (1) 56112**] h [**Telephone/Fax (1) 56113**] c).
.
Pt was discharged to inpatient skilled nursing facility and
needs hospice evaluation immediately upon arrival to skilled
nursing facility.
Medications on Admission:
pravastatin 80mg qHS
diltiazem 120mg daily
imdur 15mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
asa 325mg daily
spirivia 18mg qAM
symbicort inh [**Hospital1 **]
calcium with vit D
lisinopril 2.5mg qPM
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing or increased work of breathing.
2. Morphine Concentrate 20 mg/mL Solution Sig: [**2-15**] PO Q2H
(every 2 hours) as needed for pain, respiratory distress.
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety or respiratory distress.
4. Haloperidol Lactate 5 mg/mL Solution Sig: [**2-15**] Injection Q4H
(every 4 hours) as needed for agitation.
5. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Transdermal
once a day as needed for excessive secretions.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
PEA arrest
.
Secondary:
COPD
pulmonary hypertension
hip fracture s/p surgical repair
Diabetes Type 2
CAD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mrs. [**Known firstname 8368**] [**Last Name (NamePattern1) **] was admitted to the hospital after her heart
stopped while having her fractured hip repaired. It was unclear
why this happened given that the surgery had gone well up until
that point. Unfortunately, the lack of blood to her brain
resulted in what will likely be long standing neurologic
deficits and disability. Due to the significant decline
physcial/mental functioning and the unlikilood of recovery, the
decision was made to make the patient "comfort measures only" in
[**Location (un) **] with previously stated wishes by Mrs. [**Last Name (STitle) **] that she
would not want to live in a debilitated state. In accordance
with these wishes, Mrs. [**Last Name (STitle) **] was transferred to inpatient
hospice services where she could receive appropriate care in
line with her wishes.
.
All unnecessary medications were stopped and only those
medications which maintained the patient's optimal level of
comfort where continued.
Start taking Morphine sublingual, Haldol, Ativan, Scopalamine,
Albuterol and Dulcolax as needed for comfort.
.
Thank you for letting us be a part of your care.
Followup Instructions:
No recommended follow-up is scheduled
Completed by:[**2144-10-29**]
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9,575
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Discharge summary
|
report
|
Admission Date: [**2174-2-24**] Discharge Date: [**2174-3-8**]
Date of Birth: [**2104-5-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Suicidal Ideation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 69F with a history of end stage HOCM with fluid
sensitivity, COPD (baseline 02 4L), chronic depression/anxiety,
schizoaffective disorder who was seen by Dr [**Last Name (STitle) **] yesterday in
clinic and was noted to make statements suggestive of suicidal
ideation. She was referred from the ED for safety evaluation.
.
In the ED, initial VS were T 96.8, HR 59, BP 119/82, RR 18, O2
sat 97% 4L. She was seen by psychiatry who performed an
evaluation and felt she was safe for discharge back to [**Hospital1 1501**].
Apparently got 2 mg IV ativan, then 1 mg IV ativan for anxiety
(no nursing documentation of meds given on dash or in chart, but
these pulled from pharmacy). Labs sent from ED were notable for
Na 147, WBC 7.0, Hct of 25.4 (baseline low 30s) so she was
started on 1L IVF; after about ~170cc, she became acutely SOB.
CXR showed mild pulmonary edema, and she was admitted to
medicine for further management. Vitals on admission HR: 98.1.
HR: 77. RR: 25-36. O2: 94% 4Lnc. BP: 123/94.
.
Overnight, she reported feeling slightly SOB. She stated that
she felt her SOB was from panic and endorsed a panic attack in
the ED. She denied chest pain, cough, other pain or active
complaints. Overnight she triggered for AMS, possibly [**2-24**] ativan
administration in the ED. However, she remained vitally stable
and returned to baseline MS.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes
(wears glasses at baseline and left them at [**Hospital1 1501**]), does have mild
congestion (this is chronic), sore throat, cough, shortness of
breath, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
She has tremors in her hands and mouth occasionally at baseline.
Has occasional fecal incontinence.
.
Past Medical History:
HOCM - sensitive to fluid balance
CHF, with hx of acute flares after fluid adminsitration
COPD, baseline o2 4L
HTN
Breast CA
Major depression
Schizoaffective d/o
Osteoporosis
Anemia
Constipation
s/p TAH/BSO
s/p L hip ORIF
Social History:
Currently a resident at Newbridge on the [**Doctor Last Name **]. Sees a
psychiatrist there and has assistance with medications. Uses a
wheelchair at baseline for her hip problems. Non-[**Name2 (NI) 1818**]. Rare
social alcohol.
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM: Admission
VS - 98.1 111-139/77-88 22-28 95 4L
GENERAL - alert, aoX3, patient appears depressed
HEENT - sclerae anicteric, MM slightly dry, OP clear
NECK - supple, no thyromegaly, +JVD to angle of jaw
LUNGS - poor air entry bilaterally and has crackles bilaterally.
Unable to complete sentences.
HEART - RRR, 4/6 systolic murmur throughout precordium, loudest
at RUSB and LLSB.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - Awake and alert, has tremor of mouth and tongue which
disappears with speech. No current tremors in hands.
Discharge: [**Name2 (NI) **]
Pertinent Results:
LABS ON ADMISSION:
[**2174-2-24**] 06:20PM BLOOD WBC-7.0 RBC-2.68* Hgb-8.3* Hct-25.4*
MCV-95 MCH-30.9 MCHC-32.6 RDW-13.7 Plt Ct-167
[**2174-2-24**] 06:20PM BLOOD Neuts-81.9* Lymphs-9.5* Monos-5.2 Eos-2.6
Baso-0.8
[**2174-2-24**] 06:20PM BLOOD Glucose-96 UreaN-27* Creat-1.2* Na-147*
K-3.9 Cl-103 HCO3-37* AnGap-11
[**2174-2-25**] 07:40AM BLOOD Albumin-3.7 Calcium-9.5 Phos-3.1 Mg-2.2
[**2174-2-24**] 06:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2174-2-25**] 03:18AM BLOOD Type-ART pO2-73* pCO2-62* pH-7.43
calTCO2-43* Base XS-13
[**2174-2-25**] 03:18AM BLOOD Lactate-0.5
[**2174-2-25**] 05:42AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2174-2-24**] 06:20PM URINE CastHy-2*
[**2174-2-24**] 06:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-INDETERMIN mthdone-NEG
CXR: Mild cardiomegaly and mild pulmonary edema.
Pertinent Results:
Echo pre-ablation:
The left atrium is elongated. There is severe symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
a severe resting left ventricular outflow tract obstruction that
increases with Valsalva. Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
There is systolic anterior motion of the mitral valve leaflets.
An eccentric, anteriorly directed jet of moderate (2+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect).The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Left ventricular hypertrophy with valvular [**Male First Name (un) **] and
resting LVOT gradient. Eccentric jet of at least moderate mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2171-11-5**],
the severity of mitral regurgitation has increased.
Echo Immediately post-ablation:
Imaging performed immediately prior to, during and following
ethanol septal abaltion.
There was a severe resting left ventricular outflow gradient at
baseline (peak gradient of 123 mm Hg) and marked systolic
anterior motion of the mitral leaflets ([**Male First Name (un) **]).
Optison injections in the selected septal perforators
demonstrated enhancement in the proximal septum. Sequential
ethanol injections resulted in enhancement in the same region.
Following completion of the procedure, there was reduction in
[**Male First Name (un) **] and the peak left ventricular outflow gradient was 36 mmHg.
A lead is seen in the right ventricle.
Echo [**2174-3-5**]
The left atrium is elongated. 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%). There
is a moderate (36mmHg peak) resting left ventricular outflow
tract obstruction. Right ventricular chamber size is normal.
with borderline normal free wall function. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. There is systolic anterior motion of the mitral valve
leaflets. Mild to moderate ([**1-24**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is a very small circumferential pericardial effusion.
IMPRESSION: Prominent symmetric left ventricular hypertrophy
with normal regional and normal global (not hyperdynamic)
systolic function. Resting LVOT gradient. Pulmonary artery
hypertension. Mild aortic regurgitation. Dilated ascending
aorta. Increased PCWP.
Compared with the prior study (images reviewed) of [**2174-2-28**],
left ventricular systolic function is less dynamic, the severity
of aortic regurgitation is slightly increased, and moderate PA
systolic hypertension is now identified. The resting LVOT
gradient is lower.
Echo [**2174-3-7**]
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity is small. There is a severe resting left
ventricular outflow tract obstruction. The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated with depressed free wall contractility. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is systolic anterior motion of the mitral valve
leaflets. Mild to moderate ([**1-24**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
severe pulmonary artery systolic hypertension. There is a very
small pericardial effusion. There are no echocardiographic signs
of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2174-3-5**], the interventricular septum is now
akinetic, the left ventricular outflow tract obstruction is
worse, the pulmonary artery pressure is higher, and the right
ventricle is now dilated and hypokinetic.
[**2174-3-7**] 11:17PM BLOOD Type-ART Temp-37 pO2-121* pCO2-49*
pH-7.15* calTCO2-18* Base XS--11
[**2174-3-8**] 05:56AM BLOOD Type-ART PEEP-5 FiO2-80 pO2-107* pCO2-32*
pH-7.32* calTCO2-17* Base XS--8 AADO2-432 REQ O2-75
Intubat-INTUBATED
[**2174-3-8**] 11:31AM BLOOD Type-ART Temp-36.9 Rates-28/ Tidal V-400
PEEP-5 FiO2-60 pO2-64* pCO2-28* pH-7.35 calTCO2-16* Base XS--8
Intubat-INTUBATED
[**2174-3-2**] 04:00AM BLOOD CK-MB-117* MB Indx-16.5*
[**2174-3-2**] 12:35PM BLOOD CK-MB-63* MB Indx-15.0* cTropnT-7.84*
[**2174-3-5**] 06:03AM BLOOD CK-MB-4 cTropnT-2.94*
Brief Hospital Course:
HOSPITAL COURSE: 69F with schizoaffective d/o, depression,
anxiety, HOCM, COPD who was referred to ED by outpt cardiologist
for safety eval after making comments suggsetive of SI. Had SOB
in the ED adn was admitted to [**Hospital1 1516**]. Ethanol ablation for HOCM
occurred on [**2174-3-1**] with resultant RBBB and conduction block
requiring PPM placement. Ms. [**Known lastname **] passed on [**2174-3-8**] from
hypotension related to HOCM after she was made CMO.
# HOCM: Last echo showed moderate symmetric LVH with severe LVOT
obstruction and mild-moderate MR. We avoided IVF as likely to
cause worsening pulmonary edema and diuresed as necessary with
lasix. Patient went for ethanol ablation on [**2174-3-1**]. She was
observed in the CCU from [**Date range (1) 35379**] with a transvenous pacer in
place. A post-operative RBBB was noted. As expected, there
occurred an MB leak to a peak of 114. Diltiazem was uptitrated
to 240 q8h while in the CCU. On [**2174-3-4**], after no evidence of
pacer wire necessity, the pacer wire was pulled and Ms. [**Known lastname **]
was transferred to the floor. While on the floor, Ms. [**Known lastname **]
experienced an asystolic arrest was coded x2, intubated, and a
temporary transvenous pacer wire was placed. Diltiazem was
discontinued. Given concern for continued conduction
abnormalities a dual chamber pacemaker was placed on [**2174-3-7**].
Immediately following return to the CCU from pacemaker
placement, Ms. [**Known lastname **] became hypotensive to BP of 40s/20s.
Levophed and neosynephrine were initiated, Ms. [**Known lastname **] was bolused
with 3L NS and SBPs improved to 110s. A stat bedside echo
demonstrated RV underfilling. Broad spectrum antibiotics were
empirically started. Despite max doses of 2 pressors and
aggressive IV hydration, Ms. [**Known lastname 101114**] BP remained quite volatile
with any changes in position causing hypotension to 40s/20s.
After consultation with Ms. [**Known lastname 101114**] healthcare proxy, it was
decided that she would be made CMO. She was extubated on [**2174-3-8**]
and [**Date Range **] later that day.
# SHORTNESS OF BREATH: Prior to admission, patient had
increasing weight in [**Hospital 100**] rehab and was getting extra doses of
lasix. She also had a recent aspiration pna and was on
cefpodoxime and flagyl at the time of admission. SOB is likely
mulitfactorial in the setting of CHF d/t worsening HOCM, fluid
overload, pneumonia, and agitation in the ED. Now back to
baseline on 4L. We gave her 20 mg IV furosemide and started her
on home 40 mg lasix. We continued duonebs and 4L 02,
Advair/spiriva for COPD, cefpodoxime and flagyl for aspiration
pna diagnosed prior to admission. Inhaled bronchodilators were
continued until Ms. [**Known lastname **] was made CMO on [**2174-3-8**].
# ANEMIA: Hct 25 on admission from baseline low 30s. Normocytic.
Recent iron, B12 and folate studies have been normal. Guaiac
negative in the past and no evidence of active bleeding. Ms.
[**Known lastname **] was transfused 1 unit PRBC during her hypotensive episode
on [**2174-3-7**] as an attempt to fluid resuscitate.
# DEPRESSION/ANXIETY: Cleared by psychiatry following evaluation
in the ED for discharge back to [**Hospital1 1501**]. We continued mirtazapine,
bupropion until Ms. [**Known lastname **] [**Last Name (Titles) **] on [**2174-3-8**].
Medications on Admission:
MEDICATIONS (per hospice notes as of [**2-24**]):
BuPROPion 75 mg PO BID
Mirtazapine 15 mg PO/NG HS
Lorazepam 0.5 mg PO/NG HS:PRN insomnia and q6h;prn for anxiety
Omeprazole 40 mg PO DAILY
Metoprolol Succinate XL 100 mg PO DAILY
Tiotropium Bromide 1 CAP IH DAILY
Aspirin 81 mg PO/NG DAILY
Milk of Magnesia 30 mL PO/NG Q6H:PRN constipation
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Docusate Sodium 100 mg PO qd
Ipratropium Bromide Neb 1 NEB IH Q2H:PRN SOB
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB
oxycodone 5mg tid
Clonazepam 0.5mg po
lasix 40 po daily and 20 prn for >3lb weight gain
Discharge Medications:
[**Hospital1 **]
Discharge Disposition:
[**Hospital1 **]
Discharge Diagnosis:
Schizoaffective disorder
Hypertrophic cardiomyopathy
Discharge Condition:
[**Hospital1 **]
Discharge Instructions:
[**Hospital1 **]
Followup Instructions:
[**Hospital1 **]
|
[
"787.60",
"507.0",
"424.0",
"496",
"781.0",
"427.5",
"296.20",
"300.01",
"V66.7",
"V49.86",
"V15.51",
"428.0",
"V46.3",
"E939.4",
"V62.84",
"287.5",
"276.0",
"564.00",
"288.60",
"530.81",
"785.51",
"295.70",
"416.8",
"402.91",
"426.0",
"V10.3",
"285.9",
"780.09",
"584.9",
"428.33",
"V46.2",
"425.4",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.34",
"88.54",
"96.71",
"99.69",
"37.23",
"99.60",
"37.72",
"88.56",
"96.04",
"37.83",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
13486, 13504
|
9364, 9364
|
321, 328
|
13601, 13619
|
4413, 9341
|
13684, 13703
|
2701, 2719
|
13445, 13463
|
13525, 13580
|
12755, 13422
|
9381, 12729
|
13643, 13661
|
2750, 3435
|
1755, 2192
|
264, 283
|
356, 1736
|
3474, 4394
|
2214, 2438
|
2454, 2685
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,990
| 193,608
|
9824
|
Discharge summary
|
report
|
Admission Date: [**2188-9-2**] Discharge Date: [**2188-9-8**]
Service: NEUROSURGERY
Allergies:
Lasix
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Progressive weakness after a fall.
Major Surgical or Invasive Procedure:
Craniotomy
History of Present Illness:
89 year-old male progressive weaness on the left side got
worse over the weekend. S/P fall 3-4 weeks ago. Recently started
on Coumadin for atrial fibrillation. Last Coumadin dose was
thursday evening 1.25mg. LAst INR prior to ED visit was 2.5 his
PCP told him to stop his coumadin.
Past Medical History:
1. HTN
2. Neuropathy
3. Colon cancer, s/p right hemicolectomy in [**2185**]
Social History:
Retired, lives alone, performs all ADL's independantly; daughter
lives nearby. Former 4 ppd smoker but quit 20 yrs ago, no EtOH
Family History:
NC
Physical Exam:
Vitals: 98 84 180/47 16 97 RA
Gen:elderly gentelmen lying in strecther NAD.
Neck:No Carotid bruits, neck supple.
CV: irregular, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect
Orientation: oriented to person, place, and date
Recall: [**2-28**] at 5 minutes, naming intaact.
Language: 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, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements
Motor:
Normal bulk and tone bilaterally
No tremor
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Left 2 2 2 2 2 1 1 4- 3 3 3 3 3 1 1
left pronator drift
Sensation: Intact to light touch.
Reflexes: B T Br Pa Pl
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes were downgoing right, upgoing left.
Coordination: normal but slow on finger-nose-finger, heel to
shin also normal
Gait was not assessed.
Pertinent Results:
[**2188-9-2**] 10:35PM CK(CPK)-92
[**2188-9-2**] 10:35PM CK-MB-NotDone cTropnT-0.02*
[**2188-9-2**] 01:14PM GLUCOSE-119* UREA N-40* CREAT-1.8* SODIUM-139
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-23 ANION GAP-22*
[**2188-9-2**] 01:14PM CK(CPK)-144
[**2188-9-2**] 01:14PM cTropnT-0.01
[**2188-9-2**] 01:14PM WBC-14.1*# RBC-4.71 HGB-11.5* HCT-36.8*
MCV-78* MCH-24.4* MCHC-31.3 RDW-16.0*
Brief Hospital Course:
A head CT showed a large right subdural hemorrhage with
significant mass affect, midline shift, subfalcine herniation.
He was taken to the operating room and underwent a right sided
craniotomy without complication. Post-operatively he was awake,
alert and orientated X3 and moving all extremeties. A repeat
head CT showed decrease subdural hematoma size with reduction in
mass effect. He was placed on 100% O2 to decrease a collection
of frontal air.
On Post-op day 2 he remained neurologically intact and was
transferred to the neurostep down unit. He had a CXR on post-op
day 2 and 3 which showed worsening CHF he was given doses of IV
ethacrynic acid (due to allergy of Lasix) with good results, his
renal function remained stable but with a slightly high
creatinine, which according to his daughter is being followed by
his primary care physcian.
He was seen by physcial therapy and felt to be a candidate for
acute rehab.
On day of discharge he was awake alert and orientated following
commands, incision was clean dry and intact.
Medications on Admission:
HCTZ, Norvasc, Coumadin and Flomax
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
2. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing .
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Subdural Hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
Watch incision for redness, drainage, bleeding, swelling, fever
greater than 101.5 or any neurologic problems call Dr [**Name (NI) 17511**]
problems. [**Name (NI) **] not get incision wet until sutures out.
No heavy lifting
Followup Instructions:
Follow up in 2 weeks with CT scan at Dr[**Name (NI) 9034**] office. Call
for an appointment [**Telephone/Fax (1) 2731**]
Completed by:[**2188-10-8**]
|
[
"401.9",
"427.31",
"428.0",
"E888.9",
"V10.05",
"V58.61",
"852.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4950, 5047
|
2736, 3780
|
250, 263
|
5109, 5133
|
2321, 2713
|
5406, 5558
|
839, 843
|
3865, 4927
|
5068, 5088
|
3806, 3842
|
5157, 5383
|
858, 1065
|
176, 212
|
291, 575
|
1379, 2302
|
1104, 1363
|
1089, 1089
|
597, 678
|
694, 823
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,856
| 193,325
|
41495
|
Discharge summary
|
report
|
Admission Date: [**2138-7-16**] Discharge Date: [**2138-7-19**]
Date of Birth: [**2077-8-30**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12657**]
Chief Complaint:
CSF Otorrhea
Major Surgical or Invasive Procedure:
Right middle cranial fossa approach for repair of CSF otorrhea
and encephalocele [**2138-7-16**]
History of Present Illness:
Pt is a 60F who presented with conductive hearing loss of the
right ear. She underwent an exploratory tympanotomy on [**2138-6-11**]
which revealed serous fluid in the middle ear that was found to
be CSF on laboratory testing. She had a head CT which showed
near-complete opacification of the right mastoid air cells and
thinning of the anterior wall of the tegmen with uncertain
integrity of the tegmen. She returns for operative managment of
right CSF otorrhea.
Past Medical History:
h/o seizure x 1, gastric bypass [**2132**], exploratory tympanotomy
[**2138-6-11**]
Social History:
no tobacco, occ EtOH
Family History:
non-contributory
Physical Exam:
On day of discharge:
NAD, speaking normally
Right mastoid dressing in place, c/d/i
CN 2-12 in tact
face symmetric
Brief Hospital Course:
Pt is a 60 yo F who underwent a right middle cranial [**Last Name (un) **]
approach for repair of CSF otorrhea / encephalocele. Please see
the operative report for further details. Postoperatively the Pt
was transferred to the ICU with a mastoid dressing in place in
good condition for q1hr neuro checks and close monitoring. She
had no events overnight and all neuro checks were normal. Her
pain was controlled with IV morphine and po percocet. She
tolerated clear liquids and was advanced to a regular diet on
POD #1. She no longer required monitoring in the ICU on POD #1
and was transferred to a floor bed. Her foley was removed on POD
#2 and she voided without difficulty. On POD #2 her IV morphine
was stopped and her pain was managed on po oxycodone. On POD #3
she was tolerating a regular diet and was discharged home on
percocet 1-2 tabs q4hrs prn pain and oxycodone 1-2 tabs q4hrs
prn breakthrough pain.
Medications on Admission:
aspirin
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right CSF Otorrhea / encephalocele
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-27**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Please call you doctor or nurse practioner if there is a
problem with your ear dressing
*Please do not remove your ear dressing
*Please keep your ear dressing dry
Followup Instructions:
Please contact your doctor for your follow-up appointment
Completed by:[**2138-7-19**]
|
[
"388.61",
"389.03",
"742.0",
"V45.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
2501, 2507
|
1250, 2165
|
324, 423
|
2586, 2586
|
3649, 3738
|
1078, 1096
|
2223, 2478
|
2528, 2565
|
2191, 2200
|
2737, 3316
|
3331, 3626
|
1111, 1227
|
272, 286
|
451, 916
|
2601, 2713
|
938, 1024
|
1040, 1062
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,864
| 137,230
|
52274
|
Discharge summary
|
report
|
Admission Date: [**2122-8-9**] Discharge Date: [**2122-8-20**]
Date of Birth: [**2069-11-10**] Sex: F
Service: MEDICINE
Allergies:
Dicloxacillin
Attending:[**First Name3 (LF) 11552**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 52 year old female with history of Type I DM (off
insulin since [**2103**]) s/p kidney/pancreas transplant, glaucoma,
and HTN who presents from home with altered mental status.
History obtained per report and via patient's husband. [**Name (NI) **]
unable to provide history [**1-20**] somnolence. Husband reports
leaving patient a little after 12 p.m. yesterday to visit his
son. [**Name (NI) **] did not want to accompany him, which is unusual,
as she is normally social. [**Name (NI) **] husband returned home in
the evening and found her sleeping. He woke this morning and
found her unresponsive, and was unable to wake her. He then
called 911.
.
EMS arrived and found the patient unresponsive. FSBG was 64.
D50 was given, without improvement. Her initial vitals were
120/80 HR 80 99% RA. Narcan was also given, without
improvement. In the ED, vitals were 98.3 121/70 78 12. CT
head was obtained and was negative. She desaturated to 81%,
with sat improved to 100% with sternal rub. She received 2
liters in ED. She was then transferred to the ICU. RR 13,
100% on 2 liters n/c, HR 76 BP 145/79
.
Upon arrival to the ICU, she was somnolent, eyes closed, and
resonsive to her name. Her husband accompanied her, and stated
that she was slightly more alert now than earlier in the day.
.
[**Name (NI) **] husband notes that patient was recently upset with
worsening renal function and eyesight over the past few weeks.
He does note that she has been depressed in the past, but does
not report any recent SI.
.
Review of systems: per patient's husband
(+) Per HPI
(-) Denies fever, chills, headache, sinus tenderness, rhinorrhea
or congestion. Denied cough, shortness of breath. Denied chest
pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
Type I DM s/p kidney/pancreas transplant; off insulin since [**2103**]
h/o HTN
h/o dyslipidemia
diabetic retinopathy with glaucoma
h/o DVT on chronic anti-coagulation, has IVC filter per family
Social History:
lives in [**Location **] with husband. has one step-son. rare EtOH.
[**12-20**] PPD for many years. no other drug use
Family History:
non-contributory
Physical Exam:
VS: 145/72 HR 78 RR 12 100% RA
GA: unable to assess orientation, somnolent, opens eyes to
voice, follows commands
HEENT: right pupil reactive, left pupil ovaloid following
surgery. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: CTA anteriorly no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 1+. small degree of
ecchymosis over right trochanter
Skin: chronic venous stasis changes
Neuro/Psych: CNs II-XII intact. unable to assess
strength/sensation. withdraw to pain, arousable, follows
commands.
Pertinent Results:
[**2122-8-9**] 11:18AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2122-8-9**] 11:18AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2122-8-9**] 11:18AM PT-22.1* PTT-28.9 INR(PT)-2.1*
[**2122-8-9**] 11:18AM PLT COUNT-172
[**2122-8-9**] 11:18AM NEUTS-70.8* LYMPHS-24.3 MONOS-3.4 EOS-1.1
BASOS-0.4
[**2122-8-9**] 11:18AM WBC-9.3# RBC-3.73* HGB-11.9* HCT-36.4 MCV-98
MCH-31.9 MCHC-32.7 RDW-13.6
[**2122-8-9**] 11:18AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2122-8-9**] 11:18AM URINE GR HOLD-HOLD
[**2122-8-9**] 11:18AM URINE OSMOLAL-333
[**2122-8-9**] 11:18AM URINE HOURS-RANDOM
[**2122-8-9**] 11:18AM URINE HOURS-RANDOM UREA N-517 CREAT-123
SODIUM-18 POTASSIUM-24 CHLORIDE-21
[**2122-8-9**] 11:18AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2122-8-9**] 11:18AM ALBUMIN-3.3*
[**2122-8-9**] 11:18AM cTropnT-<0.01
[**2122-8-9**] 11:18AM LIPASE-38
[**2122-8-9**] 11:18AM ALT(SGPT)-14 AST(SGOT)-21 CK(CPK)-313* ALK
PHOS-34* TOT BILI-0.7
[**2122-8-9**] 11:18AM estGFR-Using this
[**2122-8-9**] 11:18AM GLUCOSE-254* UREA N-33* CREAT-2.8* SODIUM-138
POTASSIUM-3.8 CHLORIDE-108 TOTAL CO2-22 ANION GAP-12
[**2122-8-9**] 07:21PM PT-20.4* PTT-25.3 INR(PT)-1.9*
[**2122-8-9**] 07:21PM PLT COUNT-180
[**2122-8-9**] 07:21PM WBC-7.5 RBC-4.03* HGB-12.8 HCT-39.2 MCV-97
MCH-31.8 MCHC-32.6 RDW-13.4
[**2122-8-9**] 07:21PM CALCIUM-8.7 PHOSPHATE-3.9 MAGNESIUM-2.2
[**2122-8-9**] 07:21PM cTropnT-<0.01
[**2122-8-9**] 07:21PM ALT(SGPT)-13 AST(SGOT)-31 CK(CPK)-768* ALK
PHOS-42 TOT BILI-0.9
[**2122-8-9**] 07:21PM GLUCOSE-63* UREA N-31* CREAT-2.6* SODIUM-143
POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-21* ANION GAP-14
[**2122-8-9**] 08:42PM TYPE-[**Last Name (un) **] PO2-77* PCO2-44 PH-7.29* TOTAL
CO2-22 BASE XS--4
TECHNIQUE: Contiguous axial images of the head were obtained
without IV
contrast.
FINDINGS: There is no intracranial hemorrhage, edema, shift of
normally
midline structures, or acute major vascular territorial
infarction. Small
focal linear area of hyperdensity adjacent to the left temporal
lobe (3:6),
likely reflects streak artifact related to the overlying
calvarium. The
ventricles and sulci are normal in size and configuration. The
visualized
paranasal sinuses and mastoid air cells are normally aerated.
Osseous
structures reveal no evidence of fracture. Severe
atherosclerotic
calcifications of the cavernous carotids are noted bilaterally.
A punctate
calcification within the left lens is noted.
IMPRESSION: No acute intracranial process.
COMPARISON: Renal transplant ultrasound [**2122-2-9**].
RENAL ULTRASOUND: The right lower quadrant transplant kidney
measures 10.6 cm
and demonstrates no evidence of stones, mass, or hydronephrosis.
Vascularity
is normal throughout. Arterial and venous waveforms appear
normal with normal
upstrokes and resistive indices.
IMPRESSION: Normal renal transplant ultrasound.
IMPRESSION:
1) Terminal tip of the NG tube is in small bowel, in close
proximity to the
ligament of Treitz.
2) 4 mm nodular opacity in left mid lung is stable in
appearance. Further
evaluation with CT chest is advised.
Brief Hospital Course:
52 year old female history of Type I DM (no longer on insulin)
s/p kidney/pancreas transplant with altered mental status.
.
# Altered mental status- suspect [**1-20**] benzodiazepine overdose.
Urine tox (+) for benzos. Patient has clorazepate, a
long-acting benzo, on a recent med list. Head CT (-) for ICH.
No recent symptoms concerning for meningitis. No evidence of
cardiac ischemia. No improvement in field with D50 or Narcan.
Unclear if this was an intent to harm self; patient does have
h/o depression per life partner (not husband). In the ICU,
patient's airway was monitored. She never required endotracheal
intubation. No hypercarbia. After 48 hours, mental status
began to improve. Culture data negative to date. FSBGs were
also closely monitored. Prior to improvement in somnolence,
health care proxy was declining lumbar puncture. Patient was
transferred to floor on [**2122-8-12**]. Then became much more
interactive, back to baseline.
.
# Type I DM s/p kidney/pancreas transplant- creatinine 2.8,
slightly above baseline of ~2.5. Patient had adequate urine
output, and creatinine improved to 1.8 upon transfer. Her
creatinine fluctuated between 1.8 and 2.4 based largely on what
her fluid intake was. Her decrease in renal function appeared
to be dehydration. Creatinine has been stable prior to
discharge. Will need monthly cyclosporine levels (inhouse,
appropriate levels). Next level to be checked on [**2122-9-17**] and
sent to Dr. [**Last Name (STitle) **].
.
# Depression, likely Suicidal Ideation - High suspicion for
overdose/intent to harm, with well thought out plan. As mental
status improved, patient had 1:1 sitter. On the floor, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from the Psychiatry service had built a great
report with the patient and offered her anti-depressant therapy,
which she refused.
Once she reached the floor, she remained extremely depressed,
though more interactive. Her HCP and her were initially very
resistant to psychiatry, and became more accepting of it as her
admission went on. She was felt to not be acutely suicidal, and
psychiatry felt she could safely be discharged to an intensive
psych day program.
.
# Elevated CK - likely [**1-20**] benzo overdose. trop (-). will give
D5LR and D5NS overnight at 125 cc/hr. statin overdose less
likely. CK peaked around 750. Her CK trended down to normal
upon discharge.
.
# HTN - Anti-hypertensives have been restarted. Orthostatic
hypotension is likely due to chronic dysautonomia, known to the
patient.
.
# HL - Statin was initially held, then restarted with resolved
CK.
.
# Deconditioning: Patient felt by our physical therapists to be
deconditioned, but she was still able to walk to and from
wheelchair/bathroom. Patient and husband refusing PT. She was
given an outpatient PT script upon discharge, and this should be
discussed again with PCP.
.
#Communication: Ed, partner and HCP, [**Telephone/Fax (1) 108086**]
Medications on Admission:
Codeine unknown dose, not sure if active med
Hydrocodone unknown dose, not sure if active med
Doxazosin 1 mg tab PRN
clorazepate unknown dose
Oxycodone unknown dose, not sure if active med
ranitidine 150 mg [**Hospital1 **]
warfarin 5 mg daily
cyclosporine 75 mg [**Hospital1 **]
Cosopt 0.5% to 2% [**Hospital1 **] OD
prednisolone 1% drops 1 gtt ou qd
prednisone 5 mg daily
pravastatin 10 mg QHS
estradiol 0.01% cream QHS
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO
Q12H (every 12 hours).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Multivitamin Tablet Sig: Five (5) ML PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for Heart
burn.
8. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
11. Pilocarpine HCl 1 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
14. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
15. Estradiol 0.01 % (0.1 mg/g) Cream Sig: One (1) Vaginal at
bedtime.
16. Outpatient Physical Therapy
Evaluation and Treatment
17. Outpatient Lab Work
Please check cyclosporin level on [**2122-9-17**], with results reported
by phone to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Benzodiazepine overdose
Depression
Hypertension
.
Secondary:
Diabetes type 1
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 18**] after taking too many of your
prescription medications. You were monitored in the ICU and had
imaging tests done to make sure there wasn't any trauma to your
brain, and it was normal. You were given medications to help
with symptoms from the medication that you took.
.
You were given fluid to help your kidney function which improved
during admission. Once you were stable you were transferred to
the general medical floor. You were monitored for multiple days
and your lab values were stable, and your kidney function was
better than baseline. You had some dizziness and unsteadiness
on your feet, but this is a chronic problem for you.
.
On discharge, you were medically stable. We did not make any
changes to your medications.
.
IF YOU ARE FEELING LIKE YOU WANT TO HURT YOURSELF OR ANYONE
ELSE, PLEASE CALL 911 OR GO TO THE EMERGENCY ROOM AS SOON AS
POSSIBLE. You were followed by psychiatry as an inpatient, and
they felt you were not in immediate danger of commiting suicide,
but it is very important for you to continue at the partial
hospital program ([**Hospital **] Hospital HRI). You have an appointment
tomorrow.
You are being given a prescription for outpatient physical
therapy. Please discuss this further with your PCP at your
appointment next Tuesday.
Followup Instructions:
[**Hospital **] Hospital HRI
8:30am, [**2122-8-21**]
[**Street Address(2) 4195**]
[**Location (un) **] Ma
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4390**], [**Telephone/Fax (1) 3070**] on
[**2122-8-25**] at 11:30am.
Please follow-up with your renal doctor, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 10248**] on Friday, [**2122-9-25**] at 8:50am.
You will need your cyclosporin level checked monthly. The next
time it will need to be checked is [**2122-9-17**]. You are being
provided with a prescription.
You have the following appointments with ophthamology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2122-9-9**] 10:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2122-10-26**] 1:15
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11616, 11622
|
6619, 9598
|
297, 303
|
11767, 11767
|
3345, 6596
|
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|
2620, 2638
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2653, 3326
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236, 259
|
331, 1876
|
11782, 11926
|
2271, 2466
|
2482, 2604
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,075
| 179,159
|
22682+57311
|
Discharge summary
|
report+addendum
|
Admission Date: [**2116-2-5**] Discharge Date: [**2116-2-17**]
Date of Birth: [**2048-4-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Capsule endoscopy
History of Present Illness:
67M w/ h/o multiple myeloma since [**2111**], neuropathy, bed-bound,
cared for by Dr [**Last Name (STitle) 284**] at [**Company 2860**], last seen at [**Hospital1 18**] in [**2112**],
presented with GI bleed. Patient was at nursing home when maroon
stools were noted by staff members. Patient himself unaware of
rectal bleeding. He denies GI symptoms. He reports slight
lightheadedness. He was transferred from NH to [**Hospital1 **] ED.
In ED, he was tachy in 110s-120s, BP initially was 90/50. His
hct came back at 17.6, and he had a thrombocytopenia of 45,000.
NG lavage did not show blood. Patient was transfused 2U PRBC and
6U Plt. GI was consulted, felt there was no need for scope
tonight. They recommended supportive therapy for now. If active
bleeding, they would want angio / or tagged RBC scan.
ROS: no fever/chills/nausea/vomiting/diarrhea/abdominal pain
Past Medical History:
Per OMR / patient
Multiple myeloma. Diagnosed [**12-3**].
Depression
Schizo-affective disorder
2nd/3rd degree burns to his legs [**2109**]
Seen and being treated for myeloma at [**Company 2860**] by Dr [**Last Name (STitle) 284**].
Social History:
former smoker (1 pack/wk x 30 years). Now quit.
No EtoH use.
Family History:
NC
Physical Exam:
In ICU - VS: 98.7 BP 121/61 HR; 104 RR: 18 100% room air
general: NAD AOx3
HEENT: PERLLA, EOMI, Anicteric, pale
chest: CTA b/l
heart: RR, no murmurs rubs/gallops
abdomen: +b/s, soft, nt, nd
extremities: no edema
skin: multiple skin grafts, healing wounds
rectal guiaic positive
neuro: peripheral neuropathy
Pertinent Results:
[**2116-2-17**] 06:05AM BLOOD WBC-2.9* RBC-3.12* Hgb-9.3* Hct-28.3*
MCV-91 MCH-29.8 MCHC-32.8 RDW-14.7 Plt Ct-52*
[**2116-2-15**] 06:35AM BLOOD WBC-4.1# RBC-3.11* Hgb-9.5* Hct-28.4*
MCV-91 MCH-30.4 MCHC-33.3 RDW-14.6 Plt Ct-18*
[**2116-2-10**] 06:20AM BLOOD WBC-2.4* RBC-3.04* Hgb-9.2* Hct-26.8*
MCV-88 MCH-30.2 MCHC-34.4 RDW-14.7 Plt Ct-39*
[**2116-2-5**] 06:30PM BLOOD WBC-7.8# RBC-1.93*# Hgb-6.1*# Hct-17.6*#
MCV-91# MCH-31.7 MCHC-34.9 RDW-15.3 Plt Ct-45*#
[**2116-2-16**] 07:05AM BLOOD Neuts-67.1 Lymphs-29.1 Monos-1.2* Eos-2.6
Baso-0.1
[**2116-2-5**] 06:30PM BLOOD Neuts-82.1* Bands-0 Lymphs-16.6*
Monos-0.4* Eos-0.4 Baso-0.4
[**2116-2-16**] 07:05AM BLOOD PT-15.0* PTT-33.2 INR(PT)-1.3*
[**2116-2-17**] 06:05AM BLOOD Glucose-107* UreaN-8 Creat-0.8 Na-135
K-3.8 Cl-101 HCO3-24 AnGap-14
[**2116-2-5**] 06:30PM BLOOD Glucose-167* UreaN-37* Creat-1.1 Na-136
K-4.7 Cl-102 HCO3-22 AnGap-17
[**2116-2-5**] 06:30PM BLOOD ALT-53* AST-20 CK(CPK)-21* AlkPhos-281*
TotBili-0.5
[**2116-2-17**] 06:05AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1
[**2116-2-14**] 06:15AM BLOOD Hapto-268*
[**2116-2-5**] 06:38PM BLOOD Hgb-5.4* calcHCT-16
[**2116-2-12**] 11:23AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2116-2-12**] 11:23AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2116-2-12**] 11:23AM URINE RBC-4* WBC-37* Bacteri-MANY Yeast-NONE
Epi-1 TransE-<1
[**2116-2-5**] 11:55PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.011
[**2116-2-5**] 11:55PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2116-2-5**] 11:55PM URINE RBC->50 WBC-21-50* Bacteri-MANY
Yeast-NONE Epi-0-2
[**2116-2-12**] 11:23 am URINE Site: CLEAN CATCH Source: CVS.
**FINAL REPORT [**2116-2-15**]**
URINE CULTURE (Final [**2116-2-15**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- =>64 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Time Taken Not Noted Log-In Date/Time: [**2116-2-5**] 11:55 pm
URINE Site: CATHETER
**FINAL REPORT [**2116-2-10**]**
URINE CULTURE (Final [**2116-2-9**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- =>64 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Pathology Report INVESTIGATION OF TRANSFUSION REACTION Study
Date of [**2116-2-11**]
(ICD9 CODE: 999.8)
INDICATION FOR CONSULT: INVESTIGATION OF TRANSFUSION REACTION
INDICATIONS FOR CONSULT:
Investigation of transfusion reaction
CLINICAL/LAB DATA: Mr. [**Known lastname 14558**] is a 67 y/o man with PMH
significant for
multiple myeloma, DVT and schizophrenia admitted on [**2116-2-5**] for
GI bleeding. Two weeks ago he was admitted to [**Hospital1 112**] for similar
reasons, and he was transfused at that time. He has received
multiple
blood transfusions at [**Hospital1 18**] during this admission with no
previously
reported reactions.
On [**2116-2-11**] at 2215, following premedication with tylenol, Mr.
[**Known lastname 14558**]
was transfused approximately 170 ml of compatible leukoreduced
packed
red blood cells. Pre-transfusion vitals were: T=99.8; HR=99;
RR=20; BP=136/84. The transfusion was stopped at 2330, after his
temperature rose to 101.2. He also developed chills/rigors, but
had no
other symptoms. There were no significant changes in BP, HR and
RR during the transfusion. Of note, on admission, he had a urine
culture positive for Klebsiella Pneumonia. A routine clerical
check
revealed no errors.
Laboratory Data:
Patient ABO/Rh: Group O, Rh positive
Red Cell Product (21KQ[**Pager number 58759**]) ABO/Rh: Group O, Rh positve
Post-transfusion serum: yellow, DAT negative
Transfusion History:
Previous non-reactive red cell transfusions: 7
Previous non-reactive platelet transfusions: 4
Transfusion restriction met: Yes
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS:
Mr. [**Known lastname 14558**] experienced a mild temperature increase of 1.4
degrees F
after receiving 170 ml of a leukoreduced compatible red cell.
Laboratory
workup revealed no evidence of hemolysis. The patient had a
positive urine culture for Klebsiella Pneumonia upon admission.
Given
that leukoreduction significantly decreases the incidence of
febrile
non-hemolytic transfusion reactions, the patient's fever is
likely
secondary to his underlying illness. However, a febrile
non-hemolytic
transfusion reaction cannot be completely ruled out. No change
in
transfusion practice is recommended at this time in this
patient.
ORDERING/ATTENDING MD: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DIAGNOSED BY: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
CONSULTING PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
Cardiology Report ECG Study Date of [**2116-2-6**] 10:28:28 AM
Sinus rhythm with borderline sinus tachycardia
Normal ECG
Since previous tracing of [**2113-1-12**], rate faster, QRS voltage less
prominent and
ST-T wave changes decreased
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
EGD: Findings: Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Other Prominent papilla
Impression: Prominent papilla Otherwise normal EGD to third part
of the duodenum Recommendations: Follow HCT and transfuse as
needed
4L Golytely for colonoscopy tomorrow. Additional notes: There
was no fresh or old blood noted to the third part of the
duodenum. Would proceed to colonoscopy followed by capsule study
if colonoscopy is negative.
We were unable to capture images due to a computer error.
The procedure was done by the attending and GI Fellow.
Colonoscopy - Findings: Excavated Lesions Multiple diverticula
were seen in the sigmoid colon and descending
colon.Diverticulosis appeared to be of moderate severity.
Impression: Diverticulosis of the sigmoid colon and descending
colon Additional notes: The efficiency of colonoscopy in
detecting lesions was discussed in detail with the patient. It
was explained that colon cancer and colon polyps may on rare
occasions be missed during a colonscopy. The attending was
present during the entire procedure Routine Post-Procedure
orders No source of bleeding seen on this exam The patient??????s
reconciled home medication list is appended to this report
Capsule endoscopy read pending.
Brief Hospital Course:
67 year old man with history of advanced multiple myeloma
refractory to multiple treatments, pancytopenia, neuropathy
secondary to Velcade, recurrent UTI's and obscure overt GI
bleeding admitted with GI bleeding. Admit [**2116-2-5**]
GI bleeding/Acute blood loss anemia:
Anemia - baseline HCT 24 (as per oncologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 284**]). Recent EGD/[**Last Name (un) **] at [**Hospital6 **] for source
of bleed. Admitted to ICU here. Given 4 units of blood with
stabilization of hematocrit, resolution of melena. EGD negative
for bleeding soruce. Transferred to floor on [**2-8**]. No further
bleeding. Hematocrit drifted down again to 24 and given one
more unit on [**2-11**]. Colonoscopy without discrete bleeding
source. Capsule endoscopy [**2-13**], results pending at discharge.
hematocrit stable at discharge.
Multiple Myeloma/Pancytopenia: WBC supported by neupogen.
Bactrim and acyclovir discontinued given drop in platelets to
[**Numeric Identifier 7206**]. Transfused with effect on [**2-16**]. Plt to [**Numeric Identifier 58760**]. Crit as
above, stable
Admission discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**], oncologist at
[**Hospital6 **]. Limited remaining options, patient at
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on hospice care.
Hematology consulted here for thrombocytopenia, recommended
transfusions and consideration of steroids once patient treated
for UTI. Patient to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] after
discharge. repeat CBC recommended in [**2-2**] days of discharge.
Overall has poor prognosis and may consider hospice follow up at
facility.
Recurrent UTI's: Found to have ESBL klebsiella on admit to MICU.
Treatment deferred given possibility of chronic colinization
and clinical stability. Patient had foley on admit,
discontinued on [**2-12**] and urine culture re-sent, again growing
>100,000 ESBL klebsiella. Started on meropenem on [**2-14**]. Needs
10 day course to complete [**2-24**]. After this, consideration of
steroids for multiple myeloma as above.
Neuropathy: thought secondary to velcade. Stable throguhout,
patient bed bound.
Pain from myeloma: MS Contin; IV morphine PRN breakthrough pain,
morphine IR a ded.
Psych/schizophrenia: Pt has refused all outpatient psych
medications. Stable throughout without HI, SI, paranoia,
delusions.
Skin grafts/scars from previous burns/Wounds: wound care
maintained.
BPH: patient refuses alpha blocker. continued on finasteride.
Foley initially, d/ced on [**2-12**] with successful voiding trial.
Bactrim stopped as could contibute to pancytopenia and could be
restarted at discretion of PCP/ oncologist.
Case manager discussed with ex-wife [**Name (NI) 15406**] on day of
duischarge re. patient's discharge to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Patient aware
and was agreeable to transfer.
Midline care recommended at [**Location (un) **] [**Doctor Last Name **] as well as follow up
blood work as outlined in page 1.
Medications on Admission:
MS contin
Unclear if taking Morphine IR
neupogen
bactrim MWF
on decadron, off velcade, revlimid since [**2115-12-11**]
prilosec
Procrit
Discharge Medications:
1. Filgrastim 300 mcg/mL Solution Sig: One (1) injection
Injection MWF (Monday-Wednesday-Friday).
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Meropenem 500 mg IV Q6H
4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
5. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Procrit 40,000 unit/mL Solution Sig: One (1) Injection once
a week.
7. Bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
8. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Midline care as needed
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
1. Gastrointestinal bleeding
2. Acute blood loss anemia
3. ESBL klebsiella UTI
4. Multiple myeloma
5. Pancytopenia
6. Neuropathy
7. Schizophrenia
8. BPH
9. Neuropathy
Discharge Condition:
Stable, at baseline, afebrile.
Discharge Instructions:
Follow up as below.
All medications as prescribed. We have discontinued your
acyclovir and bactrim.
Contact your doctor if you develop recurrent blood in your
stool, abdominal pain, fevers, pain or any other new concerning
symptoms.
Intravenous antibiotics are recommended for treatment for urine
infection. To be continued as recommended.
A repeat blood work (CBC, LFT, BUN/creatinine) will be required
in [**2-2**] days at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Followup Instructions:
Follow up with your oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] [**Telephone/Fax (1) 58761**]
at [**Hospital6 **] / [**Hospital3 328**] cancer institute -
within one week of discharge from hospital.
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1355**] [**Telephone/Fax (1) 45347**] - follow up with your primary care
doctor in 1 week.
Name: [**Known lastname 887**],[**Known firstname **] Unit No: [**Numeric Identifier 10827**]
Admission Date: [**2116-2-5**] Discharge Date: [**2116-2-17**]
Date of Birth: [**2048-4-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1455**]
Addendum:
Called at about 5pm by RN - [**Doctor First Name **] that the nursing home had
called back stating that the midline catheter site was bleeding
and the nurse at nursing home did not know how to manage it or
change dressing. Discussed with [**Doctor First Name **] (RN on 11 [**Hospital Ward Name **]) who
informed me that the midline dressing was changed before
discharge and no active bleed was noted at the time of discharge
/ ambulance arrival. [**Doctor First Name **] had advised the nurse [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] to seek assistance from their IV team or call the physician
there for further evaluation.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Name6 (MD) **] [**Last Name (NamePattern4) 1456**] MD [**MD Number(2) 1457**]
Completed by:[**2116-2-17**]
|
[
"357.6",
"906.7",
"600.00",
"285.1",
"724.2",
"578.9",
"562.10",
"203.00",
"284.1",
"599.0",
"E933.1",
"E959",
"295.70",
"041.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13",
"99.05",
"99.04",
"45.19"
] |
icd9pcs
|
[
[
[]
]
] |
16980, 17211
|
10419, 13561
|
323, 359
|
14909, 14942
|
1953, 10396
|
15487, 16957
|
1606, 1611
|
13748, 14583
|
14719, 14888
|
13587, 13725
|
14966, 15464
|
1626, 1934
|
275, 285
|
387, 1257
|
1279, 1512
|
1528, 1590
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,359
| 137,873
|
980
|
Discharge summary
|
report
|
Admission Date: [**2102-2-13**] Discharge Date: [**2102-3-6**]
Date of Birth: [**2023-2-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Leukocytosis, fever, altered mental status
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Central line placement
Arterial Line placement
History of Present Illness:
Briefly, pt is a 78 year old male admitted from a [**Hospital1 1501**] with
persistent leukocytosis and a febrile epsiode. Pthad WBC of 30
on [**2-7**] and was started on levaquin for presumed urinary tract
infection, although his urine culture was polymicrobial in
nature. His WBC had trended down to 8, but yesterday he had a
fever to 100.7 and his WBC increased to 12.1. Pt is largely
non-verbal and was unable to participate in the interview.
Of particular note, pt was previously admitted in
[**Month (only) 359**]/[**2101-12-6**] after he sustained a fall complicated by
C1/C2 fractures and bilateral intraparenchymal hemorrhages, now
s/p G-tube placement. This hospitalization was also complicated
by bradycardia to the 30s, with baseline HRs in the 50s in
atrial fibrillation. Donepezil was held due to AV nodal effects
and TTE was unremarkable with a normal EF >55%. Cardiology was
consulted and considered pacemaker placement at the time.
In the ED, initial VS: 98.8 72 110/74 20 96% 2L. He was given
acetaminophen and IVFs. Repeat labs showed a leukocytosis to
13.8 without a bandemia and a mild transaminitis. RUQ U/S showed
2cm non-obstructing gallstone without gallbladder wall edema or
pericholecystic fluid (CBD not visualized). CXR was without
consolidation concerning for PNA. U/A showed significant blood,
but only 14 WBCs and small leuk esterase with no bacteria (on
levofloxacin). Vitals on transfer were: Temp: 98.7, Pulse: 80,
RR: 18, BP: 118/84, O2Sat: 97, O2Flow: RA.
On the floor, he is non-verbal and is difficult to assess any
pain or discomfort.
The patient developed increasing secretions on the floor
complicated by cardiopulmonary arrest. He was intubated and
resuscitated with return of spontaneous circulation after two
rounds of chest compressions. He was transfered to the ICU, then
made CMO and transfered to the floor after extubation.
Past Medical History:
-atrial fibrillation with bradycardia; being considered for
pacemaker placement
-Parkinson's disease c/b dementia
-BPH with urinary retention, indwelling foley in place from [**Hospital1 1501**]
-HTN
-hyperlipidemia
-s/p fall with C1 bilateral arch fx, C2 type 2 odontoid fx,
nasal bone fx, and b/l intraparenchymal hemorrhage ([**Month (only) **]
[**2101**])
-s/p G-tube placement
Social History:
Lives in [**Hospital 6503**] nursing home ([**Hospital1 **]). Previously lived with
wife in the community. No tobacco or EtOH use per records. Per
nursing at [**Name (NI) 1501**] pt is able to occasionally answer yes/no
questions, although not appropriately.
Family History:
unable to obtain
Physical Exam:
ADMISSION EXAM
VS - Tmax 97.9 Tc 96.2, BP 122/69 (104-122/55-69), HR 72-73, R
18, 96% RA O:900
GENERAL - ill-appearing male in mild distress, non-verbal, opens
eyes to voice (L>R), unable to follow any commands
HEENT - sclerae anicteric, dry mucous memebranes
NECK - [**Location (un) 2848**] J collar in place
LUNGS - difficult to ascultrate, but clear
HEART - soft heart sounds, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding; G-tube site is erythematous without purulence
or induration
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - mild excoriations over elbows bilaterally, G-tube site as
above, small tear on sacrum without surrounding erythema
NEURO - awake, unable to assess orientation, UEs with severe
contractions.
DISCHARGE EXAM
No pupillary reflex, no response to painful stimuli, absent
pulse and breath sounds. Expired 1:30 PM [**2102-3-6**]
Pertinent Results:
ADMISSION LABS
[**2102-2-13**] 02:30PM BLOOD WBC-13.8*# RBC-5.00# Hgb-15.5 Hct-45.9#
MCV-92 MCH-31.0 MCHC-33.7 RDW-14.2 Plt Ct-241
[**2102-2-13**] 02:30PM BLOOD Neuts-75.9* Lymphs-17.8* Monos-4.8
Eos-0.9 Baso-0.5
[**2102-2-14**] 07:00AM BLOOD PT-12.9* PTT-27.8 INR(PT)-1.2*
[**2102-2-13**] 02:30PM BLOOD Glucose-127* UreaN-36* Creat-0.9 Na-144
K-4.4 Cl-109* HCO3-26 AnGap-13
[**2102-2-13**] 02:30PM BLOOD ALT-73* AST-58* LD(LDH)-172 AlkPhos-96
TotBili-0.3
[**2102-2-13**] 02:30PM BLOOD Lipase-28
[**2102-2-14**] 07:00AM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.1 Mg-2.3
[**2102-2-13**] 02:37PM BLOOD Lactate-1.8 K-4.3
DISCHARGE LABS
[patient expired]
Cultures:
[**2102-2-13**] 2:25 pm URINE Site: CATHETER
**FINAL REPORT [**2102-2-15**]**
URINE CULTURE (Final [**2102-2-15**]): NO GROWTH
CXR [**2-13**]:
FINDINGS: AP upright and lateral views of the chest are
obtained. The lungs appear clear without focal consolidation,
effusion, or pneumothorax.
Cardiomediastinal silhouette appears stable with unfolded
thoracic aorta again noted. Bony structures appear intact. There
is no free air below the right hemidiaphragm.
IMPRESSION: No signs of pneumonia
CT Head w/out contrast [**2-14**]:
IMPRESSION:
1. Evolution of the previously noted frontal contusions.
2. Focal area of increased attenuation in the left temporal
region,
extra-axial in location, which may relate to the adjacent part
of the left transverse sinus or small subdural hemorrhage.
Consider close followup to assess stability and to exclude
hemorrhage in this location. Study limited due to motion-related
artifacts.
RUQ US [**2-13**]:
IMPRESSION:
1. Limited evaluation of the liver and gallbladder due to
difficulty with
patient positioning and interference with existing feeding tube.
2. Distended gallbladder with a 2.0 cm gallstone. No
pericholecystic fluid or gallbladder wall thickening seen. The
patient could not be evaluated for son[**Name (NI) 493**] [**Name2 (NI) 515**] sign.
Aside for gallbladder distention, no definite secondary signs of
acute cholecystitis, but exam is suboptimal. HIDA scan could be
considered for further evaluation.
EEG [**2102-2-22**]
This is an abnormal continuous ICU monitoring study because
of continuous spike and wave and polyspike and wave discharges,
ranging
from [**4-11**] Hz, some of which correlate with myoclonic jerk of the
body on
video. These findings are consistent with myoclonic seizures,
and in
the setting of post-anoxia, portend a very poor prognosis. Over
the
course of recording, generalized epileptiform discharges
persisted
without clear improvement.
MRI HEAD W/O CONTRAST [**2102-2-23**]
1. No acute infarct.
2. Generalized cerebral volume loss with changes of chronic
small vessel
ischemic disease.
3. Numerous microhemorrhages in bilateral cerebral hemispheres,
which likely represent changes of amyloid angiopathy.
4. Chronic- appearing odontoid fracture of undetermined age.
Brief Hospital Course:
Mr. [**Known lastname 6504**] is a 79y/o gentleman with Parkinson's dementia s/p
recent fall with intraparenchymal hemorrhage and C1/C2 fractures
who presented with persistent leukocytosis and isolated fever,
likely due to urinary tract infection. He had a PEA arrest, was
intubated, and was transferred to the MICU. Neurology was
consulted for myoclonic movements and EEG confirmed that these
were likely myoclonic seizures in the setting of anoxic brain
injury, with a dismal prognosis. Family meetings were held, and
the decision was made to make the patient CMO. He was extubated
on [**2102-3-2**] and expired on [**2102-3-6**].
Medications on Admission:
-carbidopa-levodopa 25-100 mg per GT TID
-Namenda 5 mg per GT [**Hospital1 **]
-Bowel regimen: Fleet enema PRN, Dulcolax 10mg PRN, MoM 30ml PRN
-Maalox 30ml q6h PRN GI distress
-Heparin SC 5000 units TID
-albuterol nebs PRN congestion
-levaquin 500mg daily (started on [**2102-2-7**])
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
|
[
"427.31",
"E849.7",
"934.9",
"V49.86",
"600.01",
"331.82",
"599.0",
"788.20",
"518.81",
"331.4",
"V15.88",
"997.31",
"401.9",
"V66.7",
"E879.8",
"427.89",
"E912",
"345.10",
"294.10",
"V44.1",
"277.39",
"437.9",
"427.5",
"458.9",
"348.1",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"96.04",
"38.93",
"96.6",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
7993, 8002
|
6978, 7617
|
347, 419
|
8061, 8078
|
4003, 6955
|
8142, 8160
|
3025, 3043
|
7953, 7970
|
8023, 8040
|
7643, 7930
|
8102, 8119
|
3058, 3984
|
264, 309
|
447, 2327
|
2349, 2733
|
2749, 3009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,898
| 194,531
|
38246
|
Discharge summary
|
report
|
Admission Date: [**2186-8-2**] Discharge Date: [**2186-8-21**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
Coffee ground emesis + tarry ostomy output x 1 day
Major Surgical or Invasive Procedure:
- Nasogastric tube insertion x3
- EGD w/ suction to remove ~2.5 L
History of Present Illness:
Ms. [**Known lastname 4702**] is an 88 year-old woman from [**Hospital 100**] Rehab with a past
history of hypertension, colon cancer post-resection/ileostomy,
coronary artery disease post-stenting ([**July 2185**]) and previous GI
bleeding ([**2185**]) that presented to the ED with a history of two
episodes of coffee-ground emesis at her nursing home and general
lethargy for the past 1-2 days; she had her first emesis on
[**7-31**] during her breakfast, and so was changed to a clear liquid
diet. This vomitting then subsided on [**8-1**]; however, on the
morning of [**8-2**], she had her first bout of coffee ground emesis
despite the minimal PO intake and was found to have developed
melena in her ostomy bag. She later had another episode of
coffee ground emesis, and was therefore transferred to the ED.
After initial management in the ED, she was transferred to the
ICU for management of her renal failure and observation of her
hemodynamic status.
.
In the emergency department at [**Hospital1 18**], Ms. [**Known lastname **] initial vital
signs were: T:97.7 HR:86 BP:96/72 RR:16 O2 Sat:99%. She was
hemodynamically stable, with a hematocrit of 39, which is her
baseline. Of note, she was found to have melena that was guaiac
positive in her ileostomy bag, which was leaking. She refused
the placement of a nasogastric tube, but was typed and crossed
for 2 units of blood and given 80 mg IV protonix bolus followed
by 8 mg protonix IV/hr gtt. An ECG was performed that showed no
changes from previous ECGs. One 18 and one 20 gauge cannula was
inserted for access. GI was consulted and noted her hemodynamic
stability and refusal of placement of a nasogastric tube. In
addition, they stated that the patient would need an
esophagogastroduodenoscopy (EGD) under monitored anesthesia care
(MAC) given her CAD and ARF.
.
On the floor, her vital signs were T: 97.2, HR: 91, BP: 112/49,
RR: 21. A new ileostomy bag was fitted and she was again seen by
GI, who repeated the above recommendations. She continued to
suffer from nausea and vomitted low volumes of liquid several
times which was blood-streaked and bilious.
Of note, per nursing home staff, baseline mental status is
stable confusion, but oriented x3. Per her nephew, the patient
has been having progressively worsening confusion and decreased
attentiveness over the past several months, and has also been
experiencing falls with increasing frequency (~[**1-22**]/month).
.
Review of systems:
(+) Per HPI, otherwise, patient not participating in interview
Past Medical History:
- Peripheral neuropathy on neurontin, tylenol
- Alzheimer disease
- CAD s/p RCA STEMI in [**2185-7-21**], s/p BMS x2
- Colon cancer, s/p resection, ileostomy
- Depression
- Anemia, B12 deficiency
- s/p cataract extraction
- Rhinitis
- Macular degeneration
- hx paranoid delusions
- hx incisional hernia
- hx falls
.
Cardiac Risk Factors: - Diabetes, - Dyslipidemia, +Hypertension
Social History:
Pt is a retired navy nurse, currently lives in [**Location 85247**]. Her nephew
is only family in area and his wife works as MA at [**Hospital1 18**]
[**Name (NI) **]. Remote smoking hx with no history of alcohol or
illicit drug consumption.
Family History:
Non-remarkable
Physical Exam:
Admission Exam:
Vitals: T: 97.2, BP: 117/44, P: 88, RR: 26 O2: 99% on RA
General: Patient was sleepy but arousable, oriented for some
time yet unable to maintain orientation; looks tired yet able to
converse freely (albiet delusional) barring vomitting/nausea
episodes
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly; ostomy in
left lower quadrant of abdomen
GU: no foley
Ext: cold with 2+ pulses, no clubbing, cyanosis or edema;
capillary refill normal
Discharge:
Pertinent Results:
CT ABD & PELVIS WITH CONTRAST Study Date of [**2186-8-3**]
IMPRESSION:
1. Findings suggesting small bowel obstruction with a transition
in caliber
of mid to distal small bowel in the mid pelvis. There is
potentially some
enteric contrast passing through, however, so the obstruction
may be partial.
2. Large midline abdominal hernia containing portions of the
stomach and the
small bowel, but no obstruction noted inside the hernia.
3. Left lower lobe consolidation.
CHEST (PORTABLE AP) Study Date of [**2186-8-5**]
There is diffuse opacification in almost the entire left lung
and some opacification in the right lower lung. None of these
were present on the previous chest x-ray of [**8-5**]. These
could represent diffuse aspiration
pneumonia.
CHEST (PORTABLE AP) Study Date of [**2186-8-8**]
Again seen is a diffuse left lung opacities which is unchanged
since [**2186-8-5**]. This could represent combination of diffuse aspiration and
pleural
effusion. On the right side there is mild effusion with
atelectasis of
adjacent lung is new since [**2186-8-5**] Right upper lung is
clear.
Mediastinum could not be evaluated due to left lung opacities
obscuring the
margins on left side.
____________________________________________
VIDEO OROPHARYNGEAL SWALLOW Study Date of [**2186-8-9**]
FINDINGS: Penetration and likely silent aspiration was observed
with thin
barium. For further details, please refer to the speech and
swallow division note in online medical record.
IMPRESSION: Penetration and likely silent aspiration with thin
barium.
OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION
EVALUATION:
An oral and pharyngeal swallowing videofluoroscopy was performed
today in collaboration with Radiology. Thin liquid,
Nectar-thick
liquid, pureed consistency barium, [**1-22**] of one cookie coated with
barium and one barium pill were administered. Results follow:
ORAL PHASE:
Bolus formation, bolus control, base of tongue retraction, and
mastication were mildly impaired. Oral transit was timely. Mild
oral cavity residue was noted on the tongue with liquids,
mild-moderate with solid. Residue cleared with f/u sips of
liquid. Premature spillover was noted with thin and nectar-thick
liquids to the valleculae and intermittently to the pyriform
sinuses.
PHARYNGEAL PHASE:
Swallow initiation was intermittently mildly delayed most
frequently with nectar-thick liquids. Velar elevation,
epiglottic
deflection, bolus propulsion, and UES relaxation were WFL.
Laryngeal elevation and laryngeal valve closure were mildly
impaired, and valve closure was frequently slow. No residue was
noted in the pharynx.
ESOPHAGEAL SCREENING:
The barium table passed freely through the pharynx. However, it
was noted to remain in the mid-esophagus and did not clear with
sips of thin liquid or bites of puree.
ANTERIOR TO POSTERIOR POSITION:
Not performed due to pt positioning.
ASPIRATION/PENETRATION:
Penetration occurred before the height of the swallow with thin
liquid due to slow laryngeal valve closure. Penetration did not
completely clear spontaneously, over 90% cleared with cued
throat
clear. Pt did have spontaneous throat clear intermittently in
response to penetration. Unable to fully visualize the airway
due
to pt positioning; however, given trace amounts of uncle[**Name (NI) **]
penetration noted, pt is at risk for intermittent trace
aspiration.
TREATMENT TECHNIQUES:
Cue to take small sip with cup rather than straw was effective
for preventing penetration.
SUMMARY:
Ms. [**Known lastname 4702**] presented with a mild oropharyngeal dysphagia as
characterized above. She is at risk for intermittent trace
aspiration with thin liquids, but risk is significantly reduced
with aspiration precautions listed below. Recommend PO diet of
thin liquids and soft solids with strict aspiration precautions.
Large pills should be cut or crushed as barium tablet was noted
to remain in the mid-esophagus on today's exam. However, pt is
safe to take smaller pills whole. Please call, page, or
re-consult if we can be of further assistance with this pt's
care.
RECOMMENDATIONS:
1. PO diet: thin liquids, soft solids.
2. Large pills cut or crushed, smaller pills whole with water or
applesauce.
3. 1:1 supervision with meals to maintain aspiration precautions
including:
a. Liquids by cup only, NO STRAWS.
b. Cue/remind pt to take small sips.
c. Alternate bites/sips as needed to clear oral residue.
4. TID oral care.
5. Please call, page, or re-consult if we can be of further
assistance with this pt's care.
_____________________________________________________
CTA HEAD W&W/O C & RECONS Study Date of [**2186-8-11**]
CTA NECK W&W/OC & RECONS Study Date of [**2186-8-11**]
IMPRESSION:
1. Prominent ventricles and sulci likely related to age.
Confluent white
matter hypodensity likely related to small vessel ischemic
disease.
2. Prominent right PCOM, most likely infundibular dilatation.
3. Focal area of ectasia in the left ACA. A tiny aneurysm cannot
be excluded.
4. Consolidation of the left upper lobe, likely related to
infectious
process.
5. Asymmetrically enlarged and heterogeneous thyroid gland,
stable from prior study.
[**2186-8-2**] 12:00PM BLOOD WBC-18.1*# RBC-4.10* Hgb-12.9 Hct-39.0
MCV-95 MCH-31.4 MCHC-33.0 RDW-13.9 Plt Ct-357#
[**2186-8-10**] 07:25AM BLOOD WBC-10.5 RBC-2.95* Hgb-9.4* Hct-28.2*
MCV-96 MCH-31.8 MCHC-33.3 RDW-12.8 Plt Ct-295
[**2186-8-11**] 05:00AM BLOOD Glucose-104* UreaN-15 Creat-1.0 Na-140
K-3.5 Cl-106 HCO3-26 AnGap-12
[**2186-8-6**] 07:03AM BLOOD proBNP-[**Numeric Identifier 85248**]*
[**2186-8-3**] 04:23AM BLOOD CK-MB-4 cTropnT-<0.01
[**2186-8-2**] 08:30PM BLOOD CK-MB-3 cTropnT-0.02*
[**2186-8-2**] 12:00PM BLOOD cTropnT-0.05*
[**2186-8-11**] 05:00AM BLOOD Mg-1.6 Cholest-134
[**2186-8-2**] 08:30PM BLOOD Albumin-4.1 Calcium-8.7 Phos-5.8*# Mg-2.2
Iron-29*
[**2186-8-2**] 08:30PM BLOOD calTIBC-276 Ferritn-148 TRF-212
[**2186-8-11**] 05:00AM BLOOD Triglyc-169* HDL-21 CHOL/HD-6.4
LDLcalc-79
[**2186-8-11**] 05:00AM BLOOD TSH-0.92
URINE CULTURE (Final [**2186-8-9**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/Tazobactam REQUESTED PER DR [**Last Name (STitle) 73863**] ([**Numeric Identifier 73864**])
[**2186-8-6**].
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
88 yo F with CAD, dementia, distant colon CA s/p ileostomy
admitted with nausea and vomiting due to a partial SBO,
coffee-ground emesis with complications of acute renal failure,
A Fib, aspiration pneumonia, and probable TIA.
# NAUSEA/VOMITTING/GIB: The patient initially presented with
nausea and vomiting from her extended care facility. There were
reports of coffee-grounds in the emesis and in her ostomy bag.
She presented with Hct above her baseline due to volume
depletion. With volume rescucitation, her Hct declined back to
her baseline anemia and stabilized. She did not have ongoing
signs of bleeding. She underwent EGD that did not show a source
of bleeding. It is possible that she suffered minor
[**Doctor First Name **]-[**Doctor Last Name **] tears due to vomiting but the problem resolved
spontaneously and had no identifiable source on endoscopy. She
was restarted on her home aspirin prior to discharge and will
continue on pantoprazole.
# SBO: The patient was found on abdominal x-ray and CT to have a
partial SBO. She was managed conservatively with NG-tube
decompression, IV fluids and anti-emetics. Her symptoms resolved
and she was started on a liquid diet. Surgery consult service
felt that her partial SBO improved however thought that her
obstruction was likely due to bowel within her large ventral
abdominal hernia. The surgery consult service recommended
surgical repair of the hernia for definitive therapy to prevent
recurrence if this is consistent with the patient's goals of
care. Her health care proxy is considering this option.
The patient developed extrusion of small bowel through her
ostomy, likely due to increased intra-abdominal pressure. The
surgery consult service saw this and recommended that without
signs of ischemia or necrosis this can be managed with just
conservative therapy and monitoring. She continued to make stool
without problems during this admission.
# AFIB/RVR: The patient developed tachycardia to 120-150 with
new onset Afib while in the ICU. Her HR was initially difficult
to control, and required significant medication titration.
Cardiology was consulted, and assisted with medical management.
They recommended full anticoagulation for atrial fibrillation
given concern for a possible TIA during the admission, however,
after further discussion with Neurology, who states that even if
pt had a TIA (which is not clear), that would have been due to
small vessel disease and not cardioembolic, and given her recent
GI bleed, they recommended treatment with antiplatelet [**Doctor Last Name 360**]
such as aspirin or plavix. For now she continues on aspirin
therapy only. Consideration can be made in the future for
initiation of anticoagulation though given the patient's
advanced age and multiple medical problems, the risks and
benefits must be carefully considered. She continues on oral
metoprolol and diltiazem. During the admission, she
spontaneously converted to sinus rhythm, and at the time of
discharge she is in sinus.
# PNEUMONIA: The patient developed CXR findings suggestive of
aspiration PNA. She was treated with Vancomycin and Pip/Tazo
(course complete), with improvement. A swallow evaluation was
performed, with some evidence of silent aspiration on video
swallow, however, S&S cleared pt for a modified diet. Please
see evaluation in Results section.
# TIA: During the admission, she was noted to have an episode of
acute neurologic changes, with slurred speech and possible word
finding difficulties. The stroke team was consulted and
head/neck imaging was obtained. Imaging did not show evidence
of a stroke. The Neurology team recommended treatment with
antiplatelet agents such as full dose aspirin or Plavix. Her
aspirin dose was increased to 325 mg, per their recommendations.
The risks and benefits of full anticoagulation were discussed
with the [**Hospital 228**] health care proxy, [**Name (NI) **] [**Name (NI) 32661**], who agreed
to pursue aspirin therapy.
# Renal Failure / Obstruction: She developed acute kidney injury
with a rise in her Creatinine to 2.6. Kidney ultrasound showed
new bladder distention and bilateral moderate hydronephrosis. A
Foley catheter was placed. Subsequent ultrasound showed
resolution of hydronephrosis, and the catheter was removed. The
acute kidney injury was likely from a combination of dehydration
and postrenal obstruction from bladder overdistention and
overflow incontinence. Foley was pulled and she was able to
produce some urine, but after 1-2 days accumulated PVRs of 500cc
and refused fequent straight cath. Foley was replaced and
should stay in until she follows-up with urology (see attached).
UA prior to foley being replaced was notable for 15 WBCs and <1
epi. Urine culture was negative.
# GOALS OF CARE: She refused some food and medications. Given
her frailty and poor appetite, it was communicated to her health
care proxy, [**Name (NI) **] [**Name (NI) 32661**], that her overall functional status is
quite poor. Mr. [**Name13 (STitle) 32661**] said that he and his family would think
about goals of care and desire for future hospitalizations. He
is considering DNH/CMO status in the future, but she is
currently only DNR.
# B12: The patient has a history of B12 deficiency, peripheral
neuropathy and continues on her home med regimen for these
problems.
# DEMENTIA/AGITATION: The patient has Alzheimer's dementia and
depression. She is poorly oriented at baseline and did
intermittently require olanzapine PRN and haldol PRN and
transient physical restraints to prevent pulling of NG tube and
IV's. Currently doing well on low dose haldol [**Hospital1 **].
# Diastolic HEART FAILURE: Currently euvolemic with controlled
blood pressure.
Medications on Admission:
- Cyanocobalamin (Vit B12) 250 mcg daily
- Zyprexa (olanzapine) 2.5 mg
- Cholecalciferol 1000 units QPM
- Fergon (FeSO4) 325 mg [**Hospital1 **]
- Omeprazole 20 mg daily
- Gabapentin 100 mg QAM
- Gabapentin 200 mg QPM
- Tylenol (acetaminophen) 650 mg Q8H PRN
- Calcium Carbonate 650 mg daily
- Zinc Oxide once daily
Discharge Medications:
1. ipratropium bromide 0.02 % Solution Sig: One (1) PUFF
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
3. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
INJECTION Injection TID (3 times a day).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. haloperidol 0.5 mg Tablet Sig: half Tablet PO TID (3 times a
day) as needed for agitation.
11. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Partial SBO
Upper GI bleed
Atrial fibrillation
Aspiration pneumonia
Probable TIA
Acute renal failure
Hypertension
CAD
B12 deficiency anemia
Dementia, Alzheimer's
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with nausea and vomiting due to a blockage of
the bowels. This was managed conservatively, and it improved.
You also had signs of blood in the vomit and stool, for which
you underwent EGD, but they did not find any source of bleed.
It was suspected that the bleed may be due to forceful vomiting.
You developed a rapid, irregular heart rhythm called atrial
fibrillation while in the hospital. You were treated with
medication to control your heart rate, and this improved.
You also developed a pneumonia, likely due to aspiration. You
were treated with antibiotics and this improved.
During the admission, you may have had a TIA (also known as a
"mini stroke"). You were followed by Neurology, and they
recommended that you stay on a full dose aspirin, as long as you
do not have further issues with GI bleeding.
You had an overdistended bladder, which increased the pressure
on your urinary tract and kidneys, and affected your kidney
function. This improved after we placed a catheter to drain
your bladder. We attempted to remove this catheter but were
unable to do so because you continued to accumulate fluid in
your bladder. You will have to follow-up with a urologist as
below.
Followup Instructions:
Urology:
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2186-9-21**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11307**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2186-8-21**]
|
[
"331.0",
"584.9",
"356.9",
"599.0",
"362.50",
"V45.82",
"266.2",
"276.9",
"401.9",
"276.50",
"414.01",
"276.7",
"530.7",
"041.6",
"435.9",
"412",
"V44.2",
"428.0",
"787.22",
"427.31",
"294.10",
"507.0",
"552.20",
"428.31",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
18517, 18583
|
11392, 17111
|
265, 333
|
18790, 18790
|
4384, 11369
|
20203, 20642
|
3566, 3582
|
17477, 18494
|
18604, 18769
|
17137, 17454
|
18965, 20180
|
3597, 4365
|
2823, 2887
|
175, 227
|
361, 2804
|
18805, 18941
|
2909, 3290
|
3306, 3550
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,341
| 168,977
|
39551
|
Discharge summary
|
report
|
Admission Date: [**2138-9-10**] Discharge Date: [**2138-9-23**]
Date of Birth: [**2080-5-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right lower lobe lung cancer.
Major Surgical or Invasive Procedure:
[**2138-9-10**]: Right thoracotomy and right middle lobe/right
lower lobe bilobectomy with bronchoplastic closure;
mediastinal lymph node dissection; intercostal muscle flap
buttress.
History of Present Illness:
The patient is a 58-year-old woman with a biopsy-proven right
lower lobe lung cancer. This was noticed endobronchially in the
bronchus intermedius,
coming right up to the undersurface of the takeoff of the right
upper lobe.
Past Medical History:
COPD
Depression
Right Hip Replacement [**2135**]
Breast Implants several years ago
Social History:
[**11-23**] to 1 ppd x > 40 years. Cut down to 1/2 pack per day over the
past year. Drinks at least two beers per day. Denies drug use.
Works in an office job. Two grown healthy children.
Family History:
Mother died of lung cancer in her late 60s-early 70s. She was a
smoker. Father died of [**Location (un) 6988**] disease.
Physical Exam:
VS: T: 96.8 HR: 89 Sr BP: 112-125/70 Sats: 100% 2L
General; 58 year-old female in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: decrease breath sounds right lower lobe, left scattered
faint crackles
GI: benign
Extr: warm no edema
Incision: right thoracotomy site clean, dry, intact, margins
well approximated
no erythema
Neuro: awake, alert, oriented. moves all extremities.
Pertinent Results:
[**2138-9-22**] WBC-8.3 RBC-3.88* Hgb-10.5* Hct-33.3 Plt Ct-569*
[**2138-9-10**] WBC-9.3 RBC-3.79* Hgb-10.6* Hct-32.2 Plt Ct-615*
[**2138-9-23**] Glucose-100 UreaN-23* Creat-0.6 Na-138 K-5.3* Cl-97
HCO3-32
[**2138-9-22**] Glucose-122* UreaN-25* Creat-0.5 Na-139 K-5.1 Cl-98
HCO3-32
[**2138-9-21**] Glucose-138* UreaN-27* Creat-0.6 Na-144 K-4.6 Cl-100
HCO3-32
[**2138-9-10**] Glucose-124* UreaN-12 Creat-0.5 Na-138 K-4.4 Cl-106
HCO3-22
[**2138-9-15**] CK(CPK)-99 x 3
[**2138-9-15**] CK-MB-2 cTropnT-<0.01 x 3
Micros:
Ucx [**2138-9-14**] no growth
BC [**2138-9-14**] no growth
BAL [**2138-9-14**] no growth
CXR:
[**2138-9-20**]: Again seen is a small- to moderate-sized right
effusion with
underlying collapse and/or consolidation. Chain sutures and
surgical clips at the right base. Previously described right
apical and right medial base
pneumothoraces are likely still present. Diffusely increased
interstitial
markings in the left lung are again seen, as is some increased
retrocardiac density.
[**2138-9-18**]: As compared to the previous radiograph, the patient
has been
extubated. The nasogastric tube remains in place, constant
position of the
other monitoring and support devices, including the two
right-sided chest
tubes. The extent of the diffuse left parenchymal opacity and
the right lung changes. Unchanged size of the cardiac
silhouette.
CCT [**2138-9-14**]: IMPRESSION:
1. No evidence of PE.
2. Moderate right pleural effusion, right pneumothorax (chest
tube in place) and moderate right chest wall subcutaneous
emphysema.
3. Diffuse left lower and upper lobe ground-glass opacities with
interlobular septal thickening and multifocal opacities.
Differential diagnosis includes multifocal pneumonia, pulmonary
hemorrhage, and/or asymmetric edema.
Brief Hospital Course:
Mrs. [**Known lastname 46214**] was admitted for Right thoracotomy and right middle
lobe/right
lower lobe [**Hospital1 **] lobectomy with bronchoplastic closure; mediastinal
lymph node dissection; intercostal muscle flap buttress. She
was extubated in the operating room, monitored in the PACU
overnight for hypovolemia manifested by hypotension requiring
low dose pressors for support. She was transferred to the SICU
for further monitoring. Over the next 24 hrs she titrated off
pressors with blood pressures in the 90-100's. She transferred
to the floor on [**2138-9-12**]. She did well until [**2138-9-14**] when she
developed respiratory failure transferred to the SICU for
intubation and bronchoscopy with BAL. CCT was done and revealed
left-sided pneumonia. She was started on broad spectrum
antibiotics, Vancomycin, cefepime and Cipro. Again she was
hypotensive requiring pressors, albumin and IV fluids. Her
volume status improved over the next 24 hrs and she wean off
pressors. She slowly improved and was transfer to the floor on
[**2138-9-21**].
Respiratory: extubated [**2138-9-17**]. With aggressive pulmonary
toilet, nebs, incentive spirometer her oxygenation improved 94%
on 3-4L nasal cannula. She de sats to 88-90% with activity and
would benefit from intensive pulmonary rehab. Recent spirometry
preoperative FEV1 68% predicted, FEV1/FVC 93% predicted.
Chest-tube: anterior apical and a posterior basilar [**Doctor Last Name 406**] drain.
On [**2129-9-11**] the chest film showed residual right fluid
collection for which a chest tube was placed and drained 260 cc
of serosanguinous fluid then removed on [**2138-9-12**]. The anterior
apical and posterior [**Doctor Last Name 406**] drains were placed to bulb suction
and once drainage declined were removed on [**2138-9-19**].
Chest films: she was followed by serial chest films which showed
slowly improving left pulmonary alveolar opacity. (see above
reports)
Cardiac: she remained in sinus rhythm 90-100. Once the
hypotension resolved she remained hemodynamically stable with
blood pressures of 110-140's.
GI: PPI and bowel regime.
Nutrition: Doboff was placed on [**2138-9-16**] and tube feeds were
started. Speech was consulted and on [**2138-9-18**] recommended
Continue with Dobbhoff as primary means of nutrition,hydration,
and medication, small volumes of thin liquids and pureed or
ground solids for comfort/pleasure and 1:1 supervision for all
PO intake until her mental status improved. Speech re-evaluated
her on [**2138-9-22**] and recommended a regular diet with thin liquid
and aspiration precautions. Head of the bed elevated 30 degrees
at all times and up to chair for all meals. She was seen by
nutrition on [**2138-9-22**] who recommended ensure plus with meals and
encouragement.
Renal: Foley was removed on [**2138-9-22**]. good urine output with
normal renal function. Her electrolytes were replete as needed.
ID: 7 day course of Vancomycin, Cefepime and Cipro were
completed. She was pan cultured which were all negative.
Pain: Epidural Bupivacaine and Dilaudid managed by the acute
pain service was removed on [**2138-9-14**]. She was converted to IV
pain medication transition to PO with good control.
Neurologic: She was slow to recover from sedation following
extubation but returned to baseline. Awake, alert and oriented
with no deficits.
Disposition: she was seen by physical therapy. She was
discharged to [**Hospital 5503**] [**Hospital **] Hospital [**Telephone/Fax (1) 86783**].
Medications on Admission:
advair 100/50 inh [**Hospital1 **], albuterol [**11-23**] puff inh qid, zoloft 100mg
po daily
MVI, Ca with vit D, prn aspirin
Discharge Medications:
1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) SC
Injection TID (3 times a day): while on bedrest.
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as
needed for wheeze.
5. ipratropium bromide 0.02 % Solution Sig: Three (3) mL
Inhalation Q6H (every 6 hours) as needed for wheeze.
6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day) as needed for COPD.
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
8. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for rash: apply to rash.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Right lower lobe lung cancer.
COPD
Hyperlipidemia
PSH: hip replacement, breast implants
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 87335**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
-You may shower. No tube bathing, swimming until incision
healed
-Aggressive pulmonary toilet, nebs, incentive spirometer
-Head of the bed elevated 30 degrees at all times
-Sit up in chair for all meals. Remain sitting for 30-45 minutes
after meals
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2138-10-7**]
2:30
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**].
Chest X-Ray [**Location (un) 861**] Radiology Department 30 minutes before
your appointment
Completed by:[**2138-9-30**]
|
[
"311",
"272.4",
"997.39",
"V15.82",
"458.29",
"496",
"E878.8",
"486",
"518.5",
"162.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.48",
"38.93",
"03.90",
"96.72",
"34.04",
"83.82",
"32.49",
"33.24",
"96.04",
"96.6",
"40.3",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8125, 8223
|
3541, 7061
|
352, 539
|
8356, 8356
|
1749, 3518
|
8969, 9284
|
1122, 1245
|
7238, 8102
|
8244, 8335
|
7087, 7215
|
8507, 8946
|
1260, 1730
|
282, 314
|
567, 793
|
8371, 8483
|
815, 900
|
916, 1106
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,344
| 197,249
|
19774
|
Discharge summary
|
report
|
Admission Date: [**2119-2-14**] Discharge Date: [**2119-2-21**]
Date of Birth: [**2047-8-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
variceal bleed
Major Surgical or Invasive Procedure:
upper endoscopy and banding of varices ([**2-15**], [**2-21**])
History of Present Illness:
This is a 71 year old man with history of schistosomiasis
infection, cirrhosis, thrombocytopenia and esophageal varices
status post banding now transferred from OSH status post acute
gastrointestinal bleed and to be evaluated for TIPS procedure.
.
Patient was in is usual state of health until [**2119-2-13**], when he
presented to [**Hospital 17065**] Hospital with hemetamesis (2300cc).
Patient was intubated for airway protection (there was concern
that patient had aspirated some blood). Patient was taken
emergently to the endoscopy suite where on EGD, 3 large columns
of esophageal varices were noted in the distal esophagus. The
stomach had a large amount of blood with no obvious varix and
the duodenum was normal.
.
Ligation was attempted with banding, but was unsuccessful. The
patient subsequently developed a massive gastrointestinal bleed
and sclerotherapy was initiated with good effect. Systolic blood
pressure dropped transiently to 70s and then improved to 90s.
Patient was then taken to the ICU where his hematocrit remained
stable at 29 (Hct 39 on admission with baseline of 38-43).
Patient received 4 units packed red blood cells, 3 units fresh
frozen plasma and 12 packs of platelets. Patient was also
maintained on protonix and an octreotide drop. Patient
transferred to [**Hospital1 18**] due to high risk of rebleeding, possibly
requiring a TIPS.
.
With interpreter patient denied any chest pain, shortness of
breath, no abdominal pain, no nausea/vomiting. Family was asking
about TIPS procedure.
.
Patient's remote history includes having bloody stools 30 years
ago which his physicians in [**Country 4194**] diagnosed and treated him for
schistosomiasis. He reports that he was tested after treatment
and told that he had no evidence of disease. He denies any
recurrance of bloody stool or similar symptoms. However, 5 years
ago, he was noted to have thrombocytopenia on routine
laboratory analysis. At that time, he was told that this was
likely due to liver disease and probably secondary to
schistosomiasis. He states that he was not re-tested or
re-treated for schistosomiasis at that time.
.
His recent history begins in [**2116-10-7**] when he presented to
an outside hospital with hematemesis secondary to varices. He
underwent banding at that time. He was then referred to [**Hospital1 18**]
liver center for further evaluation of his liver disease. Liver
biopsy that showed portal fibrosis but did not document ova or
parasites. Furthermore, the patient had an ophthomologic
examination that did not reveal any intraocular parasites.
Past Medical History:
1. Cirrhosis h/o variceal bleed in [**10/2116**] s/p banding
2. Schistosomasis (as above)
3. "Hepatitis" at age 18 characterized by jaundice, abdominal
pain, nausea and vomiting
4. Splenomegaly
5. Pancreatitis
6. Benign prostatic hypertrophy
7. Aplastic Anemia
8. Status post cholecystectomy
Social History:
Patient emigrated from [**Country 4194**] in [**2101**]. He last visited
approximately 5 years ago. Patient has lived only in MA since
then. No other travel. He's married with 4 children.
.
Denies tobacco, drinks alcohol rarely. Denies other drug use.
Works as a dishwasher and maintenance worker.
.
Notes PPD negative 1 year ago.
Family History:
Patient had two sisters who died with "cirrhosis" of unknown
etiology
Aunt - diabetes [**Name2 (NI) **]
Physical Exam:
GENERAL: intubated, sedated
HEENT: normocephalic atraumatic, pupils 3mm but reactive,
positive scleral icterus, conjunctiva clear
NECK: No jugular venous distention or lympadenotpathy
appreciated
CV: regular rate rhythm, no murmurs/rubs/gallops
PULM: clear to auscultation bilaterally anteriorly and
laterally, no wheezes or rhonchi
ABD: soft, round, nontender, normoactive bowel sounds, no
gaurding or rebound, no organomegaly appreciated, positive fluid
wave
EXT: no cyanosis/clubbing/edema
VASC: dorsalis pedia/posterior tibialis 2+ bilaterally, radial
pulse 2+ bilaterally
NEURO: moves all extremities to painful stimuli
Pertinent Results:
Labs on admission:
WBC-8.0# RBC-3.01*# Hgb-9.5* Hct-26.5*# MCV-88 MCH-31.5
MCHC-35.7* RDW-17.0* Plt Ct-38*
.
Neuts-85.7* Bands-0 Lymphs-9.3* Monos-4.5 Eos-0.3 Baso-0.3
.
Glucose-169* UreaN-21* Creat-1.1 Na-143 K-4.5 Cl-113* HCO3-19*
AnGap-16 Calcium-7.5* Phos-3.2 Mg-1.6
.
ALT-37 AST-46* AlkPhos-111 TotBili-3.0* Albumin-2.9*
[**2119-2-14**] 08:15PM BLOOD Lactate-4.0*
[**2119-2-15**] 02:07AM BLOOD Lactate-2.9*
.
PT-16.5* PTT-30.1 INR(PT)-1.5*
.
[**2119-2-14**] 08:15PM ABG: PO2-182* PCO2-33* PH-7.36 TOTAL CO2-19*
BASE XS--5
TEMP-37.3 RATES-14/2 TIDAL VOL-450 PEEP-5 O2-60 -ASSIST/CON
INTUBATED
.
[**2119-2-15**] 06:02PM ABG: pO2-82* pCO2-31* pH-7.44 calHCO3-22 Base
XS--1 Temp-37.2 Rates-/12 FiO2-50 -NOT INTUBA
.
Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.026 Blood-LG Nitrite-NEG
Protein-30 Glucose-NEG Ketone-TR Bilirub-MOD Urobiln-12* pH-7.0
Leuks-NEG RBC-[**11-27**]* WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0-2
.
[**2119-2-17**] 03:25PM ASCITES WBC-95* RBC-346* Polys-11* Lymphs-19*
Monos-25* Macroph-45* TotPro-0.6 Glucose-135 LD(LDH)-37
Albumin-LESS THAN
.
Blood culture [**2-17**] x2: PENDING
Fungal/Mycolytic bld cx [**2-17**]: PENDING
Urine culture [**2-18**], [**2-17**]: no growth
Peritoneal fluid [**2-17**]:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2119-2-20**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
.
Studies:
CHEST (PORTABLE AP) [**2119-2-14**]: ET tube in satisfactory position.
No radiographic evidence of pneumonia.
.
DUPLEX DOP ABD/PEL LIMITED [**2119-2-15**]: 1. Small liver with coarse
echotexture consistent with cirrhosis. 2. No focal hepatic
lesions identified. 3. Patent hepatic vessels. 4. Ascites. 5.
Splenomegaly.
.
.
EGD ([**9-12**]): 2 cords of grade I varices were seen in the middle
third of the esophagus. The varices were not bleeding.
Stomach: Mucosa: Localized discontinuous petechiae and abnormal
vascularity of the mucosa with no bleeding were noted in the
antrum. These findings are compatible with gastropathy.
Protruding Lesions Non bleeding varices were seen in the fundus.
Duodenum: Normal duodenum.
Impression: Petechiae and abnormal vascularity in the antrum
compatible with gastropathy
Varices at the fundus
Varices at the middle third of the esophagus
.
[**2119-2-15**] EGD:
Esophagus: Protruding Lesions There were 3 cords of grade II
varices were seen in the lower third of the esophagus and
gastroesophageal junction. One cord appeared to have evidence of
recent sclerotherapy; there were red [**Last Name (un) 23199**] markings on the varix.
One cord extended down past the gastroesophageal junction and
into the fundus of the stomach. There was no active bleeding. 3
bands were successfully placed.
Stomach:
Mucosa: Mosaic appearance of the mucosa was noted in the whole
stomach. These findings are compatible with portal gastropathy.
No active bleeding in the stomach.
Other No gastric varices.
Duodenum: Normal duodenum.
Impression: No gastric varices.
Mosaic appearance in the whole stomach compatible with portal
gastropathy
Varices at the lower third of the esophagus and gastroesophageal
junction
.
.
GUIDANCE FOR [**Female First Name (un) **]/ABD/PARA CENTESIS US [**2119-2-17**]: Moderate
amount of ascites within the abdomen. Successful paracentesis
with removal of approximately 1 liter of clear ascitic fluid.
The fluid was sent for Gram-stain/culture, cell counts, and
chemistries.
.
CHEST (PA & LAT) [**2119-2-17**]: No definite aspiration pneumonia.
.
BEDSIDE SWALLOWING EVALUATION [**2119-2-20**]:At this time, the pt is
not demonstrating any s&s of aspiration with any of the POs
given. The pt presents with a very functional and safe swallow.
As such, it is recommended that he be placed on a PO diet of
thin liquids and regular solids, with all PO meds taken whole in
liquid. Spoke to RN regarding pt's bloatedness and she reported
that she will give him something for the gas that he is
experiencing. In addition, I also mentioned to RN that pt is
normally on protonix, and that it should be checked whether or
not he is receiving here during his current stay.
1. PO diet consistency of thin liquids and regular solids
2. PO meds may be taken whole with thin liquids
3. RN will provide medicine for relief of gas/bloating feelings
pt is experiencing after meals
4. Should be determined whether pt is receiving protonix during
current stay here, as he stated that he normally takes this at
home.
.
EGD [**2119-2-21**]:
Esophagus: Protruding Lesions There were 3 cords of grade II-III
varices were seen in the gastroesophageal junction, lower third
of the esophagus and middle third of the esophagus. There was a
nonbleeding ulcer on one of the variceal columns consistent with
recent banding. One of the columns extended just below the GE
junction in the gastric fundus. But there were no separate
gastric varices. 2 bands were successfully placed.
Stomach: Mucosa: Mosaic appearance of the mucosa was noted in
the whole stomach. These findings are compatible with portal
gastropathy.
Duodenum: Not examined.
.
Impression: Varices at the gastroesophageal junction, lower
third of the esophagus and middle third of the esophagus Mosaic
appearance in the whole stomach compatible with portal
gastropathy
Brief Hospital Course:
This is a 71 year male with history of schistomsomiasis-induced
cirrhosis, portal hypertension status post variceal bleed on
[**2116**], presents to outside hospital with massive hemetamesis and
status post scleratherapy, transferred to [**Hospital1 18**] for possible
TIPS.
.
#. Variceal Bleed: Patient with known esophageal variceal
bleeding status post sclerotherapy at OSH on [**2-13**]/706
transferred to [**Hospital1 18**] MICU with dropping Hct and consideration
for TIPS procedure. Patient was taken for upper endoscopy which
showed evidence of prior sclerotherapy at 1 esophageal cord.
There were 3 cords of grade II varices that were banded. 1
esophageal cord extended into the fundus of the stomach. No
gastric varicese were seen. During the MICU stay, patient was
started on ciprofloxacin for spontaneous bacterial peritonitis
prophylaxis, continued on protonix and octreotide drip, had RUQ
ultrasound showed patent portal vasculature, and was
successfully extubated on [**2119-2-15**]. He received total 3 units of
PRBC's and 3 units of platelets. Hematocrits and hemodynamically
had been stable patient was transferred to the floor on [**2119-2-16**].
Patient remained stable while on the floor with some melenic
stools thought to be old blood. Patient completed a 6 day course
on octreotide drip and was continued on simethicone, sulcrafate,
hydralazine, isosorbide dinitrate and nadolol. He was cleared by
speech and swallow to have thin liquids and regular diet and was
advanced gradually. Lasix and spironolactone were started on
[**2-18**]. Per liver, no TIPS planned unless patient were to rebleed
and taken for upper endoscopy on [**2119-2-21**] and 2 bands were
successfully placed. Patient will follow-up in [**Hospital **] clinic this
Friday [**2119-2-24**] with Dr. [**Last Name (STitle) 497**] and is scheduled to have a repeat
upper endoscopy on [**2119-3-7**].
.
#. Cirrhosis: RUQ ultrasound on [**2119-2-15**] showed patent portal
vasculature. Followed LFTs and coags. Continued with lactulose
and titrated to [**2-10**] BMs per day. Ciprofloxacin SBP prophylaxis
was discontinued on [**2-17**] due to starting of levaquin and flagyl
to prophylactically treat a possible aspiration pneumonia.
Patient will complete a 7 day course of levofloxacin, flagyl was
discontinued on [**2119-2-21**]. No additional SBP prophylaxis for now
after completion of this course of antibiotics. Patient was
continued on hydralazine, isosorbide dinitrate and nadolol.
Lasix 40 QD and spironolactone 50 QD were started on [**2-18**] with
good urine output. Patient's I/O were strictly followed and IV
lasix was given as needed to avoid fluid overload. Patient was
discharged on nadolol 30mg QD.
.
#. Fever: Patient spiked a fever of 101.2 on [**2119-2-17**]. Unclear
etiology or source of infection. A paracentesis was performed on
[**2-17**] which was negative for SBP. Chest x-ray was inclusive for
aspiration pneumonia. Repeat urinalysis and urine culture were
negative. Patient was started on levaquin and flagyl for a 7 day
course given the high fever to empirically treat for possible
aspiration pneumonia as it was thought that he had aspirated at
the outside hospital prior to intubation. No growth to date on
blood cultures (including fungal/mycolytic). On day of
discharge, patient had been afebrile for 48 hours.
.
#. Aplastic anemia/coagulopathy:
Patient carried diagnosis of aplastic anemia, hematocrits here
were 38-42. Etiology was unclear. [**Name2 (NI) **] received one unit of
packed red blood cells on [**2-16**] and one pack of platelets on [**2-17**]
after paracentesis. Hematocrit remained stable while on the
floor and goals were Hct > 28, Plt count > 50, INR < 2 per GI.
Patient was given one dose of vitamin K 10mg on day of
discharge.
.
#. FEN: Patient was advanced to regular low salt diet post
procedure he was started on clears and advanced to soft diet.
Patient was instructed to continue on soft diet until [**2119-2-22**]
and advance to regular as tolerated, repleted lytes.
.
#. PPx: pneumoboots, proton-pump inhibitor, head of bed elevated
.
#. Code: Full
.
#. Communication: wife-[**Telephone/Fax (1) 53455**], son-
[**Name (NI) **]-[**Telephone/Fax (1) 53456**]
.
#. Access: PIV times 3, R femoral line sterilly placed at OSH
(and documented) was discontinued.
Medications on Admission:
1. Cipro 500mg PO BID
2. Protonix 40mg I q12H
3. Octreotide gtt
4. Lopressor 2.5mg Q4H
5. Kayexalate
6. Diprivan for sedation
7. Haldol 2mg IV Q1H:PRN agitation
8. MVI one qd
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): If you have not had three bowel movements by
dinnertime, please take one extra dose of 30mL that day.
Disp:*1 month* Refills:*0*
2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 2 weeks.
Disp:*2 weeks* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*0*
6. Nadolol 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablets* Refills:*0*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days: until [**2119-2-24**].
Disp:*3 Tablet(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Compazine 10 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
10. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
esophageal variceal bleed s/p sclerotherapy and banding
.
Secondary diagnosis:
schistosomiasis induced cirrhosis
aplastic anemia
Discharge Condition:
good
Discharge Instructions:
Please adhere to a soft consistency diet and then advance to a
regular diet tomorrow on [**2119-2-22**].
.
Please take medications as prescribed.
.
Please keep your follow-up appointments.
.
If you have any nausea/vomitting, blood in your stool or vomit,
fever/chills, shortness of breath or any other worrying symptoms
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD
Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2119-2-24**] 10:50
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD
Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2119-3-7**] 7:30
Location: [**Hospital Ward Name **] 8
There will be a Portuguese interpreter at this visit.
Completed by:[**2119-2-21**]
|
[
"456.20",
"572.3",
"284.9",
"571.5",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"42.33",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
15555, 15561
|
9742, 14050
|
329, 395
|
15753, 15760
|
4439, 4444
|
16128, 16557
|
3673, 3779
|
14275, 15532
|
15582, 15582
|
14076, 14252
|
15784, 16105
|
3794, 4420
|
274, 291
|
423, 2994
|
15680, 15732
|
15601, 15659
|
4458, 5802
|
5838, 9719
|
3016, 3309
|
3325, 3657
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,015
| 130,269
|
35356
|
Discharge summary
|
report
|
Admission Date: [**2194-3-26**] Discharge Date: [**2194-3-29**]
Date of Birth: [**2122-8-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Brain Mass
Major Surgical or Invasive Procedure:
Left sided craniotomy
History of Present Illness:
71-year-old right-handed man, with a
history of metastatic colon cancer to liver and lungs.He
presented with to Dr [**Last Name (STitle) 724**] for an evaluation of word-finding
difficulty and a left frontal brain
metastasis. His oncological problem began in [**2189-12-7**] when
a sigmoid colon adenocarcinoma was resected at [**Hospital **] Hospital.
He had a gadolinium-enhanced head MRI on [**2194-3-12**] that showed a
3-cm
solitary brain metastasis in the posterior left frontal brain.
He is admitted for an elective craniotomy.
Past Medical History:
Metastatic colon adenocarcinoma, hypertension, and
hypercholesterolemia
Social History:
He was a maintenance person and a driver. He
was smoking 2 packs of cigarettes per day for 40 years but
stopped in [**2186**]. He had 35 to 45 beers per week. He did not use
any illicit drugs.
Family History:
His mother died of colon cancer at the age of
73. His father was crushed by a bus in an accident. His sister
is healthy. His brother died of alcoholism and liver cancer. He
has 3 daughters and they are healthy.
Physical Exam:
Temperature is 98.0 F. His blood pressure
is 154/78. Heart rate is 78. Respiratory rate is 16. His skin
has full turgor. HEENT is unremarkable. Neck is supple and
there is no bruit. There is no cervical, axillary, or
supraclavicular lymphadenopathy. Cardiac examination reveals
regular rate and rhythms. His lungs are clear. His abdomen is
soft with good bowel sounds. His extremities do not show
clubbing, cyanosis, or edema.
Neurological Examination: His Karnofsky Performance Score is 70.
He is awake, alert, and oriented times 3. There is no right/left
confusion or finger agnosia. His calculation is intact. His
language is fluent with good comprehension, naming, and
repetition. But he has intermittently word-finding difficulty.
His short-term memory appears intact. Cranial Nerve Examination:
His pupils are equal and reactive to light, 3 mm to 2 mm
bilaterally. Extraocular movements are full; there is no
nystagmus. Visual fields are full to confrontation. Funduscopic
examination reveals sharp disks margins bilaterally. His face is
symmetric. Facial sensation is intact bilaterally. His hearing
is intact bilaterally. His tongue is midline. Palate goes up in
the midline. Sternocleidomastoids and upper trapezius are
strong. Motor Examination: He does not have a drift. His
muscle strengths are [**6-10**] at all muscle groups. His muscle tone
is normal. His reflexes are 0-1 bilaterally. His ankle jerks
are absent. His toes are downgoing. Sensory examination is
intact to touch and proprioception. Coordination examination
does not reveal dysmetria. His gait is normal. He does not have
a Romberg.
Pertinent Results:
[**2194-3-28**] 06:57AM BLOOD WBC-18.6* RBC-3.34* Hgb-13.0* Hct-37.0*
MCV-111* MCH-38.9* MCHC-35.2* RDW-17.2* Plt Ct-169
[**2194-3-28**] 06:57AM BLOOD Plt Ct-169
[**2194-3-28**] 06:57AM BLOOD Glucose-110* UreaN-23* Creat-0.6 Na-129*
K-4.6 Cl-95* HCO3-27 AnGap-12
[**2194-3-28**] 06:57AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.4
[**2194-3-26**] 12:00PM BLOOD Type-ART pO2-303* pCO2-44 pH-7.39
calTCO2-28 Base XS-1 Intubat-INTUBATED
[**2194-3-26**] 12:00PM BLOOD Glucose-125* Lactate-2.5* Na-124* K-4.3
Cl-88* calHCO3-28
[**2194-3-26**] 12:00PM BLOOD Hgb-15.6 calcHCT-47
Brief Hospital Course:
Mr [**Known lastname 3321**] was admitted for an elective right sided
cranitomy. He was observed for 24 hours in the ICU where his BP
was kept less than 140, he obtained a post op CT scan which was
negative for hemorrhage. Neurologically he was noted to have
dysarthria combined with some word finding difficulty. Dr [**Last Name (STitle) **]
was expecting this post operatively and we expect it to last for
4-6 weeks until all the edema subsides. He had full strenght
throughout and was orientated X3. He was transferred to the
surgical floor on his first post op day and he obtained an MRI.
On POD#2 he was ambulating with assistance and PT felt he would
benefit from short term rehab. He was tolerating a regular diet
and voiding without difficulty. Of note Mr [**Known lastname 3321**] had
baseline hyponatremia.
On Post operative day #3, Mr. [**Name13 (STitle) 31648**] was noted to have severe
expressive aphasia on rounds, but was sitting up in bed and
trying to communicate that he would like to get up in a chair.
Later in the afternoon we were alerted that he was more
lethargic, he was subsequently sent for a STAT head CT which
revealed a developing epidural hematoma on the side of the
craniotomy and hemorrhage in the tumor bed with midline shift
and uncal herniation. Upon returning from CT, pt. was found to
be somulent, unarrousable with dilated left pupil that was
unreactive. Pt. was intubated emergently by anesthesia and
transferred to the ICU. His labs revealed a PTT of 55. He
recieved Protamine and FFP in the ICU. Family was called and
arrived shortly there after choosing to make him CMO. Patiend
died in the ICU at aprox. 8:45pm.
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1
(One) Tablet(s) by mouth once a day
CAPECITABINE [XELODA] - (Prescribed by Other Provider) - 500 mg
Tablet - 3 (Three) Tablet(s) by mouth twice a day 14 days on
with one week rest
DEXAMETHASONE - (Prescribed by Other Provider) - 4 mg Tablet - 1
(One) Tablet(s) by mouth twice a day
DILTIAZEM HCL - (Prescribed by Other Provider) - 60 mg Tablet -
1 (One) Tablet(s) by mouth once a day
IRBESARTAN [AVAPRO] - (Prescribed by Other Provider) - 300 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
Medications - OTC
MULTIVITAMIN [ONE DAILY MULTIVITAMIN] - (Prescribed by Other
Provider) - Tablet - 1 (One) Tablet(s) by mouth once a day
Discharge Medications:
.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Metastatic Colon Cancer with lung and colon involvement
Brain Mass
ICH, brain herniation
Discharge Condition:
Pt. expired [**2194-3-29**]
Discharge Instructions:
Pt. expired [**2194-3-29**]
Followup Instructions:
Pt. expired [**2194-3-29**]
Completed by:[**2194-3-29**]
|
[
"197.0",
"V10.05",
"998.12",
"998.11",
"401.9",
"348.4",
"197.7",
"198.3",
"496",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6124, 6139
|
3694, 5353
|
329, 352
|
6272, 6301
|
3107, 3671
|
6377, 6435
|
1241, 1454
|
6098, 6101
|
6160, 6251
|
5379, 6075
|
6325, 6354
|
1469, 3088
|
279, 291
|
380, 918
|
940, 1013
|
1030, 1225
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,263
| 124,532
|
5002
|
Discharge summary
|
report
|
Admission Date: [**2167-5-25**] Discharge Date: [**2167-5-26**]
Date of Birth: [**2097-12-31**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
SOB/hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Hospital Unit Name 20719**] NOTE:
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**]
CC: SOB, hypoxia
.
HPI: Ms. [**Known lastname 15427**] is a 69 yo F with h/o COPD (4L NC at home at
baseline; frequent admissions for exacerbations) and s/p small
cell lung CA with post-XRT fibrosis of the right lung. She
presented to the ED this morning c/o 2-3 days of SOB, especially
at night when she was sleeping. She has also had worsening of
sputum production in the last day with change in color to green
as well as decreased ability to cough up secretions. She denied
fevers at home.
.
In the ED, VS were T 98.9, HR 73, BP 107/72, RR 20, 93% 6L. She
was started on CPAP with sats in the upper 90's, but she then
refused to continue wearing the mask. Chest x-ray did not show
an infiltrate. No studies were ordered to rule out PE because
the ED felt this was low probability in the setting of an INR
2.0. She was given solumedrol 125 mg IV,
[**Known lastname **]/ceftriaxone, and albuterol nebulizers.
Social History:
History of tobacco; quit over 10 years ago. Drinks a glass of
wine a day. Immigrated from [**Location (un) 311**] in [**2120**]. Used ot be a nanny.
Has one son
.
Family History:
Non-contributory.
.
ADMISSION PHYSICAL EXAM:
VS in the ED: T 98.9, HR 73, BP 107/72, RR 20, 93% 6L
GENERAL: elderly appearing, frail; very vocal about her
discomfort & frustration with being in the ICU; speaking in full
sentences
SKIN: No rashes; scattered ecchymoses on hands
HEENT: JVD to midneck, neck supple.
CHEST: decreased BS on right; crackles at right base; minimal
wheezing throughout; minimal accessry muscle use.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: + Ostomy, overall NT/ND
EXTREMITIES:1+ LE edema, warm without cyanosis
NEUROLOGIC: AA, Ox3; CN II - XII in tact; moving all
extremities.
.
LABS: see below; notable for WBC 11.5, 94% PMN's, 0 bands; INR
2.0; Na 128
.
MICROBIOLOGY: 2 sets of BCx sent from ED; pending
.
IMAGING:
[**2167-5-25**] ADMISSION CXR:
FINDINGS: The extensive post-treatment changes (post-surgery and
radiation) involving the right lung are similar. There is
significant radiation fibrosis at the right lung base with
persistent right pleural effusion and atelectasis. The known
spiculated right upper lobe nodule is not well seen on today's
radiograph. The cardiomediastinal silhouette is similar. The
cerclage wires and surgical clips are unchanged. The bones are
unremarkable.
IMPRESSION: Post-surgical and radiation changes in the right
lung are stable. No evidence of pneumonia.
.
[**6-/2166**] SPIROMETRY (most recent):
FEV1 0.56 (29% predicted); FVC 1.12 (41% predicted)
.
[**11/2166**] ECHO (most recent):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2164-9-20**],
the RV has further dilated and systolic function has
deteriorated. The estimated PASP has increased. The LVEF remains
normal.
.
.
.
ASSESSMENT/PLAN:
69 yo F w/ multiple medical problems including severe COPD,
right-sided pulm fibrosis, and atrial fibrillation, presenting
with SOB x 2-3 days in setting of increased (green) sputum
production.
.
#. SOB: unclear whether bronchitis-driven COPD exacerbation vs.
cardiac/pulmonary edema. CXR not especially concerning for
volume overload and patient with EF 55% on recent echo in
[**11/2166**]; however, history of worsening SOB with recumbency is c/f
cardiac source. Patient refusing additional lasix PO tonight
given she does not have a foley and does not want to be up all
night. Decreased CO in setting of poorly controlled AFib less
likely given that her HR not elevated on admission. Said she
feels better after "treatments" in the ED; on 4 - 6 L NC now,
speaking in full sentences with minimal accessory muscle use.
-- albuterol and combivent nebs standing overnight; will change
to PRN in the am if stable
-- received solumedrol 125 mg IV in the ED; will continue
prednisone 30 mg QD with taper beginning in next 1 - 2 days
pending stability
-- will wean to 4L NC (home baseline) as tolerated; no need for
CPAP currently.
-- will continue [**Year (4 digits) **] x 4 days.
-- continue home dose lasix 80 mg QD; will consider additional
dose if with continued O2 requirement > 4LNC in am or volume
overloaded on exam.
.
#. ATRIAL FIBRILLATION: rate well controlled currently
-- will cont home regimen of digxoin and sotalol
-- INR 2.0 --> will continue coumadin 3 mg QD; recheck INR in am
.
#. PULMONARY HYPERTENSION:
-- will continue sildenafil 50 mg Q8 hours
.
#. CHRONIC BACK PAIN: [**Last Name 20720**] problem in [**Name (NI) **]; on Tylenol
#3 at home
-- continue home regimen
.
#. PPX:
-- bowel regimen
-- will hold on protonix given low risk for stress ulcers (not
acutely ill currently) and eating a regular diet
-- will consider starting pneumoboots or SQH in am pending
patient agrees
.
#. FEN: no evidence of dehydration; will place on regular diet
.
#. CODE: full
.
#. DISPO: to remain in ICU overnight for observation and further
treatment; will likely transfer to floor in am
Past Medical History:
PMH:
1. Small cell lung CA
-- diagnosed ~14 years ago
-- s/p XRT and chemo (cisplatinum).
2. COPD, on 4L NC home oxygen.
3. History of atrial fibrillation
4. History of perforated diverticulum status post colostomy.
5. History of peptic ulcer disease.
6. Hypertension.
7. Severe pulmonary hypertension on Viagra.
8. Status post ASD repair.
9. Status post ventral hernia repair.
10. Status post appendectomy.
11. Depression
12. Chronic PE in the right middle lobe of the PA
Social History:
History of tobacco; quit over 10 years ago. Drinks a glass of
wine a day. Immigrated from [**Location (un) 311**] in [**2120**]. Used ot be a nanny.
Has one son
Family History:
Non-contributory.
Physical Exam:
VS in the ED: T 98.9, HR 73, BP 107/72, RR 20, 93% 6L
GENERAL: elderly appearing, frail; very vocal about her
discomfort & frustration with being in the ICU; speaking in full
sentences
SKIN: No rashes; scattered ecchymoses on hands
HEENT: JVD to midneck, neck supple.
CHEST: decreased BS on right; crackles at right base; minimal
wheezing throughout; minimal accessry muscle use.
CARDIAC: Regular rhythm; no murmurs, rubs, or gallops.
ABDOMEN: + Ostomy, overall NT/ND
EXTREMITIES:1+ LE edema, warm without cyanosis
NEUROLOGIC: AA, Ox3; CN II - XII in tact; moving all
extremities.
Pertinent Results:
[**2167-5-25**] ADMISSION CXR:
FINDINGS: The extensive post-treatment changes (post-surgery and
radiation) involving the right lung are similar. There is
significant radiation fibrosis at the right lung base with
persistent right pleural effusion and atelectasis. The known
spiculated right upper lobe nodule is not well seen on today's
radiograph. The cardiomediastinal silhouette is similar. The
cerclage wires and surgical clips are unchanged. The bones are
unremarkable.
IMPRESSION: Post-surgical and radiation changes in the right
lung are stable. No evidence of pneumonia.
.
[**6-/2166**] SPIROMETRY (most recent):
FEV1 0.56 (29% predicted); FVC 1.12 (41% predicted)
.
[**11/2166**] ECHO (most recent):
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild to moderate ([**11-26**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
moderately thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2164-9-20**],
the RV has further dilated and systolic function has
deteriorated. The estimated PASP has increased. The LVEF remains
normal.
Labs:
[**2167-5-25**] 01:15PM WBC-11.5* RBC-4.37 HGB-11.7* HCT-38.0 MCV-87
MCH-26.8* MCHC-30.7* RDW-15.9*
[**2167-5-25**] 01:15PM CK(CPK)-39
[**2167-5-25**] 01:15PM cTropnT-0.04*
[**2167-5-25**] 01:15PM CK-MB-NotDone
[**2167-5-25**] 01:15PM GLUCOSE-194* UREA N-27* CREAT-0.9 SODIUM-128*
POTASSIUM-4.8 CHLORIDE-83* TOTAL CO2-38* ANION GAP-12
[**2167-5-26**] 03:52AM BLOOD CK-MB-3 cTropnT-0.03*
[**2167-5-26**] 03:52AM BLOOD CK(CPK)-42
[**2167-5-26**] 03:52AM BLOOD WBC-6.7 RBC-4.09* Hgb-10.9* Hct-35.2*
MCV-86 MCH-26.7* MCHC-31.0 RDW-16.0* Plt Ct-382
Brief Hospital Course:
Ms. [**Known lastname 15427**] is a 69 yo F w/multiple medical problems including
severe COPD, right-sided pulm fibrosis, and atrial fibrillation,
presenting with SOB x 2-3 days in setting of increased (green)
sputum production.
1)Shortness of breath: Most likely due to bronchitis-driven COPD
exacerbation. She improved overnight with minimal intervention
and was breathing comfortably on her home level of O2 at 4LNC by
the morning following admission. She had a chest xray that was
unremarkable. She was give solumedrol 125mg IV in the ED and
then her prednisone was increased to 30mg daily. She was
started on [**Known lastname **] for suspected COPD exacerbation to
complete a 5 day course. Otherwise she was continued on her
home regimen of combivent and albuterol on discharge. She was
advised to taper her prednisone every 3 days back to her home
dose of 10mg daily. She will follow up with Dr. [**Last Name (STitle) **] in
pulmonary clinic.
2)hyponatremia - most likely hypovolemic however she did have
slight lower extremity edema on exam. Her sodium improved with
holding her lasix overnight so she was discharged on half her
home dose of lasix to follow up with her PCP by the end of the
week for a repeat sodium level.
3) ATRIAL FIBRILLATION: rate well controlled with no acute
issues during her admission. She was continued on home regimen
of digxoin and sotalol. Her INR was theraputic at 2.3 and she
was continued on coumadin 3mg daily.
4) PULMONARY HYPERTENSION: She was continued on home dose
sildenafil, to follow up with her pulmonologist.
5)CHRONIC BACK PAIN: [**Last Name 20720**] problem in [**Name (NI) **]; she was
continued on Tylenol #3
6) CODE: full
Medications on Admission:
Coumadin 3 mg QD
Furosemide 80 mg PO daily
Sildenafil 50 mg PO TID
Digoxin 125 mcg PO DAILY
Paroxetine HCl 10 mg PO DAILY
Combivent 18-103 mcg/Actuation Aerosol Sig: [**11-26**] sprays TID
Albuterol PRN
Montelukast 10 mg PO DAILY
Alprazolam 0.5 mg PO QHS
Sotalol 40 mg PO QPM
Sotalol 80 mg PO QAM
Calcium Carbonate 500 mg PO DAILY
Cholecalciferol (Vitamin D3) 400 unit PO DAILY
Ascorbic Acid 500 mg PO DAILY
Discharge Medications:
1. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO QAM (once a day
(in the morning)).
2. Sildenafil 25 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8
Hours).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Paroxetine HCl 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) spray
Inhalation three times a day.
6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. Sotalol 80 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
10. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in
the evening)).
11. CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
12. Prednisone 10 mg Tablet Sig: variable Tablet PO DAILY
(Daily) for 9 days: . Take the following:
- 3 tabs daily x3d
- 2 tabs daily x3d
- 1 tab daily x3d.
[**Month/Day (2) **]:*18 Tablet(s)* Refills:*0*
13. [**Month/Day (2) 11396**] 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 6
days: . take 40 daily x6d then can resume 80 daily after you see
your PCP.
[**Name Initial (NameIs) **]:*6 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Please have a chemistry panel checked by your PCP
16. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Acute COPD exacerbation
- hyponatremia thought [**12-27**] hypovolemia. Lasix initially held
and it improved.
Secondary:
- small cell lung ca s/p XRT and chemo
- hx of atrial fibrillation
- hx PUD
- HTN
- severe pulm HTN
Discharge Condition:
at baseline O2 requirement
Discharge Instructions:
You came in with worsening shortness of breath. You were
treated with a breathing mask as tolerated. We also treated you
with antibiotics, nebulizers, and steroids.
Please take your medications as prescribed. Please followup
with your PCP within the next 1 week. We have made the
following changes to your medications:
- lasix 40 daily (instead of 80) - until you see your PCP
[**Name Initial (PRE) **] [**Name Initial (NameIs) **] x3 more days
- prednisone taper as written
Please contact your PCP or return to the [**Name (NI) **] if you experience
worsening chest pain, shortness of breath, fevers.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2167-6-23**]
11:00
Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Date/Time:[**2167-6-26**] 9:10
Provider: [**Name10 (NameIs) 13368**] [**Last Name (NamePattern4) 13369**], MD Phone:[**Telephone/Fax (1) 1652**]
Date/Time:[**2167-7-29**] 2:10
.
Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3029**] to schedule an appointment for
early next week. You will need a chemistry panel.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"491.21",
"416.0",
"427.31",
"276.1",
"162.8",
"515"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13778, 13784
|
10045, 11741
|
291, 298
|
14061, 14090
|
7614, 10022
|
14746, 15470
|
6978, 6997
|
12200, 13755
|
13805, 14040
|
11767, 12177
|
14114, 14409
|
7012, 7595
|
14438, 14723
|
240, 253
|
326, 1356
|
6309, 6784
|
6800, 6962
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,202
| 165,035
|
265
|
Discharge summary
|
report
|
Admission Date: [**2140-4-20**] Discharge Date: [**2140-4-21**]
Service: MICU
HISTORY OF THE PRESENT ILLNESS: The patient is an
88-year-old gentleman with severe aortic stenosis, peptic
ulcer disease, hypertension, who presented to the ED with
fevers and hypotension to the 80/50 blood pressure.
Responded well to IV fluids while in the ED, but denied any
chest pain, abdominal pain, or any urinary symptoms.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Aortic stenosis.
3. Colonic polyps.
4. Anemia.
5. Hypertension.
6. Total hip replacement of the right side.
7. BPH.
8. Chronic renal insufficiency.
9. Spinal stenosis.
ALLERGIES: The patient is allergic to penicillin,
erythromycin, Ultram.
ADMISSION MEDICATIONS:
1. Ambien.
2. Clindamycin.
3. Desipramine.
4. Lasix.
5. Lactulose.
6. Lisinopril.
7. Ativan.
8. MS Contin.
The patient became progressively more listless and somnolent
in the ED and pressure continued to drop. He responded to
more fluids, and also required nasal cannula 100% 02.
PHYSICAL EXAMINATION ON ADMISSION: Initially, the patient
had a temperature of 99.2, heart rate 112, blood pressure
95/60, respiratory rate 24, saturating 100% on nasal cannula.
General: The patient was an elderly man in no apparent
distress, awaking to voice. HEENT: The oropharynx was clear.
The mucous membranes were dry. The pupils were equally round
and reactive to light. Lungs: Clear anteriorly. Heart:
Tachycardiac. There was a III/VI systolic ejection murmur.
Abdomen: Soft, nontender, nondistended. Extremities: No
endocarditis stigmata noted.
LABORATORY DATA: WBC of 10.3 with 46 bands, 35.1 hematocrit,
creatinine 2.0. Sodium 124, chloride 87. The U/A had
greater than 50 WBCs with many bacteria.
The chest x-ray had a right pleural effusion that was old,
decreasing in size compared to previous.
The EKG had no acute ST-T wave changes, tachy, appeared to be
LVH.
HOSPITAL COURSE: INFECTION: Likely his hypotension was due
to sepsis secondary to UTI. The patient also stated that he
had some instrumentation done of his heart which could also
account for his septic picture. The patient was started on
empiric antibiotics. Blood cultures were also obtained. IV
fluids were given. The patient had antibiotics of Levaquin
and clindamycin. The patient is a DNR/DNI status.
HYPONATREMIA: Appears to be hypovolemic. We will place with
normal saline. On presentation to the ICU, the patient was
already in agonal respirations.
Shortly thereafter, I was called to the room. The patient
was asystolic and the patient was not responsive to verbal
pain or tactile stimuli. No heart sounds were heard. Pupils
were midline, dilated, not reactive. There was a lack of
breath sounds.
The immediate cause of death was likely cardiac arrest.
Secondary cause sepsis.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 2584**]
MEDQUIST36
D: [**2140-6-9**] 04:23
T: [**2140-6-12**] 16:16
JOB#: [**Job Number 2585**]
|
[
"599.0",
"785.4",
"682.7",
"038.9",
"428.0",
"707.0",
"V43.3",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1956, 3080
|
753, 1065
|
1080, 1938
|
443, 730
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,515
| 189,919
|
48305
|
Discharge summary
|
report
|
Admission Date: [**2160-5-6**] Discharge Date: [**2160-5-12**]
Date of Birth: [**2110-9-29**] Sex: F
Service: MEDICINE
Allergies:
Heparin (Porcine) / Erythromycin Base
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hip pain
Major Surgical or Invasive Procedure:
right total hip replacement, Foley catheter placement
History of Present Illness:
49 year old female with med history of ESRD due to lupus s/p
cadaveric transplant, s/p fem-[**Doctor Last Name **] bypass, dilated cardiomyopathy
with EF 40%, history of bowel ischemia s/p ileostomy, coronary
artery disease, and HCV initially admitted for elective right
total hip replacement for osteoarthritis with preop Hct 27.9.
She underwent the hip replacement and was found to have a
femoral neck fracture which was repaired. On [**4-15**], patient was
admitted to the ICU post op for close monitoring given history
of cardiomyopathy and low hematocrit. She received 2 units of
blood periop along with 2800cc crystalloid and surgery was
uncomplicated with estimated blood loss of 400cc. Patient was
never hypotensive, tachycardic or hypoxic and was extubated
immediately post op.
.
In the ICU, the patient became hypotensive and was noted to have
decreased hematocrit that stabilized to her baseline after 3
units PRBC. The bleeding was found to be due to postop bleeding
into her hip. She was transferred to the medicine service in
stable condition for continued physical therapy and monitoring
before returning home.
Past Medical History:
1. End stage renal disease on hemodialysis for 14 years,
status post cadaveric renal transplant in [**2151**] on HD for 14
years prior, secondary to lupus nephritis, systemic lupus
erythematosus.
2. Dilated cardiomyopathy with echocardiogram in [**Month (only) **]
[**2157**], showing ejection fraction of 40 to 45% with significant
left ventricular hypokinesis inferior, inferolateral, and
inferoseptal hypokinesis, 1+ mitral regurgitation, 1+
aortic insufficiency.
3. History of hypothyroidism but not on any replacement
currently.
4. Severe peripheral vascular disease, status post right
first toe amputation, status post bilateral femoral popliteal
bypass.
5. Osteoarthritis, status post left total hip replacement.
6. Status post multiple AV fistula revisions.
7. Status post colectomy with end ileostomy secondary to
perforated ischemic transverse colon.
8. Coronary artery disease, status post perioperative
myocardial infarction.
9. History of Methicillin resistant Staphylococcus aureus
wound infection.
10. Positive hepatitis C.
11. hemachromatosis from mult transfusions
12. Anemia-AOCD
Social History:
No smoking, no alcohol, no illicit drugs. She works as
supervision at a credit card company.
Family History:
Positive for lupus.
Physical Exam:
T 98 HR 60, 150/70, 17, 98% RA
Gen: NAD, sitting in chair, talking on the phone, pleasant
HEENT: prrl, swelling of eyelids, mmm,
Pulm: few crackles at bases, cta otherwise
CV: 3/6 sem at rusb
Abd: obese, ostomy, nt
Ext: 2+ edema, pulses intact, r hip incision c/d/i
Pertinent Results:
ICU Admit labs
pH 7.39 pCO2 40 pO2 50 HCO3 25
Na:142 K:5.2 Hgb:9.6 Calc HCT:29 Glu:71 freeCa:1.15 Lactate:1.1
CALCIUM-8.1* PHOSPHATE-4.3 MAGNESIUM-1.3*
WBC-17.2*# RBC-3.44* HGB-10.2* HCT-28.8* MCV-84 MCH-29.6
MCHC-35.4* RDW-14.6
.
Discharge labs [**2160-5-11**]
WBC-9.5 RBC-3.25* Hgb-9.5* Hct-27.8* MCV-86 MCH-29.2 MCHC-34.1
RDW-14.9 Plt Ct-146*
Glucose-115* UreaN-69* Creat-1.4* Na-139 K-4.8 Cl-108 HCO3-21*
AnGap-15
Cyclspr-127
.
Blood, stool, and urine cultures were negative for growth.
.
CHEST (PA & LAT) [**2160-5-11**]
1) Cardiomegaly and upper zone redistribution of pulmonary
vasculature suggesting early congestive heart failure. No overt
pulmonary edema.
2) New small bilateral pleural effusions.
3) Diffuse vascular calcifications.
.
ECG Study Date of [**2160-5-7**]
Sinus rhythm. Borderline left atrial abnormality. Left
ventricular
hypertrophy. Left axis deviation. Diffuse non-diagnostic
repolarization
abnormalities consistent with left ventricular strain pattern.
Compared to the previous tracing multiple abnormalities as noted
persist without
major change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
85 160 120 [**Telephone/Fax (2) 101758**] -49 118
.
HIP 1 VIEW IN O.R. [**2160-5-6**]
Single frontal radiograph of the right hip was obtained in the
operating room without a radiologist present. Images
demonstrates the patient to be status post right hip
arthroplasty with cemented femoral prosthesis. The head of the
femoral component projects over the center of the acetabular
component on this single view. No fracture identified.
Dense vascular calcification is noted and unchanged from
[**2159-10-31**].
Surgical staples project over the posterior lateral right hip.
The left hip prosthesis is incompletely imaged.
.
Pathology
Femoral head, right:Bone and cartilage with degenerative and
regenerative changes consistent with osteoarthritis.
Brief Hospital Course:
1. s/p Right Total Hip Replacement-Pain was well-controlled on
SR morphine 15mg q12h with IR morphine 15mg prn. Neurontin was
continued. For DVT prophylaxis, per orthopedic surgery
recommendation, the patient received ASA 325mg [**Hospital1 **] with stable
hematocrit. At discharge, this was replaced with Lovenox. With
assistance of her husband, the patient worked well with physical
therapy and planned to continue at home. Follow up was organized
with orthopedic surgery as well as primary care.
.
2. Transient Hypotension in the ICu: Likely related to continued
bleeding into hip post operatively. Hematocrit was stable at
baseline after transfusion of 3 units PRBCs. For concern of
adrenal insufficiency, the patient was started on stress dose
steroids and was discharged with a gradual oral prednisone taper
back down to her normal standing dose.
.
3. s/p Renal transplant: Nephrology consultation service
provided recommendations and the patient will follow up as an
outpatient in the clinic. Cyclosporine, prednisone, and
cellcept were continued. After monitoring, cyclosporin dose was
increased for improved efficacy. She was coninued aranesp and on
Bactrim for PCP [**Name Initial (PRE) 1102**]. In the ICU course, the patient had
temporary hyperkalemia of 5.2 but no kayexolate was required and
the level normalized spontaneously. Also continued calcitrol,
bicarbonate, and added calcium carbonate 500mg tid for phos
binding.
.
4. Dilated Cardiomyopathy-In the ICU postoperatively, the
patient was total body water overloaded but intravascularly
depleted, presumed due to bleeding as above. During the hospital
course, patient had no chest pain and was breathing comfortably
with only mild crackles on exam and no elevated JVP. Chest xray
showed mild upper zone vascular redistribution and bilateral
small pleural effusions. She did not require IV hydration after
transfer to the medicine service and was at that time tolerating
a heart healthy diet and drinking fluids appropriately. Patient
was discharged on her regular cardiac medical regimen including
BB and ACEI.
Medications on Admission:
BACTRIM 400-80MG--One tablet by mouth m, w, f
BICARBONATE 650MG--3 by mouth twice a day per dr. [**Last Name (STitle) **]
CALCITRIOL 0.25MCG--One by mouth once a day
CYCLOSPORINE 25MG--3 capsules twice a day per dr. [**Last Name (STitle) **]
FOLIC ACID 4MG--[**Hospital1 **]
LISINOPRIL 5MG--One tablet by mouth every day
LOPRESSOR 25mg [**Hospital1 **]
MS CONTIN 15 mg--1 tablet(s) by mouth q 12 hours as needed for
prn
MULTIVITAMIN --One daily
MYCOPHENOLATE MOFETIL 250 MG--4 twice a day per dr. [**Last Name (STitle) **]
PREDNISONE 10mg daily
PROTONIX 40MG--One by mouth every day
Neurontin 600mg qd
Aranesp 40mg q2wk
Percocet prn
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
2. Sodium Bicarbonate 650 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
5. Alendronate Sodium 70 mg Tablet Sig: 0.5 Tablet PO QFRI
(every Friday).
6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for anxiety.
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
start [**5-17**].
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
11. Morphine Sulfate 15 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q12H (every 12 hours).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
14. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule
PO Q12H (every 12 hours).
Disp:*180 Capsule(s)* Refills:*2*
15. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): [**5-12**] - 3 tablets, [**5-13**] - 2 tablets, [**5-14**] - 2 tablets,
[**5-15**] - 1 tablet, [**5-16**] - 1 tablet, [**5-17**] and thereafter - resume
taking your regular dose of 10mg tablet daily
.
Disp:*9 Tablet(s)* Refills:*0*
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-23**]
hours as needed for pain.
18. Aranesp 40 mcg/mL Solution Sig: One (1) Injection twice
weekly.
19. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
21. Morphine Sulfate 15 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
22. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous DAILY (Daily) for 4 weeks.
Disp:*30 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. s/p R hip replacement
2. post-operative hypotension/ bleeding
Secondary diagnoses:
osteoporosis, osteoarthritis, hepatitis C, anemia, hypertension,
hemochromatosis, coronary artery disease s/p MI, cardiomyopathy,
uveitis, left ankle arthritis, lupus, severe peripheral vascular
disease with multiple bypasses in both legs, colonic polyps with
ileostomy, aortic insufficiency, h/o narcotic abuse, gynecologic
disease of unknown significance, end stage renal disease with
kidney transplant
Discharge Condition:
stable
Discharge Instructions:
Patient to be discharged to home with physical therapy services
with possible transfer a rehabilitation facility if failing to
having worsening pains, fevers, chills, nausea, vomiting,
shortness of breath, chest pain, redness or drainage about the
wound, or if there are any questions or concerns. Patient not
to drive or operate heavy machinery while on any narcotic pain
medicine such as percocet. Patient to take colace as needed for
constipation as narcotic medicine can cause this. Patient not
to have long periods of immobility as this can lead to longterm
stiffness and loss of range of motion.
-For protecting against blood clots after your hip replacement,
please administer enoxaparin (lovenox) subcutaneously for the
next four weeks.
-Doses of neurontin and cyclosporin have been increased.
-Please follow intructions for prednisone as prescribed to be
gradually tapered back down to your regular dose.
-A new blood pressure medication called amlodipine (or norvasc)
was started for high blood pressure not completely controlled on
your other medications. Follow up with your regular doctor for
future monitoring. Please check blood pressure regularly and
call your doctor if the systolic pressure is over 140 or if your
diastolic pressure is over 90. You medications may need to be
further adjusted.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 11262**] Follow-up appointment
should be in 3 weeks. Patient to follow up with Dr. [**Last Name (STitle) 7111**] and
to call to schedule an appointment in the orthopedic clinic at
[**Telephone/Fax (1) 11262**].
Primary Care Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call Dr.
[**Last Name (STitle) **] to make an appointment for within the next 2 weeks to
evaluate your blood pressure.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 177**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 60**] Follow-up appointment
should be in 2 months. You should schedule an appointment to
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the nephrology clinic at ([**Telephone/Fax (1) 26815**] in [**6-25**] weeks.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"458.9",
"V42.0",
"998.11",
"401.9",
"710.0",
"285.1",
"244.9",
"414.8",
"715.35",
"255.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.51",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10026, 10084
|
4982, 7068
|
305, 361
|
10620, 10628
|
3088, 4959
|
11995, 13055
|
2764, 2786
|
7752, 10003
|
10105, 10171
|
7094, 7729
|
10652, 11972
|
2801, 3069
|
10192, 10599
|
257, 267
|
389, 1516
|
1538, 2637
|
2653, 2748
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,158
| 157,425
|
36652
|
Discharge summary
|
report
|
Admission Date: [**2116-8-27**] Discharge Date: [**2116-8-31**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
85 yo fall from standing no loc on plavix for carotid dissection
in [**5-19**]. non focal exam
Past Medical History:
PMHx:
GERD
HTN
Prostate
Carotid Dissection
Social History:
Social Hx:
no tobacco
no etoh
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM:
O: T: BP: 183/75 HR:75 R18 O2Sats 99
Gen: WD/WN, comfortable, NAD.
HEENT: lac on occiput
Pupils: [**5-14**] bil
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: [**4-14**] 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 [**6-16**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right wnl
Left wnl
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**Known lastname **],[**Known firstname 1955**] [**Medical Record Number 82917**] M 85 [**2030-12-2**]
Cardiology Report ECG Study Date of [**2116-8-27**] 4:58:52 PM
Sinus rhythm at lower limits of normal rate. Minor T wave
abnormalities.
No previous tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 198 84 [**Telephone/Fax (2) 82918**] 10
[**Known lastname **],[**Known firstname 1955**] [**Medical Record Number 82917**] M 85 [**2030-12-2**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2116-8-30**]
9:09 AM
[**Last Name (LF) **],[**First Name3 (LF) **] J. NSURG FA11 [**2116-8-30**] 9:09 AM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 82919**]
Reason: 85 year old man with traumatic SAH was on plavix
pre-admissi
[**Hospital 93**] MEDICAL CONDITION:
85 year old man with traumatic SAH was on plavix
pre-admission, please compare
with prior
REASON FOR THIS EXAMINATION:
85 year old man with traumatic SAH was on plavix
pre-admission, please compare
with prior
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: JXRl SUN [**2116-8-30**] 10:25 AM
Decreased size of the right frontoparietal subdural hematoma. A
small focus
of left parietal subarachnoid hemorrhage, less conspicuous than
[**2116-8-27**].
Unchanged _____ left temporal hyperdensity, which may represent
a hematoma or
occult vascular malformation.
Final Report
HISTORY: 85-year-old male with subarachnoid hemorrhage. Compare
with a prior
study.
COMPARISON: Non-contrast head CT [**8-27**] and 18th, [**2116**].
TECHNIQUE: Non-contrast head CT was obtained.
FINDINGS: The right frontal acute subdural hematoma has
decreased in size, now
measuring 2 mm in transverse dimension (previously 4 to 5 mm).
The
hyperdensity in the left temporal lobe is unchanged. No new
intracranial
hemorrhage, shift of normally midline structures or edema. The
ventricular
size and configuration, sulci and basal cisterns are unchanged.
The
previously noted small focus of subarachnoid hemorrhage is
slightly less
conspicuous than [**2116-8-27**]. There is no fracture. The
visualized
paranasal sinuses and mastoid air cells remain well aerated.
IMPRESSION: Decreased size of the right frontoparietal subdural
hematoma. A
small focus of left parietal subarachnoid hemorrhage, less
conspicuous than
[**2116-8-27**].
Unchanged _____ left temporal hyperdensity, which may represent
a hematoma or
occult vascular malformation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: SUN [**2116-8-30**] 11:44 AM
Brief Hospital Course:
Pt was admitted to the neurosurgery service and monitored
closely in ICU. HD#1 he had repeat CT that was stable, his exam
remained intact and he was transferred to the floor. His diet
and activity were advanced. He had some confusion the night of
[**8-28**] and had repeat CT that showed slight extension of blood.
He recieved 6pk of platetlets. he was also seen by PT and found
to be slightly unsteady. He had repeat CT [**8-30**] which was
stable. He was cleared by PT and OT for home with moderate
supervision with PT ans OT services at home - son and wife both
agree with plan. Pt to be discharged to home.
Medications on Admission:
metoprolol
plavix
lisinopril
hctz
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. PLAVIX
YOU [**Month (only) **] RESTART YOUR PLAVIX AT YOUR PREVIOUS DOSE / YOU [**Month (only) **]
START THIS TODAY
6. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain: DO NOT DRIVE WHILE ON THIS
MEDICATION - IF YOU WANT, YOU [**Month (only) **] SIMPLY TAKE PLAIN TYLENOL FOR
YOUR PAIN .
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
traumatic brain contusion
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, or
Ibuprofen etc.
?????? You were on Plavix (clopidogrel) prior to your injury, you may
safely resume taking this today.
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.
PLEASE CONTACT [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT DRIVEWISE / [**Hospital1 18**] [**Location (un) **] AT [**Telephone/Fax (1) **] FOR AN APPOINTMENT FOR DRIVING EVAL.
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 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Completed by:[**2116-8-31**]
|
[
"851.81",
"293.0",
"V10.46",
"530.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6259, 6316
|
4841, 5458
|
269, 276
|
6386, 6410
|
1976, 2828
|
7707, 8069
|
531, 548
|
5542, 6236
|
2868, 2961
|
6337, 6365
|
5484, 5519
|
6434, 7684
|
578, 821
|
225, 231
|
2993, 4818
|
304, 400
|
1114, 1957
|
836, 1098
|
422, 467
|
483, 515
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
689
| 153,072
|
47264
|
Discharge summary
|
report
|
Admission Date: [**2185-5-20**] Discharge Date: [**2185-5-25**]
Date of Birth: [**2128-12-27**] Sex: F
Service: MEDICINE
Allergies:
Methadone
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
neck pain, feeling "awful"
Major Surgical or Invasive Procedure:
Placement of triple lumen catheter in right IJ
History of Present Illness:
56 year old woman with DM, HTN, ESRD on HD, recent MVA, who
presents with neck pain and feeling "awful." She was involved in
a MVA two weeks ago when another car struck her car from the
passenger side. She was in the passenger seat, wearing a
seatbelt, did not strike her head but did experience a jerking
motion of her neck. Afterward she began to experience severe
headaches and posterior neck pain. She was seen at [**Company 191**] on [**5-18**]
and diagnosed with whiplash. X-rays were ordered which she did
not have done. She went to [**Hospital 1474**] Hospital yesterday for the
pain and was given dilaudid and ativan and discharged home. She
continued to feel unwell so came to the ED.
In the ED she initially triggered for hypoxia of 82% on RA in
triage, but on recheck was 100% on RA. Other VS were 99.0, 47,
94/35, 16. She was A&Ox3 but slightly lethargic with pain over
her posterior c-spine. EKG with a junctional rhythm (old) and no
ischemic changes. She dropped her SBP to the 80s so a RIJ was
placed and she was given a dose of empiric zosyn and 2L NS. She
did not required pressors. [**Hospital **] notable for HCT 25 (baseline
high 20s-low 30s), stool guiac neg. CXR with mild vascular
congestion but no pneumonia or other acute process. VS prior to
transfer were 98/50 (MAP 63), 46, satting in the high 90s on 4L.
On arrival to the MICU, the patient continues to experience
severe posterior neck pain and headache. Having chest pain in
the center of her chest, GERD-like, feels like she needs to
burp, worse with deep breaths, and then vomited twice (2nd time
dark, guiac positive). Her symptoms resolved with anti-emetics,
and her hypotension and hypoxia resolved so she was transferred
to the floor. On the floor, she continued to be rather lethargic
but a rousable. She continued to complain of pain and anxiety,
requesting dilaudid and ativan, consistent with reports from
prior hospitalizations. She also complained of neck and back
pain. Her vital signs remained stable except for drops in her
pressure to the 80s systolic during hemodialysis.
Past Medical History:
- Diabetes
- Hypertension
- Hyperlipidemia
- ESRD on HD (M/W/F)
- Hepatitis C
- Anemia
- H/o PE
- Migraines
- Depression
- Narcotic dependence
- Chronic lymphedema in right leg
- Atrial flutter s/p cardioversion [**3-7**]
- Esophagitis
- MRSA bacteremia and candidemia
- Junctional bradycardia
Social History:
Lives alone in an apartment in [**Hospital1 1474**] with a PCA who comes in
M-F. Smokes [**11-29**] PPD and has smoked since age 25 (previously
smoked 1-1.5 PPD). Denies etoh or illicit drug use. Uses an
private ambulance company for transport to and from the
hospital.
Family History:
Mother had lupus.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.9, 54, 119/39, 14, 99% on 4L
General: Appears uncomfortable, in pain, vomiting
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Posterior midline tenderness
CV: Bradycardic but regular, normal S1/S2, 3/6 systolic murmur
at upper sternal border
Lungs: Poor respiratory effort but overall clear, no wheezes or
rales
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
GU: No foley
Rectal: Stool guiac neg (in ED)
Ext: WWP, chronic LLE swelling (unchanged per pt), 1+ DP/PT
pulses, well-healing LLE ulcer on lateral aspect of leg with
granulation tissue, no drainage.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally,
finger-to-nose intact, gait deferred
DISCHARGE EXAM:
Vitals: 98.4, 101-133/41-63, 60-74, 18, 95% on RA
Gen: Alert and oriented, no longer lethargic, however
emotionally labile
HEENT: NCAT, MMM, OP clear, EOMI, PERRL, sclera anicteric,
conjunctiva pink
Neck: supple, Right IJ successfully removed, no posterior
midline tenderness
CV: RRR, normal S1 and S2, 3/6 systolic murmur heard best at
LUSB and additional systolic murmur heard at the apex of the
heart
Resp: good aeration, CTAB, no w/r/r
Abd: soft, ND, NT, normoactive BS, no organomegaly, no r/g
Ext: WWP, 1+ pitting edema of [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**], well-healed and
dressed LLE ulcer on anterior tibia
Neuro: CN II-XII grossly intact, 5/5 strength, grossly normal
sensation, no focal deficits
Pertinent Results:
ADMISSION [**Last Name (Prefixes) **]:
[**2185-5-20**] 03:00PM BLOOD WBC-6.0 RBC-2.73* Hgb-8.1* Hct-25.0*
MCV-92# MCH-29.5 MCHC-32.2# RDW-15.7* Plt Ct-114*
[**2185-5-20**] 03:00PM BLOOD Neuts-56.8 Lymphs-34.2 Monos-5.6 Eos-3.1
Baso-0.4
[**2185-5-20**] 03:00PM BLOOD Glucose-155* UreaN-23* Creat-6.0*# Na-140
K-4.2 Cl-99 HCO3-27 AnGap-18
[**2185-5-20**] 03:00PM BLOOD cTropnT-0.21*
[**2185-5-20**] 08:15PM BLOOD CK-MB-2 cTropnT-0.23*
[**2185-5-20**] 08:15PM BLOOD CK(CPK)-79
[**2185-5-20**] 03:00PM BLOOD Calcium-8.1* Phos-9.1*# Mg-1.8
DISCHARGE [**Month/Day/Year **]:
[**2185-5-25**] 06:40AM BLOOD WBC-6.8 RBC-2.94* Hgb-8.6* Hct-26.7*
MCV-91 MCH-29.3 MCHC-32.3 RDW-18.2* Plt Ct-81*
[**2185-5-25**] 06:40AM BLOOD PT-11.2 PTT-28.3 INR(PT)-1.0
[**2185-5-25**] 06:40AM BLOOD Glucose-117* UreaN-37* Creat-6.2*# Na-136
K-3.8 Cl-96 HCO3-29 AnGap-15
[**2185-5-25**] 06:40AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2
[**2185-5-25**] 06:40AM BLOOD Vanco-17.4
RELEVANT [**Month/Day/Year **]:
[**2185-5-21**] 04:13AM BLOOD Type-CENTRAL VE pO2-39* pCO2-56* pH-7.32*
calTCO2-30 Base XS-0
[**2185-5-21**] 04:13AM BLOOD Lactate-1.3
[**2185-5-23**] 02:43AM BLOOD Cortsol-19.3
[**2185-5-22**] 05:46AM BLOOD Hapto-50
[**2185-5-21**] 03:53AM BLOOD CK-MB-2 cTropnT-0.23*
[**2185-5-20**] 08:15PM BLOOD CK-MB-2 cTropnT-0.23*
[**2185-5-20**] 03:00PM BLOOD cTropnT-0.21*
MICRO:
Blood Culture, Routine (Final [**2185-5-27**]): NO GROWTH.
Blood Culture, Routine (Final [**2185-5-26**]): NO GROWTH.
Unable to perform Urine Cx as pt does not produce urine.
IMAGING:
ECG Study Date of [**2185-5-20**] 2:37:52 PM
Probable junctional rhythm. Prolonged Q-T interval. Poor R wave
progression.
Non-specific ST-T wave abnormalities. Compared to the previous
tracing
of [**2185-1-28**], junctional rhythm is present, voltage criteria for
left ventricular
hypertrophy are now absent. The QRS change in lead V4 could be
due to
variability in lead placement.
Rate PR QRS QT/QTc P QRS T
41 0 102 560/526 0 9 21
[**2185-5-20**] PORTABLE SEMI-UPRIGHT AP VIEW OF THE CHEST: There is
moderate enlargement of
the cardiac silhouette which is stable. The mediastinal
contours are
unchanged. The pulmonary vascularity is mildly engorged
suggesting an element
of elevated pulmonary venous pressure. No consolidation,
pleural effusion or
pneumothorax is identified, though the left costophrenic angle
is excluded
from the field of view. There are no acute osseous
abnormalities.
IMPRESSION: Mild pulmonary vascular congestion.
[**2185-5-20**] CTA chest
1. No evidence of acute pulmonary embolism or thoracic aortic
pathology.
2. Pulmonary arterial hypertension with moderate cardiomegaly,
and findings
suggesting mild right heart decompensation.
3. Mild centrilobular emphysema
[**2185-5-20**] CTA Head and Neck
IMPRESSION:
There is no evidence of acute intracranial hemorrhage or acute
intracranial
process. There is mild-to-moderate cerebral atrophy and mild
vertebral and
internal carotid artery vascular calcifications.
The CTA of the head demonstrates moderate calcifications in both
carotid
siphons and tortuous course of both cervical internal carotid
arteries with no
evidence of occlusions or severe stenosis. No aneurysms are
identified.
Centrilobular emphysema is present. No cervical fractures are
identified.
Multilevel degenerative changes are visualized, more significant
at C5/C6.
A preliminary report was provided by Dr. [**Last Name (STitle) **] [**Name (STitle) **] and
communicated
to Dr. [**Last Name (STitle) 34918**] at 11:45 p.m. on [**2185-5-20**].
[**2185-5-22**] US LUE AVF
IMPRESSION: Patent left upper extremity AV fistula without
surrounding fluid
collection.
[**2185-5-27**] TTE
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal regional and hyperdynamic global systolic function.
Pulmonary artery hypertension. Dilated ascending aorta.
Compared with the prior study (images reviewed) of [**2183-4-3**], the
findings are similar.
Brief Hospital Course:
Primary Reason for Hospitalization:
56 year old woman with DM, HTN, ESRD on HD, recent MVA, who
presents with headache/neck pain/vomiting/hematemesis and found
to be bradycardic, hypotensive, and hypoxic.
Active Diagnoses:
# Neck Pain/Headache:
Mrs. [**Known lastname **] came to the ED complaining of pain from a prior MVA.
Pain continued throughout her hospital stay but lessened in
severity each day. CT head and neck did not show any acute
process. Her C collar was removed, and she remained
neurologically intact with full ROM. Her pain was treated with
IV dilaudid and will likely improve with outpatient PT.
# Hypotension:
Pt initially came in with SBP in the 80s, which responded to 2L
NS in the ED. Home antihypertensives were held. Her hypotension
was thought to be due to either hypovolemia (overdialysis),
sepsis, anemia, or adrenal suppression. She came in with a Hct
of 25, several points below her baseline. Her stools were guaiac
negative, but she had an episode of hematemesis while on the
MICU (see hematemesis below). Her hematemesis resolved, and she
had not other sources of active bleeding (see anemia below). Her
cortisol level was normal. Looking back at previous
hospitalizations, she has a history of MRSA bacteremia and
[**Female First Name (un) **] fungemia. She did not become febrile, however her
temperatures were higher than expected given she is a HD
patient. There was adequate concern for septicemia, and sources
of infection were investigated. She remained on empiric
treatment with vanc and zosyn for 7 days, and no definitive
source of infection was identified. After starting the abx, her
hypotension resolved and she remained normotensive throughout
her hospital stay (except during HD). She was instructed to
continue Vancomycin for 2 additional HD doses for a total 7 day
course. Post-discharge, it is still unclear whether or not she
had a transient bloodstream infection. Her blood cultures came
back negative x 4.
# Bradycardia:
The pt has a documented history of Junctional rhythm on EKG. Her
home medications, amlodipine and carvedilol, were held, and her
bradycardia resolved. The decision to restart should be based on
a discussion with her PCP.
# Hypoxia:
The patient received a CXR and CTA which ruled out PE, PNA, or
other acute process. Likely attributed to volume overload, as pt
has ESRD and receives HD MWF. Her oxygenation improved in the
MICU and was normal on the floor on RA.
# Anemia:
The pt has a longstanding hx of anemia, likely secondary to
ESRD. However, she presented with lower than normal Hct and
often complained of weakness/dizziness. She was transfused one
unit of blood with dialysis, which improved her numbers.
#Thrombocytopenia:
She has longstanding thrombocytopenia but numbers dipped below
baseline by nearly 50% since admission. She received heparin
products while hospitalized, including during dialysis. There
was low suspicion for a consumptive process. We stopped all
heparin products and considered getting HIT Ab titers, however
the pt's platelets came back up, and suspicion for HIT was low.
No further workup was deemed necessary.
# Hematemesis:
This occurred once while in the ICU. Although she has a hx of
hepatitis C she has no hx of cirrhosis (RUQ neg in 5/[**2182**]). H/o
hematemesis and had EGD in [**2-/2180**] with gastritis but no active
bleeding and no varicose. Colonoscopy in [**2-/2180**] also normal.
Patient on ASA 81mg but no other NSAIDs. Ultimately, the
hematemesis resolved, so no further wok up was necessary. If she
continues to experience hematemesis as an outpatient, she would
likely benefit from a repeat EGD.
# Elevated troponins:
Her tropnins were approx 0.2 x 3, but did not have ST changes on
EKG. Looking back at previous hospitalizations, it appears that
this is her baseline, presumably related to ESRD. She was not
symptomatic.
#Anxiety:
The pt continued to complain of anxiety throughout her stay,
requesting ativan daily. We ordered her home ativan dose, which
she normally takes prior to HD. There appeared to be some level
of dependence on ativan. She also takes wellbutrin at home. Upon
discharge she continued to complain of anxiety and will likely
need outpatient follow up with PCP or psychiatry.
Chronic diagnoses:
# ESRD on HD:
Patient was dialyzed MWF per her home schedule, and we continued
her nephrocaps. Before d/c, we ensured she has adequate
transportation to and from dialysis.
# Hypertension:
Home medications were held due to hypotension.
# Hyperlipidemia:
Continued home medication, simvastatin daily.
# DM:
She was placed on insulin sliding scale with FSBGs in acceptable
range.
# Hepatitis C:
She showed no signs of decompensation. No cirrhosis seen on RUQ
U/S in 5/[**2182**]. She is followed by a gastroenterologist, last
seen in [**2185-2-27**].
# Pituitary adenoma:
Pt has appointment for MRI scheduled in [**Month (only) **] with
outpatient neurology follow up. This is not suspected to be
related to her current condition.
Transitional Issues:
#She will need home PT for her MVA injuries.
#Her Coreg and amlodipine were held during hospitalization for
hypotension/bradycardia but may need to be restarted given ECHO
findings of LVH. Her dose may need adjustment by her PCP.
#Pt appears to have anxiety issues which could not be managed
appropriately in the hospital. She would likely benefit from
outpatient counseling and adjustment of medications
#MRI of pituitary scheduled with neuro follow up.
#She has follow up with nephrology
#She has a follow up appt with hematology for her anemia
Medications on Admission:
amlodipine 10 mg Tablet daily
B complex-vitamin C-folic acid [[**Location (un) **] Caps] 1 mg Capsule) by
mouth once a day
Benzonatate 100 mg 1 Capsule(s) by mouth three times a day as
needed for cough
Bupropion HCl 150 mg 1 Tablet(s) by mouth
Monday/Wednesday/Friday only take after hemodialysis
Carvedilol 25 mg 1 Tablet(s) by mouth twice a day
Gabapentin 300 mg Capsule by mouth q48hr
Glucagon (human recombinant) [Glucagon Emergency] 1 mg Kit use
as needed prn
Hydroxyzine HCl 25 mg 1 Tablet(s) by mouth every six (6) hours
as needed for pruritus
Insulin aspart [Novolog Flexpen] 100 unit/mL Insulin Pen inject
per sliding scale four times a day or as directed ; max 12u for
BG >400
Insulin aspart [Novolog Flexpen] 100 unit/mL Insulin Pen per sl
sc prn
Lorazepam 1 mg Tablet by mouth three times weekly before
dialysis as needed for anxiety
Omeprazole 20 mg Capsule, Delayed Release(E.C.) 1 Capsule(s) by
mouth twice a day
Oxycodone 10 mg Tablet by mouth up to tid as needed for severe
pain
Simvastatin 5 mg Tablet by mouth once a day (Prescribed by Other
Provider)
acetaminophen [APAP] 325 mg Tablet 1 Tablet(s) by mouth prn
aspirin [Aspir-81] 81 mg Tablet, Delayed Release (E.C.) by mouth
daily
Bisacodyl 10 mg Suppository 1 Suppository(s) rectally as needed
as needed for constipation
Loperamide [Lo-Peramide] 2 mg Tablet by mouth every 12 hours as
needed for diarrhea
[**Location (un) **] hydroxide [Milk of Magnesia] 400 mg/5 mL Suspension 30
ml by mouth as needed for constipation
Sodium phosphates [Enema] 19 gram-7 gram/118 mL Enema 1 Enema(s)
rectally as needed as needed for constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO MWF
AFTER HD
3. Gabapentin 300 mg PO Q48H
4. Lorazepam 1 mg PO MWF:PRN anxiety
prior to dialysis
5. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
6. sevelamer CARBONATE 1600 mg PO TID W/MEALS
7. Simvastatin 5 mg PO DAILY
8. Vancomycin 1000 mg IV HD PROTOCOL Duration: 2 Doses
take with dialysis for 2 more doses: Friday [**2185-5-28**] and
Monday [**2185-5-30**]
9. Nephrocaps 1 CAP PO DAILY
10. Benzonatate 100 mg PO TID:PRN cough
11. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
12. HydrOXYzine 25 mg PO Q6H:PRN pruritis
13. NovoLOG *NF* (insulin aspart) inject per sliding scale
Subcutaneous as prior to admission
14. Acetaminophen 325 mg PO Q6H:PRN pain or fever
15. Bisacodyl 10 mg PR HS:PRN constipation
16. Loperamide 2 mg PO BID:PRN diarrhea
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
PRIMARY
fever
hypotension
bradycardia
hypoxia
anemia
thrombocytopenia
SECONDARY
congestive heart failure
end stage [**Hospital1 **] disease on hemodialysis
diabetes mellitus
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Uses wheelchair.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure caring for you at [**Hospital1 18**]. You originally came
to the emergency department for pain in your neck and back from
your recent car accident. In the emergency department, you were
found to have a low blood pressure, fever, low oxygen levels,
and slow heart rate. The doctors were concerned that you might
have an infection, so they inserted a large IV into your neck
for easier administration of fluids and antibiotics, and they
sent you to the Medical Intensive Care Unit. You were started on
antibiotics for a presumed infection. They stopped your normal
medicines for high blood pressure (Carvedilol and Amlodipine).
The following day, your vital signs improved, and you were
transfered to the general medicine floor.
On the medicine floor, we continued your IV antibiotics and
investigated sources of possible infection because you had a
fever. We did a chest CT which did not show any pneumonia. We
did blood cultures which were pending at the time of your
discharge. We also examined your AV fistula site and chronic
left shin ulcer as possible sources.
*****On the last day of your stay, you received a transthoracic
echocardiogram to make sure you did not have a bacterial clot on
the heart valve but you decided to leave the hospital AGAINST
THE MEDICAL ADVICE of your physicians before finding out the
final result. The risks associated with this include
overwhelming infection and death.*****
Although we did not find a source of infection, you improved on
the strong antibiotics we gave you. Your fevers and low blood
pressure resolved. You are being discharged with plans to
receive Vancomycin at HD on Friday [**5-27**] and Monday [**5-30**].
Note that when you were tranferred to our service you also had a
slow heart beat. You have a history of a slow heart beat
(junctional bradycardia) according to your records. This
improved with treating your presumed infection. You also had
nausea and vomiting, which resolved as well, without requiring
intervention.
While you were here, you became quite confused and anxious,
requiring occasional doses of anti-anxiety medication. As your
infection got better, this problem seemed to resolve.
During your stay, your blood counts (hematocrit) were quite low
despite receiving medication to raise them (epogen) during
dialysis, requiring us to transfuse a unit of blood. We tested
your stool to see if you were bleeding from your digestive
tract, but those tests were negative. You did not show any
active signs of bleeding. We presume that your low blood counts
were related to your chronic kidney disease. Please follow up
with your nephrologist (at dialysis) and hematologist
(appointment listed below) to discuss the proper long term
treatment plan.
Your platelets were low during your stay as well. We looked in
your previous records and found that this has been a problem in
the past and was stable. Therefore we did not transfuse
platelets or perform any other investigations.
Throughout your stay, you received dialysis on
Monday/Wednesday/Friday as normally scheduled. No changes were
made to the treatment of your kidney disease.
We made the following changes to your medications:
-Start Vancomycin 1000mg IV with HD for 2 more doses: on Friday
[**5-27**] and Monday [**5-30**] (this will complete a 1 week course since
being afebrile, last fever was early in the morning on [**2185-5-23**])
-HOLD amlodipine until instructed to restart it
-HOLD carvedilol until instructed to restart it
Followup Instructions:
PRIMARY CARE
Department: [**Hospital3 249**]
When: TUESDAY [**2185-6-7**] at 3:00 PM
With: [**Name6 (MD) **] [**Name6 (MD) **], MD [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] [**Hospital Ward Name **] Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
HEMATOLOGY
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2185-5-26**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD / [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] [**Hospital Ward Name **] Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
NEPHROLOGY
You will be followed by your Nephrologist at hemodialysis.
Completed by:[**2185-6-3**]
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68,099
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52093
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Discharge summary
|
report
|
Admission Date: [**2135-9-16**] Discharge Date: [**2135-9-28**]
Date of Birth: [**2055-8-13**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
back pain, LE weakness
Major Surgical or Invasive Procedure:
Vertebrectomy T11 with fusion T9-L1
History of Present Illness:
Patient is an 80 yo male with prostate CA with mets to the
spine, on chemotherapy with lupron depot injections. He has
chronic low back pain that is being treated with facet blocks.
His pain is in the low back and bilateral lower quadrant pain
and became acutely worse yesterday. His baseline pain is a
[**2135-2-17**] and overnight it was a [**2135-5-23**] and as [**7-26**] in the ED. He
takes oxycontin 10 mg [**Hospital1 **] and oxycodone 5 mg po prn which did
not provide relief. His pain is worse with movement, alleviated
by rest. He has has also had increasing lower extremity
weakness, right greater than left. There have been times when he
has a tingling sensation and numbness in his right leg with
difficulty walking. He uses a cane at baseline. He also
complains of associated lower abdominal pain in band-like
formation contiguous with lower back. He complains of
constipation not relieved by senna or colace. His last BM 2 days
ago. He has urinary incontinence at baseline.
In the ED, initial VS were: 97.6 64 168/81 18 99%. On exam,
normal rectal tone, trace guaiac positive. CT abdomen without
obstruction. CXR without free air. He was given 8mg morphine and
1 mg hydromorphone. VS on transfer: P 82 BP 146/62 RR 16 O2
96RA.
Past Medical History:
Prostate cancer diagnosed in [**2117**]. S/p radical prostatectomy.
XRT to pelvis approx one and a half years after prostatectomy
for rising PSA. In [**2123**], started hormones for metastatic
prostate cancer. In [**2130-11-16**], started on KHAD trial of
Ketoconozole, Hydrocortisone, and Dutasteride as he became
hormone refractory. Was on Sutent Trial temporarily from
[**Date range (1) 31896**]. Was on diethylstilbesterol from approx [**2131**] to
[**2134-1-5**]. Has also been maintained on Lupron/Pamidronate. Last
dose of Lupron was [**2134-1-5**] at dose of 22.5 mg. He is status
post
Clinical Trial #08-359 taxotere every 3 weeks plus atrasentan vs
placebo and prednisone daily. He was unable to tolerate this
regimine secondary to toxicity. He received Taxotere every
3-4wks & lupron every 3mos. He finished cycle 15 of Taxotere on
[**2135-7-25**]. He is now on leupropride every 12 weeks, which began
on [**2135-7-5**].
Other Past Medical History:
- CABG x 4 vessels [**2120**]
- Hypertension
- Hyperlipidemia
- E. coli urosepsis in [**2135-5-17**]
- One fall with subsequent wrist fracture.
- Right heart failure (EF 65%)
Social History:
Retired construction worker. Lives at home with his son.
- Tobacco: none
- etOH: former social drinker, last use 35 yo ago
- Illicits: none
Family History:
Brother with prostate cancer
Physical Exam:
On Admission:
VS: T: 98.5, 140/80, P: 75, RR: 18, 98% RA
GEN: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal. 3/6 systolic murmur
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, NT, +BS. mildly TTP in lower abdomen, no
rebound/guarding. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: 3+ pitting edema to kness, DPs, PTs not palpable
Skin: bruises over upper extermities (at site of PIV)
Rectal: normal rectal tone, no stool in vault
Neuro/Psych: CNs II-XII intact. 5/5 strength in upper
extremities. 3-4/5 in right lower extremities, [**3-21**] in left lower
extremity. sensation intact to LT.
On discharge:
AF, VSS, no oxygen requirement
GEN: friendly, overweight elderly man in NAD, AAOx3
CV: RRR, no m/r/g
PULM: CTAB, no wheezes, rales, rhonchi
ABD: Soft, NTND, +BS
EXT: 3+ bilateral LE edema to knees, 5/5 strength in B LE
Pertinent Results:
Hematologies:
[**2135-9-28**] 06:35AM BLOOD WBC-9.4 RBC-3.37* Hgb-9.9* Hct-29.7*
MCV-88 MCH-29.3 MCHC-33.3 RDW-15.5 Plt Ct-247
[**2135-9-22**] 04:07AM BLOOD WBC-7.2 RBC-3.74* Hgb-11.1* Hct-30.7*
MCV-82 MCH-29.6 MCHC-36.0* RDW-15.7* Plt Ct-114*
[**2135-9-21**] 07:50PM BLOOD WBC-8.5 RBC-3.16* Hgb-9.4* Hct-26.7*
MCV-84 MCH-29.7 MCHC-35.1* RDW-16.2* Plt Ct-147*
[**2135-9-17**] 08:20AM BLOOD WBC-5.7 RBC-4.61 Hgb-11.9* Hct-38.6*
MCV-84 MCH-25.8* MCHC-30.8* RDW-17.0* Plt Ct-202
[**2135-9-16**] 09:30AM BLOOD WBC-10.0 RBC-4.68 Hgb-12.2* Hct-37.9*
MCV-81* MCH-26.1* MCHC-32.3 RDW-17.3* Plt Ct-201
[**2135-9-25**] 08:35AM BLOOD PT-12.0 PTT-31.0 INR(PT)-1.0
[**2135-9-16**] 10:01AM BLOOD PT-11.7 PTT-21.7* INR(PT)-1.0
[**2135-9-21**] 05:00PM BLOOD Fibrino-135*
Chemistries:
[**2135-9-28**] 06:35AM BLOOD Glucose-102* UreaN-22* Creat-0.8 Na-136
K-4.5 Cl-102 HCO3-29 AnGap-10
[**2135-9-27**] 06:25AM BLOOD Glucose-103* UreaN-18 Creat-0.7 Na-139
K-5.0 Cl-106 HCO3-31 AnGap-7*
[**2135-9-17**] 08:20AM BLOOD Glucose-120* UreaN-22* Creat-1.1 Na-139
K-5.0 Cl-103 HCO3-24 AnGap-17
[**2135-9-16**] 09:30AM BLOOD Glucose-97 UreaN-20 Creat-1.0 Na-141
K-4.2 Cl-104 HCO3-29 AnGap-12
[**2135-9-21**] 06:55AM BLOOD ALT-10 AST-9 LD(LDH)-166 AlkPhos-54
TotBili-0.2
[**2135-9-28**] 06:35AM BLOOD Calcium-8.1* Phos-2.4* Mg-2.2
[**2135-9-22**] 03:35PM BLOOD Calcium-8.4 Phos-3.5 Mg-2.2
[**2135-9-16**] 09:30AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.3
[**2135-9-27**]: L-spine AP & LAT
IMPRESSION: Thoracolumbar posterior fusion with no evidence of
hardware
complication. Metallic spacer at T11 with unchanged T11
compression and
sclerosis. Grade 1 anterolisthesis of L4 with respect to L5 and
L5 with
respect to S1 unchanged from prior study.
[**2135-9-16**] MRI C-Spine, T-Spine and L-Spine
CERVICAL SPINE:
There are no prior cervical spine MRI studies available for
comparison.
From craniocervical junction to C7 level, no evidence of bony
metastasis seen. Mild heterogeneity of marrow signal seen. At
C3-4, there is moderate spinal stenosis due to disc degenerative
change, bulging, and thickening of the ligaments identified with
indentation on the spinal cord. At C4-5, mild degenerative
changes seen. At C5-6, mild-to-moderate spinal stenosis and mild
extrinsic indentation on the spinal cord seen. At C6-7 and
C7-T1, mild degenerative changes identified. There is no
abnormal signal seen within the spinal cord.
IMPRESSION: No evidence of bony metastatic disease in the
cervical region. Cervical spondylosis with moderate spinal
stenosis at C3-4 and
mild-to-moderate spinal stenosis at C5-6 with extrinsic
indentation on the
spinal cord. No abnormal signal within the spinal cord. No
abnormal enhancement.
THORACIC SPINE:
There is a bony metastasis within the left side of the T1
vertebral body.
There are no prior MRI examinations of the thoracic spine
available. In
addition, subtle decreased signal in T10 vertebral body also
indicates
metastatic disease. The T11 vertebra again demonstrates an
infiltrative
process and compression fracture with retropulsion and
compression of the
spinal cord at this level which has remained deformed in
appearance. There is no abnormal signal seen within the spinal
cord. There are epidural soft
tissue changes seen at this level. From T1-2 to T12-L1, disc
degenerative
changes identified.
IMPRESSION: There is pathologic compression fracture at T11
level with
compression of the spinal cord and epidural soft tissue changes
which is again identified and is unchanged since [**2135-6-14**].
LUMBAR SPINE:
Focal bony abnormalities are seen in the L3 and S1 vertebral
bodies,
indicative of bony metastatic disease, not significantly changed
from previous MRI. From T12-L1 to L3-4, disc degenerative
changes are identified. At L4-5, grade 1 spondylolisthesis of L4
over L5 seen with facet degenerative changes and thickening of
the ligaments resulting in moderate-to-severe spinal stenosis
and moderate-to-severe left-sided and severe right-sided
foraminal narrowing.
At L5-S1 level, disc and facet degenerative changes and mild
anterolisthesis identified. There is severe right-sided and
moderate left-sided foraminal narrowing. Moderate spinal
stenosis seen. The sacrum demonstrates involvement of the S2
portion as well as the left ala of sacrum secondary to
metastatic disease. Focal metastasis is also seen in the right
posterior ilium.
IMPRESSION: Overall no significant change in appearance of the
lumbar spine seen compared with the previous MRI of [**2135-6-14**].
Metastatic lesions to S1 and L3 vertebral bodies are identified.
Degenerative changes with
spondylolisthesis of L4 over L5 and L5 over S1 again noted as
described above. Incidentally noted is somewhat distended
urinary bladder.
Brief Hospital Course:
#Low Back Pain: Patient has chronic back pain which became
acutely worse and was no longer controlled on his home pain
medications. He pain is secondary to prostate metastases to his
spine. He also had worsening lower extremity weakness
particularly of his right leg. MRI showed stable spinal cord
compression. He was treated with dexamethasone 4 mg iv/po q8h.
He pain was well controlled with oxycodone SR 10 mg po tid and
morphine 2-4 mg iv q4h. There was concern for instability at T11
and he went to the OR on [**2135-9-21**] where under general anesthesia
he underwent T9 to L1 fusion with vertebrectomy T11. He
required multiple transfusions peri and post op. Hematocrit
stabilized around 30. He was extubated [**2135-9-22**]. His motor exam
was full. He had JP drain that was monitored and discontinued
on [**2135-9-23**]. His decadron was transitioned to usual prednisone
dose. He was seen by PT who recommended he use a walker. He was
discharged on oxycotin 10 mg po TID and oxycodone 5 mg po q4h
prn, which had given him good pain control without lethargy.
#Metastatic Prostate Cancer: Patient has metastatic prostate
cancer, recently treated with taxotere. He receives lupron depot
injections every 3 months. He will not be able to receive
chemotherapy in the [**2-19**] week post-op to allow for healing.
#Chronic Right Heart failure: EF 65%. Patient had 3+ lower
extremity edema but no paroxysymal nocturnal dyspnea, no
orthopnea but has occasional dyspnea on extertion. He was
continued on his home doses of furosemide and atenolol.
Medications on Admission:
Atenolol 50 mg po daily
Lupron depot 22.5 mg every three months
Nitroglycerin unknown dose
Omeprazole EC 20 mg po daily
Oxycodone 5 mg po prn
oxycodone SR 10 mg po prn
Prednisone 10 mg po daily
Aspirin 325 mg po daily
Senna 8.6 mg po bid prn constpation
Docusate 100 mg 2 tabs twice a day as needed for constipation
Lasix 20 mg po daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
10. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day) as needed for spasm.
13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
16. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4316**] Rehabilitation & [**Hospital **] Care Center - [**Location (un) **]
Discharge Diagnosis:
Metastatic prostate cancer to T11
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking part in your care. You were admitted to
the hospital with increased back pain and right leg weakness.
Your pain and weakness were caused by your prostate cancer that
had spread to your spine. You were treated with steroids to
decrease the swelling around the spine. You also had surgery to
stabilize the spine.
The following changes were made to your medications:
-INCREASED oxycontin from 10 mg twice a day to 10 mg three times
a day
-ADDED Acetominophen 650 mg every 6 hours
-ADDED Cyclobenzaprine as needed for back spasms
-ADDED Gabapentin
-ADDED Bisacodyl and Miralax as needed for constipation
-ADDED Nystatin
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 548**] in 1 week for staple removal or
these may be removed at rehab on [**2135-10-5**]. His office number is
[**Telephone/Fax (1) 1669**]. Please also make appt for 6 weeks with Lumbar
xrays - call [**Telephone/Fax (1) 2992**] to arrange.
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"84.51",
"81.04",
"80.99",
"81.63",
"81.05"
] |
icd9pcs
|
[
[
[]
]
] |
12052, 12166
|
8661, 10217
|
291, 329
|
12244, 12244
|
3911, 8638
|
13126, 13518
|
2943, 2973
|
10606, 12029
|
12187, 12223
|
10243, 10582
|
12427, 13103
|
2988, 2988
|
3670, 3892
|
229, 253
|
357, 1602
|
3002, 3656
|
12259, 12403
|
2590, 2767
|
2783, 2927
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,125
| 159,125
|
54400
|
Discharge summary
|
report
|
Admission Date: [**2174-12-15**] Discharge Date: [**2174-12-16**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubation
Right internal jugular central line
Defibrilation
Arterial line
History of Present Illness:
HPI: [**Age over 90 **] y/o F with PMHx of bronchiectasis was transferred from
[**Hospital 100**] Rehab for change in mental status, fever, and respiratory
distress.
.
The patient arrived to the ER at 4:50 PM [**Hospital 111364**] [**Hospital 100**] Rehab. She
was febrile to 103.6, tachycardic to 105, tachypenic at 38, and
was 98% on NRB, bp 106/41. She was not answering questions. Labs
revelaed K of 5.7, Na of 150, WBC of 30. CXR showed LLL PNA. She
received ceftriaxone 2g IV, azithromycin 500 mg IV, Vancomycin 1
g, Tylenol 1 g PR, insulin 5u/d50 1 amp, Kayexelate 15 g PR and
was sent to 11R around 10PM to be admitted to nightfloat. The
son called 11R to speak with the NF residet. At that time, the
NF resident I was called to see the patient at 10:45PM by the NF
resident for concern of obtundation and tachypnea. At that time,
the patient's ABG was 7.08/109/144. A respiratory code was
called and the patient was intubated. When the ETT was placed,
it initially filled with yellow-tinged sputum which was
copisously suctioned. She was transferrred to the [**Hospital Unit Name 153**].
Past Medical History:
1. Chronic bronchiectasis
2. Arthritis
3. Glaucoma
4. S/p L humeral fx
5. HOH
6. Chronic UTIs
7. Hx CHF
8. Urinary incontinence
9. Dementia
10. Relative hypotension (per d/w grandson)
11. Iron-deficiency anemia
12. S/p colonic resection x 2
Social History:
SH: Lives at [**Location **], no living children or siblings per her
grandson [**Name (NI) **] [**Name (NI) 3532**]
Family History:
NC
Physical Exam:
Vitals: T NR/ HR 97// BP 97/56/ O2 Sat 99% on 10L NRB
Gen: Elderly female, not spontaneously moving or speaking
HEENT: pupil reactive, L surgical, no scleral icterus, dry mm
Neck: supple, no lad
Heart: rr, muffled by loud rhonchi
Lungs: diffusely rhonchorous r>l
Abd: soft, mildly distended, nabs, no organomegaly
Ext: thin, trace LE edema, eschar on rle, 1+ dps
Psych: Cannot assess, pt responsive only to pain
Pertinent Results:
[**2174-12-15**] 11:56PM TYPE-ART RATES-20/ TIDAL VOL-400 PEEP-5
O2-100 PO2-285* PCO2-68* PH-7.21* TOTAL CO2-29 BASE XS--2
AADO2-376 REQ O2-65 -ASSIST/CON INTUBATED-INTUBATED
[**2174-12-15**] 11:35PM GLUCOSE-159* UREA N-63* CREAT-1.9*
SODIUM-148* POTASSIUM-7.1* CHLORIDE-110* TOTAL CO2-27 ANION
GAP-18
[**2174-12-15**] 11:35PM CALCIUM-7.9* PHOSPHATE-7.5* MAGNESIUM-2.8*
[**2174-12-15**] 10:57PM TYPE-ART PO2-144* PCO2-109* PH-7.08* TOTAL
CO2-34* BASE XS--1
[**2174-12-15**] 10:57PM LACTATE-1.4 NA+-151* K+-5.6*
[**2174-12-15**] 05:10PM CK-MB-NotDone cTropnT-0.16*
[**2174-12-15**] 05:10PM WBC-29.85*# RBC-5.17 HGB-12.7 HCT-42.2 MCV-82
MCH-24.6*# MCHC-30.1* RDW-14.9
[**2174-12-15**] 05:10PM NEUTS-86* BANDS-2 LYMPHS-5* MONOS-5 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2174-12-15**] 05:10PM PLT SMR-NORMAL PLT COUNT-378#
[**2174-12-15**] 05:10PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.0
LEUK-MOD
01/12/0
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2174-12-15**] 5:26 PM
CHEST (PORTABLE AP)
Reason: please eval for infiltrate,PTX, CHF
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with fever, tachypnea
REASON FOR THIS EXAMINATION:
please eval for infiltrate,PTX, CHF
INDICATION: Fever, tachypnea.
COMPARISONS: [**2168-11-9**].
SINGLE VIEW CHEST, AP: There is a consolidation involving the
left lower lobe with patchy airspace opacities also involving
the left mid lung zone. Dense calcification of the aorta is
again identified. The right lung is essentially clear. A likely
left-sided pleural effusion is also present. An old left humeral
head fracture appears stable.
IMPRESSION: Left lower lobe pneumonia.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**First Name8 (NamePattern2) **] [**2174-12-15**] 10:32 PM
6 05:10PM URINE RBC-[**2-5**]* WBC->1000 BACTERIA-MANY YEAST-NONE
EPI-0
Brief Hospital Course:
In the [**Hospital Unit Name 153**], she became hypotensive. Levophed was begun. Vent
settings were changed after her first gas intubated was
7.21/68/285. Her CVP as 4 and she was given 5L NS and 1 unit [**12-5**]
NS once Na was back. R IJ and R art line was placed. Labs were
drawn which showed hypocalcemia, hypernatremia, and
normokalemia. At 3:43 AM, she went into an atrial tachycardia
with a rate of 160's with her pressure dropping into the 40's.
Code was initiated. She was cardioverted into sinus rhythm with
200J and blood pressure resumed. Vasopression was started with
the attempt to quickly wean off the levophed. She had very
labile BP in next 1 hour ranging anywhere from 80 on max vaso
and levo to 180 off both. She again entered into an atrial
tachycardia and I cardioverted her with 100J into sinus rhythm
again. During this time, the intern called the grandson again
and reiterated her poor prognosis. The grandson decided to make
the goals of care comfort. Pressors were stopped and the patietn
was placed on a T-piece.
Medications on Admission:
acetominophen 650 q6H
duoneb (freq not recorded)
betzolol 0.25% 1 gtt ou [**Hospital1 **]
mirtazapine 15 mg hs
risperdone 0.5 mg qd
PRNS:
Lorazepam .5 po q12H prn and before straight cath for agitation
MOM 30 mls qd prn
sorbitol 15 mg po qd prn constipation
acetominophen prn
duoneb [**Hospital1 **] prn
amoxicillin prior to dental procedures
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Cardiopulmonary arrest
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
None
Completed by:[**2174-12-16**]
|
[
"785.0",
"584.9",
"428.0",
"716.90",
"518.81",
"494.0",
"038.9",
"995.91",
"365.9",
"280.9",
"486",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.60",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5922, 5931
|
4457, 5498
|
268, 344
|
6007, 6016
|
2339, 3456
|
6069, 6105
|
1887, 1891
|
5893, 5899
|
3493, 3549
|
5952, 5986
|
5524, 5870
|
6040, 6046
|
1906, 2320
|
225, 230
|
3578, 4434
|
372, 1471
|
1493, 1736
|
1753, 1871
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
194
| 124,794
|
11566
|
Discharge summary
|
report
|
Admission Date: [**2112-5-23**] Discharge Date: [**2112-5-26**]
Date of Birth: [**2065-3-29**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 47-year-old male with
a history of two myocardial infarctions and two stents in his
left circumflex who presented to the [**Hospital3 **] with
chest pain and inferior ST elevations on electrocardiogram.
He received aspirin in the ambulance en route to the hospital
as well as three nitroglycerin which improved his chest pain.
He was started on heparin and Aggrastat drips and
transferred to [**Hospital1 69**] for
cardiac catheterization.
In retrospect, the patient gave a history of one week of
progressive intermittent chest pain as well as dyspnea on
exertion.
Upon arrival to this hospital he was transferred to the
catheterization laboratory where a left heart catheterization
showed 100% discrete proximal circumflex in-stent restenosis.
This received Dotter, but angiography showed residual
thrombus. The patient then became hypotensive requiring
dopamine and then had ventricular tachycardia requiring
cardioversion. An intra-aortic balloon pump was placed
transiently and then removed after catheterization. A
lidocaine bolus was given, and a drip was started. Attention
was again turned to the lesion in the circumflex artery. A
percutaneous transluminal coronary angioplasty was performed,
then a 3.5 mm X 15 mm stent was placed between the two
existing stents. Finally, a percutaneous transluminal
coronary angioplasty was performed along the entire area and
inside the distal stent. Final angiography revealed no
residual stenosis and normal flow. The patient was
transferred to the Coronary Intensive Care Unit for further
monitoring and care.
PAST MEDICAL HISTORY:
1. Coronary artery disease and myocardial infarction in
[**2111-9-14**]. Catheterization in [**2111-9-14**] showed a
40% proximal left circumflex lesion and a 90% middle left
circumflex lesion that received a stent. A catheterization
was again performed in [**Month (only) **] for chest pain that revealed
a 40% proximal left circumflex lesion without change and a
patent stent to the middle circumflex. A stress test was
performed in [**2111-12-15**] that provoked anginal symptoms
as well as 1-mm ST depressions in the lateral precordium, and
there nonspecific ST-T wave changes in the inferior leads.
Nuclear images showed moderate-to-severe lateral and inferior
wall defects with an ejection fraction of 33%. This prompted
another cardiac catheterization in [**2111-12-15**] that
revealed that the proximal left circumflex lesion had
progressed to 90%. This was stented. One month prior to
admission (in [**2112-4-13**]), the patient had another cardiac
catheterization that showed a 40% to 50% lesion at the first
diagonal, a 40% lesion in the distal circumflex, and a 60%
lesion at the second obtuse marginal. Both left circumflex
stents showed mild (less than 30%) in-stent restenosis.
2. Hypertension.
3. Chronic pancreatitis induced by ethanol, status post
pancreatic stone removal surgery at [**Hospital6 1130**].
4. Depression.
5. Hypercholesterolemia.
6. Anemia.
MEDICATIONS ON ADMISSION: Bisoprolol 2.5 mg p.o. q.d.,
ramipril 2.5 mg p.o. q.d., Lipitor 10 mg p.o. q.d.,
multivitamin 1 p.o. q.d., folate 1 mg p.o. q.d.,
OxyContin 40 mg p.o. b.i.d., oxycodone 5 mg p.o. t.i.d.
p.r.n., Fentanyl patch 100-mcg per hour transdermal patch
q.72h., sublingual nitroglycerin p.r.n., Colace 100 mg p.o.
b.i.d., Creon (Pancrease) 40 mg p.o. t.i.d. with meals,
Zoloft 50 mg p.o. q.d., Neurontin 300 mg p.o. t.i.d.,
trazodone 50 mg p.o. q.h.s. p.r.n., aspirin 325 mg p.o. q.d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Mother has coronary artery disease. Father
died in his middle 40s of a myocardial infarction. Sister
died of her second heart attack at the age of 45.
SOCIAL HISTORY: The patient lives in [**Location 5110**] with his wife
but is moving to [**Name (NI) 1474**] this week. He smokes five to six
cigarettes a day. He use to smoke 1.5 packs per day for 30
years. He is a former alcoholic, currently off ethanol but
does have an occasional beer. He has a history of being in
detoxification. No intravenous drug use. Vital signs on
admission revealed a temperature of 98.4, blood pressure
of 120/66, heart rate of 80, respirations of 17, oxygen
saturation of 100% on 2 liters nasal cannula. He was on a
lidocaine drip at 2 mg per minute.
PHYSICAL EXAMINATION ON PRESENTATION: In general, alert and
oriented times three. In no acute distress, lying in bed.
Head, eyes, ears, nose, and throat pupils were equal, round,
and reactive to light. Extraocular movements were intact.
Sclerae were anicteric. Neck was supple. No jugular venous
distention. No lymphadenopathy. Pulmonary was clear to
auscultation anteriorly. Cardiovascular revealed a regular
rate and rhythm. Normal first heart sound and second heart
sound. No murmurs, rubs or gallops. The abdomen was soft,
nontender, and nondistended, positive bowel sounds. Groin
revealed no hematoma, no bruit. Extremities revealed 2+
dorsalis pedis pulses. No clubbing, cyanosis or edema.
Neurologically, alert and oriented times three. Cranial
nerves II through XII were intact.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on
admission revealed potassium was 4.1, the white blood cell
count was 17.5, and the hematocrit was 29.6. At [**Hospital3 9683**] the hematocrit had been 37.4. Arterial blood gas
revealed a pH of 7.35, a PCO2 of 45, and a PO2 of 90.
Magnesium was 1.6. Creatine kinase was 3418, with a MB
of 365, with an index of 10.7.
RADIOLOGY/IMAGING: Electrocardiogram showed ST elevations in
leads II, III, and aVF with a T wave inversion in leads I and
L as well as a 1-mm ST elevation in lead aVL. ST depressions
were also seen in V1 through V5, and the rhythm was atrial
fibrillation.
After catheterization, the ST segment changes had resolved.
There were ST-T wave changes in leads I and L that had also
resolved. There was persistent T wave inversions in the
inferior leads. There were peaked T waves in leads V2 to V3.
The ST changes in the precordium had resolved. There were
small Q waves inferiorly.
IMPRESSION: This is a 47-year-old male with left circumflex
disease, prior myocardial infarction, status post two stents
to the left circumflex, who presents with an ST elevation
myocardial infarction.
Upon cardiac catheterization, there was in-stent restenosis
seen at the proximal left circumflex stent. An angioplasty
was performed and another stent was placed in between the two
existing stents with final angiography revealing normal flow.
The catheterization was complicated by cardiac arrest which
was treated with cardioversion times three, resulting in a
normal sinus rhythm. Of note, the patient had been in atrial
fibrillation prior to catheterization. He transiently
required dopamine and intra-aortic balloon pump, which were
both discontinued prior to transfer to the Coronary Care Unit
for continued care.
HOSPITAL COURSE BY SYSTEM:
1. CARDIOVASCULAR: Coronary Artery Disease: Aggrastat was
continued until 18 hours after catheterization. He was
continued on aspirin, folate, multivitamin, beta blocker, and
ACE inhibitor. We recommend that he continue Plavix for life
given his recurrent thrombosis of his left circumflex stents.
There is a strong possibility that he has a so-called
"aspirin nonresponder."
Despite some post procedure chest pain, the patient's
creatine kinases continued to trend downward, and relatively
high creatine kinases were considered a function of his
cardioversion. Of note, the CK/MB index remained within the
normal range after catheterization. Electrocardiograms were
unchanged after catheterization throughout this admission.
The patient's lipid profile was checked, and this was
extremely favorable. The total cholesterol was 82, with
triglycerides of 39, a high-density lipoprotein of 43, and a
low-density lipoprotein of 31.
In terms of his left ventricular function, an echocardiogram
was performed that revealed an ejection fraction of 40%. We
recommend that he continue on ramipril. Of note, the
patient's blood pressure was approximately 90 to 110 systolic
over 70 to 80 for the majority of his hospitalization.
In terms of the patient's rate and rhythm, he was admitted
with a rhythm of atrial fibrillation. After he was shocked
out of his ventricular fibrillation arrest he was in normal
sinus rhythm for the remainder of his hospitalization. A
lidocaine drip was weaned off within 12 hours of his transfer
to the Coronary Care Unit.
2. FLUIDS/ELECTROLYTES/NUTRITION: The patient was continued
with a cardiac diet. Electrolytes were followed and repleted
as necessary.
3. RENAL: The patient had a normal blood urea nitrogen and
creatinine during this hospitalization.
4. GASTROINTESTINAL: We continued the patient on Protonix,
Pancrease, and his pain regimen for pancreatitis.
5. HEMATOLOGY: The patient had a hematocrit of 27.7 on the
evening of admission, so he was transfused 1 unit of blood.
His hematocrit continued to increase daily throughout the
remainder of his hospitalization.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Bisoprolol 2.5 mg p.o. q.d.
3. Ramipril 2.5 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Zoloft 50 mg p.o. q.d.
6. Neurontin 300 mg p.o. t.i.d.
7. Trazodone 50 mg p.o. q.h.s. p.r.n.
8. Creon 40 mg p.o. t.i.d. with meals.
9. Duragesic Patch 100-mc per hour patch q.72h.
10. OxyContin 40 mg p.o. b.i.d.
11. Oxycodone 5 mg p.o. t.i.d. p.r.n.
12. Sublingual nitroglycerin p.r.n.
13. Multivitamin 1 p.o. q.d.
14. Folate 1 mg p.o. q.d.
15. Plavix 75 mg p.o. q.d. (for life).
DISCHARGE FOLLOWUP: Followup should be with his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**], whom he should see within
one month. An appointment was made for him with his
cardiologist, Dr. [**First Name (STitle) 31011**] [**Name (STitle) **], at [**Hospital1 26200**]
Cardiology.
CONDITION AT DISCHARGE: Condition on discharge was good..
DISCHARGE STATUS: He was discharged to home following
clearance from Physical Therapy.
DISCHARGE DIAGNOSES:
1. Myocardial infarction.
2. Status post stent to the left circumflex artery.
3. Hypertension.
4. Atrial fibrillation; resolved.
5. Chronic pancreatitis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2112-5-26**] 17:23
T: [**2112-5-26**] 17:52
JOB#: [**Job Number 36790**]
|
[
"997.1",
"427.31",
"577.1",
"414.01",
"410.41",
"458.2",
"427.1",
"427.5",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"99.81",
"37.61",
"36.06",
"99.20",
"36.01",
"37.78",
"88.56",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
3715, 3869
|
10295, 10720
|
9237, 9759
|
3184, 3698
|
7083, 9210
|
10150, 10274
|
9781, 10135
|
165, 1746
|
1768, 3157
|
3886, 7055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,048
| 129,245
|
14197
|
Discharge summary
|
report
|
Admission Date: [**2197-1-30**] Discharge Date: [**2197-2-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo woman, nursing home resident, w/ h/o dementia, CAD s/p
CABG approx 15 years ago(anatomy unknown), CVA, DM II,
hypothyroidism, presents for respiratory distress. At the
nursing home, daughter reports 5 days of wet cough and low grade
fevers and on day of admission worsening cough, sob, anxiety,
desat to 80% on RA. Pt unable to provide further history
secondary to baseline dementia.
.
In the ED she denied any complaints. V/S were T 98.4 HR 75 BP
163/66 POx 100% on 100% NRB. Patient received Aspirin 325mg x1,
Duoneb x1, levofloxacine 750mg x1, cefipime 1gm IV, and
vancomycin 1000mg IV.
.
On arrival to the floor, patient continued to deny all
complaints. She was accompanied by her daughter, her HCP.
Past Medical History:
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
.
Cardiac History: CABG, approximately 15 years, anatomy unknown
.
Other Past History: Has received all previous health care at
[**Location (un) 20026**] Hosp.
Hypothyroidism
Dementia, pleasant, no short-term memory at baseline, knows
family
CVA
s/p CEA
s/p left hip fracture repair [**3-9**]
s/p displaced left radial fracture
Depression
GERD
Social History:
Patient has remote tobacco use, social alcohol use, no drugs.
She is living in a NH - Epic of [**Location (un) 55**] since 2/[**2196**].
Family History:
Non-contributatory
Physical Exam:
VS - T 98.3 BP 157/48 HR 68 RR 22 Pox 96% on 4L NC
Gen: Thin elderly female in minimal respiratory distress.
Oriented x1. 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.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. HS distant secondary to significant wheezing.
No m/r/g. No thrills, lifts. No S3 or S4.
Chest: Profound kyphodextroscoliosis. Resp were minimally
labored, with occassional accessory muscle use. Diffuse
inspiratory wheezing. No decreased breath sounds at bases or
focal consolidation appreciated. +wet, no productive cough.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: + dry, scaling left heal pressure ucler
.
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:
[**2197-1-30**] BLOOD WBC-15.5* RBC-3.92* Hgb-11.0* Hct-33.9* MCV-86
MCH-28.0 MCHC-32.4 RDW-14.6 Plt Ct-217 Neuts-85.9* Lymphs-8.8*
Monos-5.0 Eos-0.1 Baso-0.2
PT-13.4 PTT-31.1 INR(PT)-1.1
Glucose-240* UreaN-26* Creat-1.1 Na-144 K-4.2 Cl-104 HCO3-29
AnGap-15 Calcium-9.0 Phos-3.5 Mg-2.4
[**2197-1-30**] 09:30AM BLOOD CK(CPK)-90
[**2197-1-30**] 09:30AM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 42234**]*
[**2197-1-30**] 09:30AM BLOOD cTropnT-0.03*
[**2197-2-2**] 06:45AM BLOOD TSH-5.7*
[**2197-2-2**] 06:45AM BLOOD Free T4-1.1
[**1-31**] CXR:
IMPRESSION: Limited study, with:
1. CHF with interstitial edema and small left effusion.
2. Possible patchy infiltrates, particularly in the right lung.
3. Left humeral surgical neck fracture.
[**2197-2-4**] CXR:
Single portable radiograph of the chest again demonstrates
marked rotatory S-shaped scoliosis of the thoracolumbar spine.
The cardiomediastinal contours are similar to that seen on
[**2197-1-31**]. Assessment is limited by respiratory motion, but there
are likely bilateral pleural effusions. Increased opacity
projecting over both lungs is similarly not well assessed, but
likely remains unchanged. The patient is status post median
sternotomy. Remote trauma of the left humeral head and neck is
unchanged.
[**2197-2-2**] ECHO:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion. There is an anterior space which most
likely represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate mitral regurgitation.
Brief Hospital Course:
Patient is a [**Age over 90 **] yo Female w/ CAD s/p CABG, dementia, CVA s/p
CEA, HTN, dyslipidemia, DMII who presented from a NH with 5 days
of non-productive cough, low grade fevers, and worsening hypoxia
on RA on the day of admission who was transferred to the CCU for
afib with RVR on hospital day four, with blood pressure not
tolerating nodal agents.
Patient is a [**Age over 90 **] yo Female w/ CAD s/p CABG, dementia, CVA s/p
CEA, HTN, dyslipidemia, DMII who presented from a NH with 5 days
of non-productive cough, low grade fevers, and worsening hypoxia
on RA on the day of admission. Patient s/p CCU transfer for Afib
w/RVR. Respiratory status improved in the CCU, but rate remains
uncontrolled despite continued increase in beta-blocker.
# Pneumonia: [**Hospital **] hospital-acquired pneumonia vs atypical
pneumonia in setting of acute diastolic heart failure. Admission
CXR with findings consistent with patchy right infiltrates and
curly-b lines, small left pleural effusion, no improvement on
CXR s/p 1.5L diuresis. CXR is complicated by patient's severe
kyphoscoliosis which predisposes to atelectasis. Elevated WBC
with left shift, low grade temps, and pro-BNP elevated at [**Numeric Identifier 890**]
on admission. Unclear precipitant of CHF, as patient has no
recent admissions for CHF (last admit [**3-9**] for hip facture),
and on no standing lasix at NH. On [**2-3**], antibiotics were
broadened to include Zosyn, Vancomycin and a 7 day course was
completed. Atypical coverage with azithromycin was added on [**2-7**]
and 3 day course was completed. Atrovent nebulizers provided
standing with albuterol as needed. Pulmonary status improved on
discharge with decreasing oxygen requirement.
#. CAD - s/p CABG, anatomy unknown. She had diffuse ST
depressions in setting of RVR which resolved when rate in low
100's, likely rate rate related demand ischemia. During this
admission, aspirin, statin, beta blocker were continued.
#. Pump - EF of >55% on ECHO this admission. Presented in
respiratory distress, with CXR findings consistent with volume
overload, likely acute diastolic heart failure. Patient was
provided with gentle diuresis as BP tolerated. Beta blocker,
ACE continued on discharge.
#. Rhythm: Sinus on admission EKG, continue telemetry. Now in
Afib w/ persistent RVR despite amiodarone load in CCU and
transition to po regimen and increased BB. Likely a result of
underlying pulmonary disease and anticipate as lungs improve,
rate will also. Metoprolol succinate and diltiazem were
titrated to acheive rate control as well as amiodarone 200mg
daily continued. Initiation of coumadin therapy was discussed
with daughter and her PCP and it was felt high risk of fall and
patient's non-compliance with monitoring may outweight benefit.
# HTN: Home regimen includes metoprolol, diltiazem, and
lisinopril. As her hospital course was complicated by
hypotension and ATN, diltiazem and lisinopril were held. When
SBP tolerated, beta blocker, diltiazem, and lisinopril were
resumed.
# Diarrhea: One episode in the setting of broad spectrum
antibiotics. C. diff negative x1 without further episodes of
diarrhea.
# UTI: Urine culture growing E. coli, sensitive to zosyn among
several other antimicrobials. Completed appropriate course.
# Acute renal failure: Creatinine on admission 1.1, high of 2.0
now improved after diuresis. Believed to be prerenal azotemia
with ATN from dropping her pressures (to SBP 70s) with
over-zealous control of her A-fib. Urine eosinophils were
initially positive, but are now negative. Per curbside with
renal fellow, they are in agreement with our analysis.
Creatinine currently trending down with improved urine output.
# DMII: On glipizide as outpatient. Continued po glipizide and
covered with insulin sliding scale during this admission.
# Hypothyroidism: Continued home regimen.
#. H/o CVA: Continued ASA
# Dementia: Per daughter, patient admitted at baseline with very
poor short-term memory. Patient does forget that she can not
walk unassisted and will try to get out of bed. Feeds herself,
toilets per daughter independently. [**Name2 (NI) **] had fall
precautions, bed near nursing station, bed alarm during her
stay. Her home regimen of namenda, remeron, and seroquel were
continued.
# Osteoprosis: Patient with displaced, impacted fracture of left
proximal humerus, 2 years ago, with profound diffuse osteopenia.
We initiated calcium and Vit D replacement. It is recommend to
start bisphosphonate therapy if patient can tolerate as
outpatient.
# GERD: Continued outpatient regimen.
# S/P Left Hip Facture: Out of bed with assist only, with bed
alarm.
#. FEN - heart healthy/low salt
#. Access: PIV
#. PPx: heparin SC TID, bowel regimen
#. Code: DNR/DNI
#. Dispo: to NH pending improvement in respiratory function and
rate control. Please check daily weights, if more or less than 2
lbs difference, please discuss with PCP whether lasix is
necessary. Also, please check daily oxygen saturations. The
patient was 95% on room air at discharge. Patient is on
amiodardone, and we have checked baseline thyroid function
tests. Please consider periodic LFTs and Thyroid function tests
since the patient is on amiodarone. Also, please arrange for an
outpatient cardiology appointment. If [**Hospital1 18**] cardiology is
chosen, please call [**Telephone/Fax (1) 62**] to schedule an appointment.
#. Comm: HCP: Daughter -[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (C) [**Telephone/Fax (1) 42235**]; (H)
[**Numeric Identifier 42236**]
Medications on Admission:
ASA 81mg daily
Bisacodyl 10mg 2x Tu/TH per week
Cardizem 120mg QD
Glipizide 7.5mg [**Hospital1 **]
Levothyroxine 100mcg po QD
Lisinopril 10mg QD
metoprolol 50mg [**Hospital1 **]
REmeron 22.5mg QD
Nemenda 10mg [**Hospital1 **]
MVI w/ minerals daily
Pravastin 20mg QHS
Prilosec 20mg daily
Senna [**Hospital1 **]
seroquel 12.5 mg TID
vit c 500mg [**Hospital1 **]
Mucinex 400mg [**Hospital1 **] x1 week
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO every twelve (12)
hours.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Insulin Lispro 100 unit/mL Solution Sig: One (1) units/ml
Subcutaneous ASDIR (AS DIRECTED).
6. Mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
7. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
14. Glipizide 5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed.
16. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
18. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
19. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO QID (4 times
a day).
20. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Health-care associated Pneumonia
Atrial Fibrillation with rapid ventricular rate
Acute renal failure
Urinary Tract infection
Dementia
Secondary:
Hypothyroidism
diabetes mellitus type II controlled
Discharge Condition:
Vital signs stable, with improved respiratory status.
Discharge Instructions:
You have been treated for pneumonia during your hospital stay.
This was complicated by a rapid irregular heart rate called
atrial fibrillation which resulted in a brief stay in the
intensive care unit. We have added a few new medications to
control your heart rate including Toprol XL, amiodarone, and
diltiazem. Please continue to take your medications as
prescribed.
Please call your physician or return to the hospital if you
develop any chest pain, shortness of breath, fever >100.8 or any
other concerning symptoms.
Followup Instructions:
Please see your doctor at the nursing home within one week.
Please have your doctor follow up periodic thyroid function
tests and liver function tests.
Please have set up an outpatient cardiology appointment. You
can schedule with the [**Hospital1 18**] cardiology group by calling
[**Telephone/Fax (1) 62**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
[
"733.00",
"599.0",
"428.32",
"584.5",
"041.4",
"294.8",
"486",
"V45.81",
"427.31",
"428.0",
"707.07",
"250.00",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12508, 12580
|
4771, 10326
|
282, 289
|
12821, 12877
|
2703, 2703
|
13450, 13858
|
1643, 1663
|
10776, 12485
|
12601, 12800
|
10352, 10753
|
12901, 13427
|
1678, 2684
|
223, 244
|
317, 1046
|
2719, 4748
|
1068, 1473
|
1489, 1627
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,624
| 184,828
|
39949
|
Discharge summary
|
report
|
Admission Date: [**2181-8-24**] Discharge Date: [**2181-9-17**]
Date of Birth: [**2110-12-26**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Zestril / Benicar / Codeine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea, abnormal ETT
Major Surgical or Invasive Procedure:
[**2181-8-24**] Cardiac Catheterization, Placement of IABP
[**2181-8-24**] Emergency coronary artery bypass graft x4, saphenous
vein grafts to distal left anterior descending artery, the ramus
and left posterior descending arteries and free left internal
mammary artery graft to proximal left anterior descending
artery. Endoscopic harvesting of the long saphenous vein.
[**2181-8-24**] Re-Exploration for Bleeding
History of Present Illness:
70 year old female has a history of hypertension, dyslipidemia,
prior tobacco abuse, a family history of coronary artery
disease, an abdominal aortic aneurysm and subclavian steal
syndrome. She had upcoming plans for possible subclavian
stenting at [**Hospital6 33**] on [**2181-9-12**] with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 43078**]. She reports that over the past months she has noticed
increasing dyspnea on exertion. It has been most noticeable when
walking up a [**Doctor Last Name **] or climbing up a flight of stairs, requiring
her to stop and rest for 5 minutes before continuing on. There
have even been a few times where she has noticed this while
washing her hair. She denies any specific complaints of chest
discomfort. Recent stress testing revealed possible inferior
ischemia. She was subsequently referred for cardiac
catheterization. The LAD was found to be dissected during
cardiac catheterization. IABP was placed and the patient was
transferred to the Operating Room for surgical
revascularization.
Past Medical History:
Coronary Artery Disease, s/p CABG
Iatrogenic Left Anterior Artery Dissection
Postop Atrial Fibrillation
postop renal failure
Hypertension
Hyperlipidemia
Abdominal aortic aneurysm (3.3cm)
Subclavian Steal Sydrome
Appendectomy
Tonsillectomy
Right Knee replacement c/b staph infection requiring
reoperation,
now on suppressive antibiotic therapy
Left knee replacement
Possible sleep apnea
Gout
Tubular pregnancy s/p surgery
Bilateral shoulder surgery x 2
Social History:
Lives with: Husband
Occupation: Retired
Cigarettes: 2ppd x approximately 35 years. She quit 15 years
ago.
ETOH: Denies
Family History:
Twin brother with diabetes, PVD s/p amputation, CAD s/p CABG.
Another brother died of an MI at age 57. Mother died at age 83
from CHF.
Physical Exam:
PREOPERATIVE EXAM:
BP Right:140/74 Left: 117/87 Pulse:71 Resp: 18 O2
sat:98% RA
Height: 60 INCHES Weight:210 LBS
General: Supine on cath table, no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] edentulous
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur []
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] none_
Varicosities: None [x] spider veins, right worse than left
Well healed incisions of total knee replacements bilaterally
Neuro: Grossly intact [x]
Pulses:
Femoral Right: IABP Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Pertinent Results:
[**2181-9-17**] 04:33AM BLOOD WBC-5.8 RBC-2.89* Hgb-8.6* Hct-25.2*
MCV-87 MCH-29.9 MCHC-34.2 RDW-15.3 Plt Ct-278
[**2181-9-16**] 03:57AM BLOOD WBC-7.5 RBC-3.17* Hgb-9.3* Hct-27.8*
MCV-88 MCH-29.3 MCHC-33.4 RDW-15.2 Plt Ct-338
[**2181-9-16**] 03:57AM BLOOD PT-16.7* INR(PT)-1.5*
[**2181-9-15**] 05:53AM BLOOD PT-16.1* INR(PT)-1.4*
[**2181-9-14**] 05:49AM BLOOD PT-15.4* INR(PT)-1.3*
[**2181-9-17**] 04:33AM BLOOD UreaN-20 Creat-1.5* Na-135 K-4.1 Cl-101
[**2181-9-16**] 03:57AM BLOOD UreaN-22* Creat-1.7* Na-135 K-4.9 Cl-103
[**2181-9-15**] 05:53AM BLOOD Glucose-129* UreaN-24* Creat-1.3* Na-135
K-4.4 Cl-101 HCO3-23 AnGap-15
[**2181-9-14**] 05:49AM BLOOD Glucose-91 UreaN-28* Creat-1.5* Na-137
K-4.4 Cl-102 HCO3-25 AnGap-14
[**2181-9-13**] 05:11AM BLOOD Glucose-106* UreaN-36* Creat-1.5* Na-135
K-4.1 Cl-101 HCO3-27 AnGap-11
[**2181-9-12**] 03:46AM BLOOD Glucose-114* UreaN-43* Creat-1.6* Na-137
K-4.1 Cl-100 HCO3-28 AnGap-13
[**2181-8-24**] Cardiac Catheterization:
Coronary angiography: Left dominant
LMCA: Calcified proximal 50-60% eccentric lesion
LAD: Proximal 70% stenosis moderate to severe tortuosity.
LCX: Dominant vessel with small OM branches.
RCA: Small nondominant with origin 80% stenosis supplying acute
marginals
Ramus: Origin 40%
Interventional details:
Change for 6 French XB3.5 guide. Crossed with Prowater wire
easily. Performed IVUS to interrogate the LMCA and LAD with the
Atlantis catheter. The LMCA was calcified as was the LAD. The
MLD of the LAD was 1.5 mm. The reference vessel diameter was
3.2cm. The CSA was <1.8 CM2. The LMCA had a CSA of >9.0 cm2.
Attention was then turned to repair of the LAD since the LMCA
was moderate. The Prowater wire was directed into the distal
LAD with difficulty given vessel tortuosity. At this point a
dissection in the distal LAD was noted. Over the course of the
next 2 minutes the LAD abruptly closed. Integrilin
(eptifibatide) was administered and ACT was confirmed. Pilot 50
wire and PT [**Name (NI) 13126**] intermediate wires could only be directed
into the mid LAD and septal branches within the dissection
plane. A balloon inflation with a 2.0 mm balloon was performed
restoring TIMI 1 flow to the distal vessel. A myocardial stain
was noted with distal injection but no perforation was noted.
CSURG was consulted for revascularization of the LAD. A 30 cc
IABP was inserted into the right common femoral artery
prophylactically.
The patient developed jaw pain during abrupt closure which was
improving ([**2-22**]) upon transfer to the surgical suite. She
tolerated the procedure well otherwise and left the laboratory
in stable condition.
.
[**2181-8-24**] INTRAOP TEE:
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. 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 ascending aorta.
There are simple atheroma in the descending thoracic aorta.
There is an intra-aortic balloon pump in good position with the
tip distal to the left subclavian artery. The aortic valve
leaflets are severely thickened/deformed. There is moderate
aortic valve stenosis (valve area 1.0-1.2cm2). Moderate (2+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. Trivial mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results at time of
surgery.
POST-BYPASS: The patient is on a phenylephrine infusion.
Biventricular function is unchanged. There is moderate aortic
regurgitation. There is moderate aortic stenosis which is
unchanged. There is trace mitral regurgitation. The ascending
aorta, aortic arch, and descending aorta are intact. There is a
small mobile density in the aorta at the transition from the
aortic arch to the descending aorta. The tip of the intra-aortic
balloon pump is identified several centimeters distal to this
point.
POST-SECOND BYPASS RUN: The patient is on epinephrine,
milrinone, and phenylephrine infusions. The left ventricle is
hyperdynamic. The left ventricular cavity size is significantly
reduced compared to the first post-bypass exam. Right
ventricular function is mildly depressed. Aortic regurgtation is
unchanged. Aortic stenosis is unchanged. The ascending aorta,
aortic arch, and descending aorta remain intact.
.
Brief Hospital Course:
Transferred into the cardiac catheterization [**Last Name (STitle) **] and underwent
catheterization that revealed multivessel coronary artery
disease. Percutaneous intervention was attempted and complicated
by dissection of her left anterior descending artery. An IABP
was therefore placed and she underwent emergent coronary artery
bypass grafting surgery. See operative report for further
details. Her post operative course was complicated by
postoperative bleeding secondary to Integrilin and Plavix
administration, she returned to the operating room day of
surgery for exploration. See operative report for further
details. Following surgical intervention, she was brought to
the CVICU for invasive monitoring. On postoperative day one, the
IABP was weaned and removed without complication. Over several
days, inotropic support was weaned. She was transfused with
packed red blood cells to maintain hematocrit near 30%.
Amiodarone was started for bouts of paroxysmal atrial
fibrillation. She required aggressive diuresis and was
eventually extubated on postoperative day five. She remained
somewhat lethargic and weak but displayed no neurological
deficits. Her respiratory status remained marginal with sputum
culture growing Proteus vulgaris which was sensitive to zosyn -
which she continues on for treatment with plan for 14 day course
that goes through 9/15 per ID recs.
Central line also grew out Proteus vulgaris. Based upon
sensitivities, she was started on Zosyn for a two week course.
She had remained on SR therefore her Warfarin was discontinued
but she had intermittent recurrent episodes and the coumadin was
restarted. Her INR became supratherapeutic and coumadin was held
again and restarted at a lower dose. She developed epistaxis
with the supratherapeutic INR. This resolved with packing.
Ultimately she converted to normal sinus rhythm and remained in
it therfore anticoagulation was stopped per Dr.[**First Name (STitle) **].
Her creatinine peaked to 2.1 and has trended down but not
returned to baseline. She continues on diuretic therapy and
still remains edematous. Her diuretic was changed due to
hypokalemia from lasix to spironolactone. Additionally on [**9-10**]
she was noted to have left lower extremity erythema around open
surgical vein harvest site and was started on intravenous
Vancomycin. ID was consulted for ongoing antibiotic management.
Lower extremity wounds improved and by the time of discharge
were without erythema or drainage. Vancomycin was discontinued
as discussed with ID.
She has continued to progress slowly. In light of her
deconditioned state and continued medical needs she is being
discharged to [**Hospital1 **] Rehab on POD 24. All follow-up
apppointments were advised.
Medications on Admission:
- ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth every evening
- FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth every morning
- POTASSIUM CHLORIDE - 10 mEq Tablet Extended Release - 1
Tablet(s) by mouth twice a day
- ROSUVASTATIN [CRESTOR] 20 mg Tablet - 1 Tablet(s) by mouth
every evening
- ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth every
evening
- CALCIUM CARBONATE-VITAMIN D3 - 600 mg calcium (1,500 mg)-400
unit Tablet - 1 Tablet(s) by mouth twice a day
- OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - 1,000 mg Capsule -
1 Capsule(s) by mouth twice a day
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): 12.5 mg twice a day .
2. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400 mg once a day for 7 days then decrease to 200 mg
daily until follow up with cardiology .
3. Suppressive antibiotic therapy
resume when completed IV antibiotics
Dicloxacillin 500 mg TID po
4. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): home dose 20 mg please increase back to 20 mg when
creatinine back to normal .
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): continue until wound check and will be reevaluate
at office visit .
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Mucinex 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1)
Tablet, ER Multiphase 12 hr PO BID () for 5 days.
11. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every six (6) hours.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**2-16**] puffs
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
13. Outpatient [**Name (NI) **] Work
PT/INR - first draw [**9-18**]
then please do mon/wed/fri for two weeks then decrease as
directed by physician
dosing for coumadin by rehab physician based on INR results
goal INR 2.0-2.5
14. PICC line
Heparin dependent PICC line please flush per policy
Maintain for IV antibiotics and can be removed when they are
complete
15. Zosyn 2.25 gram Recon Soln Sig: 2.25 grams Intravenous every
six (6) hours for 2 weeks: through 9/15 per ID.
16. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
18. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Three (3) Tablet, ER Particles/Crystals PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
Iatrogenic Left Anterior Artery Dissection
Postop Atrial Fibrillation
postop renal failure
Hypertension
Hyperlipidemia
Abdominal aortic aneurysm (3.3cm)
Subclavian Steal Sydrome
Appendectomy
Tonsillectomy
Right Knee replacement c/b staph infection requiring
reoperation,
now on suppressive antibiotic therapy
Left knee replacement
Possible sleep apnea
Gout
Tubular pregnancy s/p surgery
Bilateral shoulder surgery x 2
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with 1 assist
Incisional pain managed with percocet as needed
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right healing well, no erythema or drainage.
Leg Left mild erythema scant sanguinous drainage covered with
DSD changing [**Hospital1 **]
Edema +1 generalized
Alert and oriented x3 nonfocal
Ambulating with 1 assist
Incisional pain managed with percocet as needed
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right healing well, no erythema or drainage.
Leg Left mild erythema scant sanguinous drainage covered with
DSD changing [**Hospital1 **]
Edema +1 generalized
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
- Surgeon: Dr. [**First Name (STitle) **] on [**2181-10-1**] @ 1:15PM [**Telephone/Fax (1) 170**] in the
[**Hospital **] medical office building [**Hospital Unit Name 87850**]
- Cardiologist: Dr. [**Last Name (STitle) **] [**Name (STitle) **] [**2181-9-19**] @ 1030AM
.
Please call to schedule appointments with your:
Primary Care Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 6707**] [**Telephone/Fax (1) 14214**] in [**4-17**] weeks
.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation
Goal INR 2.0-2.5
First draw [**2181-9-18**]
To be dosed by rehab physician then please arrange for coumadin
management by PCP at time of discharge from rehab
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2181-9-17**]
|
[
"E879.8",
"584.9",
"287.5",
"458.29",
"790.7",
"414.12",
"482.83",
"V02.59",
"790.92",
"454.9",
"401.9",
"V43.65",
"427.31",
"998.2",
"285.1",
"999.31",
"682.6",
"441.4",
"424.1",
"276.8",
"272.4",
"435.2",
"998.59",
"275.41",
"E879.0",
"414.01",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.03",
"37.22",
"36.15",
"00.40",
"00.66",
"39.61",
"37.61",
"36.13",
"00.24",
"96.6",
"88.56",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
13622, 13694
|
8008, 10756
|
316, 733
|
14190, 14843
|
3404, 7985
|
15768, 16785
|
2446, 2584
|
11380, 13599
|
13715, 14169
|
10782, 11357
|
14867, 15745
|
2599, 3385
|
255, 278
|
761, 1816
|
1838, 2292
|
2308, 2430
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,725
| 188,088
|
35650
|
Discharge summary
|
report
|
Admission Date: [**2153-1-24**] Discharge Date: [**2153-1-26**]
Date of Birth: [**2097-5-15**] Sex: M
Service: NEUROLOGY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Sudden onset Left sided weakness
Major Surgical or Invasive Procedure:
IV tPA at outside hospital
History of Present Illness:
HPI: 55 yo RHM who was in bed felt dizzy around midnight, he did
not have a headache or neck pain. He then could not move his
left leg, and within a few seconds, he could not move his left
arm. He felt that his arm was stronger than his leg. He was
taken to [**Hospital6 3105**] and he had a CT head scan
which was unremarkable. He was not given IV tPA since he was on
Coumadin, despite an INR of 1.3, and sent to [**Hospital1 18**]. Since he was
still within the 3 h window for IVtPA the stroke fellow Dr [**Last Name (STitle) **].
[**Doctor Last Name 81111**] was contact[**Name (NI) **] immediately.
.
ROS: apart from left sided weakness, he has a baseline of
palpitations, but he had no other cardiac or respiratory or GU
or GI symptoms.
Past Medical History:
[**Doctor Last Name 933**] disease s/p radioiodine ~[**4-8**] y ago, subsequent Atrial
fibrillation
Gout
Achilles tendon surgery in '[**52**]
Social History:
Ex-smoker, occasional alcohol
Works as a doctor [**First Name (Titles) **] [**Last Name (Titles) **]
Married: [**Doctor First Name 5321**] ([**Telephone/Fax (1) 81112**])
PCP: [**Name10 (NameIs) **] [**Last Name (STitle) **] [**Name (STitle) 33474**], [**Location (un) **], [**Hospital3 **]Hosp ([**2152**])
Work partner & friend: [**Name (NI) 892**] [**Name (NI) **], fiance [**First Name4 (NamePattern1) **] [**Name (NI) 11679**] ([**Telephone/Fax (1) 81113**])
Family History:
mother had an MI aged 69
Physical Exam:
T-97.4 BP-108/56 HR-100 RR-20 O2Sat-98% on 2L oxygen
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa, proptosis b/l
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
.
Neurologic examination:
NIHSS:
1a. Level of Consciousness: 0
1b. LOC questions: 0
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 0
4. Facial palsy: 0
5a. Motor arm, left: 4
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb ataxia: 0
8. Sensory: 0
9. Best language: 0
10. Dysarthria: 0
11. Extinction and inattention: 1
.
NIHSS = 9
.
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] and writing
intact. Registers [**3-6**], recalls [**3-6**] in 5 minutes. No right left
confusion. No evidence of apraxia or neglect.
.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Fundoscopy normal. Visual fields are full to
confrontation. Extraocular movements intact bilaterally, no
nystagmus. Sensation intact V1-V3. Facial movement symmetric.
Hearing intact to finger rub bilaterally. Palate elevation
symmetrical. Sternocleidomastoid and trapezius normal
bilaterally. Tongue midline, movements intact
.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
(can wriggle left thumb slightly)
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. Extinction to DSS on the L leg
.
Reflexes:
+2 and symmetric throughout.
Toes: downgoing on the R, mute on the L
.
Coordination: finger-nose-finger normal on the R, heel to shin
normal on the R, RAMs normal on the R.
.
Gait: not assessed, dense L hemiparesis
Pertinent Results:
Admission Labs:
[**2153-1-24**] 02:15AM GLUCOSE-112* UREA N-17 CREAT-1.3* SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-20* ANION GAP-19
[**2153-1-24**] 02:15AM CK(CPK)-244* cTropnT-<0.01 CK-MB-5
[**2153-1-24**] 02:15AM CHOLEST-260* TRIGLYCER-201* HDL CHOL-50
LDL(CALC)-170*
[**2153-1-24**] 02:15AM WBC-17.4* RBC-4.66 HGB-15.1 HCT-43.5 MCV-94
MCH-32.5* MCHC-34.7 RDW-14.0
[**2153-1-24**] 02:15AM NEUTS-89.6* LYMPHS-7.8* MONOS-2.0 EOS-0.5
BASOS-0.1
[**2153-1-24**] 02:15AM PLT COUNT-194
[**2153-1-24**] 02:15AM PT-17.3* PTT-26.1 INR(PT)-1.6*
.
CTA Head and Neck:
CT OF THE HEAD: No edema, mass, mass effect, hemorrhage or
infarction is detected. The ventricles and sulci are mildly
prominent consistent with involutional changes. Periventricular
white matter hypodensities are noted. The visualized part of the
paranasal sinuses and mastoid air cells are clear.
.
CTA OF THE HEAD AND THE NECK: The vertebral and carotid arteries
and their branches are patent with no significant mural
irregularity or flow-limiting stenosis. No aneurysm is detected.
Incidental note is made of fenestration at the origin and
proximal portion of the A2 segment of the right ACA, as well as
fetal PCAs, bilaterally. The distal cervical portion of the
right carotid artery measures 6.2 mm on the right, and 5.6 mm on
the left.
.
CT PERFUSION: No abnormality of cerebral blood flow, blood
volume or the mean transit time within the middle cerebral
artery vascular territory.
.
IMPRESSION:
1. No acute intracranial process, including no hemorrhage and no
evidence of acute infarction (perfusion assessment largely
limited to the MCA territory).
2. Normal CTA of the head and neck.
.
MRI/A Head:
FINDINGS: Abnormal slow diffusion consistent with acute infarct
is seen in the right parasagittal frontal lobe, in the distal
right MCA distribution.
Additionally, there is apparent bilateral cortical parietal
parasagittal swelling, without corresponding abnormal diffusion
signal (series 12, image 20). There is no acute hemorrhage,
shift of midline structures, or hydrocephalus. Normal flow voids
are identified.
.
MRA demonstrates patent, normal-appearing A2 segments
bilaterally. The left A1 segment appears attenuated compared to
the right. This has changed from its normal appearance on CTA
performed earlier the same day. Large bilateral PComs also
identified. Limited imaging of the basilar artery is performed.
.
IMPRESSION:
1. Findings consistent with infarct in the distal right ACA
territory, not visualized on prior CT perfusion study. A2
segments appear widely patent bilaterally.
2. Relative attenuation of the left A1 segment compared to
right, possibly representing embolus or spasm. This finding is
new compared to prior CTA performed earlier the same day.
3. Bilateral parasagittal cortical swelling the parietal lobe,
without corresponding diffusion abnormality. This possibly
represents a reperfusion injury.
.
TTE:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There was few bubbles late ([**4-9**] heart beats) with
cough manuever. The right atrial pressure is indeterminate.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The aortic arch 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. Mild (1+) 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 low
normal systolic function. No definitive PFO identified.
Brief Hospital Course:
Patient is a 55 yo RHM who presented with an acute onset left
hemiparesis (leg > arm, no facial weakness, and slightly slower
production of speech, but no aphasia). Given his history of A
fib it was felt to most likely be a cardioembolic stroke, and he
was subtherapeutic on his Coumadin on presentation (INR 1.3 at
OSH prior to tPA). He received IV tPA at 3 am and was admitted
to ICU initially where he remained stable with improving L sided
weakness and no hemorrhagic transformation confirmed with repeat
CT the next day.
.
MRI showed L ACA distribution stroke likely embolic in nature
given Afib and subtherapeutic INR. Echo was performed no
obvious thrombus with LVEF 50~55% and no PFO/ASD. Coumadin was
restarted on [**1-25**] with Lovenox bridging. Lovenox should be
stopped when INR is therapeutic from 2.0-3.0. Patient's INR was
1.6 on the day of discharge to rehab facility.
.
Patient was also started on Simvastatin 40mg for LDL of 170.
The patient expressed interest in following up with Dr.
[**Last Name (STitle) **] regarding the possibility of a surigcal procedure for
ablation of A fib, so this was arranged.
.
His strength steadily improved over his hospital stay, and on
the day of discharge he was able to lift both his arm and his
leg off the bed, and had 4+/5 strength in an UMN pattern in his
arm and 4/5 strength in an UMN pattern in his leg.
Medications on Admission:
Atenolol
Coumadin has not checked INR for several months, due to work
Allopurinol
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): Discontinue once INR >2.0.
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): [**Month (only) 116**] need to titrate the dose based on INR -
please foward the INR results which needs to be drawn daily
initially.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Outpatient Lab Work
Daily INR until INR between 2~3 and stable - may need to adjust
Coumadin dosing based on INR. Once INR stable and Coumadin
dosing fixed, may need to space out the lab checks. Please
foward the results to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) 3078**] L [**Telephone/Fax (1) 65542**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
R ACA Cerebral infarct likely embolic
Atrial fibrillation
Discharge Condition:
Stable - L leg weakness more than arm but no issues with speech
or swallowing. Currently being bridged with ASA 81mg once daily
and Lovenox 90 twice daily while INR subtherapeutic. INR 1.6 on
the day of discharge.
Discharge Instructions:
You were admitted after acute L sided weakness after IV tPA in
the ED with hx of atrial fibrillation but subtherapeutic INR.
You were initially admitted to the ICU where you were monitored
and treated including follow-up CT of head which did not show
hemorrhagic transformation.
You remained stable with improving L sided weakness hence you
were transferred to the floor on [**1-25**] and you were restarted on
Coumadin with Lovenox bridging. Your INR is 1.6 on the morning
of discharge to acute rehab facility. You will be continued on
Lovenox on INR is therapeutic (INR 2~3).
Please take meds as scheduled and you have scheduled
appointments with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (neurology) and Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] (cardiology).
Please call your PCP or go to the nearest ED if you have
new/worsening weakness or numbness, speech issues or vision
problems.
You are being discharged to acute rehab facility where you will
receive inpatient physical and occupational therapy plus
Coumadin titration for your atrial fibrillation.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2153-2-13**] 3:20
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2153-3-6**] 2:00
Please follow up with you PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33474**] within 2~3
weeks of discharge including follow-up of INR and Coumadin
dosing.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2153-1-26**]
|
[
"V45.88",
"728.87",
"V58.61",
"427.31",
"244.2",
"434.11",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
10694, 10764
|
8138, 9511
|
330, 359
|
10865, 11082
|
4019, 4019
|
12241, 12915
|
1793, 1819
|
9644, 10671
|
10785, 10844
|
9537, 9621
|
11106, 12218
|
1834, 2207
|
258, 292
|
387, 1130
|
2997, 4000
|
4036, 8115
|
2584, 2981
|
2231, 2569
|
1152, 1295
|
1311, 1777
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,441
| 186,120
|
33834
|
Discharge summary
|
report
|
Admission Date: [**2137-5-8**] Discharge Date: [**2137-5-12**]
Date of Birth: [**2076-8-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2137-5-8**] Four Vessel Coronary Artery Bypass Grafting(LIMA to LAD,
SVG to Diag, SVG to OM, SVG to PLV).
History of Present Illness:
Mr. [**Known lastname **] is a 60 year old male who presented to OSH with chest
pain. He ruled out for MI. Subsequent stress testing was
positive for ischemia. He was transferred to the [**Hospital1 18**] for
cardia catheterization which revealed severe three vessel
coronary artery. He underwent preoperative evaluation and was
cleared for surgery. He was discharged on medical therapy and
returns today for elective CABG.
Past Medical History:
Coronary Artery Disease
Hypertension
Elevated Cholesterol
Type II Diabetes Mellitus
History of Peptic Ulcer Disease(H. Pylori)
Eczema
Prior Knee Arthroscopies
Social History:
80 pack year history, quit approx 25 years ago. Admits to 4 ETOH
drinks per week. He is married and works in telecommunications.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: 162/86, 87, 18
General: WDWN male in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally, no carotid or femoral bruits noted
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2137-5-8**] Intraop TEE
PRE-BYPASS:
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is 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. There are focal calcifications in the aortic arch.
There are complex (>4mm) atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened.
Physiologic mitral regurgitation is seen (within normal limits).
There is no pericardial effusion.
POST-BYPASS:
Preserved biventricular systolic function. LVEF 55%.
Intact thoracic aortic contour.
Trivial MR [**First Name (Titles) **] [**Last Name (Titles) **].
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent coronary artery bypass
grafting surgery by Dr. [**Last Name (STitle) **]. Please see seperate dictated
operative note. Following the operation, he was brought to the
CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. His
CVICU course was uneventful and he transferred to the SDU on
postoperative day one. Beta blockade was advanced as tolerated.
Over several days, he continued to make clinical improvements
with diuresis. Given his preoperative HgbA1c of 10(while on oral
agents), the [**Last Name (un) **] Service was consulted to assist in the
management of his type II diabetes mellitus. It was recommended
that he begin using NPH insulin [**Hospital1 **] with sliding scale coverage
with Humalog as instructed in the printout given ot the patient
upon discharge. He should follow-up with the [**Hospital **] Clinic for
continued treatment of his diabetes.
Medications on Admission:
Lisinopril 5qd, Zocor 20 qd, glipizide 10 [**Hospital1 **], Metformin 500
[**Hospital1 **], Metoprolol, Aspirin 325 qd, Dovenox cream
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Insulin Lispro 100 unit/mL Solution Sig: One (1) Vial
Subcutaneous four times a day: As directed on flow sheet
printout.
Disp:*1 Vial* Refills:*6*
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
vial Subcutaneous twice a day: 25 U Q am, 20 U Q HS.
Disp:*1 vial* Refills:*6*
10. syringes Sig: One (1) package four times a day: Insulin
syringes as needed.
Disp:*1 package* Refills:*6*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Hypertension
Elevated Cholesterol
Type II Diabetes Mellitus
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-9**] weeks
Dr. [**Last Name (STitle) 44890**] in [**1-6**] weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**1-6**] weeks
with Dr. [**First Name (STitle) **]/[**Hospital **] Clinic in [**12-5**] weeks
Completed by:[**2137-5-12**]
|
[
"401.9",
"250.00",
"272.0",
"413.9",
"692.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5187, 5245
|
2751, 3731
|
331, 442
|
5384, 5391
|
1694, 2728
|
5728, 6030
|
1240, 1283
|
3915, 5164
|
5266, 5363
|
3757, 3892
|
5415, 5704
|
1298, 1675
|
280, 293
|
470, 895
|
917, 1078
|
1094, 1224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,131
| 187,546
|
3216
|
Discharge summary
|
report
|
Admission Date: [**2100-7-14**] Discharge Date: [**2100-8-14**]
Date of Birth: [**2050-8-11**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
MDR Pseudomonas UTI
Major Surgical or Invasive Procedure:
PICC placement - [**2100-7-19**], [**2100-7-30**]
Gastrocutaneous Fistula Repair - [**2100-7-20**]
Laser Lithotripsy - [**2100-8-4**], [**2100-8-10**]
History of Present Illness:
49 year old womam with MDR pseudomonal UTI's related to
nephrolithiasis from medullary sponge kidney and gastrocutaneous
fistula who presents to [**Hospital **] clinic for evaluation of her
recurrent pseudomonal UTI's.
Over the last year, she noted multiple issues with kideney
stones. She had lithotripsy and ureteral stents in [**11-29**]. Since
this time she reported multiple urinary tract infections all
with Pseudomonas aeruginosa. These infections were treated with
4 courses of IV Zosyn over the last 8 months. For example, a
urine cultre on [**2100-5-14**] was significant for a pseudomonas
intermediate to ceftazidime and amikacin and resistant to zosyn
followed by a repeat culture that was sensitive only to zosyn
and amikacin. AS I mentioned, she presented to the [**Hospital **] clinic
with concern for continued dysuria, and urinary frequency that
have continued consistently despite antibiotic therapy in the
past. She had no systemic symptoms of fever or malaise. A urine
clutre grew 50-100,000 col/ml Pseudomonas Aeruginosa which was
sensitive to Meropenem and Zoysn; intermediate to Amikacin,
Cefepime, and Ceftazidime; and resistant to Ciprofolxacin,
Gentamicin, Levofloxacin, and Tobramycin. She was then referred
today for IV antibiotic treatment.
Of note, she was most recently hospitalized in [**5-29**] for a C.
tropicalis line infection at [**Hospital3 15054**] treated with fluconazole and
replacement of her picc line. She noted since this time that her
abdominal rash has continued to bother her with mild pain and
little improvement with topical antifungals. She also noted
continued gastric content leakage which she fears could be
further causing irritation. She will be seen by Dr. [**Last Name (STitle) **] in
the near future for closure of her enterocutaneous fistula. She
has a preop appointment tomorrow for surgcial clearance which
she may miss.
Of note, she has been primarily followed at [**Hospital1 **] and
[**Hospital **] [**Hospital 15055**] Health Care Center with care provided
by nephrology, ID, and urology.
ROS: all remaining systems were reviewed and symptoms were
negative.
Past Medical History:
-Anorexia from age 16
-Bilateral medullary sponge kidney
-BilateraL nephrolithiasis with "stent" placement.
-Hospitalization complicated by bilateraL pulmonaryC
onsolidations, lung biopsy complicated by pneumothorax requiring
a chest tube. Biopsy returned with interstitial pneumonitis.
When SHE awoke from the procedure, she was found to have RLE
arterial clots which were surgically removed but then she was
found to have LLE arterial clots.
-Bilateral AKA secondary to HIT in [**12-30**]
-Recurrent pseudomonal UTI's
-Recurrent bacteremias
-Candidemia (C. tropicalis) in [**5-29**] secondary to PICC line
infection, treated with 2.5 weeks of fluconazole
-G tube and J tube complicated by enterocutaneous fistula, on
long term TPN
- MRSA colonized
Social History:
She lives in [**Location **], MA with husband and sister, no children. 1
dog and 2 cats. She quit tobacco in [**11-29**] pack-year smoking
history. social etoh - 4 glasses wine/week. no IVDU. no foreign
travel. Former airline stewardess, had to stop due to
complications from anorexia.
Family History:
Noncontributory
Physical Exam:
General: pleasant, frail, in NAD, in bed
HEENT:nc/at, eomi, perrl, MMM, clear oropharynx
Neck: supple, no cervical LAD
Cardiovascular:RRR, nl s1s2, no m/r/g
Respiratory: CTAB
Back: faintly erythematous rash on coccyx
Gastrointestinal: + BS, anterior abdominal ostomy site
surrounded by erythematous rash with thickened skin and
satellite lesions, distinct borders, non cellulitic in
appearance
Musculoskeletal: b/l AKA. LUE Picc site intact with only mild
surrounding erythema
Neurological: awake, alert, oriented x 3
Psychiatric: nl affect, teary and distraught when discussing
prior hospitalization
Pertinent Results:
LABS on Admission:
[**7-8**] Urinalysis from outside lab (no MICs on report)
-Urine culture form [**7-10**] OSH
Cx: 50-100,000 col/ml Pseudomonas Aeruginosa
Sensitive: Meropenem, Zoysn
Intermediate: Amikacin, Cefepime, Ceftazidime
Resistant: Cipro, Gentamicin, Levofloxacin, Tobramycin
.
[**2100-7-14**] 05:10PM BLOOD WBC-7.2 RBC-3.53*# Hgb-10.3* Hct-31.5*
MCV-89# MCH-29.3# MCHC-32.8# RDW-16.6* Plt Ct-272
[**2100-8-5**] 08:44AM BLOOD WBC-39.6*# RBC-3.37* Hgb-9.9* Hct-30.8*
MCV-91 MCH-29.4 MCHC-32.1 RDW-16.5* Plt Ct-503*
[**2100-8-14**] 07:58AM BLOOD WBC-6.2 RBC-3.44* Hgb-10.2* Hct-31.2*
MCV-91 MCH-29.8 MCHC-32.9 RDW-17.3* Plt Ct-349
[**2100-7-14**] 05:10PM BLOOD Neuts-66.3 Lymphs-23.5 Monos-3.6 Eos-6.0*
Baso-0.5
[**2100-7-29**] 09:00AM BLOOD Neuts-70 Bands-15* Lymphs-9* Monos-4
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2100-8-5**] 08:44AM BLOOD Neuts-86* Bands-11* Lymphs-1* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2100-8-14**] 07:58AM BLOOD Neuts-62.0 Lymphs-23.6 Monos-5.3 Eos-8.0*
Baso-1.2
[**2100-7-14**] 05:10PM BLOOD PT-17.5* PTT-33.6 INR(PT)-1.6*
[**2100-7-16**] 09:30AM BLOOD PT-28.3* PTT-58.8* INR(PT)-2.8*
[**2100-8-14**] 07:58AM BLOOD PT-22.0* PTT-39.2* INR(PT)-2.1*
[**2100-7-27**] 09:41AM BLOOD ProtCFn-107 ProtSFn-63
[**2100-7-21**] 07:22AM BLOOD Lupus-POS
**FINAL REPORT [**2100-7-28**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2100-7-28**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) 3239**] [**Last Name (NamePattern1) 15056**] @ 0510 ON [**2100-7-28**] FA11
[**Numeric Identifier 15057**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
[**2100-7-20**] 03:00PM BLOOD Lupus-NEG
**FINAL REPORT [**2100-7-29**]**
URINE CULTURE (Final [**2100-7-29**]):
YEAST. >100,000 ORGANISMS/ML..
[**2100-7-20**] 01:50AM BLOOD ACA IgG-9.2 ACA IgM-7.6
[**2100-7-20**] 01:50AM BLOOD AT-95
[**2100-7-14**] 05:10PM BLOOD Glucose-85 UreaN-35* Creat-0.7 Na-141
K-4.1 Cl-107 HCO3-27 AnGap-11
[**2100-8-14**] 07:58AM BLOOD Glucose-106* UreaN-29* Creat-0.8 Na-137
K-4.7 Cl-100 HCO3-27 AnGap-15
[**2100-7-21**] 02:50PM BLOOD LD(LDH)-152 TotBili-0.2 DirBili-0.1
IndBili-0.1
[**2100-8-14**] 07:58AM BLOOD ALT-39 AST-52* AlkPhos-110* TotBili-0.2
[**2100-7-25**] 02:12AM BLOOD Lipase-149*
[**2100-8-3**] 05:45AM BLOOD Lipase-273*
[**2100-8-10**] 05:17AM BLOOD Lipase-206*
[**2100-7-16**] 09:30AM BLOOD Calcium-9.2 Phos-4.7*# Mg-1.8
[**2100-8-7**] 06:52AM BLOOD Calcium-10.5* Phos-3.9 Mg-2.4
[**2100-8-14**] 07:58AM BLOOD Calcium-10.7* Phos-4.2 Mg-2.2
[**2100-7-25**] 02:12AM BLOOD calTIBC-177* Ferritn-357* TRF-136*
[**2100-7-21**] 02:50PM BLOOD Hapto-196
[**2100-7-25**] 02:12AM BLOOD %HbA1c-5.4 eAG-108
[**2100-7-20**] 01:50AM BLOOD Triglyc-349* HDL-24 CHOL/HD-9.5
LDLcalc-134*
[**2100-8-8**] 07:38AM BLOOD PTH-9*
[**2100-7-31**] 04:26AM BLOOD Cortsol-17.7
[**2100-7-14**] 05:32PM BLOOD Lactate-0.6
[**2100-8-8**] 11:04AM BLOOD freeCa-1.44*
Test Result Reference
Range/Units
LIPOPROTEIN (a) 155 H <75 nmol/L
B2 GLYCOPROTEIN I (IGG)AB <9 <=20 SGU
B2 GLYCOPROTEIN I (IGM)AB <9 <=20 SMU
B2 GLYCOPROTEIN I (IGA)AB 21 H <=20 [**Last Name (un) **]
RESULT: NEGATIVE FOR THE R506Q (FACTOR V LEIDEN) MUTATION.
JAK2 MUTATION,QN, LEUMETA(R) NEGATIVE pg/uL
PROTHROMBIN GENE ANALYSIS see note
RESULT: NEGATIVE FOR THE G20210A (PROTHROMBIN/FACTOR II)
MUTATION.
[**2100-7-15**] CT pelvis no contrast:
IMPRESSION:
1. Bilateral medullary calcinosis consistent with medullary
sponge kidney.
2. 1.8 cm calculus in the left kidney with wall thickening of
the adjacent
collecting system.
[**2100-7-21**] CT abd with contrast:
IMPRESSION:
1. Heterogeneous soft tissue density with dispersed foci of air
anterior to
the stomach and left lobe of the liver, which given the clinical
setting is
likely hematoma.
2. Medullary calcinosis, consistent with medullary sponge
kidney.
3. Unchanged 2-cm non-obstructing calculus in the left renal
pelvis.
4. Ascites and pelvic free fluid, likely postop.
5. Postop pneumoperitoneum.
Echo [**2100-7-21**]:
The left atrium and right atrium are normal in cavity size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Doppler parameters are
most consistent with normal left ventricular diastolic function.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is no
pericardial effusion.
IMPRESSION: Normal biventricular systolic function. No PFO/ASD
identified.
[**2100-7-24**] CT head non contrast:
IMPRESSION: Subarachnoid hemorrhage seen overlying the right and
left
parietal lobes, right greater than left. Findings were discussed
with Dr.
[**Last Name (STitle) **] at 5:19 a.m. on [**2100-7-24**].
[**2100-7-24**] CTA Head:
MPRESSION: No evidence of an intracranial aneurysm or
arteriovenous
malformation.
[**2100-7-27**] CT head noncontrast:
IMPRESSION: Stable extent of subarachnoid hemorrhage. No
evidence of new
intracranial abnormalities.
[**2100-8-1**] CT head noncontrast:
IMPRESSION: Interval evolution and redistribution of previous
subarachnoid
hemorrhage. No evidence of new hemorrhage.
[**2100-7-28**] Portable abd:
IMPRESSION:
Colonic air is visualized without evidence of megacolon.
Again visualized are medulary calcifications in the kidneys
bilaterally
[**2100-8-1**] abd supine:
IMPRESSION:
1. Progressive colonic distension and air fluid levels without
evidence of
mucosal thickening. Non-specific small bowel gas pattern without
definitive
evidence of obstruction. No evidence of free air to suggest
perforation.
2. Rounded density overlying the right midlung field, which may
represent a
nipple shadow. Recommend correlation with dedicated chest
imaging if
clinically indicated. consistent with medullary sponge kidney.
Large, 2 cm laminated left renal stone.
[**2100-8-10**] Retrograde Urography:
FINDINGS: Forty eight fluoroscopic spot images from retrograde
urography are submitted for review. Initial scout images show a
pigtail stent within the left ureter. Subsequent images show
passage of a guide wire followed by a ureteral sheath into the
left collecting system. The previously seen stent is removed on
later images. Per operative note, flexible ureteroscopy was done
identifying residual stones within the renal calices. A laser
device is used to fragment the stones further. Larger stones
visualized in the lower calix were unable to be reached for
fragmentation. Final fluoroscopic images show placement of a new
stent within the left ureter. Please see operative note for
further details.
IMPRESSION: Interval replacement of left ureteral stent. Passage
of
catheters and guide wires into left ureter for laser
fragmentation of residual stone fragments. Please see operative
note for further details.
[**2100-8-16**] Retrograde Urography:
FINDINGS: Three fluoroscopic spot images from retrograde
urography are
submitted for review. These images show interval placement of a
double
pigtail stent within the left ureter. Per operative note,
lithotripsy was
performed for stones seen in the left renal pelvis. Please see
operative note for further details.
IMPRESSION:
Interval placement of a stent within the left ureter. Please see
operative
note for further details.
Brief Hospital Course:
# Pseudomonas UTI/nephrolithiasis:
The patient was initially admitted on [**7-14**] to East SIRS service
per outpatient ID for Zosyn/Meropenem sensitive Pseudomonas in
her urine cx and persistent dysuric sx. She was started on iv
Zosyn and which was continued throughout her hospital stay. She
was discharged on iv Zosyn to complete a 7 day post-procedure
course on [**8-17**]. On [**8-4**] and [**8-10**], she underwent L ureterscopy
and laser lithotripsy to eliminate a stone believed to be the
nidus of her recurrent UTIs. She experienced leukocytosis after
the first procedure which resolved. She had some post-procedure
bleeding which was still occuring at the time of discharge but
urology was aware and said this was to be expected. She still
had a small stone present after the second procedure. She has
plans to have her ureteral stent removed by urology 3 days after
discharge.
.
# Cdiff sepsis/hypotension:
On [**7-27**], the patient tested positive for Cdiff stool toxin and
started having florid diarrhea with fever, leukocytosis and
hypotension (SBP to 70s) the next day. She was started on iv
Flagyl and po Vanc which resolved her fever and leukocytosis
within 3 days. Hypotension was managed with midodrine 10 mg po
tid and regular LR fluid boluses. She was continued on po Vanc
throughout the rest of her hospital stay and was discharged on
po Vanc to complete a 14 day course after the end of her Zosyn.
Her po vanco should be discontinued on [**2100-8-31**].
.
# Thrombophilia/ Likely anti-phospholipid syndrome:
The patient was transferred to the SIRS1 service from Neurology
on [**7-26**]. Hematologic w/u revealed likely anti-phospholipid
syndrome (+lup anticoag, +beta2 glyco IgA, +apolipoprotein) as
the cause of the iliac artery thromboses responsible for her b/l
AKA earlier this year. On [**8-7**], she was started on a heparin
bridge to coumadin with INR goal of [**12-23**]. During her initial
anti-coagulation, the patient developed a nodular ecchymotic
mass in the superficial aspect of her L upper extremity,
possible thrombophlebitis vs calcified hematoma, which resolved
with heat packs. At the time of discharge, the patient's INR
was 2.1 with a stable Hct.
.
#SAH/ Call [**Doctor Last Name 8271**] syndrome:
On [**7-23**], the patient developed severe HA and was found to have
SAH. She was transferred to the Neurology service, and CTA
showed no evidence of aneurysm. Impression was that SAH was due
to either Call-[**Doctor Last Name 8271**] syndrome (vasospasm caused by
seritonergic effects of her SSRI (sertraline, here), or to
hemorrhagic conversion of thrombotic stroke. Her sertraline was
discontinued and Neurology recommended not to use seritonergic
anti-depressants in the future. Neurology started her on a
course of calcium channel blockers, verapamil, which was due to
stop the evening of her discharge. The patient did not have
severe headaches during the rest of her hospital stay, and her
last head CT on [**8-1**] showed no interval enlargement of SAH.
.
# GC fistula repair:
On [**7-20**], the patient underwent laparoscopic repair of a
gastrocutaneous fistula that had been created by PEG tube
removal in [**2100-1-18**] during a complicated stay at Bay State
hospital earlier this year (from [**Month (only) 404**]-[**2100-3-20**]). GC fistula
repair was c/b hematoma, which led the team to stop her home
warfarin (10 mg po daily), which had been started for an
unspecified thrombophilia responsible for b/l iliac artery
thromboses requiring b/l AKA in [**2099-12-21**] during the above
hospital stay. The repair site slowly healed with regular wound
care checks and clobetasol cream.
.
TPN induced pancreatitis/ hypercalcemia:
On [**8-1**], the patient developed TPN induced pancreatitis (lipase
up to 273), with symptoms of nausea and vomiting, which was
treated by cycling the fat in her TPN. She later developed
hypercalcemia (10.8) with sx of nausea and vomiting which was
later resolved with adjustments to her TPN. The patient was
discharged off TPN though she was not meeting po calorie goals
at that time. She and her husband were advised to follow up
with her outpatient psychiatrist on strategies for maintaining
an adequate dietary intake.
.
Candiduria:
The patient has 3x positive cultures for yeast, which was
treated with a 10 d course of Fluconazole. Patient was
asymptomatic and course of abx was completed prior to discharge.
.
Anorexia/Depression:
The patient's sertraline was stopped during this hospital stay
due to her possible Call [**Doctor Last Name 8271**] syndrome and it was recommended
by the Neurology service not to use SSRIs or SNRIs in the
future. The patient was scheduled with outpatient Psychiatry
to explore alternative medications without seratonergic effects.
Medications on Admission:
FENTANYL - (Prescribed by Other Provider) - 75 mcg/hour Patch
72
hr - topical change every 3 days
GABAPENTIN [NEURONTIN] - (Prescribed by Other Provider) - 600
mg
Capsule - 1 Capsule(s) by mouth three times daily
HYDROMORPHONE - (Prescribed by Other Provider) - 2 mg Tablet -
1
Tablet(s) by mouth three times daily
LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 0.5 mg
Tablet - 1 Tablet(s) by mouth every 4 hours
MIRTAZAPINE [REMERON] - (Prescribed by Other Provider) - 15 mg
Tablet - 1 Tablet(s) by mouth at bedtime
SERTRALINE - 50 mg - 1 tablet by mouth daily
PANTOPRAZOLE - (Prescribed by Other Provider) - 40 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth three times a day
SODIUM-K+-MAG-CA-CHLOR-ACETATE [TPN ELECTROLYTES] - (Prescribed
by Other Provider) - Dosage uncertain
WARFARIN [COUMADIN] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth daily at 5pm
Medications - OTC
BIOTIN - (Prescribed by Other Provider) - 1000 mcg
SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - 8.6 mg
Tablet - 1 Tablet(s) by mouth twice daily
COLON HEALTH probiotics with meals
Discharge Medications:
1. Piperacillin-Tazobactam 4.5 gram Recon Soln Sig: One (1)
Intravenous every eight (8) hours for 5 days: last dose evening
of [**8-17**].
Disp:*qs * Refills:*0*
2. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): you cannot drive or do
anything that requires a fast reaction time on this medication.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for pain.
Disp:*90 Capsule(s)* Refills:*0*
5. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
6. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 12 days: Continue for 12 days. Stop on the evening
of [**8-31**].
Disp:*72 Capsule(s)* Refills:*0*
7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
Disp:*100 Tablet(s)* Refills:*2*
8. Verapamil 40 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours) for 1 days: Please stop on [**8-14**].
Disp:*1 Tablet(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety: you cannot drive or do anything that
requires a fast reaction time on this medication.
11. Solifenacin Oral
12. Biotin Oral
13. Outpatient Lab Work
YOU MUST GET YOUR INR CHECKED 1st THING ON MONDAY [**2100-8-16**]. YOU
SHOULD HAVE YOUR INR CHECK THREE TIMES A WEEK FOR THE NEXT
SEVERAL WEEKS AS YOUR ANTIBIOTICS LEVELS HAVE BEEN CHANGING
FREQUENTLY (YOU JUST STOPPED ONE 2 DAYS AGO AND YOU WILL STOP 2
OTHERS OVER THE NEXT 3 WEEKS). THESE RESULTS SHOULD BE REVIEWED
BY YOUR [**Hospital **] CLINIC OR YOUR PCP.
14. Outpatient Lab Work
[**Last Name (un) 15058**] survelance labs until [**2100-9-1**] at primary care office:
1st labs on [**2100-8-18**]
Creat, bun, T bili, Alt, Ast, Alk ph, wbc, Hct/Hgb
15. Outpatient Lab Work
UA and Urine cx at primary care office on [**2100-8-18**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Primary diagnosis:
1) Multi-drug resistant Pseudomonas urinary tract infection tx
with zosyn
2) Nephrocalcinosis / Medullary Sponge Kidney s/p lithotripsy
and stent placemnt
3) Anti-phospholipid syndrome
4) Call [**Doctor Last Name 8271**] Syndrome causing Subarachnoid hemorrhage
5) Gastrocutaneous fistula repair
6) C diff colitis
7) TPN induced pancreatitis and hypercalcemia
8) [**Female First Name (un) 564**] in urine
.
Secondary diagnosis:
1) Anorexia
2) Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for a recurrent urinary tract
infection (UTI) that was caused by a drug resistant strain of
bacteria called Pseudomonas. The UTI was treated with an IV
antibiotic, called Zosyn, to which your strain was sensitive.
You will continue this IV medication until [**8-17**]. On CT imaging
of your pelvis, a stone in your left kidney was found to be the
likely cause of your infection. The urology service conducted a
2 stage procedure called laser lithotripsy to break up the
stone. This procedure was performed without complications.
Please consider discussing with your Primary Care Physician or
Urologist whether you should stop the Vesicare, as this
medication can increase your risk of urinary tract infection.
You were experiencing blood and occasional clots in your urine
after the procedure, which is normal. If you start feeling
lightheaded, dizzy, have abdominal pain, or inability to urinate
than you need to seek medical attention.
.
You were scheduled for a follow-up outpatient procedure with
Urology to remove a stent that was placed to facilitate your
lithotripsy in the hospital. You will need an Xray of your
pelvis, called a "KUB", the morning of this follow-up procedure.
Urology already ordered this procedure for you. If you have
questions about this call [**Telephone/Fax (1) 164**].
.
Your gastrocutaneous fistula, which had formed after your PEG
tube was removed, was causing you discomfort and irritation to
the skin and was repaired by the Surgery service. This procedure
was complicated by bleeding at the site and your home coumadin
was temporarily discontinued at that time.
.
Your hospitalization was then complicated by a bleed into your
brain which caused severe headache and was thought to be caused
by blood vessel spasms that were a side effect of your Zoloft.
Your Zoloft was discontinued and it was recommended by the
Neurology service that you not use antidepressants in the class
called SSRI or SNRI in the future. You were started on a
medication called Verapamil by the Neurology service to decrease
those blood vessel spasms but your course of this medication was
completed on the day of your discharge and you only have 1 dose
left.
.
While your were in the hospital, the [**Telephone/Fax (1) **] service ran a
number of diagnostic tests to investigate the source of blood
clotting that led to your leg amputations earlier this year.
The service discovered that you have antibodies highly
suggestive of a syndrome called anti-phospholipid syndrome that
predisposes you to forming life-threatening clots in your blood.
As a result of this it is extremely important that you are
always taking your warfarin. While on warfarin, you need to
maintain a therapeutic level of a blood test called "INR" within
the target range of [**12-23**]. Please work with your [**Hospital 3052**] to ensure that your INR stays within this range. You
have been scheduled for a follow-up appointment with [**Hospital **]
to further define your clotting disorder and manage your
anticoagulation regimen.
.
YOU MUST GET YOUR INR CHECKED 1st THING ON MONDAY [**2100-8-16**]. YOU
SHOULD HAVE YOUR INR CHECK THREE TIMES A WEEK FOR THE NEXT
SEVERAL WEEKS AS YOUR ANTIBIOTICS LEVELS HAVE BEEN CHANGING
FREQUENTLY (YOU JUST STOPPED ONE 2 DAYS AGO AND YOU WILL STOP 2
OTHERS OVER THE NEXT 3 WEEKS). THESE RESULTS SHOULD BE REVIEWED
BY YOUR [**Hospital **] CLINIC OR YOUR PCP. [**Name10 (NameIs) **] WILL ALSO NEED WEEKLY
SURVELENCE LABS WHILE YOU ARE ON YOUR ANTIBIOTICS AS WELL AS
HAVING YOUR URINE CHECKED WHEN YOU COMPLETE YOUR ZOSYN. I HAVE
GIVEN YOU SCRITPTS TO HAVE THESE DONE AND YOU SHOULD FOLLOW UP
THE RESULTS WITH YOUR PCP.
.
While you were in the hospital, you developed an infection in
your gut called C. difficile. This infection commonly occurs
when patients are taking antibiotics. You were treated with an
oral medication called Vancomycin and your infection resolved.
Because you are still taking Zosyn at the time of discharge, you
are instructed to continue Vancomycin for 14 days after you stop
Zosyn ([**8-24**]). Please seek medical attention if you redevelop
diarrhea prior to or just after completing this medication.
.
You had yeast in your urine and this was treated with an
antibiotic called fluconazole.
.
During your hospital stay, you were receiving TPN to supplement
your dietary intake that was limited due to your anorexia. The
TPN caused you to develop pancreatitis with symptoms of nausea
and vomiting. The fat in your TPN was changed to only 2 x per
week and your symptoms and pancreatitis resolved. You also had
imbalances in calcium from the TPN that caused you nausea and
vomiting. The calcium in your TPN was adjusted and these
symptoms were resolved. You were discharged home without TPN.
It is important that you maintain an adequate nutritional
intake. Please discuss strategies with a Nutritionist and your
outpatient Psychiatrist to maintain a healthy diet.
.
You have been scheduled for a number of follow-up appointment
following this very complicated hospital stay. Please make sure
you see your Primary Care Physician, [**Name10 (NameIs) **], Neurology,
Infectious Disease, Psychiatry and Urology doctors within the
next few weeks. Follow-up appointments are listed below.
.
Please note the following changes to your medications:
.
START:
1) Zosyn iv 4.5g iv every 8 hours until [**8-17**]
2) Vancomycin by mouth 125 mg every 6 hours until [**8-31**]
3) Verapamil 20 mg twice a day until evening of [**8-14**] (you have
only 1 dose left)
.
STOP:
1) Mirtazapine 15 mg daily
2) Sertraline 50 mg daily
3) Colon health (Probiotics) QD for the time being while you get
on a stable dose of coumadin and then discuss starting with
your primary care doctor
.
CHANGE:
1) Coumadin from 10 mg to 7.5 mg by mouth daily YOU MUST GET
YOUR COUMADIN LEVEL CHECK 1st THING ON MONDAY [**2100-8-16**]
2) Midodrine from 10 mg to 5 mg by mouth 3x/day
3) Gabapentin 600 mg to 300mg by mouth 3x/day
4) Pantoprazole 40 mg by mouth 3x/day to 2x a day
CONTINUE:
1) Senna Plus at night
2) Colon health (Probiotics) QD
3) Vesicare/solifenacin at previous home dose
6) Lorazepam 1 mg daily as needed for anxiety
7) Fentanyl patch 75 mcg/hr every 3 days
8) Biotin at previous home dose
Followup Instructions:
YOU MUST GET YOUR INR CHECKED 1st THING ON MONDAY [**2100-8-16**]. YOU
SHOULD HAVE YOUR INR CHECK THREE TIMES A WEEK FOR THE NEXT
SEVERAL WEEKS AS YOUR ANTIBIOTICS LEVELS HAVE BEEN CHANGING
FREQUENTLY (YOU JUST STOPPED ONE 2 DAYS AGO AND YOU WILL STOP 2
OTHERS OVER THE NEXT 3 WEEKS). THESE RESULTS SHOULD BE REVIEWED
BY YOUR [**Hospital **] CLINIC OR YOUR PCP. [**Name10 (NameIs) **] WILL ALSO NEED WEEKLY
SURVELENCE LABS WHILE YOU ARE ON YOUR ANTIBIOTICS AS WELL AS
HAVING YOUR URINE CHECKED WHEN YOU COMPLETE YOUR ZOSYN. I HAVE
GIVEN YOU SCRITPTS TO HAVE THESE DONE. YOU SHOULD CALL YOUR PCP
FOR ALL THE RESULTS THE DAY YOU HAD THE BLOOD WORK DONE TO
ENSURE THAT SHE HAS SEEN THEM GIVEN THAT SHE IS NOT WRITING THE
ORDER.
.
Department: UROLOGY/SURGICAL SPECIALTIES (to get your stent out)
MAKE SURE YOU GET YOUR KUB PRIOR TO THIS APPOINTMENT
When: WEDNESDAY [**2100-8-18**] at 8:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: INFECTIOUS DISEASE (follow up on your c diff
infection)
When: THURSDAY [**2100-8-19**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Primary Care
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1105**]
Address: 46 N. [**Location (un) **], [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 15059**],[**Numeric Identifier 15060**]
Phone: [**Telephone/Fax (1) 15061**]
Appointment: Friday [**2100-8-20**] 11:15am
.
Psychiatry
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**], MD
[**Telephone/Fax (1) 15062**]
[**Hospital 15063**] [**Hospital 9105**] Health Center, [**Hospital6 15064**]
[**Location (un) **], MA
[**8-22**]
.
Neurology
[**2100-9-27**] 01:00p [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] C.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
NEUROLOGY UNIT CC8 (SB)
.
[**Location (un) **]
[**2100-10-8**] 11:00a
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) **] [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEM/ONC FELLOWS
Completed by:[**2100-8-25**]
|
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"261",
"560.1",
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"430",
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] |
icd9cm
|
[
[
[]
]
] |
[
"59.8",
"56.0",
"44.63",
"99.15",
"99.07",
"99.04",
"38.93",
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] |
icd9pcs
|
[
[
[]
]
] |
20268, 20341
|
12262, 17042
|
294, 447
|
20858, 20858
|
4357, 4362
|
27332, 29844
|
3701, 3718
|
18213, 20245
|
20362, 20362
|
17068, 18190
|
21034, 26349
|
3733, 4338
|
26378, 27309
|
235, 256
|
475, 2606
|
20809, 20837
|
20381, 20788
|
4376, 12239
|
20873, 21010
|
2628, 3380
|
3396, 3685
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,413
| 102,253
|
9722
|
Discharge summary
|
report
|
Admission Date: [**2116-8-30**] Discharge Date: [**2116-9-1**]
Date of Birth: [**2061-4-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55F with PMH of IDDM presents after a day of feeling generally
unwell, and with nausea and vomiting, some chest pressure and
feeling of heart racing. Patient changed her insulin pump pod
prior to going to bed. Woke up around 6:30am feeling nauseated
with chest pressure. Her glucose was as 376 according to
insulin pump and remained elevated despite her increasing the
rate of insulin infusion on her insulin pump. She was concerned
that the pump may not have been working overnight. She states
that all symptoms feel identical to when she had DKA 10 years
ago. After waiting for a while, her blood sugar fell to 280, but
she still felt nauseated and unwell and her urine showed
ketones, so she presented tot he ED. She denies fevers, chills,
cough, rhinorrhea, sputum production, dyspnea, abdominal pain,
diarrhea, dysuria, rash. She did note however that she had [**3-20**]
non-loose bowel movements over the course of the day, which is
more frequent than usual for her.
.
In the ED, initial vs were: T97.6 HR111 BP138/66 RR20 O2sat 100%
RA
She had a K of 4.0 and an anion gap of 21, a normal CXR, EKG
with <1mm ST depressions that may have been rate dependent (no
priors for comparison), and a UA with 1000 glucose and ketones.
An ABG showed 7.3/31/85/16. Her lactate was 3.6. WBC14.5,
Plt241, Hct42.8 with differential: N:78.6 L:17.7 M:2.6 E:0.1
Bas:1.0. Patient was given 10 units insulin bolus, and 7 units
per hour insulin gtt, which was then turned down to 5 units per
hour when her blood sugar dropped to 193. She was started on NS
with 40meq of K+. VS on transfer were: 94, 115/48, 16, 100% on
RA.
.
When she arrived to the ICU, her vitals were: HR 93, BP 115/54,
RR 14, O2 sat 99 (RA). She felt much better, no longer
nauseated and no more chest pressure.
Past Medical History:
DM I (diagnosed
Fibromyalgia
Social History:
Works as a school nurse [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 2251**] [**Last Name (NamePattern1) **] School.
- Tobacco: none
- Alcohol: 5 glasses wine/week
- Illicits: none
Family History:
Mom died of CHF at 87; father died of old age, seven siblings
who are all healthy
Physical Exam:
Admission Physical Exam:
Vitals: HR 93, BP 115/54, RR 14, O2 sat 99 (RA).
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, non-tender, non-distended, bowel sounds
present, Ext: warm, well-perfused, no edema
.
Discharge Physical Exam:
Pertinent Results:
Admission Labs:
Significant for K of 4.0 and an anion gap of 21. UA with 1000
glucose. ABG: 7.3/31/85/16. lactate 3.6. WBC14.5, Plt241,
Hct42.8 with differential: N:78.6 L:17.7 M:2.6 E:0.1 Bas:1.0.
.
[**2116-8-30**] 01:26PM WBC-14.5* RBC-4.58 HGB-14.6 HCT-42.8 MCV-94
MCH-31.9 MCHC-34.1 RDW-13.2
[**2116-8-30**] 01:26PM NEUTS-78.6* LYMPHS-17.7* MONOS-2.6 EOS-0.1
BASOS-1.0
[**2116-8-30**] 01:26PM PLT COUNT-241
[**2116-8-30**] 01:26PM cTropnT-<0.01
[**2116-8-30**] 01:26PM GLUCOSE-364* UREA N-22* CREAT-0.8 SODIUM-140
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-17* ANION GAP-25*
[**2116-8-30**] 01:33PM LACTATE-3.6*
[**2116-8-30**] 01:33PM PO2-85 PCO2-31* PH-7.30* TOTAL CO2-16* BASE
XS--9 COMMENTS-GREEN TOP
[**2116-8-30**] 02:53PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2116-8-30**] 02:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2116-8-30**] 02:53PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2116-8-30**] 02:53PM URINE GRANULAR-1*
.
Microbiology: no cultures sent
.
Imaging:
CXR ([**8-30**]): FINDINGS: PA and lateral chest radiographs were
obtained. The lungs are clear with no evidence of
consolidations, effusions, or pneumothoraces. The
cardiomediastinal silhouette is within normal limits.
.
Labs on discharge:
[**2116-9-1**] 05:15AM BLOOD Glucose-183* UreaN-7 Creat-0.6 Na-143
K-3.7 Cl-105 HCO3-27 AnGap-15
[**2116-9-1**] 05:15AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.7
.
ETT:
INTERPRETATION: 55 yo woman with h/o DM on insulin x 36 years
was
referred for evaluation of ST segment changes while tachycardic
in ED
being treated for diabetic ketoacidosis. The patient completed
11
minutes of a modified [**Doctor First Name **] protocol representing an average
exercise
tolerance for her age; ~ 9.2 METS. The exercise test was stopped
due to
fatigue. No chest, back, neck or arm discomforts were reported
by the
patient during the procedure. In the presence of nonspecific
baseline ST
segment changes, less than 0.5 mm of additional ST segment
depression
was noted inferiorly. The rhythm was sinus with no ectopy noted.
The
hemodynamic response to exercise was appropriate.
IMPRESSION: No anginal symptoms or objective ECG evidence of
myocardial
ischemia at a high cardiac demand and average exercise
tolerance.
Appropriate hemodynamic response to exercise.
Brief Hospital Course:
55F with PMH of IDDM with insulin pump presents with general
malaise and tachycardia, found to have DKA.
.
#DKA. At the time of presentation to the ICU, the patient's
glucose remained elevated at 364. She had metabolic acidosis
with anion gap of 21 when she presented to the ED, which on
arrival to the ICU had closed to 11. Although she had an
elevated WBC, she was afebrile and had a normal CXR and UA. Her
GI distress had resolved. Given her clinical resolution, there
was no evidence of infection and no further testing was done.
Her elevated WBC was suspected to be an inflammatory response to
the DKA iself. She was treated with hydration (D5W with KCl),
for a total of 4L of fluid. She was placed on an insulin drip
overnight. In the morning, her gap had closed and her
fingerstick blood glucose was normal. She was then transitioned
back to her insulin pump and started on a diabetic diet. By the
afternoon, her blood glucose was in good control, she was eating
well, and was entirely asymptomatic. She was transferred to the
floor for further observation and planned discharge the
following day. She did well on the medical floor, was seen by
the [**Last Name (un) **] consultation and was discharged on her pump in good
working condition. She was advised to only change cartridges in
the morning and then check finger sticks several hours later.
.
Her outpatient primary care physician and her diabetologist at
[**Last Name (un) **] were contact[**Name (NI) **] regarding her presentation and to ensure
follow-up to determine the etiology of her DKA. One obvious
cause could be a malfunction of the insulin pod that was changed
immediately before she retired for the night. However, she also
reports being under unusual stress over the preior four days.
The GI distress she reported (nausea and vomiting) may have been
a result of the DKA, but may have been causal. As she has only
one prior episode of DKA, that associated with the post-op
period, it may warrant further investigation.
.
# EKG changes: ST depression was noted in inferolateral leads
while tachycardic in the ED. These ST depressions disappeared
after her heart rate slowed down. This was suspicious for
demand ischemia while tachycardic. She complained of some chest
pain overnight on [**8-31**] and given this and her EKG changes, a ETT
was done, which was negative (see above for details).
.
#Fibromyalgia: Patient was diagnosed 2 years ago for general
aches and cramps. Her home regimen was continued.
Medications on Admission:
Humalog insulin per insulin pump (no long-acting insulin)
Prednisone 2 mg daily (slow taper, has been on for 2 years for
fibromyalgia)
Lyrica 50mg qhs
Lisinopril 5mg qhs
Discharge Medications:
1. prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. insulin pump syringe Miscellaneous
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with diabetic ketoacidosis, likely due to pump
malfunction. You were treated with insulin and IV fluids and
you improved. On admission, your heart rate was fast and you
had some minor changes to your EKG. You also noted some
intermittent chest pain. You underwent an exercise treadmill
test that was negative!
***
NO CHANGES WERE MADE TO YOUR HOME MEDICATIONS.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 5445**] N.
Address: [**Location (un) 32820**], [**Location (un) **],[**Numeric Identifier 32821**]
Phone: [**Telephone/Fax (1) 32822**]
Appointment: Thursday [**2116-9-10**] 10:15am
|
[
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"401.9",
"996.59",
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] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8403, 8409
|
5397, 7904
|
292, 298
|
8475, 8475
|
2987, 2987
|
9033, 9266
|
2393, 2477
|
8125, 8380
|
8430, 8454
|
7930, 8102
|
8626, 9010
|
2517, 2941
|
239, 254
|
4331, 5374
|
326, 2103
|
3003, 4312
|
8490, 8602
|
2125, 2156
|
2172, 2377
|
2968, 2968
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,550
| 115,350
|
31518
|
Discharge summary
|
report
|
Admission Date: [**2199-8-24**] Discharge Date: [**2199-9-13**]
Date of Birth: [**2127-2-13**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Atenolol / Provera / Inderal La / Latex / Norvasc /
Levaquin / Diovan / Ambrisentan
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
GI bleed, decompensated pulmonary hypertension
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
72 yo F with idiopathic pulmonary hypertenstion (PA pressured
90-100) on 5L O2 nc, remodulin pump and sildenafil, h/o PE in
[**2194**] on coumadin. She presented to [**Hospital3 **] yesterday
with nausea and hematemesis. She had hct drop from baseline of
45--->29. She developed hypoxia to 74% in the setting of
hematemesis and was intubated. Her INR was reversed. She
received a total of 5u RBC. She underwent endoscopy in the ICU
at OSH that showed a large gastric ulcer that was not actively
bleeding. She was placed on a PPI ggt. She was transferred to
[**Hospital1 18**] as she receives her out patient care here and the OSH did
not know how to administer remodulin.
Past Medical History:
- Pulmonary embolism in [**2194**], on anticoagulation
- Severe pulmonary hypertension, O2 dependent
- COPD
- Supraventricular tachycardia
- Hypertension
- s/p Right leg vein stripping
- Arthritis
Social History:
Patient is widowed and lives alone. She has three sons. She has
a 50 pack year history and quit less than 1 year ago.
Family History:
Father had a stroke in his 80??????s. Sister had a stroke in her mid
40??????s.
Physical Exam:
98 79 115/54
Sedated, NAD
HEENT: PERRL, EOMI, Right IJ trauma line, +JVD
Lungs CTA bil
CV: irreg irreg
Abd: soft hypoactive bs, nt
Ext: 2+ DP pulses, no peripheral edema, +boots
Pertinent Results:
[**2199-8-24**] 02:42AM WBC-11.1*# RBC-3.64* HGB-11.1*# HCT-33.0*#
MCV-91 MCH-30.4 MCHC-33.6 RDW-16.0*
[**2199-8-24**] 02:42AM PLT COUNT-196
[**2199-8-24**] 02:42AM PT-16.2* PTT-24.2 INR(PT)-1.4*
[**2199-8-24**] 02:42AM GLUCOSE-112* UREA N-41* CREAT-1.0 SODIUM-150*
POTASSIUM-3.5 CHLORIDE-115* TOTAL CO2-26 ANION GAP-13
[**2199-8-24**] 02:42AM ALT(SGPT)-11 AST(SGOT)-12 LD(LDH)-184
CK(CPK)-48 ALK PHOS-44 TOT BILI-0.7
[**2199-8-24**] 02:42AM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-3.1
MAGNESIUM-1.9
[**2199-8-24**] 02:42AM cTropnT-LESS THAN
[**2199-8-24**] 03:40AM LACTATE-1.0
[**2199-8-24**] 03:40AM TYPE-ART PO2-96 PCO2-51* PH-7.32* TOTAL
CO2-27 BASE XS-0 -ASSIST/CON INTUBATED-INTUBATED
..
[**2199-9-12**] 05:50AM BLOOD WBC-8.0 RBC-3.62* Hgb-10.9* Hct-33.2*
MCV-92 MCH-30.1 MCHC-32.8 RDW-16.0* Plt Ct-326
[**2199-9-9**] 06:08AM BLOOD Neuts-80.6* Lymphs-7.2* Monos-3.4
Eos-8.7* Baso-0.1
[**2199-9-12**] 05:50AM BLOOD PT-18.5* PTT-25.1 INR(PT)-1.7*
[**2199-9-12**] 05:50AM BLOOD Plt Ct-326
[**2199-9-12**] 05:50AM BLOOD Glucose-80 UreaN-32* Creat-1.0 Na-141
K-3.4 Cl-99 HCO3-34* AnGap-11
[**2199-9-10**] 03:27AM BLOOD Digoxin-0.9
..
Blood Cultures from [**2199-9-7**]: Pending
..
Imaging:
CXR [**8-24**]: An endotracheal tube tip lies 5.7 cm above the carina.
Nasogastric tube appears appropriately positioned. The patient
is rotated. The cardiomediastinal silhouette is obscured by a
prominent retrocardiac opacity with air bronchograms. The
central vessels are enlarged consistent with known pulmonary
hypertension. There is also a right basilar opacity.
.
Brief Hospital Course:
72 y/o F with hx of pulm HTN on Remodulin, PE and CHF who
presented to an OSH on [**8-23**] with hematemesis and hct form
45-->29. She clinically deteriorated from a respiratory
standpoint, sats in 70s while vomiting, and was urgently
intubated. Her INR was reversed with FFP and she received a
total of 5 u PRBCs. She then had an endoscopy showing a
non-bleeding gastric ulcer. She was transferred to [**Hospital1 18**] for
Remodulin therapy given the OSH pharmacy did not carry the
medicine.
.
On arrival here, she was intubated and sedated. She had a stable
hct. Her SBP was moderately low and levophed was started. Her BP
was thought to be secondary to sedation. GI was consulted and
did not feel a need to rescope her given her stable hct.
Pharmacy was consulted and converted her remodulin to an IV pump
form.
.
# UGIB: OSH report with photos of large gastric ulcer, no longer
bleeding. Her anticoagulation was held, her hct remained stable,
and she was placed on a PPI. GI was consulted and saw no
indication for further endoscopy.
.
# Hypotension: Occurred in setting of sedation for vent/line and
with increase in PEEP. She required levophed transiently, and
was weaned successfully.
.
# Hypoxic respiratory failure: In setting of UGIB likely [**3-12**]
aspiration. Has underlying hypoxia at baseline from Pulmonary
Hypertension (on baseline 5L nc). No pneumonitis or infiltate
seen on CXR but given underlying lung disease was treated
empirically until cultures returned negative. For her severe
pulmonary hypertension she was continued on remodulin and
sildenafil, and the remodulin was discontinued successfully
prior to discharge. She was successfully weaned from the
ventilator.
.
# SVT: Intermittently tachy to 130s with a known h/o SVT. Here
she intermittently converted in to Afib/flutter. She was kept
on telemetry, resuscitated with blood, and treated with AV nodal
blocking agents, including diltiazem and digoxin.
.
# Pulmonary Embolus: On admission the patient was anticoagulated
for a recent PE. Her INR was reversed given GIB. Her
anticoagulation was held for a period and then restarted to in
light of need to minimize right heart strain in pt with severe
pulmonary hypertension.
.
# The patient is DNR/DNI.
Medications on Admission:
Amlodipine 5 mg Tablet
Warfarin 2 mg (held and INR reversed yesterday)
Furosemide 60mg qd
Sildenafil 80 mg TID
Gabapentin 300 mg qhs
Triamcinolone Acetonide Topical
Remodulin 16.25 ng/kg/min
Discharge Medications:
1. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 6-10 MLs
Miscellaneous Q6H (every 6 hours) as needed for wheeze.
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
3. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO
twice a day: Please take with lasix dose.
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
7. Sildenafil 20 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. Morphine Sulfate 2-4 mg IV Q2H:PRN pain, shortness of breath
hold if sedated
13. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Gastrointestinal Bleed with Gastric Ulcer
Decompensated Pulmonary Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with a bleed from an ulcer and
trouble breathing due to pulmonary hypertension. You were
intubated because you were having troulbe breathing. You were
taken off the ventilator successfully. Your blood thinner was
held briefly and then restarted. Your pulmonary hypertension
medication, remodulin, was causing you pain. It was stopped
successully.
..
The following changes were made to your medications:
You were STARTED on diltiazem, morphine, trazodone, sarna
lotion, potassium, docusate (colace), and pantoprazole.
Your furosemide (lasix) dose and gabapentin dose were INCREASED.
Your triamcinolone cream was STOPPED.
Followup Instructions:
GI [**Hospital **] Clinic 4 weeks post GI Bleed
Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11716**] [**Name8 (MD) 11717**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2199-9-18**] 2:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
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"427.31",
"427.89",
"401.9",
"716.90",
"531.90",
"V66.7",
"729.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.6",
"38.93",
"96.72"
] |
icd9pcs
|
[
[
[]
]
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7039, 7111
|
3404, 5646
|
411, 423
|
7234, 7234
|
1803, 3381
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8100, 8457
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1497, 1578
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5887, 7016
|
7132, 7213
|
5672, 5864
|
7417, 8077
|
1593, 1784
|
325, 373
|
451, 1124
|
7249, 7393
|
1146, 1345
|
1361, 1481
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,819
| 185,590
|
3466
|
Discharge summary
|
report
|
Admission Date: [**2173-11-14**] Discharge Date: [**2173-11-24**]
Date of Birth: [**2108-7-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
cardiac catheterization (no intervention)
History of Present Illness:
65M h/o poorly controlled HTN, DM2 (last HgbA1c 12.0%),
hyperlipidemia (last LDL 218), obesity with no known CAD
presents with acute SOB. Saw PCP [**2173-11-3**] complaining of
non-productive cough. CXR revealed vascular congestion. Insulin
regimen changed and c/o fatigue since this time. On the day of
admission, he had unusually poor appetite. At church, he
developed acute-onset SOB with diaphoresis. No CP or nausea.
Found to be in severe respiratory distress by EMS with RR 40 and
intubated in the field. HR 130's (regular) and SBP 292/110 mmHg.
He was given 0.8mg nitro spray and lasix IV 100mg with good
response. FSBS 436.
.
In the ED, received aspirin 325mg, insulin 10 units IV, ativan
IV 4mg, and started on nitro gtt. ECG revealed STE in V3
unchanged from prior and new TWIs in V3-V6. Cardiac enzymes
negative x 1. Transferred to CCU for further management
.
Per family, patient has been taking meds but does not check FSBG
as he dislikes needles. No chest pain, leg swelling, orthopnea
(1 pillow), worsening DOE (climbs 1 flight stairs, 1.5 blocks
before SOB). Possible recent PND. Does not follow Na-restricted
diet. No h/o asthma, COPD, or CHF. [**Month (only) 116**] have had recent occ HA
and vision 'blurring' per wife.
Past Medical History:
1)HTN
2)hyperlipidemia ([**2173-11-3**]: chol 309 LDL 218)
3)Type 2 Diabetes on insulin
4)obesity
Social History:
Married. 2 children. Retired, worked in personnel department for
[**Company 2318**]. Former golfer, now primarily sedentary lifestyle.
Nonsmoker. Occ wine. No illicits.
Family History:
Family History: DM in father; HTN in mother; no family h/o heart
disease
Physical Exam:
vitals T 96.8 HR 65 BP 149/97 RR 16
SaO2 100% AC rate 16 Vt 600 FiO2 100% PEEP 5
General: intubated and sedated
HEENT: PERRL, EOMi, anicteric sclera
Neck: supple, trachea midline, no thyromegaly, no LAD, no bruits
Cardiac: RRR, s1s2 normal, no m/r/g, unable to assess JVP
Pulmonary: crackles anteriorally, no wheezes
Abdomen: +BS, obese, soft, nontender
Extremities: warm, non-palp DP pulses, 3+ LE edema bilaterally
Neuro: sedated, spontaneously moves extremities
Pertinent Results:
Hematology:
[**2173-11-14**] 11:59AM WBC-8.4 RBC-3.71* HGB-12.2* HCT-36.4* MCV-98
MCH-32.9* MCHC-33.6 RDW-12.8
[**2173-11-14**] 11:59AM PT-12.8 PTT-26.0 INR(PT)-1.1
.
Chemistry:
[**2173-11-14**] 11:59AM GLUCOSE-371* UREA N-15 CREAT-1.0 SODIUM-138
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-26 ANION GAP-9
.
ECG ([**11-14**]): sinus. 69bpm. LVH with isolated STE V3 and TWI
V5-6, not significantly changed from prior.
.
CXR, portable ([**11-14**]):
1) ETT well positioned, though the balloon cuff may be minimally
hyperinflated.
2) Allowing for differences in technique, no interval change in
pulmonary edema.
.
CXR, 2-view ([**11-17**]):Compared with [**2173-11-15**], post-extubation with
partial interval clearing of the CHF and effusions. The left
lung base is now better aerated. A small residual effusion is
noted on the left.
No consolidating pulmonary infiltrates appreciated.
.
RUQ ultrasound ([**11-19**]):
1. Normal gallbladder.
2. Simple right renal cyst.
.
Cath ([**11-16**]):
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated 2 vessel coronary artery disease. The LMCA had no
angiographically apparent coronary artery disease. The LAD had
mid
vessel 50% stenosis. The D! was a large vessel with 70% stenosis
at its
origin. The LCX had mild luminal irregularities. The RCA was a
small
vessel with 70-80% mid vssel stenosis.
2. Resting hemodynamics were performed. The right sided filling
pressures were mildly elevated (mean RA pressure was 12mmHg and
RVEDP
was 14mmHg). The pulmonary artery pressures were mildly elevated
(mean
PA pressure was 25mmHg). The left sided filling pressures were
mildly
elevated (mean PCW pressure was 12mmHg). The systemic arterial
pressure
was mildly elevated measuring 142/76mmHg. The cardiac index was
within
normal range measuring 2.8l/min/m2.
3. Selective renal aniography demonstrated no renal artery
stenosis.
FINAL DIAGNOSIS:
1. 2 vessel coronary artery disease.
2. Mildly elevated right and left sided filling pressures.
Mildly
elvated pulmonary artery pressure and systemic arterial
pressure.
3. Normal cardiac index.
4. No anigrographically apparent renal artery stenosis.
.
CT head ([**11-20**]):
Significantly motion limited study. Allowing for these
limitations, no obvious intracranial hemorrhage or large major
vascular
territorial infarction, though if suspicion remains high for the
latter, MRI would be more sensitive to assess.
.
MRI/MRA brain and neck ([**11-21**]):
1. Multiple, scattered foci diffusion-weighted imaging
abnormality within the cerebral hemispheres bilaterally,
consistent with small areas of infarction. The distribution is
most compatible with an embolic etiology, with a low
flow/watershed distribution being a secondary diagnostic
consideration.
2. MRA of the neck and circle [**Location (un) 431**] are significantly degraded
by motion. Major tributaries of the circle of [**Location (un) 431**] appear
patent. A high-grade stenosis of the proximal right vertebral
artery is identified.
.
CTA head and neck ([**11-22**]):
1. Evolving small areas of infarction within the cerebral
hemispheres
bilaterally, most compatible with an thromboembolic disease.
2. Extensive atherosclerotic disease with stenosis of the
cavernous portions of the carotid arteries bilaterally. CTA of
the circle of [**Location (un) 431**] is otherwise unremarkable.
.
Prior studies -
.
ETT ([**8-/2165**]): [**Doctor First Name **] 4.5 min. Test terminated secondary to
hypertensive BP response to low level exercise. No anginal type
symptoms or ischemic EKG changes. Nonspecific ST-T wave changes
noted late in recovery.
.
Brief Hospital Course:
65M h/o poorly controlled HTN, DM2, hyperlipidemia, obesity
presents with acute respiratory distress [**2-4**] CHF exacerbation
s/p intubation. Extubated and SOB resolved s/p diuresis.
Transferred to floor but developed hypotension [**2-4**] meds
(received labetalol and captopril together) with SBP 70's and
given IVFs, glucagon, levophed and transferred back to CCU.
Hypotension resolved and weaned off levophed. Acute CVA likely
related to hypotensive episode.
.
# Hypertension: difficult to control. hypertensive urgency at
presentation with SBP 292, started on nitro gtt with good
response, weaned off prior to coming to CCU but then restarted
while titrating up po meds. hypotensive episode [**11-17**] on
labetalol, captopril, norvasc. remained hypertensive, slowly
increased PO meds. discharged labetalol to 400mg tid and
lisinopril 30mg qd. goal SBP 140-160, patient does not tolerate
low BPs. will need long-term outpatient titration of BP meds.
.
# Pump: EF 40%. inferior akinesis. LVH on ECG. likely diastolic
dysfunction given longstanding HTN however concern for ischemic
component with depressed EF. pro-BNP 4000 and volume overloaded
at presentation; diuresed initially and euvolemic at discharge
without lasix requirement. extubated [**11-15**]. cath revealed CAD
but no intervention performed. cont BB, ACEi. 2gm Na/cardiac
diet, fluid restriction 1500cc. patient received nutrition
consult for dietary teaching.
.
# CAD: 80% RCA and 70% D1, no intervention given no angina and
deemed not culprit. multiple risk factors and inferior akinesis
on echo. prior excercise test stopped due to hypertension. ST
changes on surface ECG likely repolarization abnormalities [**2-4**]
LVH. ROMI with cardiac biomarkers negative x 3. discharge on
ASA/statin/BB/ACEi. consider outpatient stress test when
medically optimized if symptomatic.
.
# Rhythm: sinus. monitored on telemetry with no events.
.
# Neuro: somnolent with right arm/face weakness 2 days following
hypotensive event. neuro status improved significantly prior to
discharge. MRI/MRA brain suggests acute CVA, likely watershed
from hypotensive episode per neurology consult however radiology
suggests more consistent with embolic. CTA head/neck with small
bilat acute evolving CVA and cavernous carotid disease. Started
on aggrenox and no carotid ultrasound at this time per neuro.
Increase aggrenox to [**Hospital1 **] on [**2173-11-26**]. scheduled for outpatient
neuro f/u with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] on [**2173-1-24**].
.
# Hyperlipidemia: very poorly controlled at baseline. started on
atorvastatin 80mg qd. baseline LFTs normal. f/u with PCP for LFT
checks.
.
# DM2: hyperglycemic at presentation, received 10 units regular
insulin in ED with good response. initially started on 15U
lantus but switched to 75/25 insulin [**First Name8 (NamePattern2) **] [**Last Name (un) **] consult recs.
well-controlled at discharge. cont 75/25 insulin 20U [**Hospital1 **].
[**First Name9 (NamePattern2) 15973**] [**Last Name (un) **] f/u, the patient will call [**Telephone/Fax (1) 2384**] to
schedule in 1 month.
.
# ARF: prerenal [**2-4**] diuresis, Cre returned to baseline prior to
discharge. s/p dye load at cath, received mucomyst and bicarb
for IV contrast PPx. no evidence for contrast nephropathy.
.
# Anemia: initial drop, unclear cause. iron studies c/w ACD. B12
and folate wnl. retic count 4.9. no evidence active bleeding.
received 1U pRBC with appropriate increase. Hct low but stable @
27-29. Hct goal >27. will need Hct check at rehab on Friday
[**2173-11-26**] and PCP f/u to discuss colonoscopy and further work-up
for anemia.
.
# Abdominal discomfort: diffuse pattern that improved with
defecation. LFTs normal at presentation. RUQ ultrasound
negative. ?gastroenteritis vs. reflux vs. constipation. given
simethicone, bowel regimen, PPI, and maalox prn.
.
# Bicuspid aortic valve: noted incidentally on echo. will need
outpatient endocarditis PPx.
.
# PNA: productive cough of yellow sputum and spiked temp.
retrocardiac infiltrate on CXR, started on ceftriaxone and
became afebrile. completed ceftriaxone 7 day course.
.
# RUE swelling: unclear cause, possible related to prior IV
infiltration vs. phlebitis. RUE U/S negative for DVT. resolved
prior to discharge.
.
# Conjunctivitis: left eye, improved with e-mycin ointment.
.
Medications on Admission:
HCTZ
verapamil
lipitor
lantus
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
6. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
7. Erythromycin 5 mg/g Ointment Sig: One (1) application
Ophthalmic QID (4 times a day) for 5 days: apply to left eye.
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO Q8H
(every 8 hours) as needed for constipation.
13. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
14. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12
HR Sig: One (1) Cap PO BID (2 times a day): start after daily
dose completed.
15. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12
HR Sig: One (1) Cap PO DAILY (Daily) for 1 days.
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: Twenty
(20) units Subcutaneous twice a day: with breakfast and dinner.
18. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
sliding scale Injection four times a day.
19. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
20. hematocrit Sig: One (1) once for 1 doses: check
hematocrit at rehab [**2173-11-26**].
Disp:*1 lab* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
congestive heart failure
hypertensive urgency
cerebral vascular accident
Discharge Condition:
good
Discharge Instructions:
Please take all medications as prescribed
2gm sodium diet; fluid restriction
Measure weights daily, call your doctor if increase > 3 pounds
.
New medications: aspirin, labetalol, lisinopril, aggrenox,
atorvastatin, insulin 75/25 mix
.
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, sweating, fevers, chills, bleeding, or other
concerning symptoms.
Followup Instructions:
Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2472**], at [**Telephone/Fax (1) 133**] for an
appointment in [**1-4**] weeks.
.
Call [**Last Name (un) **] at [**Telephone/Fax (1) 2384**] to schedule a follow-up appointment
within 1 month for your diabetes.
.
You are scheduled to see neurologist [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2174-1-24**] 1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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icd9cm
|
[
[
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icd9pcs
|
[
[
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337, 381
|
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2549, 4448
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2063, 2530
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277, 299
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409, 1650
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1672, 1772
|
1788, 1958
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,866
| 149,946
|
36258
|
Discharge summary
|
report
|
Admission Date: [**2151-4-21**] Discharge Date: [**2151-4-28**]
Date of Birth: [**2073-2-4**] Sex: M
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Left leg ischemia
Left 1st toe amputation site necrosis
Major Surgical or Invasive Procedure:
[**2151-4-23**] Left below knee Popliteal-peroneal BPG and 1st
metatarsal wound debridement
History of Present Illness:
This is a 78 man s/p left big toe amp 3 weeks ago subsequently
complicated by ulceration and infection of the amputation site.
He has been receiving local wound care, debridements, and oral
antibiotics at a wound care clinic at [**Hospital3 26615**] Hospital over
the past few weeks, had an diagnostic angiogram on [**2151-4-15**],
recommended to have L LE bypass on Friday [**2151-4-23**]. He is being
admitted today for IV antibiotics.
Past Medical History:
DM-2 diagnosed 10 years ago (not on insulin), bradycardia
s/p pacemaker placement 5 years ago, Renal insufficiency near
ESRD (will start PD soon per patient), HTN
Social History:
Tobacco - quit smoking 40 years ago. Denies ETOH and illicit
drug use. Lives alone in a house in [**Location (un) 745**], NH.
Family History:
Non-contributory
Physical Exam:
VS: 96.8, 79, 105/59, 20, 97 RA
Gen: NAD, AAOx3
CV: RRR, S1S2
Pulm: CTAB/L
ABD: soft, NTND
EXT: LLE - The foot and toes are warm. The ray amputaion site w/
sutures, incision line is intact, no erythema. Bypass incison
line is w/ staples, inatact. There is some erythema along the
incision line.
RLE - warm and dry, the incison line is w/ staples, inatact w/
some erythema along the incision line.
Pulses:
Fem [**Doctor Last Name **] DP PT
[**Name (NI) 167**] P P dop dop
Left P P dop dop
Pertinent Results:
[**2151-4-27**] 04:09AM BLOOD WBC-6.3 RBC-3.64* Hgb-10.9* Hct-32.3*
MCV-89 MCH-30.0 MCHC-33.8 RDW-17.4* Plt Ct-126*
[**2151-4-26**] 03:58AM BLOOD WBC-6.4 RBC-3.50* Hgb-10.5* Hct-31.1*
MCV-89 MCH-30.0 MCHC-33.8 RDW-17.3* Plt Ct-125*
[**2151-4-27**] 04:09AM BLOOD Plt Ct-126*
[**2151-4-26**] 03:58AM BLOOD Plt Ct-125*
[**2151-4-27**] 04:09AM BLOOD Glucose-109* UreaN-77* Creat-3.9* Na-144
K-3.5 Cl-120* HCO3-14* AnGap-14
[**2151-4-26**] 03:58AM BLOOD Glucose-84 UreaN-87* Creat-4.5* Na-143
K-4.1 Cl-117* HCO3-16* AnGap-14
[**2151-4-25**] 03:15AM BLOOD Glucose-73 UreaN-91* Creat-4.5* Na-144
K-4.0 Cl-118* HCO3-14* AnGap-16
ECG Study Date of [**2151-4-22**] 11:17:40 AM
Normal sinus rhythm with ventricular pacing at a rate of 72
beats per minute. Compared to the previous tracing of [**2151-4-13**]
only ventricular pacing is observed.
CHEST (PRE-OP PA & LAT) Study Date of [**2151-4-22**] 7:16 PM
FRONTAL AND LATERAL VIEWS OF THE CHEST: There is cardiomegaly,
stable. Mild congestive failure is again present, not
significantly changed. A left-sided pacemaker is seen with the
leads terminating in the expected location of the right atrium
and right ventricle, stable. Otherwise, the lungs appear clear
with no areas of definite consolidation.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Mr. [**Known lastname 49362**] was admitted on [**2151-4-21**] directly to the vascular
surgery service. He was started on empiric antibiotics for his
necrotic left foot ulcer.
Renal Failure: Nephrology was consulted for continued management
of his chronic ESRD. The decision was to hold of on HD prior to
his surgery
Chronic Anemia: The patient was transfused 2 units of PRBCs on
[**4-22**] and 1 unit PRBCs on [**4-23**] for his chronic anemia
preoperatively in anticipation of substantial blood loss in the
OR.
The patient was taken to the OR on [**4-23**] for his LLE bypass
graft, invasive monitoring lines were placed, patient tolerated
procedure and was brought to the PACU for recovery. Developed
hypothermia and acidosis, patient was intubated, sedated and
transferred to CVICU. Continued w/ broad spectrum antibiotics.
RISS for glycemic control.
[**2151-4-24**] POD1 Patient in CVICU- weaned and extubated. Fluid
resuscitated. Given Lasix IV for low urine output. Continues to
be followed by Nephrology. Hemodynamically stable. Continued w/
broad spectrum antibiotics.
[**2151-4-25**] POD2 Patient continue to be hemodynamically stable,
transferred to [**Hospital Ward Name 121**] 5 VICU for further montoring. Initiated
lower extremity bypass pathway. Continue to diurese daily.
Continued w/ broad spectrum antibiotics. Resumed home meds.
5/25-26/09 POD3-4 VSS. pain well controlled. PA line d/c'd.
Continue lower extremity bypass pathway. Continued w/ broad
spectrum antibiotics. Renal following creatinine improving.
Physical therapy referral, for discharge planning. [**Hospital 82198**] rehab
placement/screening.
[**2151-4-28**] POD5 VSS. Pain continue to be well controlled w/ current
meds. Discharged to Rehab in good condition. Will d/c on Bactrim
for 2 weeks. Staples/sutures will be removed on FU w/ Dr.
[**Last Name (STitle) 1391**].
Medications on Admission:
Aspirin 81 mg PO DAILY,
Ascorbic Acid 500 mg PO DAILY,
Oxycodone-Acetaminophen [**12-4**] TAB PO
Carvedilol 6.25 mg PO DAILY
Atorvastatin 10 mg PO DAILY
Doxercalciferol 2 mcg PO DAILY
GlyBURIDE 5 mg PO DAILY
Amlodipine 5 mg PO DAILY
Keflex 500mg QID
Levaquin 250 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
9. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Insulin sliding scale
Humalog
Breakfast Lunch Dinner
Glucose Insulin Dose
0-60 mg/dL [**12-4**] amp D50
61-150 mg/dL 0 Units
151-200 mg/dL 2 Units
201-250 mg/dL 4 Units
251-300 mg/dL 6 Units
301-350 mg/dL 8 Units
> 350 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**] Hospital
Discharge Diagnosis:
Left lower extremity ischemia
Necrotic left 1st toe amputation site
Chronic Anemia-requiring blood transfusions
Chronic Renal failure- diuresing twice daily
History of:
DM
bradycardia s/p pacemaker placement '[**44**]
CRI
HTN
PSH: s/p big toe amp on left foot
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-5**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
FU w/ PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **] [**Telephone/Fax (1) 82199**] (to monitor renal
status and adjust medication)
Please follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks. Call to make your
appointment [**Telephone/Fax (1) 1393**]
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks. Call to make your
appointment [**Telephone/Fax (1) 1393**]
FU w/ PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **] [**Telephone/Fax (1) 82199**] (to monitor renal
status and adjust medication)
Completed by:[**2151-4-28**]
|
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icd9cm
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[
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icd9pcs
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[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,326
| 176,560
|
30989
|
Discharge summary
|
report
|
Admission Date: [**2114-4-23**] Discharge Date: [**2114-5-3**]
Date of Birth: [**2042-1-24**] Sex: F
Service: MEDICINE
Allergies:
Ergot Alkaloids / Norvasc
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Transfer from [**Hospital1 **] for venous graft intervention
Major Surgical or Invasive Procedure:
Cardiac cathetherization-stent placement
History of Present Illness:
This 72-year old female with an extensive medical history
including CABG and valve replacement, PVD, CRI, presents here
from [**Hospital1 **] with chest pain/management of MI.
Patient reports being admitted for chf exacerbation in mid-[**Month (only) 116**]
at [**Hospital 4415**] with active diuresis and concern
for ACS, but because of imparied renal function, plan to medical
manage and not sent to cath lab. Patient discharged to
independant living.
On [**4-13**], patient presented to [**Hospital1 **] with cheif complaints of
left scapular pain and shortness of breath - diagnosed with
acute decompensated heart failure, subsequently diuresed, ruled
in for NQWMI with troponin up to 11.4, ck 290, 12% R/I. [**4-17**]
cardiac cath showed 3-v native disease (RCA not seen), LIMA to
LAD-40-50% mid disease, SVG to LV branch of prox CX: 80%
eccentric proximal stenosis which became worse during cath (?
catheter trauma), SVG to OM: proximal occlusion, with an
estimated EF 55-60%. Course complicated by ? of TIA vs. stroke
last Wed [**4-18**] day after cath, with clinical signs of right hand
weakness, with no other signs/symptoms since that time and CT
scan negative for acute pathology (no MRI done). On [**4-18**],
patient had another rise in ck and troponin, with rise back up
to 12 (previously 2). An Echo on [**4-18**] showed EF 40-45%. A
carotid u/s showed "no changes from previous", but by report,
unsure of previous findings. Patient has reportedly been chest
pain free over weekend on ntg and heparin gtts. Right groin site
clean, dry, and intact. Patient referred for venous graft
intervention. Vital signs upon transfer BP 170/77, 130/55
post-hydral and lopressor, hr 60s sinus, afebrile, sat 2lnc 98%.
Bilateral wheezes.
In cath lab, cobalt chronium, BMS stent placed in proximal [**11-22**]
of SVG to RCA, where a 70% stenosis was identified.
ROS+ for claudication symptoms in her lower extremities after
walking distance. + nasal symptoms thought [**12-22**] to seasonal
allergies.
Past Medical History:
1. CAD - MI complicated by cardiogenic shock in [**2107**], leading to
CABG with LIMA to LAD, SVG to OM, SVG to PLV
2. [**Last Name (un) 3843**] [**Doctor Last Name **] aortic valve replacement.
3. PVD - s/p aortobifemoral bypass graft with left renal artery
bypass
4. Abdominal aortic aneurysm - repaired [**2108**]
5. Paroxysmal atrial fibrillation
6. Chronic renal insufficiency - baseline Cr 2.5 with acute
failure with creatinine rise to 5.0. Renal artery angioplasty in
[**2107**].
7. GI bleed - unsure of nature of bleed
8. Hypertension
9. Hyperlipidemia - untreated due to side effects
10. Pulmonary hypertension
11. Right carotid stenosis - CEW [**2107**]
Cardiac Risk Factors: Dyslipidemia, Hypertension, atrial
fibrillation
Cardiac History: CABG - LIMA to LAD, SVG to OM, SVG to PLV
Social History:
Social history is significant for tobacco use - >49 pack year
history, not currently smoking, quit six years ago. There is no
significant history of alcohol abuse. Patient lives in
[**Location 47**] Housing Complex, living independently.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
PE: T: 98.5 BP: 142/51, 94/56 HR: 73 RR: 18 97% 2L
Gen: NAD, A/Ox3, lying in bed, conversant, cooperative, tensed
face - look of concern.
HEENT: no conjunctival pallor, no scleral icterus appreciated,
MMM.
NECK: no JVD appreciated, but bed broken and in fully supine
position and obese neck. Carotid bruit on left.
CV: RRR, S1+S2+S3-S4-, physiologically split S2 on inspiration.
No murmurs appreciated.
LUNGS: mild crackles at the bases bilaerally, no wheezes
appreciated
ABD: NABS, soft, non-tender, non-distended. No organomegaly
appreciated.
EXT: no lower extremity edema appreciated. 2+ palpable pulses
bilaterally dorsalis pedis, posterior tibial, radial, ulnar, all
2+.
SKIN: No rashes/lesions, ecchymoses. Right groin site with
sheath in place.
NEURO: A&Ox3, seems apropriate. CN 2-12 grossly intact, did not
do fundoscopy. Preserved sensation throughout. MSK 4+/5
bilaterally, upper extremities and lower extremities. 1+
reflexes L4 bilaterally.
PSYCH: Listens and responds to questions appropriately
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:
CXR - Single AP view of the chest in upright position
demonstrate patient to be status post CABG. There is pulmonary
vascular congestion with interstitial edema. No evidence of
pleural effusion or pneumothorax. The cardiac silhouette is
enlarged.
IMPRESSION: Cardiomegaly, pulmonary vascular congestion with
interstitial edema representing CHF.
.
ECHO - The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly depressed (ejection fraction 40-50 percent)
secondary to severe hypokinesis of the basal and midventricular
segments of the inferior and posterior walls. There is no
ventricular septal defect. Right ventricular chamber size is
normal. Right ventricular systolic function appears depressed.
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. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.
[**2114-4-28**] ECHO
Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. There is moderate regional left
ventricular
systolic dysfunction with inferior/inferolateral akinesis and
hypokinesis
elsewhere. Overall left ventricular systolic function is
moderately depressed.
[Intrinsic left ventricular systolic function is likely more
depressed given
the severity of valvular regurgitation.] The right ventricular
cavity is
mildly dilated. Right ventricular systolic function appears
depressed.
[Intrinsic right ventricular systolic function is likely more
depressed given
the severity of tricuspid regurgitation.] 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.
Moderate (2+) mitral regurgitation is seen. The mitral
regurgitation jet is
eccentric. The tricuspid valve leaflets are mildly thickened.
Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic
hypertension. Significant pulmonic regurgitation is seen. The
end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery
diastolic hypertension. There is an anterior space which most
likely
represents a fat pad.
Compared with the prior study (images reviewed) of [**2114-4-24**], the
left and
right ventricles are now more dilated and left and right
ventricular systolic
function now appears more depressed. Mitral and tricuspid
regurgitation are
now more prominent.
[**2114-4-26**] RENAL ULTRASOUND
RENAL ULTRASOUND: The right kidney measures 9.5 cm. There is
mild increased echogenicity of the renal cortex. No
hydronephrosis or stones. Bladder is partially full and
unremarkable. Left kidney was not visualized, and by report of
the patient, is scarred and atrophic.
IMPRESSION:
1. Mild increased echogenicity of the renal cortex consistent
with chronic parenchymal renal disease. No evidence of
obstruction.
2. Non-visualization of the left kidney.
[**2114-4-23**] CARDIAC CATH
COMMENTS: Successful bare metal stenting of a SVG-RCA
stenosis using
distal protection followed by a 3.5x15mm Vision stent
post-dilated to
20atm using a NC balloon.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful bare metal stenting of a SVG-RCA graft using a
3.5x15mm
Vision BMS postdilated to 4.0mm.
LAB RESULTS AT ADMISSION
[**2114-4-23**] 10:59PM TYPE-ART PO2-76* PCO2-49* PH-7.41 TOTAL
CO2-32* BASE XS-4
[**2114-4-23**] 10:59PM HGB-10.3* calcHCT-31
[**2114-4-23**] 08:10PM TYPE-ART PO2-96 PCO2-60* PH-7.28* TOTAL
CO2-29 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**]
[**2114-4-23**] 07:46PM GLUCOSE-140* UREA N-61* CREAT-2.5*
SODIUM-132* POTASSIUM-4.9 CHLORIDE-94* TOTAL CO2-28 ANION GAP-15
[**2114-4-23**] 07:46PM estGFR-Using this
[**2114-4-23**] 07:46PM CK(CPK)-58
[**2114-4-23**] 07:46PM CK-MB-NotDone cTropnT-2.31*
[**2114-4-23**] 07:46PM CALCIUM-9.2 PHOSPHATE-2.5* MAGNESIUM-2.9*
[**2114-4-23**] 07:46PM WBC-9.7 RBC-3.45* HGB-11.6* HCT-33.6* MCV-97
MCH-33.5* MCHC-34.5 RDW-15.0
[**2114-4-23**] 07:46PM PLT COUNT-219
Brief Hospital Course:
CORONARY - Patient had stent placement in SVG to RCA.
Integrillin was continued for 18 hrs, initiated on aspirin 325mg
daily, plavix 75mg daily, and beta blockade. A statin was not
started due to her reactions to statins in the past. An
echocardiogram post-cath showed mild hypokinesis. Her cardiac
enzymes trended down.
.
CHF: The patient was somewhat volumed overloaded on admission.
She underwent cath without complications and four hours later
she went into flash pulmonary edema with no EKG changes. She was
transferred briefly to the CCU, where she was aggressively
diuresed and placed on standing hydralazine and isosorbide
dinitrate. On the floor, she continued to receive 60 mg IV lasix
[**Hospital1 **] for diuresis and she stabilized, was comfortable off oxygen
and ambulatory and wanted to be discharged on [**4-26**]. However, by
then she had not been at baseline for 24 hours yet, so she was
encouraged to stay. Early on [**2114-4-27**], she had a NSTEMI with
troponins up to 7, and went into severe pulmonary edema
requiring face mask, with severe respiratory distress that did
not respond to 160 mg IV lasix. She desatted to 87% on 2 L nc.
She was transferred back to the CCU. She did not respond to a
total of 180 mg IV lasix and was put on a lasix drip. She also
received metolazone 10 mg PO. She diuresed 5 liters on this
regimen however her creatinine bumped to >4 (baseline around
2.5.) She was on a nitro gtt for 2 days as well in the CCU. She
was not intubated and required a facemask briefly. She was
weaned to room air before transfer to the floor on the 11th and
was transferred off lasix in view of the ARF. On the floor, she
remained off lasix for 24 hours with no edema. On the 12th, she
was put on 40 mg PO lasix qd, and she tolerated this regimen
well, with appropriate diuresis and creatinine down to 3.5. At
the same time, metoprolol was increased to 75 tid and nitro was
d/c.
.
NSTEMI: The patient had a cardiac enzyme leak during this
exacerbation. Her EKG was unchanged from prior. This NSTEMI
may have been causal or a result of her CHF exacerbation. We
discussed therapy options with the patient. She did not want
any further cardiac catheterizations so we opted to treat
medically. She also has a hx of A Fibrillation. She remained in
sinus rhythm, and not on coumadin due to a history of GI bleed.`
.
RENAL FAILURE: Acute on chronic renal impairment: The patient's
baseline is 2.5, which increased to 3.5 upon diuresis on the
floor. She went to CCU with creatinine of 3.5 (up from baseline
of 2.5). It rose to 4.2 then trended to 4.1 prior to transfer
back to the floor. We felt this was most likely c/w contrast
nephropathy plus possibly some prerenal azotemia in the setting
of aggressive diuresis. Thus, the team held off on aggressive
diuresis the day of transfer to the floor. As above, lasix was
held for 24 hours, then restarted at 40 mg PO qd, with
creatinine stabilized at 3.5.
Patient was initially given D5W with bicarb pre-cath and also
initially post-cath, but had to be discontinued with development
of flash pulmonary edema.
.
FEN - low sodium, cardiac heart healthy diet. Keep Mg+>2.2,
keep K+>4.2. Repleted prn.
.
CODE: DNR DNI per discussion with patient in the CCU.
Medications on Admission:
ALLERGIES: norvasc and ergots
CURRENT MEDICATIONS (from [**Hospital1 **]):
Hydral 10mg IV prn
Asa 325mg
Lopressor 100mg [**Hospital1 **]
carafate
plavix 75mg
mucomyst (unsure of amount of doses received)
Nitro gtt 175 mcg/min (during transfer)
Heparin gtt (stopped AM [**4-23**])
D5W with bicarb
colace
multivitamin
folate
ferrous sulfate
ativan prn
morphine prn
renagel
protonix
(med list from admit at [**Hospital1 **]):
Imdur 60 qd
lopressor 25 [**Hospital1 **]
plavix 75mg qd
asa 81 qd
renagel 800tid
colace 100 qd
folate 1mg qd
prilosec 20bid
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6-8H (every
6 to 8 hours) as needed.
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
14. Albuterol 90 mcg/Actuation Aerosol Sig: [**11-21**] Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 1* Refills:*2*
15. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
18. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary:
1. Coronary artery disease.
2. NSTEMI
3. Congestive Heart Failure
.
Secondary:
1. Acute on Chronic renal insufficiency -
2. Hypertension
Discharge Condition:
Patient discharged to rehab in stable condition, tolerating PO
feeds and fluids, ambulating on her own, chest pain free, no
shortness of breath, vital signs stable.
Discharge Instructions:
Patient was transferred to [**Hospital1 18**] for venous grafting
intervention, which was presumed to be occluded. Patient had
stent placement in the the SVG to RCA veinous graft in the
cardiac catheterization lab.
Patient should:
1. Take all medications as prescribed.
2. Keep all follow-up appointments.
3. Seek medical attention if she acquires chest pain, shortness
of breath, nausea, vomiting, or any other concern that is out of
the ordinary for her.
Followup Instructions:
Cardiologist -
PCP [**Name Initial (PRE) **] [**First Name8 (NamePattern2) 7325**] [**Name11 (NameIs) **] [**Telephone/Fax (1) 7328**] - [**2118-5-15**]:45am,
1-[**Telephone/Fax (2) 7329**]fax.
|
[
"414.02",
"564.00",
"443.9",
"584.9",
"041.6",
"041.4",
"427.31",
"V43.3",
"410.71",
"599.0",
"403.90",
"585.9",
"428.0",
"272.4",
"799.02",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"36.06",
"99.20",
"37.22",
"00.45",
"88.56",
"99.04",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
14670, 14753
|
9192, 12430
|
345, 387
|
14946, 15113
|
4750, 8235
|
15622, 15819
|
3508, 3590
|
13029, 14647
|
14774, 14925
|
12456, 13006
|
8252, 9169
|
15137, 15599
|
3605, 4731
|
245, 307
|
415, 2418
|
2440, 3236
|
3252, 3492
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,898
| 127,783
|
17338+56842
|
Discharge summary
|
report+addendum
|
Admission Date: [**2161-8-23**] Discharge Date: [**2161-9-2**]
Date of Birth: [**2096-4-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Nsaids / Rapamune
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
aspiration PNA, copious secretions
Major Surgical or Invasive Procedure:
none
History of Present Illness:
65 M with HepC/EtOH cirrhosis, HCC s/p orthotopic liver
transplant [**2157**], DM2, CAD, tracheostomy [**1-9**] prolonged intubation
s/p transplant, prior episode heart block c no pacemaker, [**Hospital **]
transferred from OSH for ongoing management of aspiration
pneumonia, ARF/CRI, and ongoing suctioning requirement.
.
Per OSH d/c summary, pt admitted to OSH [**8-12**] after being found in
his nursing home "unresponsive." At OSH ED he was briefly
intubated via trach, found to have a signficant amount of mucus
plugging which was recovered with trach suctioning, after which
pt rapidly improved. He was hemodynamically stable, sats 88-90%
(unclear on what), and improved with suctioning and nebs to
96-99%3L NC. He was called out to the medical floor.
.
On [**8-17**] pt noted to have increased secretions, increased RR
requiring frequent suction, ?aspiration. Sputum cx, BCx, UA
negative. creatinine 1.9, pt noted to have fever 100.2, RR 24,
sats 98%5L NC. CXR with ?infiltrate, started on levaquin/flagyl
x 7d course. S&S revealed worsening swallow, NGT placed. Pt seen
by renal for elevated BUN/Creatinine (up to 2.0), report of
elevated K (6.5), and treated with IVF x 1L and 1U PRBC, d/c'd
lasix, as was felt to be pre-renal etiology.
.
Of note, at OSH, also noted to have R elbow pain and found to
have joint effusion over R elbow. Evaluated by ortho and found
to hvae non-displaced right radial head fracture, R arm placed
in a sling. Effusion not drained. Treated symptomatically with
vicodin/oxycodone.
.
Decision was made to transfer pt to [**Hospital1 18**] hepatorenal service
given his h/o liver transplant here. Prior to transfer, pt
decline PEG tube placement for feeding.
Past Medical History:
1. Liver transplant for Hepatitis C/EtOH cirrhosis &
hepatocellular carcinoma, on tacrolimus, mycophenolate,
prednisone, bactrim followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**].
2. Tracheostomy: x2, [**8-11**] for chronic vent dependency,
subglottic stenosis, tracheomalacia. Known to the IP service;
tracheal dilation [**12-13**]. VATS [**2-10**] c organizing pneumonia [**1-9**]
Rapamune.
3. DM2
4. OSA / Pickwickian syndrome
5. COPD
6. Diastolic dysfunction
7. CKD
8. Bipolar d/o
9. HTN
10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections
11. Hiatal hernia
12. Pulmonary hypertension
13. Hx of heart block - unable to have PM placed [**1-9**] infection,
heart block resolved, avoiding nodal blockers
Social History:
Quit tobacco 8 years ago. Quit alcohol 17 years prior to
admission. Denies any recreational drugs.
Family History:
Non-contributory
Physical Exam:
VS: 100.1 96 161/71 18 100% on 35% TM.
GEN: NAD, tracheostomy tube in place, minimal drainage.
HEENT: PERRLA, EOMI, sclera anicteric, OP clear, MM dry, no LAD,
no carotid bruits. No JVD.
CV: regular, nl s1, s2, no r/g. soft 2/6 SEM at LSB
?nonradiating
PULM: CTA anteriorly, no r/r/w.
ABD: scaphoid, soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL. no LE edema.
NEURO: alert & oriented x 3, CN II-XII grossly intact.
Pertinent Results:
[**2161-8-23**] k=5.4, creat 1.5, bun 17, na 140.
[**2161-8-17**] BCx ngtd.
[**2161-8-17**] BCx ngtd.
[**2161-8-18**] Sputum - gs - gpc in clusters, rare gn bacilli, gp
bacilli.
[**8-15**] BUN/cre 25/2.0
[**2161-8-15**] hct 30.5
[**2161-8-15**] wbc 11.2
[**2161-8-12**] BCx - ngtd.
.
.
STUDIES:
[**2161-8-23**] CXR: no acute pulmonary process.
.
[**2161-8-18**] R ELBOW XRAY: joint effusion about elbow, suggestive of
ocult radial head fracture, although no definitive fracture line
is seen.
.
[**2161-8-17**] CXR (OSH): ngt in place.
.
Labs:
[**2161-8-27**] 03:44AM BLOOD WBC-6.5 RBC-3.39* Hgb-9.7* Hct-29.7*
MCV-87 MCH-28.4 MCHC-32.5 RDW-16.0* Plt Ct-174
[**2161-8-26**] 06:40AM BLOOD Neuts-83.6* Lymphs-9.8* Monos-4.0 Eos-2.5
Baso-0.1
[**2161-8-27**] 03:44AM BLOOD Plt Ct-174
[**2161-8-27**] 03:44AM BLOOD PT-12.3 PTT-32.2 INR(PT)-1.1
[**2161-8-27**] 03:44AM BLOOD Glucose-123* UreaN-21* Creat-1.4* Na-141
K-4.8 Cl-102 HCO3-37* AnGap-7*
[**2161-8-26**] 06:40AM BLOOD ALT-11 AST-15 LD(LDH)-124 AlkPhos-132*
TotBili-0.3
[**2161-8-27**] 03:44AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.7
[**2161-8-27**] 03:44AM BLOOD Vanco-43.2*
[**2161-8-27**] 03:44AM BLOOD FK506-5.9
[**2161-8-24**] 07:39AM BLOOD Type-ART pO2-112* pCO2-66* pH-7.34*
calTCO2-37* Base XS-7
Brief Hospital Course:
65 M c Hep C/EtOH cirrhosis complicated by HCC s/p liver
transplant complicated by prolonged ventilation now tracheostomy
dependent, transferred from OSH after being found unresponsive
[**1-9**] mucus plugging, hospital course complicatd by PNA and [**Hospital **]
transferred to [**Hospital1 18**] with ongoing suctioning requirement.
.
# respiratory distress - pt with h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] induced BOOP,
initially transferred to OSH [**1-9**] being found unresponsive,
however apparently due to mucus plugging, and resolved quickly
after suction. pt was briefly intubated at OSH via
tracheostomy, but quickly weaned. However pt then developed PNA
(?aspiration event), and is now s/p 7d course of levo/flagyl,
with slightly improving secretions.
.
CXR on admission to [**Hospital1 18**] demonstrated no obvious infiltrate.
ABG obtained showed increasing CO2 (66, and worsening
respiratory acidosis). Given ongoing secretions and worsening
acidosis and patient's history of multiple drug resistent
organisms in sputum, decision made to start pt on 10d course of
meropenem and vancomycin for ongoing PNA vs tracheobronchitis
(day 1 [**8-24**]). Pt's suctioning requirements gradually decreased
on meropenem and vancomycin, to q8h, and he was treated with
aggressive pulmonary toilet. On [**2161-9-1**], patient was noted to
have aspirated a significant portion of his lunchtime meal;
although he maintained his O2 sats. Video speech and swallow was
performed on [**2161-9-2**] and the results are still pending. The
results of the video speech and swallow and nutrition
recommendations will be faxed when ready.
.
# cirrhosis - pt with h/o hepC/etoh cirrhosis, s/p liver
transplant, on prograf, and cellcept, h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] induced BOOP.
LFTs wnl at OSH, AP midly elevated here 140. on [**8-14**] AST/ALT
18/18, tbil 0.7. tacro levels obtained here were initially low
(2.1), and prograf level was increased from 1 QAM and 2QPM to
2mg po BID. However due to again rising prograf levels, the
dose was decreased again to 1.5mg PO bid. Pt was discussed with
the liver service, and felt stable for discharge. He will need
to have daily prograf levels drawn, with levels faxed to his
hepatologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], ([**Telephone/Fax (1) 1582**], fax=([**Telephone/Fax (1) 48518**]), so that these can be adjusted (pt has a history of
mild rejection).
.
# ARF/CRI - baseline creatinine unclear (was 1.6-1.7 per OSH
consult report). cre= 2.2 at time of admission to OSH, trended
down to 1.9, then up to 2.0, felt [**1-9**] dehydration, and pt's home
lasix regimen d/c'd, in favor of rehydration with 125 ml/hr
D5NS. At time of admission, pt's creatinine 1.5, where it
remained during hospitalization, this was felt to represent his
baseline.
.
.
# elbow effusion - right radial head fracture of R UE,
nondisplaced, seen by orthopedics at OSH who recommended a
sling, no other intervention. Repeat films here showed no
fracture, and pt denied elbow pain.
.
.
# anemia - baseline hct ~27-30 over past 6 months, though normal
in [**12-14**]. guaiac negative stools, this admission. likely with
component of ACD. His HCT remained stable during this
admission.
.
.
# Leukocytosis - initially presented with WBC 11.8, felt likely
[**1-9**] resolving PNA, though ongoing pulmonary secretions. BCx,
UCx unremarkable. Pt was treated for ongoing PNA as above with
meropenem/vancomycin based on previous sensitivities. WBC count
resolved to 6.5 at time of discharge.
.
.
# cardiac - no known h/o cad, though h/o ?heart block.
## ischemia: no complaints of cp.
.
## rhythm: h/o ? intermittent heart block when placed on
beta-blockade in past, remained in NSR on telemetry this
admission.
.
## pump: euvolemic on exam, no need for lasix presently, had
been discontinued at OSH.
.
## htn: pt hypertensive throughout this admission, his dose of
norvasc was increased from 5mg po qdaily to 10mg po qdaily, and
hydralazine was added. Plan was to avoid beta blockade and CCB
given h/o "heart block." Given recent renal failure, plan was
to avoid ACE/[**Last Name (un) **], though these would be reasonable agents in
future once creatinine is stable at baseline. He continued to
have elevated blood pressure and clonidine 0.1mg [**Hospital1 **] was added.
.
.
#DM: pt switched from RISS to HISS, his blood sugars were well
controlled (100-150s).
.
# psych - pt on nortryptiline, trazadone, clonazepam qhs at
home, which were continued here.
.
.
#FEN: pt was initially fed via NGT. Per discharge summary, he
refused PEG at OSH after failing a speech and swallow
evaluation. He was seen by speech and swallow service here and
felt safe to advance to regular diet, with thin liquids, with
aspiration precautions. He was advanced to this diet and
tolerated well initially. On [**2161-9-1**], patient was noted to have
aspirated and a video speech and swallow was performed on
[**2161-9-2**]. The results of this study are pending and will be
faxed, along with nutrition recommendations.
.
#COMM: with patient and his niece [**Name (NI) **]: [**Telephone/Fax (3) 48519**]
Medications on Admission:
MEDICATIONS ON TRANSFER:
insulin sliding scale
glucerna TF
heparin SC tid
norvasc 5mg po qdaily
clonazepam 0.5mg po qdaily
levofloxcin 500mg po qdaily
flagyl 500mg daily
procrit 8000 units QMWF
prevacid 30mg po qam
nortriptyline 75mg po qdaily
colace 100mg po bid
senna [**Hospital1 **]
zyprexa 15mg po qpm
trazodone 25mg po qpm
clonazepam 1mg po daily (?in addition to qhs)
prograft 1mg po qam, 2mg po qpm
cellcept 500mg po bid
mvi
vitamin b 1000mcg daily
vitamin d 400 IU daily
zinc sulfate 220 mg po qdaily
mucomyst [**Hospital1 **] (unclear duration of treatment)
dulcolax prn
mom prn
[**Name2 (NI) 48520**] carbonate 500mg qid
oxycodone 5mg po q6hr prn
scoplamine patches
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Name2 (NI) **]: One (1) inj
Injection TID (3 times a day).
2. Epoetin Alfa 4,000 unit/mL Solution [**Name2 (NI) **]: One (1) inj
Injection QMOWEFR (Monday -Wednesday-Friday).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Nortriptyline 25 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO DAILY
(Daily).
5. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) tab PO BID (2
times a day).
6. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
7. Olanzapine 7.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at
bedtime) as needed.
8. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed.
9. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
BID (2 times a day).
10. Hexavitamin Tablet [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
12. Zinc Sulfate 220 (50) mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
14. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
15. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed.
16. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Last Name (STitle) **]: One (1)
neb Inhalation Q6H (every 6 hours) as needed.
17. Clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QAM (once a
day (in the morning)).
18. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
19. Clonidine 0.1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
20. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q 12H (Every 12 Hours) for 7 days.
21. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 7 days.
22. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Q6H (every
6 hours).
23. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
24. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID PRN ().
25. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours).
26. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Last Name (STitle) **]: One (1)
Appl Ophthalmic PRN (as needed).
27. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day).
28. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: One (1) Subcutaneous four
times a day: Please administer humalog sliding scale at
breakfast, lunch, dinner, and bedtime:
BS 0-60, administer 1 amp D50; FS 61-160, administer 0 units; FS
161-200, administer 2 units; FS 201-240, administer 3 units; FS
241-280, administer 4 units; FS 281-320, administer 5 units; FS
321-360, administer 6 units; FS 361-400, administer 7 units. .
29. Tacrolimus 0.5 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO Q12H
(every 12 hours): 1.5mg PO bid. Please fax daily tacrolimus
levels to office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] for further titration of
prograf dosage. .
30. Insulin Glargine 100 unit/mL Cartridge [**Last Name (NamePattern1) **]: Five (5) units
Subcutaneous at bedtime: Please administer 5 units lantus qhs
and then an additional sliding scale as needed. .
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 29393**] - [**Location (un) 2251**]
Discharge Diagnosis:
primary:
pneumonia
.
secondary:
cirrhosis s/p liver transplant
acute renal failure
hypertension
Discharge Condition:
stable.
Discharge Instructions:
You were admitted with a pneumonia/tracheobronchitis and
increased secretions. You were started on antibiotics to treat
this and suctionng requirement improved.
Followup Instructions:
please continue to have daily prograf levels drawn, and faxed to
your hepatologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], ([**Telephone/Fax (1) 1582**], fax=([**Telephone/Fax (1) 48518**]), so that the dose can be adjusted accordingly (pt has
a history of mild rejection).
Continue antibiotics for pneumonia/bronchitis to complete a
course of 10. Day 1 of [**Last Name (un) **]/Vanco on [**8-24**].
You also have the following appointments at [**Hospital1 771**]:
- Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2161-9-9**] 9:20
- Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2161-9-9**]
8:20
Name: [**Known lastname 8954**],[**Known firstname 2381**] Unit No: [**Numeric Identifier 8955**]
Admission Date: [**2161-8-23**] Discharge Date: [**2161-9-2**]
Date of Birth: [**2096-4-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Nsaids / Rapamune
Attending:[**First Name3 (LF) 8956**]
Addendum:
Please check tacrolimus troughs every other day over the next
week to adjust levels. Please also check potassium levels
daily. His values should be faxed over to Dr [**Last Name (STitle) 8957**] office for
adjustment of his tacrolimus doses.
He had a speech and swallow on the day of discharge and was
found to be at a large risk of aspiration risk. The patient has
continually refused PEG placement and continues to want to eat;
but we recommend strict NPO at this time. PEG placement will
need to be re-addressed with the patient.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5155**] - [**Location (un) **]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 8958**] MD [**MD Number(1) 8825**]
Completed by:[**2161-9-2**]
|
[
"428.0",
"571.2",
"E928.9",
"V42.7",
"486",
"813.05",
"428.32",
"585.9",
"496",
"584.9",
"V44.0",
"507.0",
"403.90",
"070.54",
"285.9",
"V45.01",
"250.00",
"414.01",
"719.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.05",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
16694, 16926
|
4722, 9936
|
325, 332
|
14810, 14820
|
3448, 4699
|
15032, 16671
|
2964, 2982
|
10664, 14568
|
14691, 14789
|
9962, 9962
|
14844, 15008
|
2997, 3429
|
251, 287
|
360, 2055
|
9987, 10640
|
2077, 2831
|
2847, 2948
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,732
| 125,708
|
1028
|
Discharge summary
|
report
|
Admission Date: [**2121-5-26**] Discharge Date: [**2121-5-31**]
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
thoracentesis
pericardiocentesis with drain
History of Present Illness:
83 yo F with history of hypothyroidism, HTN and PPM for syncope
in addition to a recent pericardial effusion for which she
underwent pericardiocentesis at OSH earlier this month now
presenting to the ED with progressive SOB. Pt had been well
until [**2121-1-9**] when she was seen at an OSH for a syncopal
episode and found to have AV Block and subsequently had a PPM
placed. Shortly thereafter was found to be in AFib for which
anticoagulation was started. Over the past month, patient had
noticed increased fatigue and DOE. She was admitted to OSH
[**2121-5-20**] after presenting with CHF and found to have a
pericardial effusion and b/l plueral effusions. She underwent CT
guided pericardiocentesis (>1 liter bloody, exudative) and left
thoracentesis (transudative). All Cx's negative, ESR 11 and
cytology pending. CT-torso unremarkable. Afterwards had
recurrent AFib for which she was started on amiodarone but
remains off anti-coagulation. Per their report, she had a TEE
prior to d/c with a residual effusion with fibrous stranding,
mild MR [**First Name (Titles) **] [**Last Name (Titles) **] hypertrophy but no obvious bleeding. 2 days after
discharged she had recurrence of Sx's improved with moderate
dose of lasix and now presenting 3 days later with similar
symptoms.
.
She describes continued shortness of breath especially with
exertion and fatigue. Denies any chest pain or new orthopnea. No
recent syncope or palpitations. No cough, hemoptysis or
pleuritic chest pain. No recent F/C/S, recent illnesses or URI
Sx's. She describes several weeks of ankle sweeling. No
abdominal pain. Tolerating PO w/o N/V/D. No major anorexia. Nl
BMs w/o melena/hematochezia. No h/o rash or joint symptoms. She
denies exertional buttock or calf pain. All of the other review
of systems as not mentioned above were negative.
Past Medical History:
hyperlipidemia
HTN with reduced renin activity
s/p PPM for syncope ? VV vs Cardiac
PAF
GERD
Grave's disease, radioactive iodine with subsequent
hypothyroidism
TO RCA on U/S ([**4-14**])
TAH in [**2093**]
osteoporosis
cataracts
Social History:
She does not smoke. She drinks alcoholic beverages occasionally.
She generally resides alone in [**State 108**] and visits family in the
[**Location (un) 86**] area.
Family History:
Father with MI at 67, no sudden death.
Physical Exam:
VS: T 98.9, BP 140/79 , HR 69, RR 18, O2 97% on RA
.
Gen: well in NAD, resp or otherwise. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP wnl, MMM
Neck: Supple with JVP of 8 cm.
CV: [**Last Name (un) **], nl S1/S2, no murmurs, no rub
Chest: No chest wall deformities. Resp were unlabored, no
accessory muscle use. Decreased breath sounds left base>right
base. No crackles, wheeze, rhonchi.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: trace pitting edema to lower shin
Skin: No stasis dermatitis, ulcers, scars. WWP
Pulses:
Right: Carotid 1+; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+; Femoral 2+ without bruit; 1+ [**Hospital **]
MEDICAL DECISION MAKING
.
Pertinent Results:
[**2121-5-26**] 12:30PM BLOOD WBC-7.3 RBC-4.30 Hgb-13.2 Hct-36.9 MCV-86
MCH-30.7 MCHC-35.8* RDW-15.5 Plt Ct-326
[**2121-5-30**] 05:45AM BLOOD WBC-7.3 RBC-4.27 Hgb-12.4 Hct-37.9 MCV-89
MCH-29.1 MCHC-32.8 RDW-15.8* Plt Ct-335
[**2121-5-26**] 12:30PM BLOOD PT-15.9* PTT-24.2 INR(PT)-1.4*
[**2121-5-30**] 05:45AM BLOOD PT-12.1 PTT-22.6 INR(PT)-1.0
[**2121-5-27**] 05:30AM BLOOD ESR-18
[**2121-5-27**] 05:30AM BLOOD CRP-6.3*
[**2121-5-26**] 12:30PM BLOOD Glucose-120* UreaN-18 Creat-0.8 Na-133
K-4.2 Cl-99 HCO3-27 AnGap-11
[**2121-5-30**] 05:45AM BLOOD Glucose-102 UreaN-17 Creat-0.8 Na-137
K-4.2 Cl-101 HCO3-29 AnGap-11
[**2121-5-27**] 05:30AM BLOOD LD(LDH)-215
[**2121-5-26**] 12:30PM BLOOD CK-MB-NotDone proBNP-4107*
[**2121-5-30**] 05:45AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2
[**2121-5-29**] 06:05AM BLOOD TSH-10*
[**2121-5-29**] 06:05AM BLOOD T4-7.6 Free T4-1.3
TTE [**2121-5-29**]:Small pericardial effusion without echocardiographic
evidence of tamponade. Normal biventricular global systolic
function. Compared with the prior study (images reviewed) of
[**2121-5-28**], pericardial effusion is slightly smaller, and a large
left pleural effusion is no longer seen.
TTE [**2121-5-28**]: Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. There is a large pleural effusion. There is
a small to moderate sized pericardial effusion. The effusion
appears organized. The apical component of the effusion is not
well visualized and may be underestimated. There are no
echocardiographic signs of tamponade.
TTE [**2121-5-27**]: There is a large pericardial effusion. The effusion
appears circumferential. The effusion is echo dense, consistent
with blood, inflammation or other cellular elements. There is
right ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology. There is significant, accentuated
respiratory variation in tricuspid valve inflows, consistent
with impaired ventricular filling.
TTE [**2121-5-28**]: 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. The mitral valve leaflets are
mildly thickened. There is a moderate to large sized
pericardial effusion. There is right ventricular diastolic
collapse, consistent with impaired fillling/tamponade
physiology. A pacemaker lead is seen in the right ventricular
apex; no definite perforation seen (cannot exclude).
C.Cath: [**2121-5-27**]
1. resting hemodynamics revealed normal left and right sided
filling
pressures and a mildly decreased cardiac index of 2.2 L/min/m2.
RA and
pericardial pressures were entrained at 6 mmHg. Pericardial
pressure
post pericardiocentesis fell to 0 mmHg and the RA pressure fell
to 3 mm
Hg.
2. Pericardiocentesis with removal of 600 cc of hemorrhagic
fluid.
3. Post tap echocardiogram reveaeld minimal residula effusion.
Brief Hospital Course:
83 yo F with recent pericardial effusion thought secondary to
anticoagulation presenting to the ED with SOB found to have a
persistent effusion and concerns for tamponade physiology.
.
# Pericardial Effusion: Etiology unknown but thought possibly
[**1-10**] pacer lead in setting of anti-coagulation. Currently
concerns for reaccumulating subacute pericardial effusion based
on clinical story and TTE showing a moderate to large sized
pericardial effusion with right ventricular diastolic collapse.
Pt remained hemodynamically stable with any evidence of
cardiogenic compromise. Underwent pericardiocentesis with
subsequent placement of drain which was d/c 24' later. Total
outp approximately 1000cc. W/U to date unremarkable, with
cultures pending at time of discharge. Pt to have f/u TTE as
outpt on Wed [**6-4**].
.
# Peural effusion: unclear etiology as w/u here and at OSH
unremarkable. Possibly secondary to decreaed C.O. in setting of
pericardial effusion with some tamponade physiology. Underwent
b/l thoracentesis with improvement in dyspnea. Pt to have f/u
CXR on wednesday [**6-4**], if reaccumulates she should see Pulmonary
as an outpt.
.
# AFIB: Amiodarone increased to 600 daily. Remained on BB.
Anticoagulation was not restarted given blood pericardial
effusion. F/U EP next week.
Medications on Admission:
Atenolol 75
amiodarone 200 [**Hospital1 **]
coumadin (recent d/c)
KCL 20
protonix 40
Levoxyl .088 ?
Lipitor 10
calcium
multivitamin
aspirin 81
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. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Amiodarone 200 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
pericardial effusion
pleural effusion
atrial fibrillation
Discharge Condition:
good
Discharge Instructions:
please take all medications as prescribed and follow up as
instructed. we increased your amiodarone dose and you are no
longer taking coumadin.
you were seen for shortness of breath because of a pericardial
effusion (fluid around heart) and pleural effusions (fluid
around lungs) which were removed. You need to follow up with Dr
[**Last Name (STitle) **] next week for an other echocardiogram
Followup Instructions:
Please call Dr[**Name (NI) 1565**] office on Monday and schedule an
appointment to be seen that week and to have a echocardiogram
done. His office will try to schedule you for an appointment on
Wednesday [**2121-6-4**] in the afternoon for both an echocardiogram
and a chest xray.
.
Please call ([**Telephone/Fax (1) 6784**] to schedule an echocardiogram on the
morning of [**2121-6-4**] prior to your appointment with Dr. [**Last Name (STitle) **].
Please go to the Radiology departement on the [**Location (un) **] of the
[**Last Name (un) 469**] building on the morning of [**2121-6-4**] to have a chest
x-ray prior to your appointment with Dr. [**Last Name (STitle) **].
|
[
"530.81",
"511.9",
"401.9",
"272.4",
"423.0",
"733.00",
"427.31",
"426.0",
"V45.01",
"244.1",
"423.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"34.04",
"89.45",
"88.72",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
8553, 8611
|
6479, 7781
|
245, 290
|
8713, 8720
|
3379, 6456
|
9165, 9845
|
2593, 2633
|
7975, 8530
|
8632, 8692
|
7807, 7952
|
8744, 9142
|
2648, 3360
|
202, 207
|
318, 2143
|
2165, 2394
|
2410, 2577
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,688
| 174,836
|
13085
|
Discharge summary
|
report
|
Admission Date: [**2149-10-12**] Discharge Date: [**2149-10-15**]
Date of Birth: [**2094-7-2**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Visipaque
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
scheduled cath
Major Surgical or Invasive Procedure:
cath [**10-13**]
History of Present Illness:
55 yr old male w/3 vessel disease, s/p MI [**9-20**], s/p LAD/LCX
intervention on [**9-26**], now returning for staged RCA intervention,
creat is 1.5, diabetic.
Originally presented to OSH on [**9-18**] with chest pressure x 10
minutes, not alleviated by rest. He did not take SL NTG at home.
At OSH he had a peak CK of 220, MB 4.2, TropI 1.18. Because of
recurrent episodes of CP with inferolateral ST depressions and
HTN (and presumably the results of the stress test), he was
transferred to [**Hospital1 18**] for cath.
The patient arrived in CCU CP free on IABP. The plan initially
was to cont the IABP and heparin until the patient could have a
CABG. However, CT [**Doctor First Name **] upon further eval felt that the patient's
obesity and DM made him a high risk surgical candidate.
Therefore, the patient went back to the cath lab on [**9-23**] where
he had his LCx and LAD stented, and the plan was to have his RCA
stented after an interval of [**1-3**] weeks to avoid dye-related ATN.
In the meantime the pt was maintained on [**Date Range **], BB, ACEI, statin,
Plavix.
The patient has been chest pain free and med compliant over this
time. He reports stopping smoking completely over the last 2
weeks. He has no chest pain w/ exertion but does have occasional
SOB after walking his dog. No SOB at rest. No PND or orthopnea.
He denies N/V,F/C or diaphoresis.
Past Medical History:
CAD w/ PTCA [**58**] yr ago, HTN, DM2 (diet controlled),
hyperlipidemia (not on meds), morbid obesity, OSA, GERD, hiatal
hernia, arthritis (knees, s/p L TKA) on vicodin, depression/
anxiety
Cardiac Studies:
[**2149-9-23**] for NSTEMI
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful stenting of the LCX w/Pixel and Cypher DES.
3. Successful stenting of the LAD w/Cypher DES.
RCA was not selectively engaged.
Cath [**9-20**]: 70% mid LAD, subtotally occluded Lcx w/ slow flow,
distal 80-90% RCA stenoses; per V-gram EF 50%, no MR
Social History:
retired roofer and carpenter; married with two sons
etoh - none
tob - 2-6ppd for 30+ years (60-180 pack years); stopped smoking
x 2 weeks
drugs - none
Family History:
GM - died from MI at 72yo; M with CRI on HD, Breast CA
Physical Exam:
PE: HR 70, RR 16, O2 sat 95% ,
Gen-well-appearing, anxious, but in NAD
HEENT- EOMI, OP Clear
Neck- no JVD
Pulm-CTA bilaterally, no r/r/w
CV- RRR. no m/r/g. nl s1/s2
Abd-obese, soft, NT,ND. suprapubic cath in place
Ext- no c/c/e. 2+ distal pulses UE/LE
NEuro-CN II-XII intact
Pertinent Results:
[**2149-10-12**] 04:10PM PT-13.5 PTT-28.4 INR(PT)-1.2
[**2149-10-12**] 04:10PM PLT COUNT-275#
[**2149-10-12**] 04:10PM WBC-5.4 RBC-3.82* HGB-11.5* HCT-33.8* MCV-89
MCH-30.1 MCHC-34.0 RDW-13.5
[**2149-10-12**] 04:10PM CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.1
[**2149-10-12**] 04:10PM CK-MB-NotDone cTropnT-<0.01
[**2149-10-12**] 04:10PM CK(CPK)-73
[**2149-10-12**] 04:10PM GLUCOSE-89 UREA N-28* CREAT-1.4* SODIUM-142
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-27 ANION GAP-14
Brief Hospital Course:
This is a 55 yr old male w/3 vessel disease, s/p MI [**9-20**], s/p
LAD/LCX intervention on [**9-26**], now returning for staged RCA
intervention, creat is 1.5, diabetic. A brief hospital course is
outlined below.
1. CAD- s/p stenting of LAD,LCX. s/p selective cath and stenting
of RCA. He was found to be chest pain free on admission, with no
EKG changes and negative enzymes. He was continued on his
[**Month/Year (2) **],B-Blocker,Plavix,Statin and Nitrates. He was pre-hydrated
with 300cc bicarb and was given two doses of acetylcysteine
pre-cath. On [**10-13**], he went for selective cath of his RCA. Per
cath report, shortly after initiation of guidewire, he became
hypotensive and flushed, without evidence of hives, rash or
respiratory compromise. The event also correlated w/ changing
visipaque to optiray dye. He required a short course of pressors
and was treated with pepcid,benadryl and Solumedrol IV. Left and
right heart pressures were not found to be elevated and cardiac
function was perserved, consistent with peripheral
vasodilatation. After stabilizing, the RCA was stented with 2
cypher stents without event. He was transferred to CCU for
monitoring post-cath. He was able to maintain his BP off
pressors, with no intubation required. He returned to the [**Hospital Unit Name 196**]
service on [**10-15**] and was found to be hemodynamically stable,
chest pain free and breathing comfortably on room air. He
continued to do well overnight without event. He has been listed
as having an allergy to dye and will need pre-medication prior
to future dye loads. He will follow-up with his pcp [**Last Name (NamePattern4) **] [**2-4**]
weeks.
2. DM- He was maintained on sliding scale insulin. Metformin was
held given his scheduled cath. Metformin will be re-started on
discharge.
3. Anxiety- Buproprion, Citalopram, trazadone prn
4. pain- tylenol prn, percocet prn
5. supra-pubic cath: The patient will follow-up with Dr. [**Last Name (STitle) **]
in Urology on [**10-16**] to have his catheter removed.
6. Health Maintenance: He was encouraged to continue smoking
cessation. He is currently taking wellbutrin to help with this.
In addition he is encouraged to maintain his diabetic
diet/healthy heart diet and exercise regularly.
Medications on Admission:
[**Month/Year (2) **],atorvastatin,pantoprazole,
donepezil,citalopram,buproprion,albuterol prn,ipatropium prn,
plavix, tylenol prn, metoprolol, lisinopril, isosorbide
mononitrate, metformin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
8. Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO
HS (at bedtime).
9. Ipratropium Bromide 0.02 % Solution Sig: [**1-3**] Inhalation Q6H
(every 6 hours) as needed.
10. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
QD (once a day).
11. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: please take 1
tab under tongue as needed for chest pain, repeat in 5 minutes
if chest pain not alleviated .
Disp:*30 tabs* Refills:*2*
14. Resume Metformin at home dose 10/14.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. CAD
Discharge Condition:
good. hemodynamically stable. chest pain free
Discharge Instructions:
Please report fever,chills, shortness of breath or chest pain to
your pcp.
Call 911 if you have chest pain not alleviated after sublingual
nitroglycerin
Please continue to refrain from smoking. Please let your PCP
know if you need further help to quit.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) 3314**] in [**2-5**] weeks. His # is
[**Telephone/Fax (1) 3183**]
2. Please follow-up with Urology (Dr. [**Last Name (STitle) **] as you have
scheduled on [**10-16**]. Call tommorrow morning to confirm your
appointment time. The number is: [**Telephone/Fax (1) 6445**]
|
[
"278.01",
"401.9",
"E947.8",
"458.29",
"412",
"414.01",
"250.00",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.07",
"88.56",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
7469, 7524
|
3365, 5622
|
306, 324
|
7575, 7622
|
2859, 3342
|
7925, 8249
|
2492, 2548
|
5862, 7446
|
7545, 7554
|
5648, 5839
|
2004, 2308
|
7646, 7902
|
2563, 2840
|
252, 268
|
352, 1729
|
1751, 1987
|
2324, 2476
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,996
| 182,455
|
43088
|
Discharge summary
|
report
|
Admission Date: [**2146-6-29**] Discharge Date: [**2146-7-27**]
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
Pt is a 83 yo m with pmh of atrial flutter, hypertension,
myasthenia [**Last Name (un) 2902**], type 2 diabetes, colon cancer s/p
hemicolectomy, COPD, chronic kidney disease, and hypothyroidism
presented to osh with afib in rvr, dehydration and altered
mental status.
.
On [**6-27**], day of osh admission, pt was weak and confused. At
that time, he denied chest pain, abd pain, headache, visual
changes, rashes. His exact history was unattainable due to
patient's confusion.
.
OSH course: At osh, pt's hr was found to be 160's a flutter.
head ct was neg. Patient was having difficulty with word
finding, speech, and was very agitated-- rec'd ativan, haldol.
He was started on an esmolol drip until today [**6-29**] and then
started on metoprolol 50 po x 1. CE neg x 2. ABG this a.m. was
7.34/33/93 on 2L nc.
.
Pt was seen by neurology who thought that confusion may be a
result of toxic encepalopathy possibly from mestinon, his
medication for myasthenia [**Last Name (un) 2902**]. He was initially admitted to
the MICU and found to be in ARF, which resolved with IVF. He
was also found to have a methacillin resistant coag negative
staph bacteremia of unclear source as the patient did not have
any indwelling lines or catheters. He was started on Vancomycin
for this infection. He was found to have a right inguinal
hernia and was seen by surgery, but no intervention was deemed
necessary.
.
He was stabilized and transferred to the medicine floor for
further workup of his acute mental status changes.
Past Medical History:
1. myasthenia [**Last Name (un) 2902**], followed by neurology, stable
2. hemi-colectomy for sessile polyp
3. atrial flutter s/p failed cardioversion [**1-23**] - failed DCCV x
3, but has been in NSR since been on amiodarone
4. CHF, EF of 50%
5. diabetes
6. CRI
7. anemia
8. COPD
Social History:
SH: walks with walker, lives at [**Hospital3 **]. baseline AOx3
but confused and poor historian at baseline. son-pathologist at
[**Hospital1 **]. Independent in most ADLs.
Family History:
NC
Physical Exam:
Gen: groaning, agitated, follows 1 step commands, no resp
distress
HEENT: dry mouth, perrla, cannot assess jvp, reluctant to turn
to right side
HEART: s1 s2 irreg irreg
LUNGS: difficult to auscultate b/s, no obvious wheezes or
crackles
ABD: obese, large surgical scar, ?ventral hernia
Ext: soft movable mass in right groin, venous stasis changes, no
edema, good pulses, down going toes
tremor in both upper extremities
Pertinent Results:
Admission:
[**2146-6-29**] 10:11PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2146-6-29**] 10:11PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2146-6-29**] 10:11PM URINE RBC-21-50* WBC-[**3-21**] BACTERIA-OCC
YEAST-RARE EPI-0-2
[**2146-6-29**] 04:24PM GLUCOSE-114* UREA N-22* CREAT-1.2 SODIUM-141
POTASSIUM-4.2 CHLORIDE-112* TOTAL CO2-17* ANION GAP-16
[**2146-6-29**] 04:24PM CALCIUM-7.9* PHOSPHATE-2.5* MAGNESIUM-1.6
[**2146-6-29**] 04:24PM VIT B12-1137*
[**2146-6-29**] 04:24PM TSH-2.0
[**2146-6-29**] 04:24PM T4-7.4
[**2146-6-29**] 04:24PM WBC-11.4*# RBC-3.60* HGB-12.1* HCT-35.7*
MCV-99* MCH-33.5* MCHC-33.8 RDW-16.4*
[**2146-6-29**] 04:24PM NEUTS-89.2* BANDS-0 LYMPHS-4.8* MONOS-3.5
EOS-1.8 BASOS-0.6
[**2146-6-29**] 04:24PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2146-6-29**] 04:24PM PLT SMR-LOW PLT COUNT-129*
[**2146-6-29**] 04:24PM SED RATE-35*
[**2146-6-29**] 04:24PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-250 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2146-6-29**] 04:24PM URINE RBC->50 WBC-[**6-26**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2146-6-29**] 04:24PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020.
.
CT head: There is no hemorrhage, mass, shift of normally
midline structures, or hydrocephalus. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. No infarction is apparent. The
sulci and ventricles are prominent consistent with generalized
atrophy. The visualized paranasal sinuses and mastoid air cells
are normally aerated. A NG tube is seen traversing the left
nostril.
.
RUE Ultrasound: no DVT
.
Echo: Ejection Fraction: >= 55% (nl >=55%)
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2145-10-29**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Normal regional LV systolic function. TDI
E/e' < 8,
suggesting normal PCWP (<12mmHg).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No masses or vegetations on aortic valve. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
mass or
vegetation on mitral valve. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or vegetation on tricuspid valve. Moderate PA
systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. 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) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. No
mass or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: No echocardiographic evidence of endocarditis. Mild
LVH with
preserved global and regional biventricular systolic function.
Moderate
pulmonary hypertension. Compared with the prior study (images
reviewed) of [**2145-10-29**], pulmonary hypertension is more severe.
The other findings are similar.
.
EEG:
This is an abnormal portable EEG due to the slow and
disorganized background rhythm as well as the bursts of
generalized
slowing. These abnormalities are suggestive of a moderate
encephalopathy which may be seen with medications, toxic
metabolic
abnormalities, or infections. There were no regions of focal
slowing
and no epileptiform discharges noted. Of note, there was an
irregularly
irregular rhythm with a tachycardic rate of 120 bpm.
.
Brief Hospital Course:
This 83 year old gentleman with a history of myasthenia [**Last Name (un) 2902**],
atrial fibrillation on Coumadin, chronic kidney disease,
diabetes and hypothyroidism was admitted from an outside
hospital for subacute mental status change. He was initially
admitted to the MICU. Over the first few days the patient was
somnolent and incoherent when aroused. It was also noted the
patient was producing a lot of secretions in his mouth and
required frequent suctioning. A head CT was notable only for
diffuse atrophy. A chest x-ray was not revealing, but zosyn was
began empirically given his secretions. LP was not pursued as
the likelihood of CNS infection was believed low. The patient
would occasionally go into atrial fibrillation with RVR but with
no hemodynamic instability; initially on an esmolol drip which
was weaned off and replaced with diltiazem PO. Digoxin, started
at the OSH, was discontinued
.
It was unclear what was the cause of this gentleman's mental
status change; he had previously been interactive and social.
On review of his medications, it was noted that Mestinon, the
cholinesterase inhibitor for his myasthenia [**Last Name (un) 2902**], could rarely
cause mental status change. This was therefore discontinued.
Some improvement in mental status was noted as the patient did
grow more alert. Furthermore his secretions did decrease. The
patient was however, more agitated and remained incoherent.
Haldol and Zyprexa was used with only limited effect. The
patient would often sundown quite severely. The patient did not
exhibit signs of relapse of myasthenia [**Last Name (un) 2902**]. On advice of
neurology, Mestinon was restarted. The patient became again
less interactive and with copious secretions. Of note, a blood
culture returned with 3 out of 4 methicillin resistant Staph
Epidermidis; this prompted 2 weeks of vancomycin therapy. His
occult bacteremia was felt to be the leading candidate for his
mental status changes.
.
The patients mental status very slowly improved and it was the
conclusion of the MICU team, the neurology and psychiatry
consult service that the patient was undergoing a prolonged
delirium. Probably related to infection along with a
toxic-metabolic insult. He continued to improve with treating
the bacteremia. .
Also of note the patient was having more frequent runs of NSVT
by week 2 of hospitalization. On advice of his cardiologist we
restarted and progressively up-titrated metoprolol for Afib,
NSVT control, and re-added diltiazem po regimen to better
control rate.
.
With improvement of his mental status, it was decided to
transfer the patient to a regular floor. Pt. mental status
continued to wax and wane on floor. He underwent an EEG which
was normal. He was found to have pan-sensitive pseudomonas UTI
confirmed by culture [**7-22**]. His foley was changed and
ciprofloxacin was started for a total of ten days. Given poor
po intake, altered mental status, and continued self d/c'ed NG
tubes, a PEG tube was placed on [**7-22**]. With treatment of UTI pt.
mental status improved and was felt to be suitable for rehab. LP
was not performed after discussion with son given a low
likelihood of CNS infection and the patient being uncooperative
with procedure.
.
His blood sugar was well controlled with insulin, and his tube
feedings were advanced to goal through the PEG tube. His renal
function returned to baseline and remained stable. His blood
pressure remained well controlled with metoprolol and diltiazem.
.
He did experience some blood clots after changing his foley. He
had already been switched from Coumadin to Lovenox for
anti-coagulation for his history of atrial fibrillation.
However, his hct was monitored and was noted to be lower (25)
than his baseline on the day of discharge. His rectal exam
revealed brown guaiac negative stool. He was started on
continuous bladder irrigation to help clear the clots. Iron
studies were sent which revealed a slightly low iron and low
ferritin. A repeat hematocrit on the afternoon of discharge
returned stable at 27.
.
Medications on Admission:
meds on transfer from OSH:
Digoxin .25'
coumadin 3mg
haldol .5 IV q4 prn
lorazepam .5mg IV prn
Levaquin 500 IV'
Cardizem 120 mg'
esmolol iv drip-recently weened off
Discharge Medications:
1. Levothyroxine 88 mcg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY
(Daily).
2. Azathioprine 50 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO BID (2 times
a day).
3. Acetaminophen 325 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (4) **]: One Hundred (100) mg
PO BID (2 times a day).
6. Senna 8.6 mg Tablet [**Month/Day (4) **]: 1-2 Tablets PO BID (2 times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Lactulose 10 g/15 mL Syrup [**Month/Day (4) **]: Fifteen (15) ML PO TID PRN ()
as needed for constipation.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Olanzapine 2.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at
bedtime) as needed.
11. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
12. Pyridostigmine Bromide 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
Q6H (every 6 hours).
13. Diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3
times a day).
14. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H
(every 4 hours).
15. Enoxaparin 100 mg/mL Syringe [**Last Name (STitle) **]: One Hundred (100) mg
Subcutaneous [**Hospital1 **] (2 times a day).
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Hospital1 **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Hospital1 **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
18. Ciprofloxacin 400 mg/40 mL Solution [**Hospital1 **]: Four Hundred (400)
mg Intravenous Q12H (every 12 hours) for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
1. Toxic metabolic encephalopathy
2. Methicillin resistant coag neg staph bacteremia
3. Pseudomonas urinary tract infection
4. NSVT
5. Acute renal failure
Secondary:
1. Hypertension
2. Diabetes
3. Afib/flutter
4. Myasthenia [**Last Name (un) **]
5. Anemia
6. CHF- diastolic dysfunction
7. Hypothyroidism
Discharge Condition:
Good
Discharge Instructions:
You were hospitalized and treated for bacteremia, urinary tract
infection, and altered mental status.
.
Please take all of your medications as instructed.
.
Please call your doctor or return to the hospital if you
experience chest pain, shortness of breath, fevers or chills.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3833**], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2147-4-25**]
9:00
.
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3649**] after discharge from
rehab. Call [**Telephone/Fax (1) 3070**] for an appointment.
|
[
"V09.0",
"403.90",
"250.00",
"349.82",
"285.9",
"995.92",
"041.7",
"428.0",
"427.31",
"244.9",
"585.9",
"427.1",
"584.9",
"599.0",
"038.11",
"276.51",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13509, 13581
|
7163, 11242
|
239, 260
|
13938, 13945
|
2769, 4105
|
14269, 14602
|
2311, 2315
|
11457, 13486
|
13602, 13917
|
11268, 11434
|
13969, 14246
|
2330, 2750
|
178, 201
|
288, 1800
|
4115, 7140
|
1822, 2104
|
2120, 2295
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,459
| 120,861
|
53553
|
Discharge summary
|
report
|
Admission Date: [**2180-7-23**] Discharge Date: [**2180-7-29**]
Date of Birth: [**2112-4-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Oxycodone / Propafenone / Percocet / Meperidine
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Atypical chest pain
Major Surgical or Invasive Procedure:
[**2180-7-23**]
1. Left ventricular lead placement with left thoracotomy.
2. Generator change.
History of Present Illness:
Mr. [**Known lastname **] is a 68 year old male with a past medical history
significant for congestive heart failure with ICD placement in
[**2178-10-30**], paroxysmal atrial fibrillation, history of stroke,
mitral valve regurgitation status post two mitral valve
surgeries, aortic insufficiency, history of cardiac arrest in
the
setting of hypokalemia and hyperlipidemia. He recently
presented
to [**Hospital6 33**] complaining of atypical chest pain. The
patient has no known coronary disease based on previous cardiac
catheterizations. A CXR revealed cardiomegaly, without signs of
congestive heart failure. His amiodarone had been recentlty
discontinued. The patient denied any associated fever, chills,
or
malaise. The chest pain at that time was thought to be cardiac
pain. He also notes extreme fatigue and dyspnea with exertion.
His amiodarone was stopped with improvement in his symptoms. It
was decided that he would be best served with biventricular
pacing to help alleviate his symptoms however it was felt that
it
would be best performed either by thoracotomy or thoracoscopy.
The patient was evaluated by Dr. [**Last Name (STitle) **] last week and is now
being referred to Dr. [**Last Name (STitle) **] for thorascopic versus left
thoracotomy, left ventricular epicardial lead placement to
upgrade his ICD to a biventriclar pacemaker. He is being
admitted
today for heparin bridge therapy and OR in the AM
Past Medical History:
Systolic heart failure - EF 10-15%
Mitral valve regurgitation s/p Mitral valve repair in [**2164**] and
replacement in [**2175**]
Aortic insufficiency
Hyperlipidemia
Paroxysmal atrial fibrillation
Hx of Embolic infarct. He has had 3 strokes.
Obesity
History of ventricular fibrillation arrest following severe
hypokalemia on Zaroxoyln.
Chronic Renal Insufficiency - baseline Cr 1.6
History of ETOH abuse
History of electrocution
Prostate cancer treated with radiation
AICD in [**10/2178**]
Right total hip replacement
Back surgery (Diskectomy)
Right vein stripping
Social History:
Lives with: Single. Has girlfriend [**Name (NI) **] [**Name (NI) 2093**]
Occupation: Retired - previously employed as a Rigger.
Cigarettes: Smoked no [] yes [X] last cigarette [**2143**] Hx: 1/2ppd
for 3 years.
ETOH: abuse in past
Illicit drug use: None
Family History:
Brother has Diabetes and AICD
Physical Exam:
Vital Signs sheet entries for [**2180-5-24**]:
BP: 106/56. Heart Rate: 61. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 97.
Height: 6'2'' Weight: 235 lbs
General: WDWN in NAD
Skin: Warm, Dry, intact. Left upper chest pacer/AICD. Sterntomy
and right inframammary incison well healed.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP Benign. Teeth in
fair condition.
Neck: No JVD, Supple, Full ROM
Chest: Breath sounds clear
Heart: Irregular, Valve click heard at apex.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] 1+ Edema lower
extremity
erythema with dependent position
Varicosities: Vein stripped on right with residual superficial
varicosities. left with superficial spider angiomas and
varicosities. GSV likely dilated.
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:trace Left:trace
PT [**Name (NI) 167**]: trace Left:trace
Radial Right:2 Left: +1
Carotid Bruit - None
Pertinent Results:
[**2180-7-24**] Intra-op TEE
Conclusions
The left atrium is markedly dilated. Mild spontaneous echo
contrast is present in the left atrial appendage. The left
atrial appendage emptying velocity is depressed (<0.2m/s). No
atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. The inferoseptal and
inferior walls are dyskinetic. The anteroseptal and anterior
walls are severely hypokinetic. The anterolateral wall is mildly
to moderately hypokinetic. Overall left ventricular systolic
function is severely depressed (LVEF= [**11-13**] %). Right
ventricular chamber size and free wall motion are normal.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. No thoracic
aortic dissection is seen. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. Mild to
moderate ([**1-31**]+) eccentric aortic regurgitation is seen.
A bileaflet mechanical mitral valve prosthesis is present. The
motion of the mitral valve prosthetic leaflets appears normal.
No mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen.
Dr.[**Last Name (STitle) **] was notified in person of the results at time of study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **]
[**2180-7-26**] 16:12
.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2180-7-24**] where
the patient underwent Biventricular ICD Placement via left
thoracotomy with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Device was interrogated Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tube was
discontinued without complication. Coumadin was started for his
mechanical mitral valve. He was bridged with heparin. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD five the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. He
refused the scheduled Keflex due to diarrhea, which resolved
after he stopped taking this medication. Dr. [**Last Name (STitle) **] felt he had
sufficient Keflex up to that point and it was decided that he
would not be prescribed further antibiotics. The patient was
discharged to home in good condition with appropriate follow up
instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient Pt list.
1. Pravastatin 80 mg PO HS
2. Furosemide 120 mg PO BID
3. Warfarin MD to order daily dose PO DAILY
5mg on tues/wed/thurs/sat/sun
7.5mg Mon/Friday
4. Atenolol 25 mg PO DAILY
5. Potassium Chloride (Powder) 20 mEq PO DAILY
Hold for K >
6. Metolazone 2.5 mg PO as needed as directed by MD
7. Lisinopril 5 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Aspirin 81 mg PO DAILY
10. Spironolactone 25 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Furosemide 120 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Pravastatin 80 mg PO HS
6. Warfarin MD to order daily dose PO DAILY
5mg on tues/wed/thurs/sat/sun
7.5mg Mon/Friday
7. Spironolactone 25 mg PO BID
RX *spironolactone 25 mg 1 Tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*2
8. Potassium Chloride (Powder) 20 mEq PO DAILY
Hold for K >
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN severe pain
RX *tramadol 50 mg 1 Tablet(s) by mouth every four hours Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
1. Congestive heart failure - EF 10-15%
2. Mitral valve regurgitation
3. s/p Mitral valve repair in [**2164**] and replacement in [**2175**]
4. Aortic insufficiency
5. Hyperlipidemia
6. Paroxysmal atrial fibrillation
7. Hx of Embolic infarct. He has had 3 strokes.
8. Obesity
9. History of ventricular fibrillation arrest following severe
hypokalemia on Zaroxoyln.
10. Chronic Renal Insufficiency - baseline Cr 1.6
11. History of ETOH abuse
12. History of electrocution
13. Prostate cancer treated with radiation
Past Surgical History:
1. Mitral Valve repair in [**2164**] and replacement in [**2175**]
2. AICD in [**10/2178**]
3. Right total hip replacement
4. Back surgery (Diskectomy)
5. Right vein stripping
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tylenol
Incisions:
Left subclavian generator site - healing well, no erythema or
drainage, small amount of ecchymosis
Left thoracotomy healing no erythema. Slight serosanguinous
drainage.
1+ LE Edema
Discharge Instructions:
-Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
-You might have slight itching at the incision. Try not to
scratch the incision or rub it.
-Look at your incisions daily for redness or drainage
-Please NO lotions, cream, powder, or ointments to incisions
-Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
-No driving until cleared by cardiologist
-For six weeks, [**Male First Name (un) **]??????t lift, carry, push, or pull anything
weighing more than five pounds using the arm on the side where
your pacemaker is inserted.
-During the first six ?????? eight weeks, you will need to watch how
you use the arm on the side where your pacemaker was inserted.
You may wash your face, brush your teeth, shave, and comb your
hair. But do not raise your elbow above the height of your
shoulder. You may not swim or play tennis or golf. Now is a good
time to ask for help with things like raking leaves, cleaning,
painting, ironing, vacuuming, or walking a dog.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2180-8-31**]
1:00
Cardiologist: Dr. [**Last Name (STitle) 13175**] [**2180-8-11**] at 1:00p
Electrophysiologist: Dr. [**Last Name (STitle) 13177**] [**2180-8-17**] at 2:00p [**Hospital3 **]
Cardiology [**First Name8 (NamePattern2) **] [**Location (un) **]
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 17663**] in [**5-4**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Mechanical MVR and Afib
Goal INR 2.5-3.5
First draw [**2180-7-30**]
To be followed by [**Hospital3 **] coumadin clinic
phone [**Telephone/Fax (1) 89968**]
Patient plans to have girlfriend take him into hospital for INR
draws
Completed by:[**2180-7-29**]
|
[
"585.9",
"428.22",
"V10.46",
"V58.61",
"427.31",
"425.4",
"V12.54",
"278.00",
"424.1",
"V12.53",
"272.4",
"V43.64",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.98",
"00.52"
] |
icd9pcs
|
[
[
[]
]
] |
7998, 8057
|
5415, 6869
|
335, 432
|
8813, 9103
|
3839, 5392
|
10391, 11459
|
2762, 2794
|
7429, 7975
|
8078, 8591
|
6895, 7406
|
9127, 10368
|
8614, 8792
|
2809, 3820
|
275, 297
|
460, 1886
|
1908, 2474
|
2490, 2746
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,102
| 195,317
|
40438
|
Discharge summary
|
report
|
Admission Date: [**2158-6-11**] Discharge Date: [**2158-6-15**]
Date of Birth: [**2073-5-13**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85F on Coumadin for afib who is s/p mechanical fall down 2
stairs with positive LOC. She struck the left side of her head
and vomited once following striking her head. She initially was
taken to [**Hospital6 **] and a head CT showed a small
left frontal IPH. As a result she was transferred to [**Hospital1 18**] for
further management. On arrival she complained only of a mild
headache and the OSH reported her INR to be 1.8. She denies
nausea, dizziness, changes in vision, hearing, spreech,
difficulty ambulating, or changes in bowel or bladder function.
Past Medical History:
# Dextrocardia
# Atrial Fibrillation
-- on Metoprolol, Amiodarone, Warfarin
# Hyperlipidemia
# Hypertension
# Hypothyroidism
# Chronic Kidney Disease
# CN VI palsy
Social History:
# Tobacco: None, but husband was heavy smoker
# Alcohol: None
# Drugs: None
Family History:
Noncontributory. No other family members with dextrocardia.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL 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: [**3-9**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: old CN VI palsy (unable to look laterally with left
eye)
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 [**5-11**] throughout. 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
.
PHYSICAL EXAM ON DISCHARGE:
VS: T 96.6, BP 138/80, HR 81, RR 12, SpO2 95-97% on RA
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Periorbital ecchymosis left eye. Sclera anicteric. PERRL.
Lateral gaze palsy bilaterally. MMM, OP benign, dentures.
Neck: Supple, full ROM. JVP to lower neck at 45 degrees. No
cervical lymphadenopathy.
CV: Dextrocardia. Irregularly irregular. Normal S1 S2. No
M/R/G appreciated.
Chest: Respiration unlabored, no accessory muscle use. Scattered
rhonchi on left side. No wheezes or rales.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: No C/C/E. Pulses radial 2+, DP trace, PT trace bilaterally.
Neuro: CN II-XII grossly intact except for CN VI bilaterally.
Moving all four limbs. Normal speech.
Pertinent Results:
LAB RESULTS ON ADMISSION:
[**2158-6-11**] 01:45AM BLOOD WBC-6.4 RBC-3.96* Hgb-11.1* Hct-33.4*
MCV-84 MCH-28.0 MCHC-33.2 RDW-15.7* Plt Ct-237
[**2158-6-11**] 01:45AM BLOOD Neuts-76.6* Lymphs-17.9* Monos-4.2
Eos-0.8 Baso-0.5
[**2158-6-11**] 01:45AM BLOOD PT-21.4* PTT-25.4 INR(PT)-2.0*
[**2158-6-11**] 01:45AM BLOOD Glucose-110* UreaN-58* Creat-2.8* Na-139
K-5.1 Cl-103 HCO3-24 AnGap-17
[**2158-6-11**] 08:13AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.7*
[**2158-6-11**] 08:25PM BLOOD Type-ART pO2-130* pCO2-56* pH-7.26*
calTCO2-26 Base XS--2
[**2158-6-11**] 08:25PM BLOOD Lactate-1.7
URINALYSIS:
[**2158-6-11**] 03:10AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2158-6-11**] 03:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
.
[**2158-6-11**] 08:49PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008
[**2158-6-11**] 08:49PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2158-6-11**] 08:49PM URINE RBC-32* WBC-16* Bacteri-FEW Yeast-NONE
Epi-6
[**2158-6-11**] 08:49PM URINE CastHy-3*
[**2158-6-11**] 08:49PM URINE Mucous-RARE
.
CARDIAC ENZYMES:
[**2158-6-11**] 08:04PM BLOOD CK(CPK)-102 CK-MB-4 cTropnT-<0.01
[**2158-6-12**] 02:49AM BLOOD CK(CPK)-75 CK-MB-3 cTropnT-0.02*
[**2158-6-12**] 10:40AM BLOOD CK(CPK)-75 CK-MB-3 cTropnT-0.02*
[**2158-6-12**] 07:03PM BLOOD CK(CPK)-77 CK-MB-3
.
LAB RESULTS ON DISCHARGE:
[**2158-6-15**] 06:05AM BLOOD WBC-5.1 RBC-3.59* Hgb-10.1* Hct-31.0*
MCV-86 MCH-28.0 MCHC-32.4 RDW-16.0* Plt Ct-234
[**2158-6-14**] 05:50AM BLOOD PT-14.1* PTT-24.6 INR(PT)-1.2*
[**2158-6-15**] 06:05AM BLOOD Glucose-82 UreaN-49* Creat-2.4* Na-140
K-4.2 Cl-102 HCO3-27 AnGap-15
[**2158-6-15**] 06:05AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.2
.
IMAGING / STUDIES:
# CT HEAD W/O CONTRAST ([**2158-6-11**] at 9:03 AM):
There is a 6 x 5 mm hyperattenuating focus involving the left
frontal lobe (2:23), compatible with left intraparenchymal
hemorrhage. No new area of acute intracranial hemorrhage is
identified. There is no loss of [**Doctor Last Name 352**]-white matter
differentiation or cerebral edema to suggest acute ischemic
event. Confluent hypodensities primarily in periventricular
distribution of both cerebral hemispheres are most compatible
with chronic, small vessel ischemic disease. Sulci and
ventricles are prominent, likely age-related involutional
changes. There is no shift of normal midline structures. There
is no hydrocephalus. Axial calcifications involving the
vertebral and coronary arteries are noted. Visualized soft
tissues and osseous structures are unremarkable. Mild mucosal
thickening of maxillary sinuses is noted. Mastoid air cells
appear under-pneumatized, which may be congenital or
alternatively, sequelae of chronic prior infections.
IMPRESSION:
1. A 5 x 6 mm hyperattenuating focus involving the left frontal
region, compatible with intraparenchymal hemorrhage.
Alternatively, this lesion may represent a vascular
malformation, cavernoma or hypercellular neoplasm. There is no
additional imaging available for comparison. No additional area
of acute intracranial hemorrhage or hydrocephalus.
2. Confluent hypodensities in periventricular distribution, most
likely small vessel ischemic disease.
3. Prominent sulci and ventricles, likely age-related
involutionary changes.
.
# CT HEAD W/O CONTRAST ([**2158-6-13**] at 1:29 PM):
A subcentimeter focus of hyperdensity in the left frontal lobe
measures 4 x 4 mm, not definitely changed since two days ago.
There is no clear surrounding edema. There is a new small right
subdural collection, slightly denser than CSF. There is no shift
of normally midline structures, or evidence of major vascular
territorial acute infarction. There is unnchanged appearance of
periventricular white matter hypodensity indicative of
microangiopathic ischemic disease. The visualized paranasal
sinuses and soft tissues appear unremarkable.
IMPRESSION:
1. Unchanged subcentimeter hyperdense focus in the left frontal
lobe, without interim development of surrounding edema. This
raises the possibility of a cavernous malformation, rather than
a hemorrhagic contusion. Continued follow-up is recommended. MRI
could help assess for a cavernous malformation, if not
contraindicated.
2. New small right subdural collection, only minimally denser
than CSF. Its low density and new appearance since two days
earlier suggests the possibility of a hygroma (and raises the
question of a dural tear), rather than a subdural hematoma.
.
# TTE (Complete) ([**2158-6-14**] at 1:55:11 PM):
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 45 %) with mild global hypokinesis. No masses
or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size is
normal. with mild global free wall hypokinesis. 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 to moderate ([**1-8**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Brief Hospital Course:
ICU COURSE:
Patient presented to [**Hospital1 18**] after a mechanical fall and then was
admitted to the Neuro ICU for monitoring given her INR of 2.0
and her status of being on Coumadin. She received 2 units of FFP
with an INR drop to 1.8. She was transferred to the floor but
was transferred back to the ICU for rapid AFib and respiratory
distress. On the morning of 6.6 she was stable in the ICU and on
an Amiodarone drip. Her HR remained stable between 70-88 on the
Amiodarone drip. On [**2158-6-12**], she was started metoprolol and
amiodarone was discontinued. CXR was concerning for flash
pulmonary edema. She received 20 mg of Lasix IV and 100 mg of
torsemide in the AM with good response.
Medicine team was consulted in Neuro ICU, and patient was
transferred to Medicine for further management.
MEDICINE COURSE:
# Acute on Chronic Systolic Heart Failure:
Patient appeared to have an episode of flash pulmonary edema on
the neurology floor and responded well to IV and po diuretics.
TTE confirmed EF 45% with mild global systolic function, likely
secondary to CAD. Diuretics were held upon transfer to medical
floor, and patient maintained negative fluid balance. Prior to
discharge, Torsemide was restarted at lower dose of 20 mg daily
to which she responded with fair urine output. She will need to
follow up with her primary care physician in one week to monitor
fluid status and check creatinine. Patient was felt to be
euvolemic upon discharge with dry weight of 171 lbs. While
working with PT, she had intermittent ambulatory oxygen
desaturation to the high 80s, but would increase back to the mid
90s if encouraged to take a few deep breaths.
# Intraparenchymal Hemorrhage:
Head CT scan on presentation showed a 5 x 6 mm hyperattenuating
focus involving the left frontal region, compatible with
intraparenchymal hemorrhage, though the differential also
included AVM, cavernoma, or hypercellular neoplasm. She
remained neurologically intact without focal findings besides
old CN VI palsy. Repeat head CT after two days was stable.
Followup CT scan will be needed in 8 weeks with Neurosurgery
followup.
# Acute on Chronic Renal Failure:
Per information from her PCP, [**Name10 (NameIs) **] recent baseline creatinine is
somewhere between 2 and 3. Her creatinine was 2.8 on admission
and remained stable around this level for several days, but
decreased to 2.4 on the day of discharge, after several days off
diuretics.
# s/p Mechanical Fall:
The patient's fall was in the setting of not using cane while
walking up stairs at home. She was evaluated by physical
therapy who felt that she would benefit from [**Hospital 3058**]
rehabilitation prior to returning home. She was encouraged to
use an assistive device when walking in the future.
# Atrial Fibrillation:
Coumadin was held on presentation in setting of intraparenchymal
head bleed and should be held for a total of 7 days. Coumadin
should be restarted on [**2158-6-18**] at her home dose with regular INR
monitoring. Her heart rate was well controlled with her home
regimen of Metoprolol and Amiodarone during her stay on the
Medicine floor in the 70s-80s bpm. She was monitored on
telemetry without any concerning events noted.
# Transitional Care:
-- Blood cultures from [**2158-6-11**] showed no growth to date but final
results were pending on discharge.
-- Restart Warfarin anticoagulation on [**2158-6-18**] with regular INR
checks
-- Electrolyte panel in one week and PCP followup after
restarting Torsemide
-- Neurosurgery followup with CT head prior to appointment
Medications on Admission:
Aspirin 81 mg PO daily
Simvastatin 80 mg PO daily
Metoprolol ER 50 mg PO daily
Amiodarone 200 mg PO daily
Torsemide 100 mg PO daily (? discontinued [**2158-6-6**])
Warfarin 2 mg PO daily except on Sundays (1 mg on that day)
Levothyroxine 75 mcg PO daily
Celexa 20 mg PO daily
Oxazepam PRN (unknown dose, last filled in [**2157-12-7**])
Vicodin (last filled [**2158-3-15**]) 50 tablets
Fluticasone Nasal Spray 1 spray Qnostril daily
Triamcinalone Cream 0.1% apply [**Hospital1 **] PRN itchy rash
Vitamin B Complex 1 tablet PO daily
Vitamin D 50,000 IU Qweekly on Sundays
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
except Sundays. Restart usual regimen on [**2158-6-18**].
7. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: On
Sundays. Restart usual regimen on [**2158-6-18**].
8. levothyroxine 75 mcg Capsule Sig: One (1) Capsule PO once a
day.
9. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal once a day: each nostril.
11. Vitamin B Complex Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary Diagnoses:
Mechanical Fall
Left Frontal Intraparenchymal Hemorrhage
Acute on Chronic Systolic CHF
Secondary Diagnoses:
Dextrocardia
Atrial Fibrillation
Chronic Kidney Disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a mechanical fall in
which you hit your head and developed a small hemorrhage in the
brain. You were briefly in the ICU, but were soon transferred
to the general Medicine floor. During your stay, you had
several episodes in which the oxygen level in your blood dropped
to a low level. You also had evidence of fluid buildup in your
lungs. An echocardiogram (ultrasound of the heart) was
performed and showed a somewhat decreased ability of your heart
to pump. This likely contributed to the fluid buildup in your
lungs and in your legs and ankles.
Several changes were made to your medications. You were
restarted on a lower dose of Torsemide to help prevent fluid
buildup in your body. Your Simvastatin was decreased since at
recent research has shown that the 80 mg has a higher risk of
muscle pain and other complications. Your Oxazepam was stopped
since it can make it more likely for you to fall and injure
yourself. Your Warfarin (Coumadin) was temporarily stopped
after your head injury. You will need to start taking it again
on [**2158-6-18**]. You should restart your prior regimen at that time
with frequent INR checks until the level is stable again.
START: Torsemide 20 mg by mouth daily
DECREASED: Simvastatin 40 mg by mouth daily (was 80 mg daily)
STOP: Oxazepam
TEMPORARILY STOP: Warfarin 2 mg daily except 1 mg on Sundays
(restart usual regimen on [**2158-6-18**])
You should continue taking your other medication as previously
prescribed and as indicated on your discharge medication sheet.
Because your heart has some difficulty pumping properly, you
should limit the amount of salt in your diet and pay close
attention to your weight. You should weight yourself each
morning after urinating wearing similar clothes, write down the
weights, and contact your doctor if your weight increases by
more than 3 lbs in one day of 5 lbs in 3 days.
After discharge from the hospital, you will be going to a rehab
facility to have intensive physical therapy and help build up
your strength prior to returning home. You will need to follow
up with your PCP after discharge from the rehab. You will also
need to follow up with Neurosurgery in several weeks and have a
repeat CT scan of the brain. Details are below.
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:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R
Location: [**Doctor Last Name **] RIVER MEDICAL
Address: [**Hospital1 **], [**Apartment Address(1) 26660**], [**Location (un) **],[**Numeric Identifier 45328**]
Phone: [**Telephone/Fax (1) 77997**]
When: Wednesday, [**6-21**], 2:30PM
Department: RADIOLOGY
When: TUESDAY [**2158-8-15**] at 1 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2158-8-15**] at 1:30 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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"244.9",
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"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
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|
8934, 12502
|
303, 310
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14486, 14486
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3374, 3386
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3400, 4547
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,512
| 145,212
|
13593
|
Discharge summary
|
report
|
Admission Date: [**2147-3-21**] Discharge Date: [**2147-3-29**]
Date of Birth: [**2087-7-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
SOB and change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 41033**] is 59-year-old male with a past medical history
significant for multiple episodes of pneumonia and possible
achalasia, tongue cancer s/p chemotherapy and radiation
treatment, hypothyroidism, hyperlipidemia presenting to the
medicine team with presumed aspiration pneumonia after a 3-day
stay in the MICU. Mr. [**Known lastname 41033**] states that 2-3 weeks prior to
presentation he noticed that he developed a productive cough
with yellow sputum, SOB and decrease appetite. He denied fever,
night sweat, chills, nausea, vomiting and chest pain. He states
that over the course of [**1-5**] weeks his cough worsened, he lost
approximately 8lbs and his wife told him that he was ??????acting
funny??????. Mr. [**Known lastname 41033**] also noticed that his memory was declining
and he had a harder time expressing himself. His wife, alarmed
that his mental status and respiratory status was not improving
took him to the ED.
Mr. [**Known lastname 41033**] states that he has had recurrent episodes of
pneumonia for the past 2 years. The last episode was
approximately 6 months ago while he was vacationing in [**State 622**].
He states that he is usually hospitalized for 3-5 days with
each episodes and he was told in [**2145**] that his recurrent
pneumonia is secondary to achalasia. Mr. [**Known lastname 41033**] also states
that his achalasia was most likely due to his radiation
treatment for tongue cancer (see PMHx).
Mr. [**Known lastname 41033**] does not remember most of the events of the days
proceeding to his hospitalization and his wife was not available
at the time of this interview.
Past Medical History:
1. Recurrent episodes of Pneumonia
aPatient states that starting 2 years ago he has had reoccurring
pneumonia (see HPI)
2. Tongue Cancer
Diagnosed 10 years ago
Treated with chemotherapy and radiation
Hypothyroidism secondary to radiation therapy
3. Depression/Anxiety
Diagnosed at the age of 57
Treated with Symbyax
Denies hospitalizations due to depression, also denies past and
present suicidal ideation.
4. Hyperlipidemia
Treated with Lipitor
5. Left ear ?squamous cell carcinoma
Patient not sure if it was squamous or not.
Treated by resection of tumor
6. Pancreatitis
Diagnosed at the age of 33
Treated by removing part of the pancreas
Also had spleenectomy at time of partial pancreas removal
Not sure of etiology
7. Hypothyroidism
Due to radiation treatment for tongue cancer
Treated with Levothyroxine
Social History:
Lives with his wife in an apartment in [**Name (NI) **], MA; married for
11 years no children; graduated from high school currently works
as a security guard; states that he worked for airline for 15
years and inhaled many ??????toxic fumes??????.
Tobacco: Denies present and past use
EtOH: Denies
Drugs: Tried marijuana in the distant past; denies cocaine or
heroine use in the past or present
Currently not sexually active because of decrease libido from
Symbyax
Family History:
Mother-died at the age of 88 of ??????old age??????
Father-did not stay in contact with father, not sure of
circumstances of his death
5 siblings-Many have various psychiatric illnesses including:
Depression and anxiety.
Patient denies family history of hypertension, cancer and lung
disease.
Physical Exam:
VS: T 99.8 P86 BP124/80 RR14 O2sat 96% on 4L
nasal cannula
General: Well-developed, well-nourished male sitting up in bed
looks older than his states age, in no apparent distress,
pleasant
HEENT: Normocephalic, atraumatic. Moist mucus membranes, no
lymphadenopathy. Ears and eyes were not assessed.
CV: RRR, nl s1 and s2 with no extra heart sounds or murmurs.
Dorsalis pedial pulses palpated bilaterally
Chest: Right lung field had inspiratory crackles in the lower
[**1-5**]; Left lung field had inspiratory crackles is the lower [**12-5**]
base
ABD: Decrease bowel sounds; soft, non-tender, non-distended,
liver span was approximately 10cm
Musculoskeletal: no lower extremity edema and no calf-pain
elicited on palpation
Neuro: A&Ox3; CNII-XII intact; LUE 5/5 strength and RUE [**3-7**]
strength; 5/5 strength in both RLE and LLE, gross sensory
intact, reflexes not assessed. Finger to nose was accurate, but
slow bilaterally. Mini-mental status exam scored 28/30, patient
had difficulty with following command of taking paper in right
hand and folding it (would take paper in left hand). No mask
facies appreciated, no cog wheeling in upper extremities, gait
was not tested.
Pertinent Results:
[**2147-3-21**]
WBC-18.1* RBC-3.87* HGB-11.0* HCT-33.8* PLT COUNT-394 MCV-88
MCH-28.5 MCHC-32.6 RDW-14.1
NEUTS-87.9* BANDS-0 LYMPHS-7.8* MONOS-3.9 EOS-0.2 BASOS-0.2
HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL
MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL ACANTHOCY-1+
[**2147-3-21**] CXR
Right lower lobe pneumonia. Followup study post-treatment is
recommended to demonstrate complete resolution.
[**2147-3-23**] Chest CT
1) Mediastinal and hilar lymphadenopathy as described above,
concerning for metastatic disease.
2) Bilateral, multifocal aspiration pneumonia.
3) Moderate right, and small left-sided pleural effusion.
4) Dilated esophagus.
5) Cholelithiasis without evidence of acute cholecystitis.
[**2147-3-23**] Neck CT
1) Thickening of the pharyngeal/prevertebral soft tissues
consistent with prior radiation therapy. No evidence of soft
tissue masses or abscesses identified.
2) No lymphadenopathy or soft tissue masses identified within
the neck.
3) Right lung apex pneumonia.
4) Right anterior mandible lytic focus of uncertain nature,
please correlate with clinical findings.
[**2147-3-24**] Head CT
The brain appears normal. Again identified is right mastoid
opacification.
Brief Hospital Course:
ED Course: In the ED Mr. [**Known lastname 41033**] was noted to be short of breath
with an O2 sat of 88% on RA, hypotensive (70/47, his baseline is
120/60) with a low-grade temperature of 100.4. His physical
exam was notable for decreased breath sounds with rhonchi.
After 2 liters of fluid his systolic BP was in the 90s. His SOB
did not improve after albuterol and ipratropium neb treatments.
His CBC showed a WBC of 18.1 and his CXR showed RLL pneumonia.
He was then started on Levaquin, Ceftriaxone and Flagyl for
pneumonia. Due to his initial hypertension he was admitted to
the MICU. Urine, sputum and blood cultures were sent.
MICU Course: While in the MICU Mr. [**Known lastname 41033**] had persistent
low-grade fever (100.3) and was continued on Flagyl, Ceftriaxone
and Levaquin for presumed aspiration pneumonia and sepsis. He
was noted to have Cr 1.5, it was believed that the cause of his
acute renal failure was pre-renal and he was given IVF. His
blood pressure stabilized during his stay in the MICU. He was
seen by GI who felt that Mr. [**Known lastname 41033**] had 3 processes affecting
his ability to swallow: 1) esophageal muscle weakness resulting
from radiation treatment, 2) non-specific esophageal motility
disorder and 3) compromise ability to eat secondary to poor
dentures. They recommended speech and swallow consult to
determine safest consistency of food for patient. Speech and
swallow states that Mr. [**Known lastname 41033**] had moderate to severe pharyngeal
dysphasia with trace aspiration. They state that his anatomy
may be concerning for a mass and recommended a neck CT. They
also recommended neurology consult because his change in mental
status and difficulty swallowing seem consistent with
neurodegenerative disease. Chest CT showed mediastinal and
hilar lymphadenopathy concerning for metastatic disease. His
mental status, RLL pneumonia and hemodynamics improved
therefore, MR. [**Known lastname 41033**] was transferred to medicine team.
1. RLL Pneumonia
-Patient was started on Flagyl 500 mg every 8 hours IV and
Levaquin 500 mg every 24 hours
-Was also put on albuterol and ipratroprium nebs every 6 hours
-Initially in the MICU he was on 4L oxygen, by time of discharge
he was down to 2L
-By the time of discharge his shortness of breath had resolved
on 2L oxygen and his lung exam had improved
-After physical therapy saw him they recommended that on
discharge he would go home on 2L oxygen while at rest and 4L
during activity until pneumonia resolves
2. Tongue Cancer
-On neck CT a lytic lesion was seen on right mandible concerning
for metastases
-On chest CT mediastinal and hilar lymphadenopathy was noted
more on right than left
-Heme/onc consult was ordered, they stated that the "lytic
lesion" was consistent with tooth fragment seen on clinical exam
and that his lymphadenopathy was consistent with pneumonia or TB
-Therefore, PPD was placed and read negative after 48 hours
-Out-patient chest CT scan was ordered for a month after
discharge to make sure the lymphadenopathy had resolved with the
treatment of pneumonia.
3. Change in Mental Status
-Possible etiologies include early neurodegenerative disease or
delirium secondary to pneumonia
-Improved clinically as patient was moved from MICU to the floor
-Mini-mental status scores remained stable at 28/30
-RPR was non-reactive, TSH and B-12 was WNL
-Head CT was negative
-Outpatient appointment with Neuropsychiatry was made to
evaluate for memory loss
4. Anemia
-Baseline HCT 41.7 recorded in [**9-5**]
-Since his hospitalization his HCT has been low in late 30s, but
steady and normocytic throughout his hospital stay
-Folate and B-12 were within normal limits
-His TIBC was decreased, which was consistent with anemia of
chronic disease
5. Depression/Anxiety
-Per patient he has a history of depression and anxiety
-Was not an acute issue throughout his hospital stay
-He was kept on Fluoxetine and Olanzapine throughout his
hospital stay
6. Hypothyroidism
-Was not an acute issue throughout his hospital stay
-Continued patient on Levothyroxine 175 mcg po every day
Medications on Admission:
(Patient unsure of doses)
Levothyroxine
Lipitor
Symbyax
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. oxygen
patient requires 2 liters oxygen at rest
patient requires 4 liters oxygen with activity
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aspiration Pneumonia
Discharge Condition:
Good
Discharge Instructions:
Please call Dr. [**First Name (STitle) **] for any problems you may have
[**Name (NI) **],[**First Name3 (LF) 569**] E. [**Telephone/Fax (1) 250**]
Please come directly to the ED if you have chest pain, shortness
of breath, fevers or any other medical concerns
Followup Instructions:
The following appointments have been made for you:
1. Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2147-5-15**] 1:30
2. CT scan Where: [**Hospital6 29**] RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2147-4-26**] 3:00
3. Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], [**MD Number(3) 41034**]: RA [**Hospital Unit Name **]
([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) HMFP Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2147-5-2**] 1:00
4. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Where: [**Hospital6 29**]
SURGICAL SPECIALTIES Phone:[**Telephone/Fax (1) 6317**] Date/Time:[**2147-4-4**] 11:30
Completed by:[**2147-7-2**]
|
[
"038.9",
"995.92",
"244.9",
"788.20",
"785.52",
"507.0",
"V10.01",
"787.2",
"584.9",
"285.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11198, 11256
|
6161, 10282
|
347, 353
|
11321, 11327
|
4896, 6138
|
11637, 12525
|
3367, 3662
|
10389, 11175
|
11277, 11300
|
10308, 10366
|
11351, 11614
|
3677, 4877
|
276, 309
|
381, 2025
|
2047, 2865
|
2881, 3351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,917
| 156,910
|
10267
|
Discharge summary
|
report
|
Admission Date: [**2136-2-8**] Discharge Date: [**2136-2-12**]
Date of Birth: [**2085-9-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
from [**Hospital1 **] with acute renal failure
Major Surgical or Invasive Procedure:
Swan-ganz catheter placement
intubation
History of Present Illness:
admitted [**Date range (1) 23271**] for ARF (2.3), supratherapeutic INR (3.2)
after mechanical fall with R orbital fracture. Noted to have
a.fib with RVR but rate controlled with b-blocker. Cardiology
felt cardioversion not indicated. Baseline BP's noted to be
80-110 in legs and undetectable in arms.
ACE-I and lasix held. Cr improved with gentle diuresis and d/c
to rehab.
*
At rehab he was re-initiated on his lasix for increasing lower
extremity edema and increasing evidence of CHF. The lasix was
titrated to a dose of 80mg PO BID with good urine outpt but
progressively increasing creatinine from 2.0 to 4.0.
*
Also, he had mutliple episodes of a.fib with RVR requiring large
doses of lopressor. On [**2-6**] he was noted to be more lethargic
and have gross hematuria. His coumadin was held for INR 6.1 and
bladder irragation initiated. On [**2-7**] ABG 7.21/53/71 (2L NC)
and started on BiPAP. Subseqent ABG 7.23/54/79 (3L NC) but not
in significant respiratory distress at time of d/c per rehab
notes and remained at 2-3L NC throughout rehab course.
*
In ED was given 1 unit FFP for INR 4.9 and initial CXR with
right sided consolidation. Subsequently, he was noted to have
mild resp distress and decrease in SBP to 80's which transiently
responded to dopamine gtt. However, he developed a.fib c RVR at
rate of 150s and dopamine weaned off after 1L NS bolus.
However, resp distress continued with CXR showing CHF and
intubated. His SBP's dropped again to 80's. Fem line placed
and started on levophed. He was given decadron, vancomycin,
levofloxacin.
Past Medical History:
-End stage renal disease, status post living related kidney
transplant [**2132-2-5**]
-hypertension,
-atrial fibrillation
-peripheral vascular disease
-hypothyroidism
-OSA
-DM2 with peripheral neuropathy
-CHF EF mildly depressed (poor echo studies)
echo [**2136-1-24**]: poor study, EF not documented but mildly
depressed; PASP 52 and +2 TR.
Social History:
SOCIAL HISTORY: The patient lives alone in an apartment in
[**Location (un) **], but is close with his sister, who helps him out
often. States he does his own shopping and cooking. Gets around
in a motorized scooter. He is a lifetime nonsmoker and states
he has not had any EtOh in 10 years. Before that had only
occasional drinks. Priorly a machinest but now on disability.
Family History:
not-contributory
Physical Exam:
PE 98.0 124/104 (on 1 mcg/kg/min levophed) HR 130 (irregular)
A/C 650/16 PEEP 5 FiO2 100% PIP 28 SpO2 100%
ABG: 7.22/50/188
Gen: intubated, sedated but responds to pain
Heent: R orbital eccymosis, conjuncival and subscleral hematoma
Neck: elevated JVD @20 degrees
CV: tachy, irregular
Pulm: decreased breath sounds and faint crackles at bases
Abd: minor eccymosis, nd, soft, +bs
Ext: dusky appearing hands and feet b/l; +2 DP on left foot, +1
DP on right foot, ulcerations on left shin and toes of left
foot; +2 pitt edema to upper thighs b/l and dependent areas.
Pertinent Results:
[**2136-2-8**] 11:22PM GLUCOSE-166* UREA N-58* CREAT-3.9* SODIUM-133
POTASSIUM-5.1 CHLORIDE-99 TOTAL CO2-20* ANION GAP-19
[**2136-2-8**] 11:22PM CK(CPK)-39
[**2136-2-8**] 11:22PM cTropnT-0.13*
[**2136-2-8**] 11:22PM CK-MB-NotDone
[**2136-2-8**] 11:22PM CORTISOL-11.3
[**2136-2-8**] 11:22PM WBC-5.9 RBC-4.10* HGB-12.6* HCT-39.6* MCV-97
MCH-30.8 MCHC-31.9 RDW-20.2*
[**2136-2-8**] 11:22PM NEUTS-96* BANDS-1 LYMPHS-0 MONOS-2 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2136-2-8**] 11:22PM PLT SMR-NORMAL PLT COUNT-186
[**2136-2-8**] 11:22PM PT-22.3* PTT-46.4* INR(PT)-3.6
[**2136-2-8**] 08:49PM TYPE-ART PO2-188* PCO2-50* PH-7.22* TOTAL
CO2-22 BASE XS--7 -ASSIST/CON INTUBATED-INTUBATED
Brief Hospital Course:
50 M c h/o CHF, a.fib on coumadin, renal transplant on
immunosuppresive meds with ARF, hypercarbic respiratory failure,
coagulopathy, and hypotension.
The etiology of his respiratory failure was not clear but pt was
kept on ventilator to help compensate for metabolic aciodosis.
In addition, he had lung collapse on CXR that suggestive of
mucus plugging. He was bronched with good results. However his
resp status continued to decline as his urine output decrease
and he developed more pulm edema. He was noted to have R lung
collapse again and repeat bronchoscopy did not show mucus
plugging. The likely etiology of his hypotension was felt to be
cardiogenic. Echocardiogram showd he had dilated RV but
relatively preserved LV suggesting that he needed pre-load to
maintain cardiac output. Trials of diuresis and IV hydration
were not successful in optimizing his BP, urine outpt, and pulm
edema. Ultimately, he had PA catheter placed that showed CI of
2.91 by Fick but PCWP 30 and PA 90/45. At this point he was
felt to have biventricular failure and unlikely to be weaned off
vent as well as require inotropes/pressors to optimize
hemodynamics. He had progressive uremia requiring hemodialysis
however family opted to not intiatiate renal replacement
therapy. Given his deteriorating condition and poor prognosis,
the family made the pt [**Name (NI) 3225**] on [**2136-2-11**]. He was put on morphine
gtt and passed on AM [**2136-2-12**].
Medications on Admission:
coumadin (held since [**2-10**])
prednisone 5mg QDay
tacrolimus 2 mg [**Hospital1 **]
lopressor 100mg TID
lasix 80mg [**Hospital1 **]
bactrim DS MWF
elavil 10mg QHS
vit C 500mg [**Hospital1 **]
synthroid 125mcg QDay
prevacid 20 QDay
zoloft 100mg QDay
zinc 220mg QDay
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
ARF
cardiogenic shock
coagulopathy
anemia
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"E878.0",
"250.60",
"428.0",
"244.9",
"682.6",
"584.9",
"518.81",
"996.81",
"780.57",
"V58.61",
"403.91",
"427.1",
"486",
"397.0",
"785.51",
"357.2",
"276.2",
"585.6",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.07",
"00.17",
"38.93",
"89.64",
"33.24",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5940, 5949
|
4139, 5594
|
359, 401
|
6035, 6045
|
3401, 4116
|
6097, 6103
|
2780, 2798
|
5912, 5917
|
5970, 6014
|
5620, 5889
|
6069, 6074
|
2813, 3382
|
273, 321
|
429, 2004
|
2026, 2370
|
2402, 2764
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,319
| 123,326
|
28809
|
Discharge summary
|
report
|
Admission Date: [**2175-3-18**] Discharge Date: [**2175-3-26**]
Date of Birth: [**2110-12-17**] Sex: M
Service: MEDICINE
Allergies:
Dolasetron Mesylate / Percocet / Solu-Medrol/Diluent
Attending:[**Known firstname 7591**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64 yo male with history of AML presenting with fever. He was
recently admitted [**Date range (3) 69584**] for HIDAC therapy which he
tolerated well. He was at home at 5pm the day prior to admission
when he developed a fever to 100.2 and chills. He immediately
came in to the hospital as he has been advised. He had a brief
headache at the time of the fever. He had no sore throat, cough,
shortness of breath. He had no abdominal pain. He regularly has
6 loose bowel movements a day and he actually had less at the
time of the fever. He had no vomiting. He had no urinary
symptoms. He had no rash.
.
In ED he was found to have a Temp to 102.3 and remained symptom
free. On a CXR there was concern for pneumoperitoneum an
abdominal CT with contrast was obtained. The CT scan showed some
free air and dilated loops of small bowel. Surgery evaluated him
in the emergency department and felt that based upon his lack of
abdominal pain and stable clinical status they would not operate
on him at this time. They recommended antibiotics, NPO, and
close observation. In the ED he was treated with Cefepime,
Vancomycin, Flagyl, and Neupogen.
Past Medical History:
Oncology history:
He was diagnosed with AML M6a erythroleukemia in [**2174-8-23**].
He was treated with 7+3, but did not achieve a complete
ablation, and on day 24 was given a course of high dose ARA-C.
His induction hospitalization was complicated by a crohn's
disease exacerbation requiring an ICU stay, which resolved with
high dose steroids and prolonged bowel rest. He is currently 2
months s/p successful ileal resection for his Crohn's. Patient
is currently s/p 4 cycles of HIDAC consolidation. On [**1-9**], his
marrow had recovered and peripheral smear reviewed by Dr.
[**Last Name (STitle) 410**], who noted atypical cells, mostly monocytes, but no
blasts.
.
Past Medical History:
1) Crohn's Disease, diagnosed in the 60's. Denies arthritis and
rashes. Last flair approximately 10 months ago.
- 20 yrs ago: s/p partial small bowel resection (20 cm), 20
years ago.
- [**2174-11-21**]: s/p Ileocolectomy with stapled side-to-side
anastomosis.
2) Herpes zoster- on acyclovir
3) MVP
4) EBV infection
5) Hx appendectomy
6) Hx cholecystectomy
7) Hemochromatosis
8) AML as above
Social History:
Quit smoking in [**2133**]. No longer drinks- used to have 1-2 beers
with dinner. No IVDU. Has three children (ages 41, 38, and 35)-
one son living at home, 4 grandchildren. Works in home
inspection.
Family History:
Mother died of cancer (age 67), father died of cerebral
aneurysm. No other family history of cancer. Has one brother, in
good health. Children are well.
Physical Exam:
VS: Temp 97.6, Pulse 86, BP *84/48*, RR 20, 96% on RA
Gen: alert, oriented, cooperative male in NAD
HEENT: MMM, OP clear with no lesions or petechiae, PERRL
Neck: no lymphadenopathy, supple
Lungs: clear to auscultation bilaterally
CV: RRR, nl S1S2 with systolic click
Abd: soft, non-distended, non-tender, positive BS, no HSM
Rectal: guiaic - in ED
Ext: no edema
Skin: no rashes
Pertinent Results:
[**2175-3-17**] 09:20PM BLOOD WBC-0.2* RBC-2.69* Hgb-8.3* Hct-24.6*
MCV-92 MCH-30.8 MCHC-33.6 RDW-15.1 Plt Ct-29*#
[**2175-3-26**] 12:00AM BLOOD WBC-6.0# RBC-3.43* Hgb-10.1* Hct-31.2*
MCV-91 MCH-29.5 MCHC-32.4 RDW-15.0 Plt Ct-17*
[**2175-3-26**] 12:00AM BLOOD Neuts-66 Bands-7* Lymphs-9* Monos-14*
Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0
[**2175-3-18**] 09:37AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ Tear
Dr[**Last Name (STitle) 833**]
[**2175-3-25**] 12:00AM BLOOD PT-15.1* PTT-32.7 INR(PT)-1.4*
[**2175-3-18**] 09:37AM BLOOD Fibrino-384#
[**2175-3-25**] 12:00AM BLOOD Gran Ct-870*
[**2175-3-17**] 09:20PM BLOOD Gran Ct-60*
[**2175-3-18**] 09:37AM BLOOD Gran Ct-10*
[**2175-3-24**] 12:02AM BLOOD Gran Ct-260*
[**2175-3-17**] 09:20PM BLOOD Glucose-118* UreaN-15 Creat-0.8 Na-139
K-3.3 Cl-104 HCO3-26 AnGap-12
[**2175-3-26**] 12:00AM BLOOD Glucose-85 UreaN-16 Creat-0.8 Na-140
K-3.8 Cl-104 HCO3-24 AnGap-16
[**2175-3-26**] 12:00AM BLOOD ALT-15 AST-18 AlkPhos-102 TotBili-0.2
[**2175-3-18**] 09:37AM BLOOD Albumin-3.3* Calcium-7.9* Phos-2.3*
Mg-1.6
[**2175-3-26**] 12:00AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9
[**2175-3-25**] 12:00AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.2 Mg-2.0
[**2175-3-21**] 12:02AM BLOOD Triglyc-104
[**2175-3-18**] 09:37AM BLOOD Cortsol-15.8
[**2175-3-17**] 09:15PM BLOOD Lactate-1.3
[**2175-3-18**] 11:55AM BLOOD Lactate-1.2
[**2175-3-20**] 01:59PM BLOOD Lactate-0.9
.....
Blood cultures:
..........
[**2175-3-17**] CXR: Probable free air beneath the hemidiaphragms. Lungs
clear.
[**2175-3-18**] Abdominal/pelvic CT scan: Small amounts of free air are
seen within the abdomen. There is mesenteric stranding within
the right mid abdomen, just superior to the neoterminal ileum,
indicating acute inflammation. There is no thickening of the
bowel wall, however. There are mildly dilated loops of small
bowel in the right lower quadrant, though there is no
obstruction as oral contrast passes
through to the rectum. The findings are consistent with
neoterminal ileitis related to Crohn's flare, with perforation.
No abscesses are seen at this time.
Brief Hospital Course:
Possible bowel perforation: patient found to have free air on
initial cxr and was then found to have inflammation in the
terminal ileum concerning for perforation secondary to long
standing crohn's. The patient was evaluated by surgery and
elected to watch the patient with serial abdominal exams as well
as with IV antibiotics. Patient was followed and did well
without abdominal pain or other symptoms. He continued to
improve and was discharged on a regular (crohn's diet) and
should follow up with surgery as an outpatient. For Crohn's the
patient was started on asacol per GI recommendations.
.
2. Febrile neutropenia - Presenting symptoms was fever in the
setting of low counts after chemotherapy (HIDAC). Blood
cultures showed pan sensitive Klebsiella that cleared with
antibiotics. He was kept on cefepime, flagyl and vancomycin for
concern that other bowel flora could seed the blood in the
setting of a bowel perforation. Patient did well and
antibiotics were tailored to only cefepime and flagyl. Patient
was then discharged on cipro and flagyl for further coverage.
He received G-CSF daily and counts rapidly improved at time of
discharge.
source at this time is most likely abdominal.
.
3. Hypotension - Initially transferred to the [**Hospital Unit Name 153**] with
hypotension likely in a SIRS/sepsis picture. He was briefly on
pressors but BP rapidly improved with IV fluids as well as
antibiotics and patient was transferred out of the [**Hospital Unit Name 153**] (approx
1 week prior to d/c)
.
4. Crohn's: patient has chronic diarrhea 6x/day. CT scan
consistent with possible Crohn's flair although he is
asymptomatic. Started asacol when tol POs. Will likely need
further GI follow up.
.
5. Pancytopenia related to HIDAC therapy Transfused to HCT >25
- Transfused for platelets <10
.
6. H/O Herpes zoster with post-herpetic neuralgia:
- continued acyclovir. d/c'd amitryptaline for marrow
suppression while counts were low. Should be restarted as an
outpatient.
Medications on Admission:
protonix 40mg qd
amitryptline 25mg qhs
acyclovir 400mg tid
simethicone 80 mg QID prn
Kcl 20 mEq qd
Magnesium 500mg PO qd
Discharge Medications:
1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. Cipro 750 mg Tablet Sig: One (1) Tablet PO twice a day for 14
days.
Disp:*28 Tablet(s)* Refills:*0*
5. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Magnesium Oxide 500 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
9. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Bacteremia
Bowel perforation
...
AML
Post-herpetic neuralgia
Discharge Condition:
improved, tolerating food without difficulty.
Discharge Instructions:
You were admitted with fever and low blood counts and found to
have a bacteria in your blood. This was probably caused by a
small hole in your colon because of your Crohn's.
While you were here you received several antibiotics and
improved. Your counts have also increased rapidly.
.
Please call the oncall physician or come to the ER if you have
any vomiting, fever (over 100.5), chills, shortness of breath,
abdominal pain, or any other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 410**] within 1 week - call Monday for
appt.
Please also follow up with Dr. [**Last Name (STitle) 1924**] within a week.
|
[
"555.9",
"569.83",
"424.0",
"041.3",
"053.19",
"E933.1",
"205.00",
"790.7",
"568.89",
"288.03",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"99.15",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
8803, 8809
|
5543, 7541
|
319, 326
|
8914, 8962
|
3398, 5520
|
9472, 9644
|
2829, 2983
|
7713, 8780
|
8830, 8893
|
7567, 7690
|
8986, 9449
|
2998, 3379
|
274, 281
|
354, 1489
|
2202, 2595
|
2611, 2813
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,289
| 117,461
|
29674
|
Discharge summary
|
report
|
Admission Date: [**2140-12-26**] Discharge Date: [**2141-1-2**]
Date of Birth: [**2114-12-26**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Aleve
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
"nausea, vomiting."
Major Surgical or Invasive Procedure:
none
History of Present Illness:
26yoF with h/o leukopenia reportedly in the past when taking
Aleve and Bactrim a few years ago who presents with fever to
104, sore throat, nausea x1d, and body aches. Felt well
yesterday, went to a club in [**Location (un) 7349**], drove back before super bowl.
Woke up febrile today, took Tylenol with some relief, and had
emesis x3 (no blood). Frontal, retro-orbital headache that is
pounding/disabling. Stiff, sore neck. Pt denied diarrhea,
abdominal pain, CP, SOB, cough. Endorses sick contacts with
colds.
.
In the ED, initial vs were: 102.6 p120 98/53 20 98%RA. Pt was
found to be leukopenic with WBC count 1.4, neutrophil 54%.
Peripheral smear sent per Heme Onc recommendation; also pan
culture and start broad spectrum ABx. Pt was given Ceftriaxone
and Flagyl and 3L NS. Admit VS: Temp: 100.6, Pulse: 82, RR: 16,
BP: 114/67, O2Sat: 98, Pain: 2
.
On the floor, complaining of nausea, shortness of breath, and
body aches. HR was sustained at 140. Temp near 104. Arterial
lactate was drawn and was 4.0. Given high fevers, tachycardia,
and evidence of hypoperfusion, she was transferred to the MICU
for further evaluation.
Past Medical History:
-Leukopoenia [**2136**]
-Nipple abscess from piercing [**2136**]
-Chlamydia [**2135**]
Social History:
She is a nonsmoker. She drinks alcohol twice a
week on average. She denies illicit drug use. Works two jobs,
BOA and Insurance company. Previously worked as a lab tech at
[**Hospital1 2025**]. She lives alone at school with her mother when she is at
home. She has no pets. She denies exotic travel. She is sexually
active with women. Past partners have been men and women. But no
men since before [**2136**]. She has a remote history of genital warts
and chlamydia, which were treated and have not recurred.
Family History:
Mother is 37, has a history of hypertension.
Father is 40 and healthy. She has one brother who is healthy.
There is no family history of early coronary disease,
malignancies, or diabetes.
Physical Exam:
ADMISSION EXAM
Triage 102.6 p120 98/53 20 98%RA.
Admit VS: Temp: 100.6, Pulse: 82, RR: 16, BP: 114/67, O2Sat: 98,
General: Alert, oriented, no acute distress, uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear. tongue piercing.
Neck: supple, JVP not elevated, no LAD, lymphadenopathy along
left anterior cervical chain. tattoo along left clavicle
Chest: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachy and reg rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender LUQ, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, umbilicus
piercing
GU: foley in place, clitoral piercing
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
.
DISCHARGE EXAM:
99.6, 100.1, 80-90, 100-126/50-80, 18, 96-100RA
General: Alert, oriented, no acute distress, comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, full ROM
Lungs: CTAB
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, normal bowel sounds no
rebound tenderness or guarding, no organomegaly
GU: exfoliative rash with scale, limited to external vulva and
surrounding skin, minimal erythema and well healed skin below
scale
Ext: warm, well perfused, 2+ pulses, bilateral calf tenderness
to palpation
Skin: Rash improved on ble
Pertinent Results:
ADMISSION LABS
[**2140-12-26**] 03:50PM BLOOD WBC-1.4*# RBC-3.88* Hgb-12.1 Hct-35.4*
MCV-91 MCH-31.2 MCHC-34.2 RDW-12.5 Plt Ct-164
[**2140-12-26**] 03:50PM BLOOD Neuts-54 Bands-4 Lymphs-27 Monos-3 Eos-0
Baso-1 Atyps-0 Metas-7* Myelos-4* NRBC-1*
[**2140-12-27**] 08:01AM BLOOD PT-18.1* PTT-31.5 INR(PT)-1.7*
[**2140-12-27**] 04:19AM BLOOD Ret Aut-1.4
[**2140-12-26**] 03:50PM BLOOD Glucose-114* UreaN-10 Creat-1.1 Na-135
K-3.6 Cl-100 HCO3-22 AnGap-17
[**2140-12-26**] 03:50PM BLOOD ALT-22 AST-25 AlkPhos-54 TotBili-0.8
[**2140-12-26**] 03:50PM BLOOD Lipase-38
[**2140-12-27**] 04:19AM BLOOD Albumin-3.1* Calcium-6.6* Phos-0.8*
Mg-0.8* UricAcd-4.8 Iron-PND
[**2140-12-27**] 04:19AM BLOOD PTH-64
[**2140-12-27**] 04:19AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2140-12-27**] 08:04AM BLOOD PEP-PND IgG-693* IgM-72
[**2140-12-27**] 04:19AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2140-12-27**] 03:21AM BLOOD Type-ART pO2-89 pCO2-24* pH-7.44
calTCO2-17* Base XS--5
[**2140-12-26**] 09:12PM BLOOD Lactate-3.8*
[**2140-12-27**] 04:30AM BLOOD freeCa-0.88*
.
DISCHARGE LABS:
[**2141-1-2**] 07:40AM BLOOD WBC-9.7 RBC-3.59* Hgb-11.2* Hct-33.2*
MCV-93 MCH-31.3 MCHC-33.8 RDW-13.2 Plt Ct-286
[**2140-12-29**] 08:31PM BLOOD Neuts-77* Bands-2 Lymphs-11* Monos-6
Eos-2 Baso-1 Atyps-1* Metas-0 Myelos-0
[**2141-1-2**] 07:40AM BLOOD PT-11.1 INR(PT)-1.0
[**2141-1-2**] 07:40AM BLOOD Glucose-94 UreaN-15 Creat-0.7 Na-134
K-4.1 Cl-101 HCO3-23 AnGap-14
[**2141-1-2**] 07:40AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.1
[**2140-12-29**] 05:54PM BLOOD Lactate-1.6
.
MICRO:
Blood Culture, Routine (Final [**2141-1-1**]):
Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2140-12-29**], 8:33AM.
NEISSERIA MENINGITIDIS. BETA LACTAMASE NEGATIVE.
Blood Culture, Routine (Final [**2141-1-1**]):
NEISSERIA MENINGITIDIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
340-1950R
[**2140-12-26**].
Blood Culture, Routine (Final [**2141-1-2**]): NO GROWTH.
Blood Culture, Routine (Final [**2141-1-3**]): NO GROWTH.
Blood Culture, Routine (Final [**2141-1-4**]): NO GROWTH.
.
CXR [**2140-12-26**]
Subtle left base retrocardiac opacity could relate to
atelectasis, although in the appropriate clinical setting an
early consolidation due to infection is not entirely excluded.
CT Neck with contrast [**2140-12-27**]
1. No evidence of retropharyngeal abscess.
2. Prominent lymph nodes in the carotid spaces, but none are
pathologically enlarged.
3. Ectatic right jugular vein is of unclear significance, and
likely a
chronic finding.
4. Small bilateral pleural effusions and right mid lung
opacification are
better evaluated on concurrent chest CT.
CT Abd/Pelvis/Chest [**2140-12-27**]
1. Findings consistent with multifocal pneumonia involving the
right lung
2. Small-to-moderate bilateral pleural effusions.
3. Soft tissue in the anterior mediastinum likely represents
thymic remnant. This could be confirmed with MRI if clinically
warranted.
4. Gallbladder wall edema without evidence for cholecystitis,
this may
represent third spacing. Please correlate with albumin level.
ECHO
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild global
left ventricular hypokinesis (LVEF = 45-50 %). 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 leaflets are structurally normal. No
mass or vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Brief Hospital Course:
26 F with hx of leukopoenia presents with leukopoenia,
neutopoenia and fever.
.
# Meningitis/Bacteremia: She wasa starteed on broad spectrum
antibiotics including ceftriaxone on admission. An lumbar
puncture was attempted twice but was unsuccessful. However blood
cultures grew neisseria meningitidis. She had high grade fevers
as well as a petechial rash that both improved throughout her
admission. Surveillance blood cultures drawn on several
following days. She did have diffuse myalgias which improved but
did not resolve by the time of her discharge so she was started
on vicodin on discharge. She completed 8 days of ceftriaxone as
per infectious disease recommendations. Follow up with
infectious disease was set up prior to discharge as well as
instructions to return to the emergency department if she had
new fevers headache or neck stiffness.
.
# Volume overload: During this admission she was given
significant volume of IV fluids and she developed significant
peripheral and pulmonary edema. She underwent an echo cardiogram
which showed global systolic dysfunction. Myocarditis was
considered but she did not have an CK, CKMB, or troponin
elevations. This was felt to be stress-induced cardiomyopathy.
The cardiomyopathy, IV fluids and leaky cappiliaries sepsis was
believed to be the cause of her edema. She was diuresed with IV
lasix and she was euvolemic on discharge.
.
# Chronic Neutropenia - She has a history of neutropenia and
presented with a WBC count of 1.4 with 50% polys. She rapidly
developed a robust WBC elevation in the setting of her
infection. Hematology was consulted though no clear cause of her
neutropenia was found. It is unclear if this low initial WBC
count predisposed her to an infection or is only an incidental
finding. She should follow up with hematology/oncology for
further work up.
.
# Transitional Issues
-Follow up pending viral stool cultures
-Follow up with ID in [**12-24**] weeks and you PCP [**Last Name (NamePattern4) **] [**11-21**] weeks and
consider Dermatology follow up if vulvar/perineal rash is not
resolving
Medications on Admission:
none
Discharge Medications:
1. ibuprofen 200 mg Tablet Sig: 2-4 Tablets PO every eight (8)
hours.
2. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain for 1 weeks.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
presumed n. meningitidis Meningitis
Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 8260**],
Thank you for coming to the [**Hospital1 1170**]. You were in the hospital because you had a serious
infection called meningitis and bacteria in your blood. We
treated you with IV antibiotics. We are happy that you are doing
much better. You finished your course of antibiotics and do not
need to continue taking these. You should follow up with the
infectious disease clinic as instructed.
.
You were also noted to have a low white blood cell count. White
blood cells are the cells that fight infections. It is not
likely that this made your infection worse but you should follow
up with the Hematology doctors to make sure you are not at risk
of future infections.
.
Medication Recommendations:
Please START
-Vicodin 1-2 tabs every 4-6 hours as needed for pain
-Ibuprofen 400-800 mg every eight hours as needed for pain
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2141-1-6**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], RNC [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] None
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: TUESDAY [**2141-2-14**] at 9:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2141-1-25**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"995.91",
"275.2",
"276.2",
"782.1",
"780.61",
"285.9",
"428.0",
"036.2",
"036.0",
"275.3",
"275.41",
"428.21",
"429.83",
"288.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10020, 10026
|
7667, 9743
|
297, 303
|
10117, 10117
|
3730, 4819
|
11150, 12109
|
2117, 2306
|
9798, 9997
|
10047, 10096
|
9769, 9775
|
10268, 11127
|
4835, 7644
|
2321, 3111
|
3127, 3711
|
238, 259
|
331, 1465
|
10132, 10244
|
1487, 1576
|
1592, 2101
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,384
| 198,705
|
5730
|
Discharge summary
|
report
|
Admission Date: [**2126-9-18**] Discharge Date: [**2126-10-6**]
Date of Birth: [**2061-11-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Versed
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Stage III A nonsmall cell lung cancer.
Major Surgical or Invasive Procedure:
[**2126-9-18**] Completion Right pneumonectomy with serratus flap
History of Present Illness:
Ms. [**Known lastname 22867**] is a 64-year-old female with a history of stage IIIA
non small cell lung cancer diagnosed in [**2116**] at which time she
underwent neoadjuvant chemotherapy with carboplatin and Taxol,
surgery and then subsequent chemo and radiation. She was doing
well until [**2124-6-5**] when an irregular lesion was found in her
right lower lobe on CT scan. Core needle biopsy revealed it to
be
bronchioalveolar type carcinoma. On her scan at that time there
was also two other areas of ground-glass opacities in the left
upper lobe raising the possibility of multifocal disease. On
[**2124-6-14**], she underwent a reoperative
thoracotomy, pulmonary lysis of adhesions and right lower lobe
wedge resection. Pathology revealed a 3.5 cm well
differentiated adenocarcinoma that was originally identified as
a pT2 N0 Mx lesion, but within the same wedge, a 1-cm satellite
nodule of adenocarcinoma peripheral to the dominant mass was
identified and therefore she was deemed T4. She subsequently
received Gemzar
and Avastin for a total of eight cycles for presumptive adjuvant
therapy. She reports that she did not complete all the Avastin
given some visual changes she was having given her previous
history of stroke. After this time she underwent surveillance
CT scans and most recently had a PET scan in [**2126-7-7**] which
revealed a new nodular abnormality with increased activity in
the right lower lobe. She is being admitted for a Right
completion pneumonectomy.
Past Medical History:
NSCLC stage IIIA s/p neoadjuvant chemo
Open Right upper Lobectomy '[**16**] s/p chemo/radiation
Right lower lobe wedge in [**2124**] for tumor recurrence
Hypertension
Cerebral vascular accident x 2 on coumadin
GERD
Gout/Arthritis
Social History:
Married Lives in [**State 531**].
60 pack-years, quit 16 years ago.
ETOH wine with dinner
Family History:
non-contributory
Physical Exam:
VS: 99.5 97.3 HR(90's - 110's) 110/70 18 96RA FS 97-150
Gen: NAD, AAOx4
Card: irreg irreg, SEM
Lungs: no breath sounds on R; CTA on L
Abd: +BS, soft, nt/nd
wound: c/d/i
ext: no c/c/e
Pertinent Results:
[**2126-9-24**]: Echocardiogram: The left atrium is mildly dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with mid lateral and inferior
hypokinesis. Right ventricular chamber size and free wall motion
are normal. 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. An
eccentric, laterally directed jet of moderate to severe (3+)
mitral regurgitation is seen. Severe [4+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a small pericardial effusion.
[**2126-10-1**] CHEST, PA AND LATERAL
Since yesterday, filling of the right pleural cavity with fluid
progressed. Subcutaneous emphysema on the right slightly
decreased. Central catheter ends in mid SVC. Tiny atelectasis in
the left with tiny pleural effusions are unchanged. No other
change.
[**2126-9-24**] IMPRESSION:
1. Negative examination for pulmonary embolism.
2. Status post right pneumonectomy with multiple air-fluid
levels raising the concern for a fistula between the right
bronchial stump and the right
pneumonectomy space.
3. The hyperdense material in the right pneumonectomy space and
the right
extrathoracic collection are concerning for hemoraghe in the
right
pneumonectomy and extra thoracic hematoma.
4. Extensive subcutaneous emphysema underneath the right breast
tissue and
adjacent to the right lateral chest wall.
5. Small left pleural effusion.
[**2126-10-3**] WBC-8.3 RBC-3.69* Hgb-10.9* Hct-32.9* Plt Ct-761*
[**2126-9-17**] WBC-5.3 RBC-4.20# Hgb-12.6# Hct-38.4# Plt Ct-275
[**2126-10-4**] PT-24.4* INR(PT)-2.4*
[**2126-10-2**] Glucose-93 UreaN-10 Creat-0.4 Na-137 K-4.4 Cl-101
HCO3-30 AnGap-10
[**2126-9-17**] Glucose-98 UreaN-16 Creat-0.6 Na-139 K-4.0 Cl-100
HCO3-30 AnGap-13
[**2126-9-23**] TSH-9.3*
[**2126-10-4**] Digoxin-0.6*
Brief Hospital Course:
Mrs. [**Last Name (STitle) 22868**] was admitted on [**2126-9-18**] for Completion Right
pneumonectomy with serratus flap. She was extubated in the
operating room and transferred to the SICU
for further management. Her pain was well controlled with a
Dilaudid/Bupivicane epidural managed by the acute pain service.
The chest-tube remained clamped and the foley was to gravity.
She remained hemodynamically stable, oxygen saturations were
100% on 3 Liters via nasal cannula and her electrolytes were
repleted. She was started on IV lopressor for tachycardia. On
POD #1 she was transfused with 1 unit PRBC for a Hct of 24. The
chest-tube was removed. Her diet was advanced as tolerated, she
transferred to the floor. On POD #2 she was followed by serial
chest x-rays which remained stable. On POD #3 she developed
atrial fibrillation with a RVR of 130-140's. The beta-blocker
was increased, amiodarone drip was started and her electrolytes
were repleted, and her cardiac enzymes were negative. Her TSH
was mildly elevated in the immediate postoperative state. She
was transfused with 1 unit of PRBC for a Hct of 23 to a Hct of
25. The epidural was removed and she was converted to PO pain
medications. On POD #4 she remained in rapid atrial
fibrillation. Cardiology was consulted who recommended stopping
amiodarone, increasing beta-blockers and starting diltiazem. On
POD #5 she remained in atrial fibrillation, DOE and still
requiring 02 at 4L via nasal cannula for a saturation of 96%. An
echocardiogram revealed mild LVH. mild regional LV systolic
dysfunction, lateral and inferior hypokinesis. No AS or AR.
Moderate to severe (3+) MR, Severe [4+] TR. moderate PA systolic
HTN and a small pericardial effusion. She was ruled out for
Pulmonary Embolism by CT. Her coumadin was restarted. On POD #6
her heart rate was better controlled with PO/IV diltiazem, and
lopressor. On POD #[**8-13**] her IV diltiazem was titrated down. Her
atrial fibrillation remained 80-100's. On POD #9 she was weaned
from the diltiazem drip. Her blood pressure remained stable.
The foley was removed and she voided without difficulty. On POD
#10 her heart rate increased and she was started on digoxin with
better rate control. Her coumadin was held for an elevated INR.
On POD #12 cardiology recommended to continue the diltiazem 60
Q6h, lopressor 100 mg [**Hospital1 **], and digoxin 0.125 daily. She was
seen by Physical Therapy. On POD #13 she developed episodes of
bradycardia with pauses in the 30's. Her digoxin level was 0.6.
Cardiology recommended decreasing the diltiazem and
beta-blockers. She was started on ACE for afterload reduction.
She was transfused to a HCT of 30. On POD #14 her heart rate
increased her meds were adjusted to maintain a heart rate in the
100's. She was continued on her coumadin with goal INR of
2.0-3.0. On POD#15-18, her coumadin was adjusted daily to
maintain INR at goal - she received 1mg daily. Her atrial
fibrillation with RVR continued with HR at times spiking above
140's. She continued to be asymptomatic. Cardiology continued to
follow and give recommendations.
At discharge, the patient's heart medications are as follows:
Metoprolol 62.5mg PO TID
Diltiazem 45mg PO TID
Captopril 12.5mg PO TID
Digoxin 0.125mg PO Qdaily
She will take 1mg of coumadin on [**10-6**], the date of discharge,
and 1mg on [**10-7**]. She will be followed by cardiology for coumadin
maintenance and appropriate lab studies.
Cardiology is planning to contact her on [**10-8**] for further
instructions, regarding her coumadin levels and INR testing, as
well as when to follow up for cardioversion. She and her husband
will be staying in the Holiday Inn on [**Location (un) **], and so will be
close to [**Hospital1 18**] for follow up.
She will follow up with Dr. [**Last Name (STitle) **] in his clinic in a week.
On [**10-6**], the patient and her husband, the nursing staff, and the
thoracic surgery team felt that it was appropriate to discharge
her with close follow-up. She is being discharge stable, in good
condition.
Medications on Admission:
Coumadin 4 daily, except thursday 2 mg, folate 1 mg daily,
fosamax 70 qweekly, MVI, KCl 20meq [**Hospital1 **], zocor 20 daily, ziac
10/6.25 daily, caltrate, senna, colace
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
5. 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*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: take
1 tablet on [**10-6**] and 1 tablet on [**10-7**]; will call with further
instructions on [**10-8**]; goal INR 2.0 - 3.0.
Disp:*30 Tablet(s)* Refills:*2*
8. Levalbuterol Tartrate 45 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) Inhalation q6h PRN as needed for shortness of
breath or wheezing.
Disp:*1 MDI* Refills:*1*
9. Klor-Con 20 mEq Packet Sig: Two (2) PO once a day.
10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
11. caltrate
take as before
12. centrum silver
take as before
13. fiber
take as before
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
16. Diltiazem HCl 30 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
Disp:*135 Tablet(s)* Refills:*2*
17. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. Metoprolol Tartrate 25 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
19. Ativan 0.5 mg Tablet Sig: 0.5 tablet Tablet PO qhs prn as
needed for insomnia for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
NSCLC stage IIIA s/p neoadjuvant chemo
Open Right upper Lobectomy '[**16**] s/p chemo/radiation
Right lower lobe wedge in [**2124**] for tumor recurrence
Hypertension
CVA
GERD
Gout
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if you experience: Fever >
101 or chills, Increased cough or shortness of breath, chest
pain, if your incision develops drainage, if you cough up blood,
experience plapitations or have any lightheadedness, nausea of
vomiting.
You may shower.
No swimming or tub bathing for 6 weeks
No driving while taking narcotics. Continue stool softners with
narcotics.
Cardiology will contact you on Tuesday about your coumadin labs
and dosing, as well as your cardioversion which will take place
2 weeks after this discharge.
If you do not receive a call from cardiology by Tuesday
afternoon, please call the hospital and page cardiology or
[**First Name8 (NamePattern2) 3692**] [**Last Name (NamePattern1) **], the cardiology PA. If you are not able to contact
cardiology, please call the cardiothoracic at [**Telephone/Fax (1) 4741**].
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 4741**], to schedule
a follow up appointment for a week after your discharge. This
will be at the [**Hospital Ward Name 517**] [**Hospital Ward Name 121**] building, [**Location (un) 453**] [**Hospital1 **],
Chest Disease Center.
Please report to the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **]
Radiology Department 30 minutes before your appointment for a
Chest X-Ray
Follow-up with your cardiologist - you will be contact[**Name (NI) **] with
these instructions, as above.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Numeric Identifier 22869**]
Completed by:[**2126-10-6**]
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icd9cm
|
[
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[]
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,068
| 128,182
|
6952
|
Discharge summary
|
report
|
Admission Date: [**2106-2-26**] Discharge Date: [**2106-3-27**]
Date of Birth: [**2034-10-10**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
Resection of C5-C6 intradural mass along with laminectomy
History of Present Illness:
71M with a history of melanoma, s/p wide local excision and
sentinel LN Bx in [**2100**] for 0.8 mm thick, [**Doctor Last Name 10834**] level IV
melanoma located in the R-posterior auricular area admitted with
new metastitic melanoma. In [**2100**], sentinel LN Bx showed melanoma
so pt underwent a complete node dissection with no residual
melanoma documented in the remaining nodes. He did well until
[**2103-1-2**] when a second melanoma, 1.3 mm thick, [**Doctor Last Name 10834**] level IV
was found in the R-submental area. Pt underwent a wide local
excision and sentinel LN Bx with the sentinel LN w/o evidence of
melanoma. Pt then did well until approximately 6 weeks ago. At
that time, he noted increased neck pain and pain in his upper
and lower extremities. The pt saw his PCP at that time who
treated him with NSAIDs and muscle relaxants. However, four
weeks ago, the pt noted two small moles on the right side of his
scalp. He saw his dermatologist who did punch biopsies
consistent with melanoma. At that time, the pt contact[**Name (NI) **] his
oncologist and was referred to Dr. [**Last Name (STitle) 1729**] at [**Hospital1 18**] for further
care. The plan was for the pt to come to [**Hospital1 18**] this week for MRI
and PET scan. However, last Thursday, the pt developed sudden
onset weakness of his lower extremities resulting in a fall. The
pt reports that the strength in his LE returned and he was able
to walk normally over the weekend. However, on Monday, his LE
once again felt very weak and he had trouble walking and a
repeat fall. At that time, he called Dr. [**Last Name (STitle) 1729**] and was advised
to come in for evaluation.
Pt attempted to come to [**Hospital1 18**] but no beds were available so he
went to [**Hospital 1562**] Hospital for further care. At the OSH, he
received a MRI of the cervical spine on [**2-24**] that showed an
enhancing, likely malignant extradural lesion at the level of
mid C5 to mid C6 displacing the sac and cord posteriorly. This
was felt to be consistent with metastitic disease. Screening
sagittal views of the spine demonstrated no other abnormalities.
Pt also underwent a MRI of the brain that showed diffuse age
related changes but no evidence of malignancy. At the OSH, the
pt was placed on emperic Decadron 10 mg IV loading dose followed
by 4 mg IV Q6H. This was continued following the MRI findings.
Pt was also given morphine for pain. He is now transferred to
[**Hospital1 18**] for further oncologic and neurosurgical care.
In further ROS, pt denies fevers and chills. He reports that he
has chronic, intermittent headaches that are unchanged. No CP or
palpitations. No SOB. Pt has a mild cough lately that is rarely
productive of a small amount of sputum. No abdominal pain,
nausea, or vomiting. Good appetite. Pt suffers from occasional
constipation but has moved his bowels in the last couple of
days. No dysuria or hematuria.
Past Medical History:
1. Melanoma: as above; initial diagnosis in [**2100**], 2nd lesion in
[**2103**], 3rd [**2106**]; never had staging CT
2. Cervical DJD
3. HTN treated with Norvasc and Hytrin
4. Osteoporosis Tx w/Fosamax
5. Hyperactive bladder Tx w/Detrol
6. BPH
Social History:
Pt is married and lives with his wife in [**Name (NI) 1562**]. He is a
retired investment banker. No ETOH, tobacco, or drug use.
Family History:
Brother who is alive and well. No history of melanoma or cancers
Physical Exam:
PE:
VS: 97.9 150/80 72 20 96% RA
Gen: Pleasant man resting in bed. NAD.
HEENT: NC AT. PERRL. EOMI. Anicteric sclera. MMM. No lesions in
the oropharynx.
Neck- Supple. Scar on right from previous melenoma and lymph
node disection. No cervical or supraclavicular lypmhadenopathy.
Lungs: CTAB. No wheezes, rales, or rhonchi.
CV: Distant heart sounds. RRR. No m,r,g.
Abd: Obese. Soft. Mildly distended (pt reports is baseline). NT.
Positive bowel sounds. No appreciable organomegaly. Guiac
negative.
Extr: No c/c/e. 1+ DP pulses bilaterally.
Neuro: Alert and oriented x3. CN II-XII intact. 4/5 strength
right upper extremity. 5/5 strength left upper extremity. [**3-6**]
strength right lower extremity. 4/5 strength left lower
extremity. Normal rectal tone.
Pertinent Results:
Labs on Admission:
135 / 101 / 20 131
------------< 131
4.2 / 28 / 0.7
Ca: 8.8 Mg: 2.1 P: 2.9
ALT: 17 AP: 48 Tbili: 0.3 Alb: 4.0
AST: 13 LDH: 201
MCV= 88 WBC=15.0 HgB=14.8 Plt=304 Hct=43.2
PT: 13.1 PTT: 22.1 INR: 1.1
Discharge labs:
[**2106-3-24**] 06:58AM BLOOD WBC-8.2 RBC-3.97* Hgb-11.6* Hct-34.0*
MCV-86 MCH-29.3 MCHC-34.2 RDW-16.4* Plt Ct-326
[**2106-3-24**] 06:58AM BLOOD Plt Ct-326
[**2106-3-26**] 04:53AM BLOOD Glucose-93 UreaN-19 Creat-0.4* Na-139
K-3.9 Cl-102 HCO3-31* AnGap-10
Cardiac Enzymes:
[**2106-3-8**] 01:30AM BLOOD CK-MB-5 cTropnT-<0.01
[**2106-3-7**] 05:29PM BLOOD CK-MB-5 cTropnT-<0.01
[**2106-3-7**] 08:37AM BLOOD CK-MB-7 cTropnT-<0.01
[**2-27**] ct chest, abd, pelvis:
CT OF THE CHEST WITH IV CONTRAST: Small axillary lymph nodes,
but none of
them meet CT criteria for pathology. The largest one on the
right side
measures 5 mm and the largest one on the left side measures 6
mm. There are 2
enlarged mediastinal lymphnodes. The largest one is located on
series 3 image
18, and measures 1.7 mm in the precarinal region. The other one
is
pretracheal and measures 1.4 cm.There are no significant hilar
lymph nodes.
The heart and great vessels are unremarkable. There is a
subcutaneous soft
tissue density seen on series 3 image 9 that measures 7 mm in
the anterior
chest wall. In the setting of melanoma, this could represent
metastasis.
Innumerable lung nodules consistent with metastasis. The largest
one in the
right upper lobe measures 1.4 x 1.4 cm. There are no pleural
effusions and no
evidence of pneumothorax.
CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is a
hypodense lesion
in the segment 7 of the right lobe of the liver that measures
2.7 x 2.1 cm and
could represent a liver metastasis. There are also 2 possible
faint lesions
in the left lobe of the liver. One of them is in the segment 2
of the liver
just on the left side of the falciform that is too small to
characterize.
There is right adrenal nodule that measures 2.0 x 1.4 cm. It
measures 50
Hounsfield units in the noncontrast images and could represent
metastasis, but
is not well characterized in this study. There is a nodule
(series 3 image
48) in the paraspinal region that may represent metastasis. Just
above it
(series 2 image 44), there is a increased density adjacent to
the diaphragm.
that could represent a small pleural effusion or less likely
could represent
metastatic disease. The kidneys and left adrenal gland are
unremarkable. The
pancreas is unremarkable. The ureters are unremarkable. The
small and large
bowel appears unremarkable. In the abdomen, there is a lymph
node in the left
paracolic gutter (series 4 image 46) that measures 8 mm and is
of a normal
significance. It could represent a small lymph node or
metastatic disease. In
the right lower quadrant just below the right kidney, there is
another nodule
that measures 7 mm (series 4 image 48). There is also a lymph
node. Multiple
other small mesenteric lymp nodes are seen, but none of them
meet CT criteria
for pathology.
CT OF THE PELVIS WITH ORAL AND IV CONTRAST: The urinary bladder,
distal
ureters, prostate, and seminal vesicles are unremarkable. The
rectum and
intrapelvic bowel loops are unremarkable. There are small mid
iliac lymph
nodes that do not meet CT criteria for pathology. The largest
one located in
the right side (series 4 image 63) measures 8 mm and contains a
fatty hilum.
Small inguinal lymph nodes do not meet CT criteria for
pathology. The largest
one is located on the right inguinal region and measures 8 mm.
BONE WINDOWS: No obvious destructive lesions seen.
IMPRESSION:
1) Innumerable pulmonary nodules consistent with metastasis.
2) Enlarged mediastinal lymph nodes could represent metastasis.
3) Soft tissue subcutaneous lesion in the subcutaneous tissue of
the anterior
chest wall, may represent metastasis.
4) Hypodense lesion in the right lobe of the liver is suspicious
for
metastasis.
5) Paraspinal lymph node on the right side is suspicious for
metastasis.
6) Right adrenal nodule not well characterized in this study,
may represent
metastasis.
7) Multiple mesenteric small abdominal lymph nodes.
[**2-27**] MRI cervical spine:
CT OF THE CHEST WITH IV CONTRAST: Small axillary lymph nodes,
but none of
them meet CT criteria for pathology. The largest one on the
right side
measures 5 mm and the largest one on the left side measures 6
mm. There are 2
enlarged mediastinal lymphnodes. The largest one is located on
series 3 image
18, and measures 1.7 mm in the precarinal region. The other one
is
pretracheal and measures 1.4 cm.There are no significant hilar
lymph nodes.
The heart and great vessels are unremarkable. There is a
subcutaneous soft
tissue density seen on series 3 image 9 that measures 7 mm in
the anterior
chest wall. In the setting of melanoma, this could represent
metastasis.
Innumerable lung nodules consistent with metastasis. The largest
one in the
right upper lobe measures 1.4 x 1.4 cm. There are no pleural
effusions and no
evidence of pneumothorax.
CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: There is a
hypodense lesion
in the segment 7 of the right lobe of the liver that measures
2.7 x 2.1 cm and
could represent a liver metastasis. There are also 2 possible
faint lesions
in the left lobe of the liver. One of them is in the segment 2
of the liver
just on the left side of the falciform that is too small to
characterize.
There is right adrenal nodule that measures 2.0 x 1.4 cm. It
measures 50
Hounsfield units in the noncontrast images and could represent
metastasis, but
is not well characterized in this study. There is a nodule
(series 3 image
48) in the paraspinal region that may represent metastasis. Just
above it
(series 2 image 44), there is a increased density adjacent to
the diaphragm.
that could represent a small pleural effusion or less likely
could represent
metastatic disease. The kidneys and left adrenal gland are
unremarkable. The
pancreas is unremarkable. The ureters are unremarkable. The
small and large
bowel appears unremarkable. In the abdomen, there is a lymph
node in the left
paracolic gutter (series 4 image 46) that measures 8 mm and is
of a normal
significance. It could represent a small lymph node or
metastatic disease. In
the right lower quadrant just below the right kidney, there is
another nodule
that measures 7 mm (series 4 image 48). There is also a lymph
node. Multiple
other small mesenteric lymp nodes are seen, but none of them
meet CT criteria
for pathology.
CT OF THE PELVIS WITH ORAL AND IV CONTRAST: The urinary bladder,
distal
ureters, prostate, and seminal vesicles are unremarkable. The
rectum and
intrapelvic bowel loops are unremarkable. There are small mid
iliac lymph
nodes that do not meet CT criteria for pathology. The largest
one located in
the right side (series 4 image 63) measures 8 mm and contains a
fatty hilum.
Small inguinal lymph nodes do not meet CT criteria for
pathology. The largest
one is located on the right inguinal region and measures 8 mm.
BONE WINDOWS: No obvious destructive lesions seen.
IMPRESSION:
1) Innumerable pulmonary nodules consistent with metastasis.
2) Enlarged mediastinal lymph nodes could represent metastasis.
3) Soft tissue subcutaneous lesion in the subcutaneous tissue of
the anterior
chest wall, may represent metastasis.
4) Hypodense lesion in the right lobe of the liver is suspicious
for
metastasis.
5) Paraspinal lymph node on the right side is suspicious for
metastasis.
6) Right adrenal nodule not well characterized in this study,
may represent
metastasis.
7) Multiple mesenteric small abdominal lymph nodes.
[**3-6**] head MRI:
EXAM: MRI of the brain.
CLINICAL INFORMATION: The patient with melanoma and
postoperative confusion.
TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility, and
diffusion axial
images of the brain were obtained.
FINDINGS: There is no evidence of acute infarct seen on
diffusion-weighted
images. Severe brain atrophy is identified. There is evidence of
blood
products in the posterior portion of both lateral ventricles
with fluid-fluid
levels. Additionally, air is seen in both lateral ventricles and
also in the
frontal region, which could be secondary to recent surgery.
Small amount of
blood is also seen in the posterior fossa involving the
subarachnoid space.
There is no evidence of midline shift seen. Moderate ventricular
prominence
is visualized. There is no periventricular edema seen.
IMPRESSION: Blood products are seen within the ventricles and
subarachnoid
space, which could be postoperative in nature. Small amount of
air is seen in
the lateral ventricle and frontal subarachnoid space, which
could be also
postoperative in nature. No acute infarct is seen.
[**3-6**] head CT:
COMPARISON: MRI performed 3 hours prior.
FINDINGS: As described in the recent MRI, there is a small
amount of layering
hemorrhage within the lateral ventricles. In addition, punctate
foci of
subarachnoid hemorrhage are visualized within both
temporoparietal regions.
Small foci of gas are visualized in the frontal regions as well
as lateral
ventricles. There is no hydrocephalus, mass effect, or shift of
the normally
midline structures. Visualized osseous structures and paranasal
sinuses are
unremarkable.
IMPRESSION:
Small amount of intraventricular and subarachnoid hemorrhage as
above.
Additional foci of gas within the lateral ventricles and frontal
regions.
These findings may be postoperative in nature. These results
were conveyed to
the neurosurgical house staff covering for the patient.
[**3-8**] CTA chest:
CT CHEST WITH INTRAVENOUS CONTRAST: The pulmonary arterial
vasculature is
well visualized down to the segmental branches. No definite
filling defects
are identified. The heart, pericardium and great vessels are
visualized
within normal limits. There has been interval development of
small bilateral
pleural effusions. No pericardial effusion is identified. Again
identified
are multiple enlarged mediastinal lymph nodes, the largest
located within the
pretracheal region measuring 15 mm. There has also been interval
development
of a large prevascular lymph node, which measures 10mm. No
pathologically
enlarged axillary or hilar lymph nodes are seen.
There has been interval development of bibasilar
collapse/consolidation.
Additionally seen are multiple small bilateral pulmonary
nodules, which are
not significantly changed since the prior examination,
consistent with
metastatic disease. The airways are patent to the level of the
segmental
bronchi bilaterally. An endotracheal tube is seen, with tip in
appropriate
location in the trachea.
In the imaged portion of the upper abdomen, again demonstrated
is a hypodense
lesion within the right lobe of the liver, not significantly
changed since the
prior examination. The visualized spleen and stomach appear
unremarkable.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
present.
CT RECONSTRUCTIONS: Coronal and sagittal reconstructions were
essential in
delineating the pulmonary arterial vasculature.
IMPRESSION:
1) No definite CT evidence for pulmonary embolism.
2) Interval development of bibasilar consolidation/collapse with
small
bilateral pleural effusions.
3) Interval increase in size and number of mesenteric lymph
nodes. Relatively
stable appearnace of multiple small pulmonary nodules consistent
with
metastatic disease.
4) Stable appearance of hypodensity within the right lobe of the
liver
suspicious for a metastasis
[**3-10**] MRI C-spine:
PROCEDURE: An MRI of the cervical spine with and without
contrast.
INDICATION: Spinal canal lesion status post excision.
COMPARISON: Comparison is made to previous examination of
[**2106-2-27**].
TECHNIQUE: Sagittal and axial T1 and T2, as well as
post-gadolinium, T1 axial
and sagittal images of the cervical spine were performed.
MRI OF THE CERVICAL SPINE WITH AND WITHOUT CONTRAST: There has
been interval
resection of the previously described intradural extramedullary
lesion at the
C5-C6 level. The patient is status post C4 through C6 posterior
laminectomy.
On the current study, central increased signal intensity is
identified within
the spinal cord at the site of prior resection at the C5-C6
level. This was
appreciated on the prior exam, but due to severe compression on
that
examination, it is difficult to appreciate whether this amount
of edema has
increased. Post-surgical changes are noted in the area of prior
laminectomy.
No cord compression is appreciated on the current exam. There is
a small
amount of linear enhancement seen along the anterior margin of
the spinal cord
at the resection site, which may indicate post- surgical change
but residual
tumor cannot be excluded at this site.
Vertebral body alignment and signal intensity is normal. No
prevertebral soft
tissue abnormality is seen.
IMPRESSION:
1. Status post excision of intradural, extramedullary mass at
the C5-C6 level
with decompression of the spinal canal.
2. Spinal cord edema at the level of resection, seen on previous
exam but
unclear whether increased as the spinal cord had been severely
compressed.
3. Small amount of linear enhancement along the anterior portion
of the cord
at the resection site. This could indicate post-surgical change
but the
possibility of residual tumor cannot be excluded.
[**3-10**] head CT:
TECHNIQUE: Noncontrast head CT.
FINDINGS: There is a stable amount of high attenuation layering
fluid in the
lateral ventricles consistent with hemorrhage. The previously
noted punctate
foci of increased attenuation within both temporoparietal lobes
has decreased,
consistent with resolving subarachnoid hemorrhage. There are no
new areas to
indicate intra- or extra-axial hemorrhage. There is no shift of
midline
structures. The [**Doctor Last Name 352**]-white matter differentiation remains
intact. The
ventricles are overall stable in size. Previously described
pneumocephalus
has resolved. New from the prior study, is opacification of the
ethmoid air
cells, maxillary sinuses, and sphenoid sinus. This may be
related to the
interval intubation.
IMPRESSION: Stable small amount of intraventricular hemorrhage
with decreased
subarachnoid hemorrhage and resolution of pneumocephalus. Sinus
opacification
likely related to intubation.
[**3-16**] head CT:
INDICATION: Patient with recent removal of intradural
extramedullary lesion
in cervical spine, post-operative subarachnoid hemorrhage.
Follow up, and
query hydrocephalus.
COMPARISON: Head CT [**2106-3-10**].
FINDINGS: Again, noted is small amount of layering high-density
fluid within
the lateral ventricles, which is slightly decreased. The
ventricles and sulci
remain stable in size. No regions of intracranial hemorrhage are
seen. There
is no shift of normally midline structures, and the [**Doctor Last Name 352**]/ white
matter
differentiation is unchanged. Opacification in the ethmoid,
sphenoid, and
maxillary sinuses is essentially unchanged. Osseous structures
are
unremarkable.
IMPRESSION: No significant interval change.
[**3-17**] head CT:
INDICATION: 71-year-old man with known metastatic melanoma
status post spinal
surgery, now with acute mental status changes, nonverbal.
TECHNIQUE: Noncontrast enhanced CT scan.
FINDINGS: The study is being compared to prior examination dated
[**2106-3-16**]. No significant changes are seen compared to prior
examination. Please
refer to prior report for complete detail of findings. No change
in the
amount of intraventricular hemorrhage is noted.
IMPRESSION: No significant interval change compared to prior
exam dated [**3-16**], [**2106**].
[**3-25**] MRI T and L spine:
INDICATION: A 71-year-old man with metastatic melanoma, recent
resection of
cervical spine intradural mass, now with possible incontinence.
TECHNIQUE: Multiplanar T1, T2, inversion recovery images of the
thoracic
spine; multiplanar T1, T2, and inversion recovery images of the
lumbar spine.
COMPARISON: None.
THORACIC SPINE MRI: There is kyphosis of the midthoracic spine,
however,
vertebral body signal is within normal limits. No abnormal
signal is detected
within the spinal cord. There is no expansion of the cord or
spinal stenosis.
There is mild right pleural thickening.
LUMBAR SPINE MRI: Vertebral body alignment and signal is within
normal
limits. The distal spinal cord, and conus medullaris also have
normal signal
characteristics. The cauda equina roots are aggregated and
anteriorly
displaced; additionally, there is a region of abnormal signal
within the
spinal canal at the S2-S3 level.
IMPRESSION:
1. Thoracic spine MRI: No cord compression seen.
2. Lumbar spine MRI: Abnormal signal within the most distal
portion of the
spinal canal, with aggregation and displacement of the cauda
equina roots.
This is concerning for arachnoiditis; the focus of abnormal
signal in the
distal spinal cord can represent a drop metastasis. Clinical
correlation is
requested.
[**3-17**]: LP positive for malignant cells-melanoma
Brief Hospital Course:
Mr. [**Known lastname 26122**] is a 71 year-old man with past medical history
significant for melanoma (3 separate lesions) s/p wide local
excision who presented on this admission with recurrent melanoma
and a probable met from mid C5 to C6 displacing sac and cord
posteriorly. The patient was initially admitted to the OMED
service and then transferred to the neurosurgical service for
resection of intradural C5-C6 mass. After resection, patient
developed respiratory distress secondary to pneumonia requiring
intubation and was transferred to the MICU. Patient then
transferred to the medical floor. This discharge summary is a
reconstruction from the medical record of the hospital course
during the neurosurgical and ICU stays since discharge summaries
were not dictated by those services. OMED course dictated and
included here (only first 2 days of course.) Course after [**3-14**]
known first-hand to this writer. Admitted to OMED on [**2-26**],
transferred to neurosurgery on [**2-27**]. Transferred to MICU on [**3-8**]
for respiratory distress secondary to pneumonia, intubated.
Extubated on [**3-10**]. To floor on [**3-14**].
1. Spinal lesion at C5-6 w/cord displacement: Felt to be most
consistent with metastasis of the pt's recurrent melanoma.
Neurosurgery was contact[**Name (NI) **] upon admission. The decision was
made not to take patient to emergent neurosurgery given his
dismal prognosis and extensive metastatic disease. Radiation
onocology was contact[**Name (NI) **] to evaluate if radiation therapy would
be appropriate but felt that their role was limited and that
neurosurgical option was preferrable. Decision with respect to
treatment options was made with primary oncologist,
neurosurgery, and radiation oncology. Patient reported few week
history of severe right-sided weakness
associated with mild left-sided weakness. This progressed to the
point that his right lower extremity was paretic, and the motor
strength of his right upper extremity was anywherebetween 2-4/5.
Metastatic disease/melanoma was identified onCT of the chest,
abdomen and pelvis, and a lesion on the MRIof his cervical spine
which seemed to be extramedullary but intradural. After
extensive discussion, including the
prognosis, neurosurgery decided to proceed with debulking of the
tumor.
Following that, the risks and the benefits, especially thechance
of being paralyzed were discussed, and the patientwanted to
proceed. Posterior cervical laminectomy, C4, C5, C6, resection
of extramedullary intradural spinal cord tumor was performed.
Surgery was successful without significant complications.
Patient was started on decadron on admission and it was
continued throughout hospital course. Pathology returned
consistent with metastasis of melanoma. Patient noted on
subsequent head CT's to have blood in ventricles which as per
neurosurgical service was to be expected post-operatively.
Patient was closely monitored for neuro changes and evidence of
hydrocephalus. Repeat head Ct's did not demonstrate evidence of
hydrocephalus and serial neuro exams were unchanged.
Post surgery, patient's admission complaint of right-sided
weakness mildly improved and remained stable. Some left sided
weakness as well.
2. Metastatic Melanoma: He has had 3 separate melanoma lesions
which have been excised (most recently 6 weeks ago). Staging CT
on admission showed extensive metastatic disease throughout
chest and abdomen. Resection of intradural extramedullary met
as above. Patient maintained on decadron throughout hospital
course. On [**3-23**] question of possible bowel/bladder
incontinenece. MRI of L and T spine obtained on [**3-25**] and
demonstrated drop mets in cauda equina. LP on [**3-17**] returned
positive cytology for melanoma. Given leptomeningeal
involvement, extensive mets, patient's prognosis poor, likely a
few months.
Dr. [**Last Name (STitle) **], oncologist, covering for Dr. [**Last Name (STitle) 1729**], was made
aware of new CNS findings and treatment options were
re-considered. At this time, no good treatment options available
and prognosis grim.
Future plan is to have patient complete rehab course. At that
time, if patient regains sufficient strength, radiation and
potential chemotherapy will be considered. Thus will need to
routinely assess patient's progress at rehab and re-address
treatment options as well as possible Hospice if patient not
improving at rehab/re-gaining strength. Rad-onc and Dr. [**Last Name (STitle) 1729**]
of oncology aware. It is very unlikely that there are treatment
options from here, but Dr. [**Last Name (STitle) 1729**] should be contact[**Name (NI) **] to update
progress.
As noted above, patient followed with daily neuro exams which
did not significantly change while the patient was on the
medical service. He continues to have right-sided weakness
which is slightly improved post surgery.
Steroids should be tapered by 1 gram per dose per week.
3. Respiratory Failure: After resection of intradural mass,
patient developed respiratory distress on [**3-8**] requiring
intubation and transfer to Medical ICU. After extensive work-up
including infecious, negative CTA for PE, ultimately felt to be
due to pneumonia, most likely aspiration. The patient had
self-d/ced his NGtube while getting tubefeeds. The patient was
extubated on [**3-10**]. He was treated with 14 day course of
vancomycin and Zosyn. Patient was gradually weaned from
supplemental oxygen and by [**3-20**] was satting well on room air.
He was largely asymptomatic, exam was much improved and repeat
chest x-rays demonstrated resolution of pneumonia.
4. HTN: Pt was mildly hypertensive on admission. Norvasc was
initially continued in-house. Post operatively while on
neurosurgical and MICU services, patient's blood pressure became
difficult to control. Incrementally, medications were added.
Ultimately, the patient required norvasc, metoprolol, captopril
and hydralazine to effectively control pressures. Captopril
switched to lisinopril on [**3-24**]. Patient's blood pressure
becoming more labile over [**Date range (1) 26123**]. Some blood pressure meds
have been held by parameters but continuing on current regimen.
5. Mental Status: Patient's mental status waxed and waned
throughout hospital course. Post-operatively and in MICU s/p
extubation the patient's orientation varied. He was often
confused and demonstrated varying levels of delirium. Altered
mental status attributed to sedating meds, pneumonia, long
hospital course and metastatic melanoma. Additionally,
developed hyponatremia secondary to SIADH. Narcotics and
sedating meds were limited, hyponatremia, pneumonia were
treated. Neurology was consulted on [**3-8**] and followed patient
until [**3-16**]. On [**3-17**] patient was found to be more confused,
lethargic and there was concern for acute event. Patient had
extensive work-up at that time including repeat head CT, LP,
EKG, ABG, toxic-metabolic work-up which revealed no significant
new cause of altered mental status. Gradually over the course
of [**3-17**] and [**3-18**] the patient's mental status returned to
previous baseline. Ceftazidime was given for 2 days around this
period after LP returned large number of white cells with
lymphocytic predominance. Patien already on vanc/zosyn at that
time, but ceftaz started given good BBB penetration. Ultimately,
however, in consultation with neurology and neurosurgery,
determination was made that given patient afebrile with no new
significant signs or symptoms, infectious meningitis was not
likely. White cells consistent with inflammation from surgery.
Large number of red cells also consistent with prior surgery and
blood in ventricles from surgery. Gradually patient's mental
status improved and by [**Date range (1) 26124**] patient was less confused and
more consistently oriented. He did continue to have some
confusion, but his delirium was improving. Narcotics continue
to be limited, patient requires occasional re-orientation.
Demonstrates some delirium but is generally oriented,
re-directable and logical in thought process. Of note, HSV from
LP still pending at time of discharge.
6.Hyponatremia: Patient developed hyponatremia secondary to
SIADH. Resolved with fluid restriction by [**3-16**]. As above, felt
to be contributory to altered mental status.
7. Hyperactive bladder-Detrol was initially continued, but then
stopped. Pai
8. BPH: Hytrin was continued in-house.
9. Thrombocytopenia: During the patient's MICU course, noted to
be thrombocytopenic. Had been on heparin flushes. Thought to
be secondary to hit, although hit antibody negative x 2.
Serotonin assay sent and pending at this time. All heparin
products were stopped. Thrombocytopenia resolved from that time.
By discharge platelets stable in 300,000's. No significant
bleeding complications.
No heparin products.
10. Goals of care: Multiple meetings with patient, wife, health
care team held to determine goals of care. Patient has
expressed desires to minimize treatments and maximize palliative
efforts. Given his continued delirious state, however, wife's
input as spouse and health care proxy is also determinant of
future care. At this point, mutual agreement has been made to
pursue rehabilitation and then re-assess goals of care and
treatment option at that point. We have explained very grim
prognosis, especially after CNS findings/leptomeningeal
involvement. Likely very limited treatment options. Need to
consider hospice if patient not doing well, regaining strength
at rehab. The medical team following including PCP will need to
be involved in evaluating patient while at rehab with possible
transition to hospice care if patient not regaining strenght or
deteriorating.
11. CODE STATUS: After extensive discussion with patient's
wife, patient made DNR/DNI on [**3-26**].
Medications on Admission:
Meds on Admission:
1. Norvasc 5 mg daily
2. Hytrin 10 mg QHS
3. Fosamax
4. Detrol 2 mg daily
5. Advil PRN
6. Decadron at the OSH
7. Morphine at the OSH
.
Allergies:
NKDA. However, pt reports that he had severe difficulty
urinating following general anesthesia in the past.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Terazosin HCl 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
5. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
10. Acetaminophen 160 mg/5 mL Elixir Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
12. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
HS (at bedtime) as needed for confusion/sleep.
18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
19. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO three
times a day.
20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
malignant melanoma, pneumonia, hyponatremia, hypertension,
delirium
Discharge Condition:
Stable, residual right hemiparesis, restricted diet
Discharge Instructions:
Contact MD if you develop chest pain, shortness of breath or if
you experience any new weakness or sensory changes or any other
concerning symptoms.
Follow-up as below. All medications as prescribed.
Followup Instructions:
Patient should be seen by PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] while he is at
rehab. His number is [**Telephone/Fax (1) 26125**].
Patient will be considered for further chemotherapy and
radiation pending his progress at rehab. Progress should be
communicated to Dr. [**Last Name (STitle) 1729**]. He should be called at [**0-0-**]
to be updated about progress of rehabilitation. If patient
progresses significantly and regains strength, treatment options
would be considered for melanoma. At this point, there are no
realistic treatment options. As nearing discharge, appointment
with Dr. [**Last Name (STitle) 1729**] will need to be made.
Dr. [**Last Name (STitle) 26126**] [**Name (STitle) **], hospitalist, or Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], intern
can be contact[**Name (NI) **] with questions. Dr. [**First Name (STitle) **] can be contact[**Name (NI) **] by
calling [**Hospital1 18**] and asking operator to contact her. Dr.
[**Last Name (STitle) **] can be reached through [**Telephone/Fax (1) 250**].
|
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26,136
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3721+3722+55501
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2144-3-21**] Discharge Date: [**2144-4-20**]
Date of Birth: [**2070-6-18**] Sex: F
Service:
CHIEF COMPLAINT: Transfer from [**Hospital3 **] with a
left hip fracture.
HISTORY OF PRESENT ILLNESS: The patient is a 73 year-old
female with end stage renal disease on hemodialysis since
[**2141**], secondary to diabetes mellitus. She has atrial
fibrillation and several other medical and surgical problems
and is a resident of an [**Hospital3 **] facility, who at
baseline has a history of mechanical falls and is a fall
risk. She most recently fell on [**2144-3-16**] (mechanical fall)
and was admitted to [**Hospital3 **] where she was
diagnosed with a left intratrochanteric fracture of the
femur. She was given morphine for pain and has had altered
mental status since then. Per her [**Hospital3 **]
discharge summary, the patient had a pharmacology stress
test, which was normal as well as ruled out for myocardial
infarction by serial enzymes. The patient was placed on a
heparin drip for deep venous thrombosis prophylaxis and was
transferred to the [**Hospital1 69**] for
further evaluation/surgery.
PAST MEDICAL HISTORY:
1. End stage renal disease secondary to diabetes mellitus,
on hemodialysis since [**2141**].
2. Diabetes mellitus type 2 - diabetic neuropathy, diabetic
retinopathy.
3. Hypertension.
4. Question peripheral vascular disease.
5. Gastroesophageal reflux disease.
6. Atrial fibrillation (has a history of rapid atrial
fibrillation).
7. Congestive heart failure ? diastolic. EF of greater then
55% in [**4-28**].
8. Coronary artery disease. Per OMR in [**2136**] she had clean
coronaries by cardiac catheterization.
9. Glaucoma.
10. Hypercholesterolemia.
11. Depression.
12. Vertebral compression fractures.
13. Ligation of left AV graft secondary to ulna steel
phenomenon.
14. Breast cancer (left DCIS) status post lumpectomy.
15. Osteoarthritis.
16. History of Klebsiella bacteremia in [**4-28**].
17. Question restrictive lung disease.
18. Left ulnar nerve palsy secondary to steel phenomenon
from left forearm AV graft.
PAST SURGICAL HISTORY:
1. Total abdominal hysterectomy.
2. Left third toe amputation, gangrene with focal chronic
osteomyelitis.
3. Left partial mastectomy for left DCIS in 7/98.
4. [**3-/2141**] vitreous hemorrhage, retinal detachment of left eye
status post partial vitrectomy.
5. [**6-/2141**] right brachial cephalic AV fistula and right IJ
Quinton catheter.
6. [**8-/2141**] carotid right IJ. Removal and insertion.
7. [**1-29**] right IJ Tesio hemodialysis catheter.
8. [**4-28**] removal/insertion of right IJ Tesio catheter
secondary to Klebsiella bacteremia.
9. [**5-29**] removal/insertion of right IJ Tesio secondary to
malfunction.
10. [**11-29**] left forearm AV graft with [**Doctor Last Name 4726**]-Tex.
11. [**12-29**] ligation of left AV graft secondary to steel
phenomenon.
ALLERGIES:
1. Codeine (Percocet/Darvocet) - THE PATIENT IS VERY
SENSITIVE TO ANY NARCOTICS. SHE WILL HAVE A DECREASE MENTAL
STATUS FOR TWO TO THREE DAYS POST ADMINISTRATION OF SMALL
DOSES OF NARCOTICS.
2. Penicillin.
3. Sulfa.
4. Question Verapamil (no documented reaction or history).
MEDICATIONS ON ADMISSION (PER OMR IN [**10-29**]):
1. Effexor XR 150 mg po q.h.s.
2. Lactulose 30 cc po q.o.d.
3. Lipitor 20 mg po q.h.s.
4. Lopresor 25 mg po b.i.d./t.i.d.
5. Nephrocaps one cap po q.d.
6. Prevacid 15 mg po q.a.m.
7. Renagel 800 mg po t.i.d.
SOCIAL HISTORY: The patient lives at an [**Hospital3 **]
facility.
CONTACTS: The patient's primary contact should be is [**Name (NI) **]
work number is 1-[**Numeric Identifier 16782**]. [**Doctor First Name 16783**] home
number is [**Telephone/Fax (1) 16784**]. Her cell phone number is
[**Telephone/Fax (1) 16785**].
PHYSICAL EXAMINATION ON ADMISSION: Temperature 100.4. Blood
pressure 140/70. Pulse 98. Respiratory rate 20. O2
saturation 96% on room air. In general, she was awake,
oriented only to person. Her HEENT poor dentition. Mucous
membranes are moist. Oropharynx is pink. Cardiovascular
irregularly irregular 1 to 2/6 systolic murmur. No elevated
JVP. Chest bilaterally clear to auscultation, bilateral
basilar crackles. No wheezing. Abdomen soft, nontender,
nondistended, positive bowel sounds, normal bowel sounds
times four quadrants. Extremities bilateral lower
extremities are warm, no edema. Skin right neck with
hemodialysis line intact, no erythema of skin. No
tenderness. Stage 1 sacral decubitus ulcers.
LABORATORY DATA ON ADMISSION: White blood cell count is 7.9,
hemoglobin 10.1, hematocrit 33.7. (Baseline 32 to 34% on
[**12-29**]). Mean corpuscular volume 103, RDW 15, platelets 187,
PT 13.4, INR 1.2, sodium 141, potassium 4.5, chloride 107,
Bicarb 20, BUN 26, creatinine 4.6 (baseline is 3.8 to 8.3
through [**2143**]), glucose 253, ALT 11, AST 15, alkaline
phosphatase 162 (baseline is 156 to 180 through [**2142**]-[**2143**]),
total bilirubin is 0.6, albumin 3.4, calcium 9.1, phosphorus
3.6, magnesium 1.8.
DATA: Echocardiogram on [**4-28**] mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 13385**], mild left
ventricular hypertrophy, EF greater then 55%. Physiologic
(normal) mitral regurgitation, trivial tricuspid
regurgitation, left ventricular retinal wall motion is
normal. Holter ([**3-1**]) - atrial fibrillation with average
ventricular response. No symptoms during monitoring.
IMPRESSION ON ADMISSION: This patient is a 73 year-old
female with end stage renal disease on hemodialysis and
atrial fibrillation who suffered a mechanical fall and is now
transferred to [**Hospital1 69**] for a
left intratrochanteric hip fracture. She had a low grade
temperature currently question infectious etiology. Blood
cultures were drawn on admission. Orthopedic surgery was
consulted for evaluation and recommendations. For evaluation
of her left hip AP pelvis and AP true lateral films of the
left hip were done. Preoperative cardiac assessment of this
patient revealed a history with no coronary artery disease,
but positive hypertension, positive hypercholesterolemia, but
a clean catheterization in [**2136**]. Cardiac risk gratification
for noncardiac surgical procedures was intermediate to high
with orthopedics surgery with a reported cardiac risk of
generally less then 5%. The patient had a Persantine
(pharmacologic) stress test at [**Hospital3 **], which was
negative on [**2144-3-18**]. The official report from [**Hospital3 16786**] was reviewed. The patient subsequently had a very
extensive prolonged medical stay for approximately one month.
The following is a date synopsis of the major events during
her hospital admission.
[**2144-3-22**]: The patient was admitted. Patient with low grade
fever 100.4, white blood cell count was normal at 7.9.
[**2144-3-22**]: The patient was in the preop orthopedics area prior
to surgery. Became hypotensive with rapid atrial
fibrillation, heart rates in the 140s to 150s. The patient
was taken back to the floor, and intravenous Diltiazem was
pushed. Blood cultures that were taken on admission
subsequently grew out gram positive coxae. The patient was
started on Vancomycin empirically.
[**2144-3-23**]: Right IJ Perm-A-Cath pulled by transplant surgery.
[**2144-3-24**]: Temporary line number one was placed in her right
groin by renal.
[**2144-3-26**]: Question of endocarditis. PTE is negative.
[**2144-3-28**]: Temporary groin line number one in the right
femoral area was discontinued by renal.
[**2144-3-31**]: Question infectious fossae from the gram positive
coxae bacteremia, which has subsequently grown out to be
MRSA. White blood cell scan was obtained to evaluate for
septa fossae given the fact that the patient had a right
temporary groin line in, has an old left AV [**Doctor Last Name 4726**]-Tex graft.
The white blood cell scan was negative or any septic fossaei.
It showed increased uptake in the bone marrow (consistent
with infectious process), and increase uptake in the sacral
area, consistent with her sacral decubitus ulcers.
[**2144-3-30**]: Nasogastric tube was placed. Tube feeds and po
medications administered this way.
[**2144-3-31**]: Temporary right groin line hemodialysis number two
was placed.
[**2144-4-2**]: Transplant surgery is unable to place a left or
right IJ or right subclavian. Procedure was aborted in the
Operating Room.
[**2144-4-2**]: Left open reduction and internal fixation, DHS by
orthopedics surgery procedure. No problems or complications.
[**2144-4-4**]: Left IJ Perm-A-Cath placed by transplant surgery.
Postoperatively, the patient had increased white blood cells
in urine, hypotensive. The patient was neo-synephrine.
Transferred to the MICU. Since her blood cultures from [**3-21**]
through [**3-25**] were positive, since [**2144-3-25**] cultures have been
negative.
[**2144-4-5**]: Urine cultures are growing out proteus. Blood
cultures are with gram negative bacteremia in the MICU. The
patient was started on Levofloxacin. The patient was also
weaned off neo-synephrine.
[**2144-4-7**]: The patient is growing out gram positive coxae in
her blood cultures. Presumed to be enterococcus, started on
Linezolid given her recent hip surgery as well as
Port-A-Cath.
[**2144-4-8**]: The patient was transferred back to the floor
hemodynamically stable.
[**2144-4-9**]: Infectious disease was reconsulted.
[**2144-4-10**]: PICC was placed on the right basilic vein. Right
groin line (was pulled).
[**2144-4-11**]: Left Perm-A-Cath is malfunctioning. There was no
flow. Hemodialysis was aborted.
[**2144-4-13**]: Interventional radiology replaced a Perm-A-Cath in
the same site.
[**2144-4-14**]: IR had to change the Perm-A-Cath again, ? puncture
of the first Perm-A-Cath they placed when changing over a
guidewire.
[**2144-4-15**]: The patient developed a right common femoral vein,
superficial femoral vein deep venous thrombosis.
[**2144-4-17**]: Increased alkaline phosphatase to the 190s. Right
upper quadrant ultrasound showed gallstones, in common bile
duct 3 mm, no acute process.
[**2144-4-18**] - [**2144-4-19**]: The patient's INR is therapeutic.
Heparin was discontinued.
HOSPITAL COURSE: 1. Orthopedic: The patient has a left
intratrochanteric hip fracture. It was repaired by
orthopedic surgery with a left open reduction and internal
fixation and dynamic hip screw on [**2144-4-2**]. The patient
tolerated the procedure well. No problems.
2. Cardiovascular: The patient has a history of atrial
fibrillation, with a history of rapid ventricular response.
Various times throughout the admission she has required 10 to
20 mg if intravenous Diltiazem to bring her rate down. She
is currently stable on a po (via nasogastric tube) regimen of
Metoprolol 50 mg po t.i.d.
3. Renal: The patient has end stage renal disease on
hemodialysis. Hemodialysis is typically done on Tuesday,
Thursday, Saturday. She has had numerous transplant catheter
Perm-a-Cath issue as dated above with the time line synopsis.
She currently has a left sided Perm-A-Cath, which is
functioning well.
4. Prophylaxis: The patient was placed on a PPI, and then
switched to PPI intravenous when she was not taking po and
then was changed to H2 blocker via her nasogastric tube.
Because she is a renal patient Lovenox should not be used as
the levels cannot be monitored. The patient was initiated on
a heparin drip with various therapeutic levels, when she
developed the right femoral vein/right common femoral
vein/right superficial femoral vein deep venous thrombosis.
Her right thigh was greatly enlarged and tender to palpation.
She was started on Coumadin and was therapeutic on Coumadin
times two days before the heparin was discontinued. Per
orthopedic recommendations the patient is to remain
anticoagulated for six weeks postoperatively. The patient's
surgery was on [**2144-4-2**], and she should be anticoagulated for
six weeks postoperatively. Recommend reultrasound of her
right thigh in six weeks to determine the
presence/absence/resolution of deep venous thrombosis. Given
the fact that this patient is nonmobile, she is likely to
need anticoagulation or prophylactic anticoagulation with
subQ heparin for the time that she is immobile/decreased
mental status/not walking/nonmobile at all. Of note, her
right popliteal vein is patent.
5. Allergies/adverse reactions: The patient is exquisitely
sensitive to narcotics. 1 mg of morphine causes this patient
to have decreased mental status for approximately one to two
to three days. Narcotics (Darvocet/Percocet/morphine) should
be judiciously avoided in this patient.
6. Pulmonary: Throughout this patient's entire admission
her oxygen saturation has remained 95 to 100% on room air.
She shows no signs of aspiration pneumonia, though she is an
aspiration risk. Recommend keeping her bed at 30 degrees to
45 degrees and using all aspiration precautions. Serial
chest x-rays were obtained on this patient, which have been
negative for any pneumonia. She does have coarse breath
sounds anteriorly, which sounds like transmitted upper airway
sounds.
7. Left foot drop: The patient has a left foot drop, which
is consistent with a peroneal nerve distribution. MRI of the
lumbosacral spine was obtained to evaluate for any anatomic
abnormalities. The MRI showed numerous compression fractures
in L3-S1 region, but no distinct abnormalities that would
cause a specific foot drop. Her foot drop is likely
secondary to compression from behind her knee, during
orthopedic surgery or secondary to placement of her legs
while she was [**Date Range **]. No nerve conduction studies were done.
8. Decreased mental status: The patient has had a decreased
mental status since admission on [**2144-3-21**]. She has had
numerous CTs, white blood cell scans of her head, which have
all revealed no evidence of subdural hematomas, no
intracranial or axial hemorrhage, no evidence of any
infarcts. There are no mass lesions or any shift effect. Her
decreased mental status is likely secondary to her
toxic/metabolic state. A lumbar puncture was considered,
however, the patient's mental status has been improving over
the week prior to discharge and she is now able to state her
name and communicate somewhat though this does wax and wane.
It is anticipated that her mental status should clear
somewhat as her medical condition improves, however, and she
has a depressed mental status times one month, question how
much toxic metabolic recovery she will have.
9. MRSA/bacteremia: The patient completed Vancomycin
treatment times twelve days. In addition, after the patient
was placed on Linezolid this would also cover MRSA bacteremia
as well.
10. Proteus urinary tract infection, causing sepsis: The
patient completed a two week cousre of Levofloxacin.
11. VRE bacteremia: The patient is to finish completing a
two week cousre of Linezolid. This cousre will end on
[**2144-4-23**].
12. Anticoagulation: The patient is to continue
anticoagulation for six weeks [**Last Name (LF) **], [**First Name3 (LF) **] [**2144-4-2**] orthopedics
surgery. Recommend continuing PPI/H2 blocker.
13. Right deep venous thrombosis, common femoral vein,
superficial femoral vein, with a greatly enlarged right
thigh: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter was considered for prophylaxis
against pulmonary embolis. However, it is thought that the
patient had her heparin turned on and off intermittently for
different procedures and though her heparin levels were
therapeutic, question of whether she had transient
subtherapeutic levels that were not detectable by laboratory,
which may have contributed to her TPT. It is recommended she
discontinue all anticoagulation.
14. FEN: The patient is being given tube feeds
(nephro/renal diet) per nutrition recommendations. The
patient has had an nasogastric tube in her nose since
[**2144-3-30**]. If the patient's mental status does not improve
within the next month, ? consideration of a PEG. When the
patient is more awake recommend a bedside speech and swallow
evaluation for this patient. She is NPO except for ice chips
right now. She is an aspiration risk and her head of the bed
should be elevated at 30 degrees to 45 degrees. She showed
no signs of aspiration pneumonia at this time.
15. Hypoglycemia: The patient is on regular insulin sliding
scale. Her finger sticks have been in the range from the
100s to 250. Recommend continuing insulin sliding scale. If
her blood glucose level is greater then 200 consistently,
recommend starting low dose of NPH.
16. Elevated alkaline phosphatase: Total bilirubin is
normal. The patient has a history of increased alkaline
phosphatase. A GGT level was obtained, which was 114. Right
upper quadrant ultrasound revealed gallstones, but no
gallbladder wall thickening and a common bile duct of 3 mm.
No cholecystitis. No abdominal pain, no right upper quadrant
tenderness. Abdominal examination has been benign.
17. Code status: The patient is full code per her families
wishes.
DISCHARGE DISPOSITION: The patient is to be discharged to a
rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Atorvastatin 20 mg po q.h.s.
2. Tylenol 325 to 650 mg po q 4 to 6 hours prn.
3. Miconazole powder b.i.d. prn.
4. Linezolid 600 mg po q 12 hours times three days through
[**2144-4-22**].
5. Ranitidine 150 mg po q.d.
6. Metoprolol 50 mg po t.i.d.
7. Coumadin 2.5 mg po q.h.s.
8. Regular insulin sliding scale.
9. Epoetin 3000 units subQ three times per week (Monday,
Wednesday and Friday).
DISCHARGE INSTRUCTIONS:
1. INR levels should be checked q day to monitor for
variations. She is to be kept therapeutic with an INR level
between 2 to 3. If her INR is stabilized, INR can be checked
q week. She is to be anticoagulated for six weeks [**Month/Day/Year **]
orthopedic surgery.
2. The patient requires hemodialysis for her end stage renal
disease. Typically on Tuesday, Thursday, Saturday. This is
to be arranged by renal/hemodialysis team.
3. The patient has low grade fevers and it is recommended
that she recieve blood cultures times two, urinalysis via
straight catheter as well as urinary culture.
4. If mental status has not improved in the next several
weeks recommended PEG tube for administration of medications
as well as tube feeds.
DISCHARGE DIAGNOSES:
1. MRSA bacteremia.
2. VRE bacteremia.
3. Proteus urinary tract infection leading to sepsis/proteus
bacteremia.
4. Left intratrochanteric hip fracture.
5. End stage renal disease on hemodialysis.
6. Atrial fibrillation, with RVR.
7. Altered mental status.
8. Left foot drop.
9. Vertebral compression fractures.
10. Diabetes mellitus type 2.
11. Hypertension.
12. Gastroesophageal reflux disease.
13. Question congestive heart failure, EF is approximately
80%. Left ventricular systolic function was hyperdynamic.
Trivial mitral regurgitation, tricuspid regurgitation, left
atrium mildly dilated. This is per an echocardiogram done on
[**2144-3-26**].
14. Status post numerous Perm-A-Cath placements/removal.
15. Right deep venous thrombosis.
16. Elevated alkaline phosphatase of unknown significance.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 16787**]
MEDQUIST36
D: [**2144-4-20**] 10:00
T: [**2144-4-20**] 10:27
JOB#: [**Job Number 16788**]
Admission Date: [**2144-3-21**] Discharge Date: [**2144-4-20**]
Date of Birth: [**2070-6-18**] Sex: F
Service:
ADDENDUM: Additional final discharge diagnoses of sacral
decubitus ulcers, stage 2. Recommend the patient be
alternated from side to side to avoid pressure in this area.
Avoid supine position as much as necessary. Sacral area
should be checked every q two to three days to evaluate for
progression/infection of the sacral decubitus ulcers.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**First Name3 (LF) 16789**]
MEDQUIST36
D: [**2144-4-20**] 10:14
T: [**2144-4-20**] 11:52
JOB#: [**Job Number 16790**]
Name: [**Known lastname **], [**Known firstname 779**] Unit No: [**Numeric Identifier 2641**]
Admission Date: [**2144-3-21**] Discharge Date: [**2144-4-20**]
Date of Birth: [**2070-6-18**] Sex: F
Service:
STAT DISCHARGE SUMMARY - ADDENDUM #2
TAG THIS ONTO THE FIRST DISCHARGE SUMMARY, JOB #[**Numeric Identifier 2642**]
HOSPITAL COURSE BY SYSTEMS:
1. ? Peripheral vascular disease. The patient had cool
extremities, nonpalpable pulses. Bilateral arterial dopplers
were obtained. Impression was vessels are noncompressible.
Normal triphasic doppler signals at the posterior tibialis as
well as dorsalis pedis levels, suggests no appreciable
arterial disease. However, this was a limited study due to
patient discomfort.
[**First Name8 (NamePattern2) 399**] [**Last Name (NamePattern1) 400**], M.D. [**MD Number(1) 401**]
Dictated By:[**Dictator Info 2643**]
MEDQUIST36
D: [**2144-4-20**] 13:50
T: [**2144-4-20**] 14:24
JOB#: [**Job Number 2644**]
|
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41,976
| 179,418
|
35279
|
Discharge summary
|
report
|
Admission Date: [**2201-12-31**] Discharge Date: [**2202-1-3**]
Date of Birth: [**2136-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Fever, hypotension
Major [**First Name3 (LF) 2947**] or Invasive Procedure:
[**1-2**] PICC line placement
[**1-3**] PICC line replacement
History of Present Illness:
Mr. [**Known lastname 8182**] is a 65-year-old gentleman with a complicated PMH
including CVA (nonverbal and does not move arms/legs at
baseline), afib on warfarin, h/o chronic aspiration and multiple
PNA (s/p trach/PEG [**3-/2200**]), multiple prior episodes of
UTI/urosepsis with drug-resistant organisms, C diff s/p
colectomy, DM2, PVD, and several recent admissions for
UTI/sepsis, who presents now with fever to 101, leukocytosis to
27.7, one episode of vomiting earlier today, and question of
aspiration. He was given a dose of tylenol in his nursing home
prior to transfer. He was brought to ED by ambulance from his
nursing home.
.
In the ED, initial vitals were 97.6 67 101/64 18 99% 2L.
Patient reported left chest pain as he is able to nod yes or no.
Labs notable for WBC 23.7 with 87% N. UA showed mod leuk, tr
bld, neg nitr, 7 RBC, 101 WBC, mod bacteria, no epis. EKG was
sinus at 69, LAD, RBBB, c/w prior per report. CXR revealed
infiltrates concerning for pneumonia. He received broad
spectrum antibiotics including levaquin, vancomycin 1 gram, and
cefepime 2 grams. He was initially assigned a floor bed, but
his BP dropped to mid 80's systolic. A 18G was placed on the
right with a 20G on the left. He was bolused with IVF for a
total of 3L. Was admitted for treatment of PNA and UTI. Most
recent vitals prior to transfer were 64 101/64.
.
Of note, patient has had several recent admissions, including
admission to [**Hospital Unit Name 153**] in [**2202-11-17**]/11 with urosepsis treated with
vancomycin and meropenem, and Medicine [**Date range (1) 80455**] with
UTI/sepsis treated with ceftriaxone and a right cold foot felt
to be secondary to vasospasm, that did not require [**Date range (1) **]
intervention. Patient received pain control, was seen by
Vascular surgery, and had return of palpable pulses during the
admission.
.
Upon arrival to the MICU, his vital signs were T 36.1, p 72, bp
116/67, r 11, 94% trach mask. On interview, he acknowledged that
he was in some discomfort but indicated that it was not in his
chest, abdomen, extremities, or genital area. Interview was
limited by his inability to respond beyond nodding yes/no, and
he was only responsive to very simple questions.
Past Medical History:
* Hypertension
* Hypothyroidism
* H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**])
* Type II Diabetes mellitus
* Peripheral neuropathy
* Depression
* h/o DVT (? - no [**Hospital1 18**] records)
* Atrial fibrillation (on coumadin)
* Peripheral vascular disease
* Hyperlipidemia
* Anemia of chronic disease
* Tracheostomy and GJ tube for chronic aspiration ([**3-/2200**]) -
Portex Bivono, Size 6.0
* C.diff colitis in [**1-29**] requiring total abdominal colectomy
with end ileostomy [**1-29**], repeat positive C diff toxin [**2200-5-20**]
(outside facility, [**12/2198**] here)
Social History:
Resident of [**Hospital 16662**] Nursing Home, previously at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
Family very involved in care. Patient does not take anything by
mouth due to history of aspiration. Spanish-speaking. Patient is
a former 60 pack year smoker but quit in [**2183**].
Family History:
Patient has a mother with diabetes and brother with heart
disease.
Physical Exam:
GENERAL: well-appearing in NAD, comfortable, appropriate
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK: supple, no cervical LAD, no JVD, no carotid bruits
LUNGS: CTAB, no wheezing/rales/rhonchi, good air movement,
respirations unlabored, no accessory muscle use
HEART: RRR, nl S1-S2, no r/m/g
ABDOMEN: normoactive bowel sounds, soft, NT, ND, no
organomegaly, no guarding or rebound tenderness
EXTREMITIES: warm, well-perfused, no edema, 2+ peripheral pulses
SKIN: no rashes or lesions
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-24**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
On discharge:
VSS, HR in mid 50s, pressures 110-120/60s
Complains of right leg pain when asked, but pulses strong and no
open lesions. Otherwise as above.
Pertinent Results:
Admission Labs:
[**2201-12-31**] 06:10PM LACTATE-1.0 K+-4.7
[**2201-12-31**] 06:00PM GLUCOSE-140* UREA N-33* CREAT-0.7 SODIUM-145
POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-30 ANION GAP-15
[**2201-12-31**] 06:00PM estGFR-Using this
[**2201-12-31**] 06:00PM WBC-23.7*# RBC-5.62 HGB-12.5* HCT-40.2
MCV-72* MCH-22.3* MCHC-31.2 RDW-16.1*
[**2201-12-31**] 06:00PM NEUTS-87.0* LYMPHS-8.9* MONOS-3.1 EOS-0.8
BASOS-0.2
[**2201-12-31**] 06:00PM PLT COUNT-212
[**2201-12-31**] 06:00PM PT-17.1* PTT-32.6 INR(PT)-1.6*
[**2201-12-31**] 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2201-12-31**] 06:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2201-12-31**] 06:00PM URINE HYALINE-4*
[**2201-12-31**] 06:00PM URINE HYALINE-4*
.
Other relevant labs:
[**2202-1-1**] 03:33AM BLOOD WBC-12.1* RBC-4.32* Hgb-9.8* Hct-31.4*
MCV-73* MCH-22.7* MCHC-31.1 RDW-16.2* Plt Ct-181
[**2202-1-2**] 07:55AM BLOOD WBC-7.9 RBC-4.38* Hgb-9.6* Hct-32.8*
MCV-75* MCH-22.0* MCHC-29.4* RDW-16.3* Plt Ct-167
[**2202-1-2**] 07:55AM BLOOD PT-19.3* PTT-31.2 INR(PT)-1.8*
[**2202-1-2**] 07:55AM BLOOD Vanco-18.3
[**2202-1-2**] 05:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2202-1-2**] 05:00PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2202-1-2**] 05:00PM URINE RBC-2 WBC-7* Bacteri-FEW Yeast-NONE Epi-0
CXR [**2201-12-31**]:
New bibasilar opacities, with low lung volumes. Considerations
include pneumonia in the appropriate clinical setting, but
atelectasis or even aspiration could be considered depending on
clinical circumstances.
.
[**1-3**] CXR:
FINDINGS: Tip of right PICC terminates in the lower superior
vena cava. The tip of the catheter is about 3.3 cm below the
level of the radiodense
guidewire, which terminates in the mid superior vena cava.
Tracheostomy tube remains in standard position. Stable
cardiomegaly, and improving pleural effusion and left basilar
atelectasis.
.
MICROBIO:
[**12-31**] Blood cult1ure x 2: Negative to date
[**12-31**] Urine: URINE CULTURE (Final [**2202-1-1**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
[**12-31**] and [**1-1**] Sputum: GRAM STAIN (Final [**2202-1-1**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS
SPP..
Unable to definitively determine the presence or absence
of commensal
respiratory flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
[**12-31**] Legionella: Negative
Studies pending at Discharge:
[**1-2**] Urine Cx
Brief Hospital Course:
65-year-old gentleman, nonverbal status post a prior stroke with
residual paraplegia status post trach/PEG, atrial fibrillation
on warfarin, history of chronic aspiration and multiple
pneumonias, urinary tract infections and sepsis with
drug-resistant organisms admitted with pneumonia, sepsis, and
possible urinary tract infection
.
#Septic Shock/Pneumonia/Urinary tract infection:
Patient was initially admitted to the MICU with fluid responsive
hypotension. He had a dirty UA and chest X-ray consistent with
pneumonia. He was empirically treated with Vancomycin and
Cefepime with improvement in his hypotension and leukocytosis
(initially 27 but normal on discharge). A PICC line was placed
to complete an 8 day course of Vancomycin/Cefepime for health
care associated pneumonia which was felt to cover urinary
pathogens as well. Sputum grew Proteus. Although urine culture
was pending at time of discharge, the overall clinical
improvement suggested that any urinary pathogens would be
sensitive to Vancomycin and Cefepime. Urine culture however
should be followed at rehab. Given chronic Foley catheter if
urine culture is positive would consider treating for two weeks
with antibiotics to cover urinary sources and Foley should be
changed at next Urology appointment.
..
#Diabetes mellitus: Continued on home glargine and ISS
.
# Depression: Continued on Duloxetine and Mirtazapine
.
# Atrial fibrillation: Continued on Warfarin. INRs were mildly
subtherapeutic at 1.8
.
# Pain, probably neuropathic: Pt complained of right leg pain.
Pulses were strong and there was no wound. Pt continued on
Fentanyl, Morphine, Tylenol, Gabapentin, and Cymbalta.
.
# Hypothyroidism: Continued Levothyroxine
.
# Sacral decubitus ulcer: Healing. Would continued wound care
with frequent repositionings and dressings daily as needed.
.
.
Code status: DNR/DNI.
.
TRANSITIONAL:
1) Complete antibiotics-Last day: [**1-8**] if urine culture
negative, [**1-14**] if urine culture positive.
2) Follow up with urology for consideration of suprapubic
catheter placement given recurrent urinary tract infections and
sepsis
3) Follow up sensitivities for proteus positive sputum culture
and enteroccocus urinary tract infection with adjustment of
antibiotic course as dictated by urine culture
Medications on Admission:
MEDICATIONS (per [**2201-12-9**] d/c summary):
1. fentanyl 75 mcg/hr Patch 72 hr [**Month/Day/Year **]: One Patch 72 hr
Transdermal Q72H (every 72 hours).
2. mirtazapine 15 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO HS (at
bedtime).
3. insulin glargine 100 unit/mL Solution [**Month/Day/Year **]: Thirty Two (32)
units Subcutaneous at bedtime.
4. insulin sliding scale, continue insulin sliding scale as
prior to admission
5. senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed for constipattion.
6. Cymbalta 30 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One
capsule, Delayed Release(E.C.) PO once a day: g/j tube.
7. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization [**Month/Day/Year **]: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
8. baclofen 10 mg Tablet [**Month/Day/Year **]: 1.5 Tablets PO QID (4 times a
day).
9. docusate sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: One (1) PO HS (at
bedtime).
10. levothyroxine 25 mcg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY.
11. coumadin 4mg coumadin daily
12. gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO every 8
hours.
13. ascorbic acid 500 mg/5 mL Syrup [**Month/Day/Year **]: One (1) PO BID
14. therapeutic multivitamin Liquid [**Month/Day/Year **]: One (1) Tablet PO DAILY
15. zinc sulfate 220 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO DAILY
16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
18. magnesium hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
19. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
20. furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
21. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback [**Last Name (STitle) **]:
One (1) Intravenous Q24H (every 24 hours) for 7 days.
22. morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: Ten (10) mg PO Q6H (every
6 hours) as needed for pain.
23. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
Discharge Medications:
1. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
2. insulin glargine 100 unit/mL Solution [**Last Name (STitle) **]: Thirty Two (32)
units Subcutaneous at bedtime.
3. Humalog 100 unit/mL Solution [**Last Name (STitle) **]: sliding scale Subcutaneous
QACHS: Continue insulin sliding scale.
4. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Last Name (STitle) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization [**Last Name (STitle) **]: One (1) inh Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
7. baclofen 10 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO QID (4 times a
day).
8. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2
times a day).
9. levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. warfarin 4 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
11. gabapentin 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q8H (every
8 hours).
12. ascorbic acid 500 mg/5 mL Syrup [**Last Name (STitle) **]: Five (5) mL PO twice a
day.
13. cefepime 1 gram Recon Soln [**Last Name (STitle) **]: One (1) gram Injection Q12H
(every 12 hours): Completed after [**1-8**].
14. vancomycin in D5W 1 gram/200 mL Piggyback [**Month/Year (2) **]: One (1) gram
Intravenous Q 12H (Every 12 Hours): Finished after [**1-8**].
15. multivitamin Liquid [**Month/Year (2) **]: One (1) dose PO once a day.
16. zinc sulfate 220 (50) mg Capsule [**Month/Year (2) **]: One (1) Capsule PO
once a day.
17. heparin, porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Flush with
10mL Normal Saline followed by Heparin as above daily and PRN
per lumen. .
18. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
19. magnesium hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
mL PO once a day as needed for constipation.
20. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Rectal at bedtime
as needed for constipation.
21. furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
22. morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: 10mg PO Q6H (every 6
hours) as needed for pain.
23. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
24. fentanyl 100 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Transdermal
every seventy-two (72) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **]
Discharge Diagnosis:
Primary: Sepsis from UTI and possibly Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive, non-verbal, but
able to answer questions with nods and shakes and follows
commands.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname 8182**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted for sepsis that was found to be most likely from your
urine and possibly from your lungs. You were given fluids and
IV antibiotics which improved your infection. A PICC line was
placed so that you may take these antibiotics at your extended
care facility.
You should follow up with urology regarding evaluation for
suprapubic catheter placement as this may decrease your episodes
of urinary tract infection and sepsis.
Changes to your medications:
STARTED Vancomycin
STARTED Cefepime
STOPPED Ceftriaxone
Followup Instructions:
The following appointments were made for you:
Department: [**Hospital1 **] SPECIALTIES
When: WEDNESDAY [**2202-1-6**] at 10:30 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name 706**] CARE UNIT
When: WEDNESDAY [**2202-1-27**] at 8:30 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Street Address(1) 706**]
When: WEDNESDAY [**2202-1-27**] at 10:00 AM [**Telephone/Fax (1) 8243**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Completed by:[**2202-1-4**]
|
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"V58.61",
"401.9",
"584.9",
"438.89",
"311",
"995.92",
"276.3",
"707.03",
"V44.0",
"285.9",
"250.60",
"272.4",
"357.2",
"707.20",
"599.0",
"427.31",
"038.9",
"244.9",
"486",
"V58.67",
"V12.51",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15107, 15206
|
7544, 9818
|
15298, 15298
|
4594, 4594
|
16166, 17033
|
3646, 3714
|
12290, 15084
|
15227, 15277
|
9844, 12267
|
15517, 16056
|
3729, 4418
|
7209, 7487
|
7501, 7521
|
4432, 4575
|
16085, 16143
|
264, 405
|
433, 2657
|
4610, 7168
|
15313, 15493
|
2679, 3298
|
3314, 3630
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,191
| 175,521
|
42584
|
Discharge summary
|
report
|
Admission Date: [**2179-2-3**] Discharge Date: [**2179-2-5**]
Date of Birth: [**2109-6-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
chest pressure/pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Ms. [**Known lastname 88403**] is 69 yo female with numerous cardiac risk factors
(HTN, HLD, smoking, +FHx) as well as AFib and SSS s/p pacemaker
who presented to [**Hospital3 1443**] ED this AM with chest
pressure. Symptoms started around 4am, when she woke up with
left-sided substernal chest pressure/tightness, non-radiating,
[**2177-2-27**] in severity. There was no associated shortness of breath,
nausea, vomiting or diaphoresis. When the pain did not go away,
she called the ambulance. In the ambulance she received NTG
SLx3, which made the pain resolve. In the ED, she was
hypertensive to >200 and started on NTG gtt for chest pain and
HTN. While on the NTG gtt, she reported L arm
discomfort/pressure and midsternal burning, which resolved with
uptitration of the drip. Initial EKG showed T wave changes in
aVL, but repeat EKG later in AM showed TWI in II,III,aVF, and
V3-V6. Labs significant for: Trop T <0.01, 0.35, 0.46 [ref range
0.01-0.04]; CK 59, 84, 87; MB 7, 7; MBI 8,8. D-dimer elevated to
0.61 so pt had V/Q scan which found low probability of PE.
Patient given ASA 325mg, Lopressor, morphine, Plavix loaded.
Prior to transfer to [**Hospital1 18**] for cath, she developed nausea which
was treated with Zofran.
.
On arrival to [**Hospital1 18**] CCU, patient is hemodynamically stable,
hypertensive to 160/100 on NTG gtt. She complains of persistent
nausea but denies chest pain, arm/jaw pain, shortness of breath,
or diaphoresis. EKG unchanged from prior. Labs show Trop T 0.39,
CK 85, MB 7.
.
Patient denies recent h/o anginal symptoms: no recent chest
pain, dyspnea on exertion, etc. She did have a similar episode
of chest pressure 2-3 years ago, for which she was worked up for
PE (CTA negative). She notes chronically decreased exercise
tolerance since getting her pacemaker 4 years ago. Per her
report, she had a nuclear stress test 3 months ago for health
maintenence purposes, which was completely normal.
.
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:
-Paroxysmal AFib (on flecainide, off coumadin)
-SSS with pacemaker
-HTN
-HLD
-Hypothyroidism
-Raynaud's syndrome
Social History:
Pt is retired lab worker. Divorced, lives alone at home. Former
smoker (1 pack/week, quit 25 years ago). Drinks ~1 bottle of
wine per week. Denies illicits.
Family History:
Mother died of CAD (age 58). Aunt with stroke. No known FHx HTN,
HLD, arrythmias, cardiomyopathies, sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: pleasant F who appears uncomfortable [**1-28**] nausea, AAOx3.
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 JVD of 3 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAM: unchanged from admission exam
Pertinent Results:
ADMISSION LABS:
WBC-6.5 RBC-3.55* Hgb-11.7* Hct-34.1* MCV-96 MCH-32.8* MCHC-34.2
RDW-12.1 Plt Ct-149*
PT-9.9 PTT-69.4* INR(PT)-0.9
Glucose-133* UreaN-18 Creat-0.8 Na-141 K-4.0 Cl-106 HCO3-26
AnGap-13
Calcium-8.9 Phos-3.3 Mg-2.2
ALT-37 AST-41*
.
CARDIAC ENZYMES:
[**2179-2-4**] 12:00 AM: CK (CPK) 85, MB 7, Trop T 0.39*
[**2179-2-4**] 06:07 AM: CK (CPK) 77, MB 6, Trop T 0.21*
.
ECHO ([**2179-2-4**]): The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No clinically-significant valvular disease seen.
.
CHEST X-RAY ([**2179-2-4**]): Heart size is moderately enlarged.
Mediastinum is unremarkable. Lungs are essentially clear with no
pleural effusion and pneumothorax. There is no evidence of
pulmonary edema. Left-sided pacemaker is placed with two leads,
one of them terminating most likely in the right atrium and the
other one in the right ventricle. The right ventricle lead makes
a loop most likely within the posterolateral aspect
of the right atrium. No pneumothorax.
Brief Hospital Course:
# CHEST PAIN: Pt with multiple cardiac risk factors including
HTN, HLD, cigarettes and +FHx presenting with new-onset
substernal chest pressure. Symptoms improved with SL NTG and
resolved with initiation of NTG gtt + morphine bolus. Troponins
peaked at 0.46, CK 87, MB 7. Initial EKG without changes at OSH,
but repeat EKG showed TWI in II,III,aVF and V3-V6. Per OSH
records she was hypertensive to SBP>200 in the ED. Patient's
TIMI score was 5, putting her at 12% risk of death/MI at 2
weeks, and 26% risk of death/MI/urgent revascularization at 2
weeks. She was Plavix loaded and started on heparin gtt and NTG
gtt at OSH. Prior to cath, she was also treated with home
metoprolol tartrate 100mg PO BID (goal HR 60-70), atorvastatin
80mg PO daily, ASA 325mg PO daily, and Plavix 75mg PO daily, and
she was weaned off NTG gtt. She underwent cardiac cath on the
morning of [**2-4**], which showed mild CAD, LVEDP of 22, and anatomic
anomoly (bronchial arteries take off from RCA with AV
malformation). No interventions were performed. Patient did well
after cath, with no recurrence of chest pain or nausea. It was
felt that given that she had had SBP>200 at OSH, her chest pain
was most likely [**1-28**] hypertensive emergency. Therefore, on
discharge she was started on Lisinopril in addition to her home
Metoprolol for better control of blood pressure. She will also
continue her home dose of atorvastatin 40mg daily and ASA 325mg
daily. Patient agreed to purchase a BP cuff and monitor her
blood pressure regularly at home.
.
#.Nausea: patient c/o persistent nausea starting 2-3 hours prior
to arrival at [**Hospital1 18**] CCU. No evolving EKG changes or increasing
enzymes. Nausea most likely [**1-28**] morphine and NTG. Resolved with
zofran + ativan, and did not recur once NTG discontinued.
.
#.AFib: Per patient, she is no longer on Coumadin as her
cardiologist found that she only has paroxysmal afib. Her home
Flecainide was held in the setting of concern for NSTEMI; home
metoprolol and ASA were continued. Once NSTEMI had been ruled
out via cath, her home flecainide was restarted. Heart rate
well-controlled throughout hospitalization.
.
#.Sick Sinus Syndrome: patient has pacemaker, and is sinus paced
on EKG. Pacer interrogation was normal.
.
#.HTN: patient hypertensive to 160 on NTG gtt and home
metoprolol on arrival. Given that her chest pain was most likely
[**1-28**] hypertensive emergency ([**Last Name 788**] problem #1), she was discharged
on Lisinopril in addition to her home Metoprolol 100mg [**Hospital1 **].
.
#.HLD: patient on lipitor 20mg at home. She is discharged on
atorvastatin 40mg daily.
.
#.Hypothyroidism: continued home levothyroxine.
.
TRANSITION OF CARE:
1. Needs Chem 10 checked in 1 week because started Lisinopril
2. Please note RCA AVM found on cardiac cath.
Medications on Admission:
-ASA 325mg PO daily
-Simvastatin 20mg PO daily
-Metoprolol tartrate 100mg PO BID
-Flecainide 100mg PO BID
-Levothyroxine 100mcg PO daily
-Fish oil
-Vitamin C
-Calcium+D
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. flecainide 100 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Outpatient Lab Work
Please check A1C and potassium on Tuesday [**2-9**] at 2:30p
at Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 92136**] office
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Chest Pain
Hypertensive urgency
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had chest pain that did not result in a heart attack. We are
not sure why you had chest pain but it might be because of high
blood pressure. An echocardiogram showed normal heart function
and a cardiac catheterization did not show any acute blockages.
We have started a new medicine to lower your blood pressure
further which is called lisinopril. This medicine can sometimes
raise your blood potassium level so we would like you to get
your potassium checked at Dr.[**Name (NI) 92137**] office next week. A
prescription was written for this, please bring it to your appt.
.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Address: [**Street Address(2) **]
[**Hospital1 3597**] [**Numeric Identifier 20777**]
Phone: [**Telephone/Fax (3) 92138**] fax
Date/Time: please call the office on Monday for an appt
.
Name: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD
Specialty: Internal Medicine
When: Tuesday [**2-9**] at 2:30p
Address: [**Apartment Address(1) 92139**], [**Location (un) **],[**Numeric Identifier 92140**]
Phone: [**Telephone/Fax (1) 92141**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
[
"443.0",
"244.9",
"427.31",
"272.4",
"V45.01",
"427.81",
"V17.3",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9500, 9557
|
5842, 8652
|
321, 346
|
9648, 9648
|
4225, 4225
|
10403, 11108
|
2994, 3117
|
8872, 9477
|
9578, 9627
|
8678, 8849
|
9799, 10380
|
3157, 4150
|
4487, 5819
|
262, 283
|
374, 2667
|
4241, 4470
|
9663, 9775
|
2689, 2804
|
2820, 2978
|
4175, 4206
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,493
| 140,127
|
49541
|
Discharge summary
|
report
|
Admission Date: [**2148-6-20**] Discharge Date: [**2148-6-25**]
Date of Birth: [**2102-7-10**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Erythromycin Base / Nsaids / Lisinopril / Lipitor
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
45-year-old Female with lupus nephritis s/p living related renal
x-plant in [**2136**] who presented with right flank pain for the past
4 days. She has had rising creatinine over the last couple of
months and had a biopsy in [**2147-2-11**] with evidence of chronic
allograft nephropathy. She is currently undergoing another
transplant evaluation from another brother as she is chronically
rejecting.
.
On admission, the patient reported 3-4 days of right flank pain.
She described the pain as a burning [**11-19**] pain, without
significant radiation, located over the flank and the back
approximately at the level of the iliac crest. She denied any
pain over her transplanted kidney. She had been tolerating POs
without any n/v/d. She denied any trauma to the site prior to
development of pain or musculoskeletal strain. She also denied
any f/c/r, hematuria, dysuria, and urinary frequency. The
patient also denied any sick contacts (although she works as a
clinical lab technician drawing labs from patients in local med
center), as well as any travel or exposure to new pets. Of note,
she did have an illness with diarrhea approximately one month
ago, but recently she had been having one regular stool/day. In
terms of medications, she has been compliant with her
medications without any missed doses. She has been prescribed
Ultram for PRN pain which she has been taking nightly for years.
With the onset of pain, she has been taking 1-2 tabs Q6 hours
over the last 4 days. The only new medications are Aranesp
injections as well as iron tablets started 6 weeks ago for
anemia. She was previously on lisinopril for several months
which was stopped in [**Month (only) 547**] due to Angioedema.
.
In the ED, she was thought to have had some tenderness to
palpation. A renal graft ultrasound was performed and
demonstrated increasing size and edema of the kidney. The
transplant service was called, but did not have any specific
recommendations. The patient was given morphine 2mg x2, at which
point she developed nausea and vomiting. She was subsequently
given Dilaudid 2mg x1, and Anzemet 12.5mg x2.
.
At 4AM her peripheral IV infiltrated. The IV nurse found her
unresponsive, grey, clammy, and hypoxic (?) with an oxygen sat
of 40%. She was hypotensive to 100/palp (nl sbp 180) and mildly
tachycardic with a heart rate of 100. Her fingerstick at that
time was 200. She was placed on a NRB with an increase of her
oxygen sats to 100% at which time she quickly regained
consciousness. She was rapidly titrated down to 2L via nasal
cannula with an O2 sat of 100%. Her ABG (?timing and ?FiO2) was
7.3/65/70.
.
On review of systems here in the ICU, she has not had any
fevers, chills, SOB, CP, weight loss, recent diarrhea, rashes,
hematuria, or traumatic injuries. She does snore at night and
likely has sleep apnea from what her husband has told her. On
further reflection, she has felt much more tired recently and
has been "sleepy."
Past Medical History:
1. Lupus diagnosed in [**2120**].
2. Lupus nephritis status post transplant; baseline creatinine
rising over the last last 6mo.
3. Gout.
4. Childhood rheumatic fever.
5. Hypertension.
6. Cataracts.
7. S. pneumonia in her sputum in 02/[**2144**].
8. CMV viremia in [**2140**] treated with ganciclovir.
9. Squamous cell CA followed by derm.
10. CHF- EF 35%
Social History:
Lab technician who lives with her husband and her two adopted
children. Tob: five-pack-year history of smoking but quit 10
years ago EtOH: three glasses of ethanol per week.
Family History:
Mother: MI in her 60s.
Father: AAA rupture in 60s
Physical Exam:
Initial Vitals on Admission: 98.3 162/104 16 93%3L
ICU Vitals: T 100.1, HR 112, BP 153/105, RR 14, O2 sat 83-87%
RA, 93-94% on 2L NC
GEN: Overweight. NAD.
HEENT: EOMI, anicteric, op clear, mmm.
CV: Regular tachycardia without m/r/g. Difficult to assess JVD.
Chest: Bibasilar crackles
Back: slight point tenderness to palpation over right superior
iliac crest at its lateral margin.
Abd: soft, NT, ND, no tenderness to palpation over the
transplanted kidney, no rebound or guarding. +BS.
Ext: Warm. Trace bilateral LE edema. No pain with rotation or
flexion/extension of the right hip.
Skin: no rashes.
Pertinent Results:
[**2148-6-20**] 07:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2148-6-20**] 07:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2148-6-20**] 07:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2148-6-20**] 04:10PM GLUCOSE-95 UREA N-57* CREAT-3.0* SODIUM-141
POTASSIUM-3.2* CHLORIDE-98 TOTAL CO2-32 ANION GAP-14
[**2148-6-20**] 04:10PM CALCIUM-8.6 PHOSPHATE-3.2 MAGNESIUM-2.0
[**2148-6-20**] 04:10PM WBC-8.2 RBC-4.15* HGB-11.9* HCT-34.7* MCV-84
MCH-28.8 MCHC-34.4 RDW-15.9*
[**2148-6-20**] 04:10PM NEUTS-57.4 LYMPHS-34.5 MONOS-5.6 EOS-1.4
BASOS-1.1
[**2148-6-20**] 04:10PM MICROCYT-1+
[**2148-6-20**] 04:10PM PLT COUNT-172
[**2148-6-20**] 04:10PM PT-11.0 PTT-19.9* INR(PT)-0.9
.
CT without contrast [**2148-6-21**]-
1. Comment on PE cannot be made without IV contrast.
2. Peribronchial cuffing and interstitial edema with bilateral
basilar pleural effusions and consolidation.
3. Atrophy of both native kidneys.
.
RENAL TRANSPLANT ULTRASOUND [**2148-6-20**]: Transplanted right kidney
now measures 12.3 cm in length, and previously measured 9.7 cm.
There is a heterogeneous and edematous appearance of the
transplanted kidney. There are no peritransplant fluid
collections. There is no hydronephrosis or stone. The arterial
and venous flow is patent and normal. The RIs range from
0.58-0.67. IMPRESSION: Compared to the prior examination, the
transplanted kidney has increased in size and has an edematous
appearance. There is normal flow demonstrated with RIs within
normal limits. There is no peritransplant fluid collection.
.
CXR: Subtle opacity in the right lower lobe concerning for early
pneumonia or aspiration. Mild cardiomegaly. Pulmonary arterial
hypertension.
.
V/Q scan [**2148-6-21**]:
Perfusion images in 8 views show slightly heterogeneous
perfusion without definite focal perfusion defect. Ventilation
images obtained with Tc-[**Age over 90 **]m aerosol in the same 8 views
demonstrate
some central deposition of tracer consistent with airway
disease. There are no mismatched defects.
Chest x-ray shows right lower lobe pneuomonia.
IMPRESSION: Low likehood ratio for recent pulmonary embolism.
.
[**2148-6-21**] Chest CT: IMPRESSION:
1. Comment on PE cannot be made without IV contrast.
2. Peribronchial cuffing and interstitial edema with bilateral
basilar pleural effusions and consolidation.
3. Atrophy of both native kidneys
.
ECHO [**2148-6-21**]: EF 35%, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated, mild symm LVH,
moderate global LV HK, 1+ AR, 2+ MR
Brief Hospital Course:
# Hypoxia/Hypercarbia - The patient was ruled out for PE with a
V/Q scan that was low-prob. CXR was consistent with pneumonia
and the pt was started on levofloxacin. Her O2 sats improved
gradually as did her cough and on day of discharge her
ambulatory sats were 94% on RA. She was discharged to complete a
10 day course of levofloxacin.
.
# Flank pain: Given the increase in size as well as the
edematous appearance of the x-planted kidney with associated sx
of pain and nausea, there was a possibility of acute on chronic
rejection of the x-planted kidney. However she had no
pain/tenderness over her transplanted kidney and she has a
creatinine of 3 which was lower than it has been since [**Month (only) 958**]
[**2148**]. Ultrasound of the transplanted kidney showed that it had
increased in size and had an edematous appearance. However,
normal flow was demonstrated with RIs within normal limits. On
the 3rd day of admission the pt developed a vesicular rash on
the skin in her flank area consistent with herpes zoster. She
was started on valacyclovir and neurontin. This was felt to be
the likely culprit of her pain. She continued to have pain and
was d/c'd on oxycontin with oxycodone for breakthrough pain
related to the zoster. The rash did remain within one dermatome
and did not cross the midline.
.
# h/o kidney transplant: Pt was continued on prednisone 5mg and
rapamune alternating 2mg and 1mg doses. Rapamune levels were
therapeutic.
.
# HTN: The pt had elevated BP in ED of max SBP 200. It was felt
that pain may have been contributing, but even when her pain
appeared to be controlled she still was hypertensive. She was
continued on Diltiazem 240 mg daily and Imdur 30mg po daily was
added and her BP came down to the 140's/70's. The renal
transplant team recommended decreasing her lasix from 80 mg to
40mg daily since her Cr had risen slightly over the admission.
She was continued on Aspirin 325 mg daily for primary CAD ppx.
.
# Anemia: The pt has had chronic stable anemia with Hct in the
30s since [**Month (only) **]. of '[**47**]. Hct was relatively stable and she did not
require any transfusions. She was continued on Fe. Aranesp was
held while in house.
.
# FEN: She was continued on nutritional supplementation with
Calcium carbonate 500mg [**Hospital1 **], Multivitamins and Fish oil 1g [**Hospital1 **].
.
# PPx: Heparin SC, PPI
.
# Code Status = Full Code
Medications on Admission:
1. Prednisone 5mg once daily
2. Rapamune 2mg alternating with 1mg once daily
3. Lasix 80 mg daily
4. Diltiazem 240 mg daily.
5. Allopurinol 200 mg daily.
6. Aspirin 325 mg daily
7. Aranesp once weekly
8. Ultram p.r.n. -> which she has been taking 1-2 tabs Q4-6hours
over the last couple of days
9. Potassium chloride 20 mEq daily
10. Fe
11. Calcium carbonate 600mg [**Hospital1 **].
12. Multivitamins.
13. Fish oil 1g [**Hospital1 **].
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO MWF
(Monday-Wednesday-Friday).
4. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO QTU, THURS, SA,
SUN ().
5. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Omega-3 Fatty Acids 550 mg Capsule Sig: Two (2) Capsule PO
BID (2 times a day).
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 5 days: Last day [**6-30**].
Disp:*3 Tablet(s)* Refills:*0*
12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO qd () for
10 days.
Disp:*20 Tablet(s)* Refills:*0*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 10 days: may refill if pain continues after 10
days. .
Disp:*20 Capsule(s)* Refills:*1*
16. Oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for 10 days: may cause sedation. Do not drive
or operate machinery while taking this med. .
Disp:*30 Tablet(s)* Refills:*0*
17. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
18. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
19. Promethazine 12.5 mg Suppository Sig: One (1) suppository
Rectal every 4-6 hours as needed for nausea.
Disp:*10 suppositories* Refills:*1*
20. OxyContin 10 mg Tablet Sustained Release 12HR Sig: [**2-12**]
Tablet Sustained Release 12HRs PO every twelve (12) hours as
needed for pain for 10 days: may cause sedation. Do not drive or
operate heavy machinery. .
Disp:*20 Tablet Sustained Release 12HR(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Shingles
pneumonia
hypertension
Discharge Condition:
stable
Discharge Instructions:
If you develop fevers, chills, irretractable nausea, vomiting,
chest pain, or shortness of breath, please call your PCP or
return to the ED.
Changes to medications:
allopurinol - please only take 100mg every other day.
lasix - please only take 40mg daily.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in the next 1-2 weeks.
Provider: [**Name Initial (NameIs) 394**]/[**Name8 (MD) **] MD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2148-7-3**] 10:30
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2148-7-18**] 11:20
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2148-7-18**] 2:00
|
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icd9cm
|
[
[
[]
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[
"38.93"
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icd9pcs
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[
[]
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|
7239, 9634
|
341, 347
|
12494, 12502
|
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14,566
| 171,329
|
6069
|
Discharge summary
|
report
|
Admission Date: [**2177-12-11**] Discharge Date: [**2177-12-18**]
Date of Birth: [**2130-2-8**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Acute left lower extremity ischemia.
HISTORY OF PRESENT ILLNESS: This is a 47 year old male who
is status post multiple revisions of distal leg bypass graft,
severe cramping pain of the left leg from calf to toes. The
patient reports pain started at 5 a.m. the morning of
admission. The foot has since then gotten cold, numb and
painful. He denies any chest pain or shortness of breath.
PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. He is a smoker.
PAST SURGICAL HISTORY:
1. Aorta-bifemoral with a left femoral-popliteal in [**Month (only) **]
of [**2176**].
2. Redo femoral-popliteal above the knee with Dacron in [**Month (only) 205**]
of [**2176**].
3. Right femoral-popliteal above the knee with a right arm
vein in [**2177-5-2**].
4. A left femoral above the knee popliteal with reverse
saphenous vein.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION
1. Coumadin 7 mg q. day.
2. Lopressor 12.5 twice a day.
3. Prilosec 20 mg twice a day.
4. Procardia 30 mg q. day.
5. Zestril 10 mg q. day.
6. Darvon 80 mg three times a day.
PHYSICAL EXAMINATION: Alert and oriented male in no acute
distress. Lung examination was clear. Heart is a regular
rate and rhythm. Abdominal examination was unremarkable.
Pulse examination shows palpable femorals bilaterally. The
right fem-[**Doctor Last Name **] graft is palpable. The left fem-[**Doctor Last Name **] graft is
nonpalpable. The right dorsalis pedis is palpable. The
posterior tibial is palpable. The left dorsalis pedis and
posterior tibial are neither palpable nor able to get Doppler
signal. The foot is cold to the ankle level with diminished
sensation, capillary refill, motor function.
LABORATORY: Admitting labs include CBC with white count of
11.6, hematocrit 35, platelets 376,000. PT, INR 18 and 2.1.
PTT was 38. BUN 6, creatinine 0.8, potassium 3.6.
EKG was a normal sinus rhythm.
The patient was typed and screened for fresh frozen plasma.
HOSPITAL COURSE: The patient went to angiography immediately
which demonstrated occluded left limb of an ABF graft. There
was direct access of the limb which showed CFA or any runoff.
The patient was taken urgently to surgery. He underwent
exploration of the right femoral above the knee popliteal.
An arteriogram interoperatively antegrade and retrograde
thrombectomy with revision of the distal anastomosis of the
left femoral AK popliteal bypass graft. The patient
tolerated the procedure well and was transferred to the PACU
in stable condition.
Postoperatively, he remained hemodynamically stable. His
postoperative hematocrit was 23, requiring transfusion. His
INR was 2.0 post correction. Electrolytes were normal. He
had a left foot that was warm with intact motor and sensory
function. The popliteal was palpable and triphasic signal.
The posterior tibial was Doppler-able only. The graft was
palpable at the knee level.
The patient continued to do well and was transferred to the
VICU for continued monitoring and care. He required two
units of packed cells for his hematocrit. His
post-transfusion hematocrit was 27.6. He continued to do
well. He remained in the VICU. Heparin drip was done
postoperatively and continued during his initial course.
He had multiple drifts in his hematocrit requiring careful
monitoring. A lot of this was secondary to hemodilution, and
he required diuresis. An angiogram was repeated on
[**2177-12-15**], which demonstrated the renal arteries and the
aorta-[**Hospital1 **]-femoral bypass in both limbs were well patent. The
left femoral-popliteal bypass was patent. The first 1 to 2
cm of the left profunda occluded. The rest of the left
profunda is opacified, retrograde from the left popliteal
artery, and too short narrowings of the left popliteal
artery. There is one moderate stenosis seen after the distal
bypass anastomosis and more significant at the knee level.
The anterior and posterior tibial are patent at the perineal,
the stent and incomplete. The dorsalis pedis is patent and
the plantars are perfused.
He was continued on his heparin and transferred to the
regular nursing floor. He underwent, on [**2177-12-16**], a right
groin exploration and left common femoral to profunda bypass
graft with 6 mm Dacron and tolerated the procedure well and
was transferred to the PACU in stable condition with a
palpable left dorsalis pedis and posterior tibial at the end
of the procedure. He was transferred to the VICU for
continuing monitoring and care. His postoperative hematocrit
was 25. He continued to do well. Coumadin was initiated and
he was transferred to the regular nursing floor.
On postoperative day seven he was therapeutic on his heparin.
His Coumadin was initiated 15 mg. He was to be discharged to
home. Wounds were clean, dry and intact. The feet were
warm. He had palpable dorsalis pedis and posterior tibial
bilaterally.
He was discharged in stable condition.
FOLLOW-UP INSTRUCTIONS:
1. He should follow-up with Dr. [**Last Name (STitle) 1391**] in two weeks' time.
DISCHARGE MEDICATIONS:
1. Coumadin 7 mg q. day. He is to have his INR checked on
a daily basis and the results called to Dr.[**Name (NI) 1392**]
office and they will adjust his anti-coagulation.
2. He will continue on Lovenox at 80 mg twice a day
subcutaneously until therapeutic on his Coumadin.
3. Percocet tablets 5/325, one to two q. four hours p.r.n.
4. Protonix 40 mg q. day.
5. Procardia XL 30 mg q. day.
6. Zestril 10 mg q. day.
7. Lopressor 12.5 mg twice a day.
DISCHARGE DIAGNOSES:
1. Left leg ischemia secondary to left limb thrombus status
post thrombectomy.
2. Peripheral vascular disease status post left groin
exploration with left common femoral to profunda bypass
with 6 mm Dacron.
3. Blood loss anemia, corrected.
4. Gastroesophageal reflux disease, stable.
5. Hypercholesterolemia, treated.
6. Hypertension, controlled.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2177-12-18**] 08:57
T: [**2177-12-18**] 09:28
JOB#: [**Job Number 23817**]
|
[
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"440.22",
"305.1",
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"E878.2",
"401.9",
"272.0",
"285.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.49",
"88.48",
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
5732, 6373
|
5241, 5711
|
2158, 5110
|
652, 1253
|
1276, 2140
|
160, 198
|
227, 553
|
5134, 5218
|
575, 629
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,751
| 122,823
|
44865
|
Discharge summary
|
report
|
Admission Date: [**2117-5-23**] Discharge Date: [**2117-6-3**]
Date of Birth: [**2049-9-12**] Sex: M
Service: MEDICINE
Allergies:
Wellbutrin / Zithromax / Keflex
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
Left carotid endarterectomy [**2117-5-25**]
TIPS redo [**2117-6-2**]
History of Present Illness:
Mr. [**Known lastname 4033**] is a 67 yo M w/ h/o severe COPD, ETOH cirrhosis s/p
TIPS [**2106**], CAD s/p CABG [**2106**], bladder CA s/p resection [**2104**],
chronic neuropathy, GERD and h/o R CEA s/p left sided weakness
[**2114**] who presents with right sided weakness for 4-5 days.
.
Of note, the pt was recently admitted to [**Hospital3 4107**] from
[**Date range (1) 52350**]. Originally he presented with diarrhea and a COPD
exacerbation. He was found to have pan-colitis on CT abdomen
thought to be [**2-23**] c diff and started on flagyl and vanco. He was
given gentle hydration in the ICU. He then developed a distended
abd with ileus on KUB. He was made NPO and given golytely with
some relief. He also had a paracentesis with 3.3 L removed
resulting in improved respiration and ileus. He also recieved
stress dose steroids and levoquin. The pt was treated for
"borderline hypotension" thought to be [**2-23**] hypoalbuminemia,
cirrhosis and sepsis with gentle hydration and albumin. Prior to
d/c, he was placed back on aldactone and lasix.
.
Of note, the pt's d/c summary from [**Hospital1 **] noted "baseline" right
arm weakness. The pt states he thinks this started around the
time of his paracentesis at the OSH. Neuro was consulted in the
ED who noted proximal > distal R sided weakness was well as
likely chronic distal weakness 2/2 neuropathy. CT head showed
hypodensity in the parietal corona radiata. Neuro thought pt
may have had a watershed infarct during a period of hypotension,
perhaps after large-volume paracentesis but also thought embolus
couldn't be excluded. Thusly, neuro recommended CTA head and
neck (which showed no e/o vascular aneurysm, occlusion or
dissection), antiplatelet [**Doctor Last Name 360**], keep BP elevated, MRI, TTE,
LENI on R to look for clot.
.
In the ED, CXR also showed ? pneumomediastinum for which CT [**Doctor First Name **]
was consulted. On CT chest, this was thought to be [**2-23**] medial
right sided subpleural bleb without pneumotosis and CT surgery
signed off.
.
In the ED, initial vs were: T P BP R O2 sat. Patient was given
Hydrocortisone at stress dose, levofloxacin 750mg IV, flagyl
500mg IV, vancomycin 1gm IV, Albuterol nebs x3, ipratropium nebs
x2, lorazepam and 2L NS. Pt has free air on CT abd- there was
concern for perf from colitis but thought more likely [**2-23**]
persistent leak from para site. Leaking from parasite with
ostomy on. Transplant surgery consulted in ED said NTD but they
would continue to follow. Pressures have been stable in
80s-90s/40s-50. Vitals on transfer to ICU T 97.1 HR 85 BP 93/44
RR 14 O2 sat 99% on 3L NC.
.
On arrival to the ICU, the pt denies any pain. Pt states he is
having some baseline SOB but feels better after neb in ED. Pt
having liquidy stools.
Past Medical History:
- Coronary artery disease, s/p PTCA to mid LAD in [**2097**], CABG
([**2106**])
- Chronic obstructive pulmonary disease (no PFT's in system)
- Alcohol cirrhosis status post TIPS in [**2106**]
- Bladder carcinoma status post resection in [**2104**]
- Umbilical hernia repair in [**2106**]
- Depression
- History of benign prostatic hypertrophy
- History of carotid disease bilaterally, right greater than
left with right carotid endarterectomy in [**10-28**]
- History of left intertrochanteric hip fracture s/p ORIF
([**6-/2109**])
- Chronic back pain
- Apparent past diagnosis of OSA, past BiPAP use
Social History:
The patient lives at a nursing home full time in
[**Location (un) 1411**]. He is wheelchair and often bed bound secondary to
fatigue from COPD. He does not walk at baseline. No family. He
is still an occasional smoker (when he gets a chance) - he has a
2PPD x 50 year smoking history. Long prior h/o EtOH abuse, but
none for 1 year, no drugs
Family History:
The patient was adopted and does not know his family history.
.
Physical Exam:
On admission to floor:
VS: T97.6 BP 86/87 P84 R26 100% 4L NC FS 142 Wt
77.9kg
Gen - Alert, interactive, cachectic, chronically ill appearing
male in NAD
HEENT - PERRL, no cervical LAD, thrush on tongue, mmm
CV - Irregularly irregular, tachycardic, RV heave, no m/g/r
Pulm - CTAB, poor air exchange b/l, no wheezes/rales/rhonchi
Abdomen - Soft, moderately distended, non-tender, +BS
Extr - 2+ pitting edema to above knees b/l
Neuro - Strength 5/5 in LUE and LLE, [**4-26**] in RLE and RUE, CN
II-VII grossly intact
Pertinent Results:
[**2117-5-23**] 01:25PM LACTATE-2.1*
[**2117-5-23**] 01:21PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2117-5-23**] 01:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2117-5-23**] 01:21PM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2117-5-23**] 12:35PM GLUCOSE-91 UREA N-21* CREAT-0.4* SODIUM-138
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-37* ANION GAP-10
[**2117-5-23**] 12:35PM ALT(SGPT)-27 AST(SGOT)-31 LD(LDH)-248 ALK
PHOS-134* TOT BILI-0.4
[**2117-5-23**] 12:35PM LIPASE-20
[**2117-5-23**] 12:35PM ALBUMIN-2.5*
[**2117-5-23**] 12:35PM WBC-17.0*# RBC-4.40* HGB-12.2* HCT-37.5*
MCV-85 MCH-27.8 MCHC-32.7 RDW-15.0
[**2117-5-23**] 12:35PM NEUTS-95* BANDS-1 LYMPHS-1* MONOS-1* EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2117-5-23**] 12:35PM HYPOCHROM-2+ ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL TARGET-OCCASIONAL STIPPLED-1+
PAPPENHEI-OCCASIONAL
[**2117-5-23**] 12:35PM PLT SMR-NORMAL PLT COUNT-179
[**2117-5-23**] 12:35PM PT-11.8 PTT-27.0 INR(PT)-1.0
.
Carotid Series:
FINDINGS: With B-mode ultrasound, a moderate amount of plaque
was seen in the left internal carotid artery. No significant
plaque was seen in the right internal carotid artery. On the
right side, peak systolic velocities were 97 cm/sec for the
internal carotid artery, and 81 cm/sec for the common carotid
artery. The right ICA/CCA ratio was 1.1.
On the left side, peak systolic velocities were 212 cm/sec for
the internal carotid artery, and 77 cm/sec for the common
carotid artery. The left ICA/CCA ratio was 2.75.
Both vertebral arteries presented antegrade flow.
COMPARISON: The left carotid artery flap mentioned on the CTA
scan could not be visualized on this duplex scan.
IMPRESSION:
1. No evidence of internal carotid artery stenosis on the right
side.
2. 60-69% stenosis of the left internal carotid artery.
.
TTE with bubble:
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is preserved (focused views only obtained).
Right ventricular systolic function is preserved. The mitral and
tricuspid valve leaflets are mildly thickened. There is a
trivial/physiologic pericardial effusion. There is at least mild
to moderate tricuspid regurgitaiton.
.
MR HEAD:
IMPRESSION:
1. Findings consistent with acute-to-early subacute MCA
distribution infarcts of the left hemisphere, predominantly
involving the left posterior frontal and parietal lobes. The
distribution suggests an embolic source.
2. Bilateral maxillary sinus disease.
.
Right-Sided LENI:
CONCLUSION:
1. No ultrasound evidence of deep venous thrombosis of the right
lower
extremity.
2. Edema of the soft tissues of the right lower extremity.
.
CTA HEAD:
IMPRESSION:
1. Regions of hypodensity in the left frontal and parietal
lobes, most
consistent with acute-to-subacute infarcts, perhaps embolic.
2. Atherosclerotic plaque at the bifurcation of the left carotid
artery, with suggestion of an intimal flap traversing the left
carotid bulb, concerning for a dissection. This may be secondary
to atherosclerotic plaque at the carotid bulb, and may serve as
source of emboli.
3. Emphysema with a small right pleural effusion.
.
CTA CHEST:
IMPRESSION:
1. No central, segmental or subsegmental PE.
2. Free air with diffuse proctocolitis likely due to C Diff,
with possible
superimposed perforation. The amount of free air being more than
expected from paracentesis performed at OSH.
3. Cirrhosis with free fluid. TIPS patency not evaluated given
phase of
enhancement.
4. Unchanged L1 compression fracture.
5. Diffuse vascular calcifications also involving the mesenteric
splanchnic vasculature.
6. LLL calcified hamartoma.
7. Right 11th posterolateral rib fracture. Correlate with
clinical exam.
[**Month (only) 116**] represent acute fracture (favored) versus chronic ununited
fracture.
.
Abdominal US ([**2117-5-31**]):
Ultrasound images of the four abdominal quadrants were obtained.
There is moderate amount of ascites. The area in the right lower
abdominal
quadrant was marked as appropriate site for paracentesis.
.
LE US ([**2117-5-31**]):
No evidence of deep vein thrombosis in the right leg.
Superficial edematous tissues noted in the right calf.
.
Abdominal US with Duplex ([**2117-5-31**]):
1. Occluded TIPS shunt. Hepatopetal flow is seen within the
portal veins.
2. Cirrhotic-appearing liver with no focal liver lesion and no
biliary
dilatation.
3. Small amount of ascites and right pleural effusion.
4. Mild splenomegaly.
Brief Hospital Course:
Mr. [**Known lastname 4033**] is a 67 yo M w/ h/o severe COPD, ETOH cirrhosis s/p
TIPS [**2106**], CAD s/p CABG [**2106**], bladder CA s/p resection [**2104**],
chronic neuropathy, GERD and h/o R CEA s/p left sided weakness
[**2114**] who presents with right sided weakness for 4-5 days. Pt
also had recent admission for COPD exacerbation, ascites, ileus,
pneumonia, c diff, hypotension requiring ICU stay, and
malnutrition.
# Hypotension: The patient was admitted to the MICU with SBP in
the 90's. This was believed to be his baseline [**2-23**] chronic
liver disease, as records showed no SBPs were recorded >90
systolic. The patient was mentating well, the he received gentle
IVF hydration initially with SBPs stable in the 90s. On return
from left CEA on [**5-25**], SBPs were in the 70s-80s, thought likely
[**2-23**] vagal stimulation with the procedure. BP was supported with
neosynephrine transiently then weaned. BPs have been stable in
the 80s to low 100s since that time, both in the MICU and on the
medicine floor without any associated symptoms.
.
# Right sided weakness: Pt evaluated by neuro in ED and thought
to have subacute parietal stroke causing R sided weakness
possibly a watershed infarct related to his hypotension at the
OSH. On the morning of admission to the ICU the pt had a brain
MRI which showed acute to subacute infarcts in the left MCA
distribution. CTA head and neck performed in the ED was
concerning for L carotid dissection, thought possible to be the
cause of the infarcts. The pt elected to have a L carotid
endarterectomy performed on [**5-25**]. He was hypotensive post-op as
discussed above but BP subsequently stabilized. His R-sided
extremity weakness was stable throughout his hospital stay,
though the patient believed weakness may have slightly improved
following CEA. He was followed by PT.
.
# Pancolitis: Thought to be [**2-23**] c. difficile. PO vanc, IV
flagyl were given in the ICU. A rectal tube was placed in the
MICU and was subsequently pulled on the floor when his diarrhea
improved. He had a midline placed for a 4 week course of
Vanc/Flagyl (First dose [**2117-5-25**]) given his improving but
continued diarrhea.
.
# Occluded TIPS: The patient had an abdominal US given his
abdominal distension and ascites, which showed occlusion of his
TIPS. Hepatology was consulted and felt this was likely his
condition for years. He successfully underwent a TIPS redo on
[**6-2**] via Interventional Radiology and will need a follow-up
ultrasound on [**2117-6-12**] for monitoring.
.
# Alcoholic cirrhosis: LFTs and INR all wnl except for mild
increase in alk phos. Alb 2.5 possible [**2-23**] low synthetic fxn but
also likely [**2-23**] poor nutritional status. Per patient, has not
undergone paracentesis in several years. He underwent
paracentesis at [**Hospital3 **] prior to admission to [**Hospital1 18**] with
~3L removed. He had persistent leakage from his paracentesis
site, and the site was sutured in the MICU with resolution of
leakage. Home Lasix and Spironolactone were initially held in
the setting of hypotension, but the patient's abdomen becamse
slightly more distended with IV fluids received for hypotension
in the MICU and he was re-started on lasix 10mg IV BID abd
aldactone. On transfer to the medicne floor, the patient
underwent therapeutic paracentesis x2 (the second being IR
guided) with a total of 3L fluid removed and with subsequent
improvement of abdominal distension, discomfort, and respiratory
status. Ascitic fluid was negative for SBP.
.
# RLL Nodule: Found incidentally on CT scan was a 15 x 11 mm RLL
nodule. Radiology recommended CXR f/u in 3 mos.
.
# Goals of care: Patient was initially DNR/DNI, although this
was reversed for his CEA. After extubation patient refused
several therapies including central lines, a-lines, pneumoboots
and SC heparin. He was evaluated by palliative care and after a
long discussion decided that he wants to return to his nursing
home with hospice care after this hospital admission.
.
# COPD: Patient has baseline very poor lung function and gets
short of breath and hypoxic with ADLs, including eating. He was
maintained on nebs and advair. He was continued on a slow
steroid taper (currently at 20mg prednisone daily) and
Levofloxacin for a ten day course for a possible COPD flare.
The patient has baseline dyspnea from severe COPD and breathes
through pursued lips with minimal exertion, including position
changes and eating.
.
# Paroxysmal SVT: Patient was noted to be in SVT with rate in
the 190s on telemetry 1 day post-op. This was in the setting of
eating and becoming slightly more hypoxic, which was believed to
be the trigger. Metoprolol 12.5 was attempted but discontinued
as the patient was hypotensive. He was loaded with Digoxin and
then placed on a maintenance dose of digoxin with good HR
control. Also, because the patient's hypoxia while eating was
believed to trigger SVTs, supplemental oxygen was increased to
4L while the patient was eating his meals. He did not have
further episodes of SVT on the floor.
.
# Oliguria: Patient had oliguria in the MICU, initially thought
[**2-23**] hypovolemia from massive diarrhea. However, after fluid
boluses, patient's abdomen became distended (history of
cirrhosis) and lasix 10mg IV BID was initiated with increase in
urine output. Oliguria was exacerbated by hypoalbuminemia. On
transfer to the floor, the patient's oliguria had resolved.
.
# Cold RLE: RLE had been colder and more edematous than left
since stroke. Likely [**2-23**] decreased perfusion given patient his
difficulty moving R extremities, and from gravitational
redistribution of anasarca [**2-23**] cirrhosis as the patient has been
frequently positioned on his side with the R side down. LE US
was negative for DVT.
.
# Peripheral neuropathy - continued home gabapentin
.
# BPH - continued home finasteride
.
# Thrush - continued home nystatin swish and swallow
.
# Code: DNR/DNI confirmed with pt
Medications on Admission:
- Folic acid 1mg qd
- Multivitamin qd
- Protonix 40mg qd
- Finasteride 5mg qd
- Guaifenesin 1200mg [**Hospital1 **]
- Gabapentin 600mg TID
- FeSO4 325 qd
- NaCl nasal spray
- Lactobacillus 1 tab [**Hospital1 **]
- Nystatin swish and swallow TID
- Aldactone 50mg qd
- Vancomycin PO 500mg q6h
- Flagyl 500mg q8h
- Levaquin 500mg qpm x 10day (done on [**2117-5-30**])
- Prednisone 40mg qd taper
- Percocet 2 tabs q6h
- Lasix 20mg qd
- Advair 500/50 INH [**Hospital1 **]
- Albuterol/Atrovent NEBS PRN
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO three times a
day as needed for sputum.
6. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Ocean Nasal Mist 0.65 % Aerosol, Spray Nasal
9. Lactobacillus Acidophilus Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day.
10. Nystatin 100,000 unit/mL Suspension Sig: 500,000 PO three
times a day.
11. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*0*
15. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation every four (4) hours as needed for SOB.
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain for 10 days: please titrate down as
tolerated.
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
20. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO DAILY (Daily).
21. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
22. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Do not exceed 2gm per day.
24. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 28 days: Last day of antibiotics [**2117-6-30**]. Capsule(s)
25. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 28 days: Last day
of antibiotics [**2117-6-30**].
26. Prednisone 5 mg Tablets, Dose Pack Sig: as directed Tablets,
Dose Pack PO once a day for 26 days: Take 4 tablets (20mg)
[**Date range (1) 95973**]. Take 3 tablets (15mg) [**Date range (1) 95974**]. Take 2 tablets
(10mg) [**Date range (1) **]. Take 1 tablet (5mg) [**Date range (1) 95975**]. Then stop.
27. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO TID (3 times a day) as needed for abd pain.
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
acute CVA with left carotid artery dissection, s/p left carotid
endarterectomy
Clostridium Difficile colitis
Occluded TIPS
Secondary Diagnosis:
Alcoholic cirrhosis
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for right sided weakness. You
were found to have damage to an artery supplying your brain
which had caused a stroke, and you underwent surgery to repair
the damaged artery.
You also had diarrhea which was believed to be from an infection
called Clostridium Difficile, and you were treated with
antibiotics with improvement of your diarrhea.
Your abdomen was distended, and an ultrasound showed your TIPS
was occluded. You underwent a successful revision of your TIPS
to open the occlusion. You will need a repeat ultrasound of
your liver in 10 days on [**2117-6-12**] to reassess the liver. You
also had 3 liters of fluid removed from your abdomen with
improvement of your breathing.
You were thought to have a flare of your emphysema and you were
started on a slow prednisone taper and breathing treatments.
You also developed a rapid heart rate in the setting of having
low oxygen levels while eating, and you were started on a
medication and had your supplemental oxygen level increased
while eating without any further episodes of rapid heart rate.
The following changes were made to your medications:
- Flagyl duration was extended, last dose on [**2117-6-30**]
- Vancomycin duration was extended, last dose on [**2117-6-30**]
- Digoxin was started for heart rate
- Ipratropium nebulization breathing treatments were started
- Xopenex nebulization breathing treatments were started
- Prednisone was started, to be decreased according to your
taper
- Aspirin was started
- Atorvastatin was started
- Tramadol was started for pain, to be titrated down as
tolerated
- Tylenol was started as needed for pain
- Maalox was started as needed
- Calcium and Vitamin D supplements were started
- Heparin subcutaneous shots were started
- Tramadol was started to be used as needed for pain
- Percocet was stopped
Followup Instructions:
You have the following [**Date Range 4314**] scheduled:
Department: LIVER CENTER
When: TUESDAY [**2117-6-8**] at 10:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
**You will need an ultrasound of your TIPS re-do at the time of
your hepatology appointment for follow-up.
Department: INFECTIOUS DISEASE
When: MONDAY [**2117-6-28**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: 110 LM [**Hospital Unit Name **] Basement, suite G
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please follow-up with your primary care physician [**Name Initial (PRE) 176**] [**1-23**]
weeks after discharge from rehab.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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icd9cm
|
[
[
[]
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] |
[
"39.49",
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"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
18849, 18890
|
9522, 15502
|
310, 380
|
19137, 19137
|
4811, 9499
|
21186, 22157
|
4184, 4249
|
16049, 18826
|
18911, 19035
|
15528, 16026
|
19313, 21163
|
4264, 4792
|
251, 272
|
408, 3181
|
19056, 19116
|
19152, 19289
|
3203, 3806
|
3822, 4168
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
865
| 147,052
|
43502
|
Discharge summary
|
report
|
Admission Date: [**2199-5-23**] Discharge Date: [**2199-6-14**]
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: A 78-year-old gentleman,
followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who has been having several
months of substernal chest pain and shortness of breath,
usually relieved with sublingual Nitroglycerin. Recently,
the pain has increased to weekly and currently almost daily.
The pain is with exertion, but not at rest, and is always
relieved with one sublingual Nitroglycerin. He has no
complaints of orthopnea, paroxysmal nocturnal dyspnea, or
lightheadedness.
He underwent a cardiac catheterization on [**2199-5-7**] which
demonstrated severe three-vessel disease, a 70% lesion in the
LAD, a 100% occlusion of the left circumflex, and a 100%
occlusion of the RCA; ejection fraction was 47%. The patient
was booked for the OR on [**2199-5-23**] for coronary artery
bypass grafting.
PAST MEDICAL HISTORY: 1) Insulin dependent diabetes
mellitus, 2) Coronary artery disease, status post MI in [**2185**],
3) Hypertension, 4) Hyperlipidemia, 5) Former smoker, 6)
Status post right inguinal herniorrhaphy.
MEDS AT ADMISSION: 1) NPH Insulin 24 U in the morning, 14 U
in the evening, 2) regular Insulin 14 U in the morning, 12 U
in the evening, 3) Lopressor 50 mg po bid, 4) Zestril 80 mg
po qd, 5) Benicar 40 mg po qd, 6) Avandia 4 mg po qd, 7)
Zocor 80 mg po q pm, 8) Flomax 0.4 mg po bid, 9) Imdur 30 mg
po qd, 10) hydrochlorothiazide 12.5 mg po qd, 11) Proscar 5
mg po q pm, 12) aspirin 325 mg po qd.
ALLERGIES: No known allergies except to shellfish.
EXAM AT ADMISSION: This was a moderately obese gentleman in
no acute distress. His neck was supple without
lymphadenopathy. He had no bruits. His chest was clear.
His heart had a regular rate and rhythm without murmurs. His
belly was soft, nondistended, nontender. Extremities were
warm and well-perfused with mild pedal edema.
BRIEF HOSPITAL COURSE: The patient was brought to the
operating room on [**2199-5-23**] and underwent a four-vessel
CABG with LIMA to LAD, saphenous vein graft to the OM-1, to
the PD and the diagonal. He did very well in the OR and was
weaned and extubated postoperatively in the CSRU. His urine
output was adequate, and his blood sugars were elevated, and
an insulin drip was started. He was otherwise alert and
oriented, moving all of his extremities, with somewhat labile
blood pressure. He was A-paced with a heart rate of 80 with
an underlying rhythm of 40s in sinus brady. He continued to
require a Nitroglycerin drip to maintain his blood pressures
adequately low.
By postop day #1, the patient was doing well. The
Nitroglycerin was weaned off. He was delined and transferred
to Far-2. On the floor, he was doing well until
postoperative day #3, when he complained of sudden onset of
chest pain in the lower sternal area. On examination, he was
found to have a sternal click with some scant serous drainage
from the lower part of the incision. He was placed on
sternal precautions, and his pain was controlled, and serial
exams were performed throughout the day. Throughout the
course of the day, he continued to develop worsening wheezing
despite nebulizer treatments. The decision was ultimately
made to take the patient back to the OR for reclosing of his
sternal dehiscence which was carried out on [**2199-5-27**].
The patient tolerated the procedure well and came out on
low-dose of neo-synephrine. He remained intubated, and a
chest tube had to be inserted when his postoperative x-ray
demonstrated a large effusion on the left. His vent was
weaned, and his Nitroglycerin drip was DC'd, and the patient
was extubated on postop day #2 without complication. He had
been empirically started on Levofloxacin and vancomycin while
we waited for the cultures to come back. All intraoperative
cultures were negative. The patient was
started on his oral cardiac meds. He was fed a diet. His
insulin schedule was restarted while the insulin drip was
weaned off. His sternal wound had a constant infusion of 1%
Betadine. By postop day #4, the patient was
still having periods where he was requiring a Nitroglycerin
drip, despite being treated with hydralazine, lisinopril,
Lopressor and lasix. We changed his Lopressor to atenolol PO
which is what he was taking preoperatively, and this seemed
to have a better effect with him. His chest tubes and Foley
were discontinued on postop day #4.
His subsequent ICU course was notable for marginal
respiratory status. On postop day #5, the patient was noted
to have an unstable sternum with drainage from the sternal
wound, nonpurulent in nature. His white count which had been
elevated prior was on its way down, however; and, the patient
had remained afebrile. The decision was made to observe with
serial exams before deciding if the patient needed to go to
the operating room. Fortunately, over the next several days,
the patient remained afebrile, his white count continued to
decline, and he was improving. His cultures ultimately grew
out MRSA from the sputum, but everything else had been
negative. Vancomycin was continued.
On postop day #9, he was doing well. He was off all drips,
oral Lopressor. His respiratory status was good, and he was
transferred to the floor where he had a relatively uneventful
course with the exception of a few episodes of atrial
fibrillation for which he was started on amiodarone. These
episodes of PAF all occurred within the same 48-hour period,
and he has been in sinus ever since achieving adequate levels
of amiodarone. The incision stopped draining fluid on postop
day #15, although he still had a small click. White count
and creatinine continued to normalize, and a PICC was placed
for IV vancomycin and Levofloxacin. Physical therapy had
seen the patient and recommended that he be discharged to
rehab when he was medically cleared.
On postoperative day #16, his respiratory status was somewhat
worsened, and a chest x-ray was obtained which demonstrated a
left effusion that had been increasing in size. Placement of
a Cook catheter in the left chest was attempted
unsuccessfully, and a 28 French chest tube was placed in
instead which was successful in draining approximately 100 cc
of serosanguineous fluid immediately, followed by
approximately 200 since insertion. His chest x-ray and his
respiratory status improved, and the chest tube was removed
approximately 48 hours later. He continued to do well, be
maintained on oral medications, but was still unable to
ambulate very well. The patient is being discharged to a
rehab facility on [**2199-6-14**] in stable condition.
DISCHARGE DIAGNOSES: 1) Coronary artery disease. 2) New
onset atrial fibrillation. 3) Status post coronary artery
bypass graft x 4.
DISCHARGE EXAMINATION: Neck was supple without
lymphadenopathy or bruits. His chest was clear anteriorly
with diminished breath sounds at the bases. His heart had a
regular rhythm and rate. His abdomen was soft, nontender,
nondistended. His incisions were all clean, dry and intact.
He had 1+ pedal edema. His extremities were warm and
well-perfused.
DISCHARGE MEDICATIONS: 1) tamsulosin 0.4 mg q hs, 2)
finasteride 5 mg po qd, 3) simvastatin 80 mg po q hs, 4)
rosiglitazone 4 mg po qd, 5) percocet 1-2 tabs po q 3-4 h
prn, 6) ipratropium bromide 0.2 mg/ml solution 1 neb
inhalation q 6 h prn wheezing, 7) colace 100 mg po bid, 8)
potassium chloride tablets 20 mEq po bid for 5 days, 9) lasix
40 mg po bid for 5 days, 10) Zantac 150 mg po qd, 11) aspirin
325 mg po qd, 12) guaifenesin codeine cough syrup [**6-1**] ml po
q 6 h as needed, 13) Insulin 24 U NPH, 14 U regular subcu q
am, 14) Insulin 14 U of NPH, 12 U of regular subcutaneous q
pm, 15) heparin 5,000 U subcu [**Hospital1 **], 16) Lopressor 75 mg po
bid, 17) amiodarone 400 mg po tid x 1 week, then 400 mg po
bid x 2 weeks, then 400 mg qd x 2 weeks, then 200 mg
thereafter.
The patient is to see Dr. [**Last Name (STitle) **] in 2 weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2199-6-14**] 12:33
T: [**2199-6-14**] 13:30
JOB#: [**Job Number 93624**]
|
[
"412",
"511.9",
"413.9",
"401.9",
"414.01",
"427.31",
"998.32",
"E878.8",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.61",
"36.13",
"36.15",
"38.93",
"39.61",
"34.04",
"34.79"
] |
icd9pcs
|
[
[
[]
]
] |
1987, 6681
|
6703, 7175
|
7199, 8304
|
130, 955
|
978, 1963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,955
| 160,846
|
44739
|
Discharge summary
|
report
|
Admission Date: [**2132-1-19**] Discharge Date: [**2132-1-23**]
Date of Birth: [**2073-7-8**] Sex: M
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
Chief Complaint:somnolence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: 58 yo M with hx of EtOH abuse, clean
for last 6 months but started EtOH in last week. Per friend,
drank [**1-24**] bottle vodka yesterday 3pm, friend returned at 9pm and
found pt on ground, she stayed at his place to watch him, still
today pt remained in same spot. No known SI, OD attempt.
.
In the ED, initial vs were: T 97 HR 116 BP 155/95 RR 30 POx 94O2
sat 2LNC. Initial exam pt obtunded and minimally responding to
sternal rub but protecting airway, DMM, R axilla and R hip with
pressure sores with blisters as e/o being on ground. Patient was
given Thiamine 100mg, 1L Sodium Bicarbonate 150mEq in D5W, 2L NS
IVF, Magnesium Sulfate 2 g, FoLIC Acid 1mg, Levofloxacin 750mg,
MetRONIDAZOLE 500mg x1, Vancomycin 1g x1. CT head was neg for
acute process, CXR - RLL consolidation. LP was performed,
opening pressure 18. Patient seems to respond to IV thiamine
with improved movement. Urine tox was positive for Benzos. VS
prior to transfer BP 146/76 HR 113 RR 27 POx 95% on 2L Nc, made
400cc of urine. Access 2 -18g PIVs.
.
When his lactate remained high despite adequate IVF
resuscitation, reevaluation of abdomen revealed distention and
tenderness and a CT ab/pelvis was performed showing a right
puborectalis muscle hematoma measuring 6.5 x 3.1cm. Surgery was
consulted on the ED with plan to follow in the [**Hospital Unit Name 153**].
.
On arrival to the [**Hospital Unit Name 153**], the patient remained minimally
responsive to commands and was unable to provide further
details.
.
Review of sytems:
(+) Per HPI
(-) Limited by patient non-responsiveness.
Past Medical History:
Past Medical History:
ETOH relapsed 1 week ago
Prostate CA - stage 2, undergoing XRT and lupron
Perforated Gastric Ulcer s/p gastrectomy [**2131-8-20**]
Rectal Abcess s/p ID [**11/2131**]
HCV - s/p tx w/ interferon, cleared
Psoriasis
Anemia
Hypertension
Social History:
The patient was born in [**Hospital1 392**], MA and grew up with his mother,
father and 7 brothers and sisters. [**Name (NI) **] graduated high school and
went to college at [**Location (un) 86**] State where he studied English. The
patient now works as a social work supervisor and lives in an
apartment in [**Location (un) 86**] with his partner of 10yrs. [**Name2 (NI) **] reports that
he is not close to any of his siblings and his father died long
ago.
About 10yrs ago the patient was arrested for a DUI, but
otherwise
denies legal trouble.
Substance Abuse History:
Patient has along history of alcohol dependence and has been in
detox multiple
times. States he quit ETOH 4 months ago. He denies any h/o
withdrawal seizures or DTs. Does not smoke cigarettes or use
illicit drugs currently, but has tried cocaine in the past.
Family History:
Family History: Alcoholism in father and brother
Physical Exam:
VS: 96 130/74 96 21 97%4LNC
General:Somnolent, sluggish in following commands such as moving
extremities, no acute distress
HEENT: Sclera anicteric, pupils sluggish but reactive, MMD,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: rhonchi at right base, otherwise clear throughout on
limited exam
CV: Tachy but rate and rhythm, HS distant, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley with light yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: slowly following commands, responsive to sternal rub,
loud name calling but falls back asleep quickly, reflexes 1+
bilaterally symmetric, no clonus, tone, bulk WNL, unable to
assess strength
Skin: stage I pressure wounds on right hip and right axilla w/
some intact and broken blisters, no oral lesions
Pertinent Results:
[**2132-1-18**] 08:30PM BLOOD WBC-14.8*# RBC-5.41# Hgb-14.0 Hct-42.0
MCV-78* MCH-26.0* MCHC-33.4 RDW-15.9* Plt Ct-289
[**2132-1-18**] 08:30PM BLOOD Neuts-82.5* Lymphs-11.6* Monos-5.4
Eos-0.2 Baso-0.3
[**2132-1-19**] 06:00AM BLOOD PT-12.4 PTT-19.2* INR(PT)-1.0
[**2132-1-18**] 08:30PM BLOOD Glucose-182* UreaN-25* Creat-0.9 Na-143
K-3.5 Cl-103 HCO3-24 AnGap-20
[**2132-1-18**] 08:30PM BLOOD ALT-110* AST-318* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-74 TotBili-0.8
[**2132-1-19**] 06:00AM BLOOD ALT-110* AST-294* LD(LDH)-447*
CK(CPK)-[**Numeric Identifier 35771**]* AlkPhos-59 TotBili-0.7
[**2132-1-19**] 03:29PM BLOOD ALT-96* AST-247* LD(LDH)-383*
CK(CPK)-6530* AlkPhos-55 TotBili-0.6
[**2132-1-20**] 04:20AM BLOOD ALT-95* AST-219* CK(CPK)-5238* AlkPhos-51
TotBili-0.6
[**2132-1-18**] 08:30PM BLOOD Lipase-17
[**2132-1-20**] 04:20AM BLOOD Lipase-13
[**2132-1-18**] 08:30PM BLOOD CK-MB-97* MB Indx-0.7
[**2132-1-18**] 08:30PM BLOOD cTropnT-<0.01
[**2132-1-19**] 06:00AM BLOOD CK-MB-54* MB Indx-0.5 cTropnT-<0.01
[**2132-1-19**] 03:29PM BLOOD CK-MB-20* MB Indx-0.3 cTropnT-LESS THAN
[**2132-1-18**] 08:30PM BLOOD Albumin-4.7 Calcium-9.9 Phos-4.4 Mg-1.9
[**2132-1-18**] 08:30PM BLOOD Osmolal-312*
[**2132-1-20**] 11:08AM BLOOD Ammonia-18
[**2132-1-20**] 04:45PM BLOOD TSH-2.7
[**2132-1-18**] 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2132-1-18**] 09:17PM BLOOD Type-ART pO2-93 pCO2-35 pH-7.45
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2132-1-18**] 10:59PM BLOOD Lactate-5.3*
[**2132-1-19**] 12:50AM BLOOD Lactate-6.5*
[**2132-1-19**] 06:14AM BLOOD Lactate-3.1*
[**2132-1-19**] 10:39AM BLOOD Lactate-2.6*
[**2132-1-19**] 08:15PM BLOOD Lactate-1.2 K-3.7
MICRO:
[**2132-1-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-1-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2132-1-20**] URINE URINE CULTURE-PENDING INPATIENT
[**2132-1-20**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY INPATIENT
[**2132-1-19**] URINE Legionella Urinary Antigen -FINAL INPATIENT
[**2132-1-19**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2132-1-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-1-18**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY EMERGENCY [**Hospital1 **]
[**2132-1-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
REPORTS:
CT HEAD W/O CONTRAST [**2132-1-18**]:
FINDINGS: There is no intracranial hemorrhage, edema, shift of
normally
midline structures, or acute major vascular territorial
infarcts. Ventricles and sulci are normal in size and
configuration. Visualized paranasal sinuses and mastoid air
cells are normally aerated. Osseous structures reveal no
abnormality. IMPRESSION: No acute intracranial process.
CT ABDOMEN/PELVIS [**2132-1-19**]:
1. Right obturator internus muscle hematoma. No active
extravasation is
identified.
2. Right lower and middle lobe atelectasis.
3. Mesenteric vessels are patent and without abnormality
evident, though
evaluation is limited because of respiratory motion. No definite
bowel
abnormality to suggest ischemia.
CXR AP [**2132-1-20**]:
Lungs are low in volume but clear, exaggerating heart size which
is probably top normal. Azygous distention suggests increased
intravascular volume but there is no pulmonary plethora and no
edema or pleural effusion.
Brief Hospital Course:
MICU COURSE:
58 yo M with h/o ETOH abuse, prostate CA, gastrectomy presented
after drinking binge and being down for 24 hours from home with
somnolence, found to have a RLL aspiration pneumonia, lactic
acidosis, and rhabdomyolysis. In [**Name (NI) **], pt was minimally responsive
to sternal rub, and AMS was thought to be [**12-25**] benzo overdose.
Did not respond to narcan. Further work up revealed negative
head CT, negative LP with negative blood, urine, and CSF
cultures. CXR showed ?infiltrate with likely aspiration etiology
therefore was started on vanc/levo/flagyl. Flagyl was DC'd the
following morning (today [**2132-1-20**]). Rhabdo, lactic acidosis both
had been trending down. However, initially pt's mental status
did not dramatically improve (was very somnolent) and also had
RUE and RLE flaccidity and weakness (had been lying unconscious
on his R side for >24 hours) and therefore neuro was consulted
who recommended EEG and MRA head/neck completed on [**2132-1-21**] which
were negative. He spiked a temp to 101 on [**2132-1-20**] and blood,
urine, and sputum cx were sent. AMS slowly getting better. On
the night of [**2132-1-20**] developed acute RUE swelling/erythema,
initial plain film of on entire RUE negative for fracture on my
read, final report showed no fracture. RUE U/S negative for DVT.
Concern persisted for compartment syndrome, ortho was consulted
who did compartmental manometry, which was completely negative;
his R arm swelling improved with elevation. OT consult was
placed to be completed [**2132-1-24**] to increase strength and R arm
mobility. On ICU day #3, his mental status cleared and he was
sent to the floor. When clear, the patient admitted to taking 3
Klonopin the night that he passed out in order to sleep. He
denied SI. A formal psych c/s was called to evaluate the
patient.
.
Primary Diagnosis: 293.0 DELIRIUM, NOS
Likely substance abuse related. Cleared to normal. MRI head/neck
and EEG wnl.
.
Secondary Diagnosis: 507.0 PNEUMONIA, ASPIRATION
Was likely just a pneumonitis. Did have an initial WBC of 15,
but once he cleared the secretions, his CXR revealed no further
infiltrate and he had no O2 requirement. There was MRSA(along
with multiple other bacteria and yeast) in his sputum culture,
so he was treated with vanco for 5 days then changed to
doxycycline for the remainder of the course.
.
Secondary Diagnosis: 728.89 RHABDOMYOLYSIS
Mostly from injury to arm. Was improving rapidly. Left arm was
back to normal. Right arm still with some ROM limitation from
swelling. Ortho eval unrevealing.
.
Secondary Diagnosis: 303.90 DRUG USE/DEPENDENCE, ALCOHOL
Encouraged cessasion. Not interested in inpatient intervention.
.
Secondary Diagnosis: 285.9 ANEMIA, UNSPECIFIED
stable. B12, folate pending at the time of discharge.
.
Secondary Diagnosis: 401.1 HYPERTENSION, BENIGN
Home meds restarted w/o event.
.
Secondary Diagnosis: 311 DEPRESSION, NOS
See by psychiatry. No SI. Discharged home with recommendations
for psych f/u.
.
Dispo:Patient was discharged home in good condition without any
respiratory symptoms. He will f/u with his PCP [**Last Name (NamePattern4) **] 1 week.
Medications on Admission:
ATENOLOL - 50 mg Tablet once daily
BICALUTAMIDE - 50 mg
CITALOPRAM 40 mg once a day
HYDROCHLOROTHIAZIDE 25 mg by mouth once a day
LEUPROLIDE
LISINOPRIL 10 mg once a day
METRONIDAZOLE
PANTOPRAZOLE 40 mg once a day
ASCORBIC ACID 500 mg Tablet by mouth daily
MULTIVITAMINS WITH IRON
OMEGA-3 FATTY ACIDS-FISH OIL 360 mg-1,200 mg daily
VITAMIN E 800 unit daily
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Doxycycline Monohydrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
aspiration pneumonia
rhabdo
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Please refrain from any alcohol use. We found that you had an
injury to your muscles from a prolonged duration of compression
that caused damage. We believe that your arm with continue to
improve rapidly. If there is any worsening in the symptoms
please call your doctor to be evaluated. You also developed
injury to your lung from aspiration. You received 5 days of
antibiotics for this. We have given you antibiotic pills to
complete a 7 day course. You were also found to have a normal
MRI of the head and neck, and normal EEG, and no other sights of
injury. We have scheduled follow up with your PCP in the near
future. Please keep that appointment.
Followup Instructions:
Name: [**Last Name (LF) 1968**], [**First Name7 (NamePattern1) 333**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 3329**]
Appt: [**1-30**] at 8:30am
|
[
"401.1",
"293.0",
"V12.71",
"401.9",
"303.91",
"728.88",
"V15.3",
"285.9",
"729.92",
"969.4",
"696.1",
"276.2",
"E853.2",
"V12.04",
"980.0",
"V87.41",
"E860.0",
"185",
"507.0",
"296.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
11869, 11875
|
7523, 9356
|
293, 299
|
11947, 11947
|
4089, 7500
|
12777, 13151
|
3078, 3112
|
11069, 11846
|
11896, 11926
|
10688, 11046
|
12095, 12754
|
3127, 4070
|
243, 255
|
1862, 1919
|
355, 1844
|
10410, 10662
|
9375, 9475
|
11962, 12071
|
1963, 2197
|
2213, 3046
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,464
| 155,436
|
1402
|
Discharge summary
|
report
|
Admission Date: [**2137-8-1**] Discharge Date: [**2137-8-14**]
Date of Birth: [**2070-12-30**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Adhesive Tape
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p MVC [**7-21**] with associated L1 burst fracture
Major Surgical or Invasive Procedure:
[**8-5**]: 1. Posterior decompression with laminectomies T12-L1.
2. Open reduction.
3. Instrumented fusion T10-L4 with bilateral pedicle
screws.
4. ICPG of right iliac crest plus BMP plus allograft.
History of Present Illness:
66F with MVA sustained on [**2137-7-21**], restrained passenger,
with ongoing abdominal and back pain. Patient initially
evaluated at [**Hospital6 8432**] Center and had stable vitals,
tenderness left sacrum, left SI jt; was eurologically intact,
sacral and coccyx films neg for fracture. Subsequently pain in
low back radiating to both hips. Persistently painful to sit,
walk, change position but patient denies radiation down legs,
sensation changes, and bowel/bladder incontinence.
Past Medical History:
hypertension
hyperparathyroidim s/p 3.5 gland resection
s/p Hysterectomy
Social History:
30 pack year history quit 17 years ago
etoh [**1-11**] drink per day
Family History:
non-contributory
Physical Exam:
on admission:
AFVSS
Gen: WD/WN, comfortable, NAD.
HEENT:NCAT
Pupils: [**4-11**] bil
EOMsintact
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.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right WNL
Left WNL
Propioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control
On Discharge:
Patient is alert, orieted to person, place and date. Full
strength in the upper extremities bilaterally. LLE is full
strength and sensation. RLE is full strength and sensation. RLE
full strength with the exception of [**Last Name (un) 938**] [**3-14**], AT 3/5, Gastroc
[**3-14**]. There is also hypersensation along this region.
Pertinent Results:
[**2137-8-1**] 10:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.003
[**2137-8-1**] 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2137-8-1**] 07:00PM GLUCOSE-98 UREA N-11 CREAT-0.9 SODIUM-141
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-16
[**2137-8-1**] 07:00PM estGFR-Using this
[**2137-8-1**] 07:00PM LIPASE-22
[**2137-8-1**] 07:00PM WBC-7.1 RBC-4.55 HGB-14.4 HCT-41.2 MCV-90
MCH-31.7 MCHC-35.1* RDW-14.0
[**2137-8-1**] 07:00PM NEUTS-64.0 LYMPHS-23.2 MONOS-7.1 EOS-4.2*
BASOS-1.4
[**2137-8-1**] 07:00PM PLT COUNT-397#
[**2137-8-1**] 07:00PM PT-12.4 PTT-24.3 INR(PT)-1.0
.
MRI [**8-1**]: CONCLUSION: L1 burst fracture with retropulsed
fragment narrowing the spinal canal but no evidence of spinal
cord compression. Smaller fracture of the anterior-inferior
corner of T12.
.
Long TR images signal loss in the intervertebral discs from L2
through L5, a manifestation of degenerative disc disease. At
L2-3, there is a
small bulge with no significant canal narrowing.
At L3-4, a slightly larger bulge produces moderate spinal canal
narrowing with no evidence of cauda equina compression. There
are mild facet osteophytes at this level.
At L4-5, bulging of the intervertebral disc, facet osteophytes,
and ligamentum flavum thickening produce moderate spinal
stenosis. The neural foramina appear normal.
At L5-S1, prominent facet osteophytes extend posterolaterally
and do not
encroach on the spinal canal. There is no abnormality of the
intervertebral disc detected. The neural foramina appear normal.
.
CT [**8-1**]; 1. Comminuted burst fracture of L1 with retropulsed
fragment encroaching on
the spinal canal. Refer to the MR report from earlier today for
details on
spinal cord injury and degenerative changes in the lumbar spine.
2. T12 spinous process non-displaced fracture.
.
[**8-4**] CXR; There are no old films available for comparison. The
heart is
upper limits normal in size. The aorta is mildly tortuous. The
lungs are
clear without infiltrate or effusion. Clips are seen overlying
the lower
neck.
.
CT spine [**8-6**]:IMPRESSION:
1. Unchanged appearance of the L1 burst fracture. Please refer
to the
concurrent MRI report for further detail about its effect on the
thecal sac.
2. Status post posterior fusion from T10 through L4. Anatomic
alignment.
3. Probable small bone island in the T9 vertebral body. If the
patient has a known primary malignancy which may present with
sclerotic metastasis, then a bone scan could be obtained to
exclude a more aggressive lesion.
MRI spine [**8-6**]:
L1 burst fracture again seen. Status post posterior fusion from
T10 through L4. No new abnormalities, aside from the expected
postsurgical
changes.
.
L XR [**8-8**]:
Two views of the lumbar spine from the operating room
demonstrates interval placement of screws within T12 and L2 with
left lateral spinal rod fixating a burst fracture of L1. There
is also subsequent placement of radiolucent disc prostheses at
T12-L1 and L1-L2. Patient has undergone posterior stabilization
with multiple pedicle screws spanning T10 through L4. Please
refer to the procedure note for additional details.
.
Brief Hospital Course:
Ms [**Known lastname 1637**] is a 66yo female HTN/Hyperparathyrodism and
hysteretcomy s/p MVA on [**2137-7-21**] where she was a restrained
passenger, that presents with ongoing abdominal pain, pain with
sitting and walking. On imaging noted to have L1 vertebral body
burst fracture that was unstable, with kyphotic deformity. A
portion of the vertebral body was retropulsed into the spinal
canal and causing significant stenosis. The conus end just
superior to fracture so there was no cord compression.
She was admitted to neurosurgery service for [**8-1**] for repair.
She underwent a 1. Posterior decompression with laminectomies
T12-L1. 2. Open reduction. 3. Instrumented fusion T10-L4 with
bilateral pedicle screws and 4. ICPG of right iliac crest plus
BMP plus allograft. Postoperatively she did well overall however
was noted to have a L foot drop and L toe extension weakness,
associated with hyperesthesias at RLE up the calf. A f/u MRI
showed a L1 burst fracture s/p posterior fusion from T10 through
L4. There were no new abnormalities, aside from the expected
postsurgical changes. It was felt that perhaps she while [**Last Name (un) 8433**]
patient over, there was temporary compression of sciatic nerve
vs. deep peroneal. There were no abnormalities in screw
placement that would account for her symptoms/signs. Over the
next two days, strength in TA improved to 4-/5 and [**3-14**] at [**Last Name (un) 938**].
A CT spine showed similar findings as well as small bone island
of the T9 with concern regarding ? sclerotic metastases as part
of ddx....
On [**8-8**] she underwent anterior fusion of T12 to L2 to stabilize
the posterior fusion. This was an uncomplicated procedure which
she tolerated well. She resumed PO intake, bowel and bladder
functions were intact. She underwent PT and will require LSO
until she is seen in follow up. She was discharged to an
appropriate rehab facility on [**8-14**].
Medications on Admission:
vit d 1000
unavasc 30 dily
norvasc 10mg daily
Fenoxidine 60 daily
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day.
4. Moexipril 15 mg Tablet Sig: Two (2) Tablet PO once a day.
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm.
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
13. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
L1 burst fracture
Discharge Condition:
Neurologically Stable
Discharge Instructions:
- Do not smoke.
- Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
-You must continue to wear your LSO brace at all time when out
of bed and walking. You may remove it briefly to shower.
- No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
- Limit your use of stairs to 2-3 times per day.
- Have a friend or family member check your incision daily for
signs of infection.
- Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
- Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
- Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
- Clearance to drive and return to work will be addressed at
your post-operative office visit.
-You must also have a PET scan of your thoracic spine as an
outpatient to further evaluate a lesion seen on CT at T9. Your
PCP can follow up on this result and schedule this for you.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
- Pain that is continually increasing or not relieved by pain
medicine.
- Any weakness, numbness, tingling in your extremities.
- Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
- Fever greater than or equal to 101?????? F.
- Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
Follow up Instructions:
- Please return to the office in [**7-19**] days (from date of surgery
approx [**8-22**]) for removal of your staples and sutures and a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
[**Name Initial (NameIs) **] Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 3 months. You will also need a CT of your
thoracic and lumbar spine prior to your appointment.
*You will also need an outpatient PET scan(see above for
recommendations).
Completed by:[**2137-8-14**]
|
[
"737.19",
"733.00",
"493.90",
"805.2",
"530.81",
"V10.05",
"241.1",
"401.9",
"805.4",
"E812.1",
"736.79",
"733.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.05",
"81.04",
"84.51",
"81.62",
"84.52",
"03.53",
"77.79",
"81.63",
"80.99"
] |
icd9pcs
|
[
[
[]
]
] |
8666, 8736
|
5556, 7487
|
345, 550
|
8798, 8822
|
2320, 5533
|
10540, 11289
|
1267, 1285
|
7604, 8643
|
8757, 8777
|
7513, 7581
|
8846, 10517
|
1300, 1300
|
1968, 2301
|
253, 307
|
578, 1068
|
1314, 1512
|
1527, 1954
|
1090, 1165
|
1181, 1251
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,933
| 148,919
|
8323
|
Discharge summary
|
report
|
Admission Date: [**2108-6-18**] Discharge Date: [**2108-6-23**]
Date of Birth: [**2055-3-2**] Sex: F
Service: NEUROSURGERY
Allergies:
Cipro / Doxycycline / Paxil / Quinine / Compazine / Levaquin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Persistent headache
Major Surgical or Invasive Procedure:
Cerebral angiogram
History of Present Illness:
53 yo woman initially seen in [**Hospital 21145**] hospital for headache
past 2 weeks progessivelly getting worse. She admits mild
nausea, and photophobia; denies any vomiting, chest pain, SOB,
diplopia or blurred vision, seizure. Denies any fall or trauma.
OSH Head CT revelaes small left SDH, probable aneurysm rupture
on the right frontal region. Patient transferred to [**Hospital1 18**] for
further evaluation and treatment.
Past Medical History:
Past Med Hx:
1. CHF w/EF 20%: unclear etiology, ? cardiac sarcoid vs viral
cardiomyopathy, workup ongoing. Cath [**2-17**] revealed low EF but
PCWP 12.
2. COPD, seen in pulmonary by [**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **]
3. SAH [**2101**] s/p coiling, 2 new aneurysms seen on angio here
[**2108-6-21**]
4. ? sarcoidosis - had liver biopsy revealing this five years
ago per pcp
5. Hypothyroidism
6. s/p hysterectomy
7. s/p ccy
8. RSD
Social History:
The patient quit smoking earlier this year in [**2108**]. She has a
36-pack-year history. She denies alcohol use and recreational
drug use. She had a tattoo done in [**2089**] and [**2094**]. She had a
recent blood transfusion in [**2108-2-12**], two units. The
patient is currently not working. She used to work in
housekeeping. She has been on disability since [**2097**].
Family History:
Grandmother had thyroid disease. Grandmother had
osteoarthritis.
Mother had diabetes mellitus and coronary artery disease.
Father's health history is unknown. Brother and
sister are healthy. There is no relative with known autoimmune
condition or sarcoidosis in the family.
Physical Exam:
O: T:102.3 BP:125/58 HR:87 R:16 O2Sats:99%RA
Gen: WD/WN, comfortable, NAD.
HEENT: no carotid bruits, no scleral hemorrhage/icteria.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-13**] 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, 3 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 finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-15**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
Pertinent Results:
[**2108-6-18**] 05:25PM PT-37.5* PTT-50.2* INR(PT)-4.1*
[**2108-6-18**] 05:25PM WBC-11.5*# RBC-3.12* HGB-9.0* HCT-25.7*
MCV-82 MCH-28.9 MCHC-35.1* RDW-16.8*
[**2108-6-18**] 05:25PM GLUCOSE-125* UREA N-26* CREAT-0.9 SODIUM-136
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-20* ANION GAP-16
[**2108-6-18**] 11:52PM PT-17.1* PTT-38.5* INR(PT)-1.6*
CTA HEAD W&W/O C & RECONS; CT 150CC NONIONIC CONTRAST [**2108-6-18**]
[**Hospital 93**] MEDICAL CONDITION:
53 year old woman with elevated INR and subdural hematoma from
OSH
REASON FOR THIS EXAMINATION:
evaluate evolution of R subdural
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Evaluate evolution of right subdural hematoma.
Note is made of the prior study of [**2102-1-30**].
NON-CONTRAST HEAD CT SCAN: There is a roughly 7-mm wide left
frontal subdural hematoma. There is a thin right parafalcian
subdural collection. Subarachnoid hemorrhage is seen in the
right frontal sulci. A 2.5 x 2.2 cm rounded focus of extraaxial
hemorrhage is seen adjacent to an area of right frontal/temporal
cystic encephalomalacia. This does not impress the brain, but
extends into the atrophic area. There is slight 7 mm rightward
subfalcine herniation. There is no hydrocephalus. Again seen are
right middle cerebral aneurysm coils. The osseous structures are
unremarkable. There is bilateral maxillary mucosal, as well as
sphenoid sinus mucosal thickening, and fluid with aerosolized
secretions.
IMPRESSION: Left frontal subdural hematoma. Parasagittal
subdural hematoma. Right frontal subarachnoid hemorrhage. Right
frontal/temporal hemorrhage adjacent to area of encephalomalacia
which likely is extra-axial. Mild rightward shift of midline
structures.
Acute pansinusitis.
CTA HEAD SCAN:
Dynamically acquired CTA images and 2Drefomatted scans are
reviewed.
The internal carotid arteries, as well as the major vessels of
the circle of [**Location (un) 431**] appear opacified. Beam hardening artifact
from right MCA coils limits evaluation of the right MCA artery.
IMPRESSION: Beam hardening artifact from right MCA coils limits
evaluation of the right MCA artery. Specifically right MCA
aneurysm/ruptured aneurysm cannot be excluded on the basis of
this examination.
ECHO:[**2108-6-19**]
Indication: Cerebrovascular event/TIA. Syncope
Conclusion:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. There is
mild to moderate global left ventricular hypokinesis. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
VERT/CAROTID A-GRAM [**2108-6-21**]
[**Hospital 93**] MEDICAL CONDITION:
53 year old woman with s/p R MCA aneurysm coiling '[**01**], developed
infarct to R MCA post coiling, on Coumadin for RUA DVT, now
there is blood into infacted area.
REASON FOR THIS EXAMINATION:
r/o aneurysmal bleed
IMPRESSION: 1. No sign of reperfusion of the previously coiled
right MCA aneurysm.
2. Tiny approximately 1.5-mm aneurysm of the distal right middle
cerebral artery bifurcation separate from the previously coiled
aneurysm.
3. Questionable broad-based 1-mm aneurysm at the left middle
cerebral artery bifurcation.
4. Atherosclerotic plaque present at the origins of the internal
carotid arteries bilaterally, left greater than right.
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 53 year old woman who presented with
persistent headache past 2 weeks. Her head CT in ED revealed
small left frontal subdural hemorrhage. Patient admitted to
neurosurgery service to further investigate the bleed whether is
a right MCA aneurysmal bleed given the history of coiling on the
right middle cerebral artery in [**2101**]. She transferred to neuro
ICU for close neurologic an hemodynamic monitoring. Her initial
INR was 4.1 reversed with Proplex, vitamin K as well as FFP's.
She is kept NPO overnight. Systolic blood pressure goal is less
than 140 mmHg, then liberalize to less than 160 mmHg. Her
hematocrit on admission was low and dropped from 25.3 to 21.1.
Hematology consulted for anemia work up. She had a fever of
102.3 on admission her urine and blood cultures showed no growth
for microorganism.
She underwent for cerebral arteriogram on [**2108-6-21**] which is
revealed no sign of reperfusion of the previously coiled right
MCA aneurysm. Tiny approximately 1.5-mm aneurysm of the distal
right middle cerebral artery bifurcation separate from the
previously coiled aneurysm. Questionable broad-based 1-mm
aneurysm at the left middle cerebral artery bifurcation.
Atherosclerotic plaque present at the origins of the internal
carotid arteries bilaterally, left greater than right. Post
cerebral angio her neurologic exam remained same, right groin
procedure site is free of hematoma, bleeding, pulses are
palpable.
Patient transferred to neuro regular floor on [**2108-6-23**], kept on
telemetry, she remained on sinus rhythm. Neurologically she i
alert, awake, oriented to time, place and person. Cranial nerves
II-XII are intact, motor strength full, no pronator drift,
sensation is intact.
Patient discharged home in stable condition on [**2108-6-23**] with
discharge instruction and follow up instructions.
Medications on Admission:
Gabapentin 300 mg once a day,
Prednisone 20 mg daily,
Ambien 10 mg at bedtime,
Albuterol p.r.n.,
Spiriva 30mg daily,
Advair inhaler two times daily,
Miacalcin,
Levothyroxine 0.075 mg daily,
amitriptyline 50 mg at bedtime,
Coreg 6.25 mg twice a day,
Digoxin 0.125 mg daily,
Warfarin 5 to 7.5 mg daily, this is secondary to clot in right
upper extremity from PICC line placement,
Hydralazine 10 mg three times a day
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
6. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times
a day: continue until follow up with Dr [**Last Name (STitle) **].
Disp:*90 Capsule(s)* Refills:*2*
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day:
take while on prednisone.
Disp:*60 Tablet(s)* Refills:*2*
14. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Capsule Sig: [**2-13**]
Tablets PO Q4-6H (every 4 to 6 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
6. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times
a day: continue until follow up with Dr [**Last Name (STitle) **].
Disp:*90 Capsule(s)* Refills:*2*
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day:
take while on prednisone.
Disp:*60 Tablet(s)* Refills:*2*
14. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Capsule Sig: [**2-13**]
Tablets PO Q4-6H (every 4 to 6 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral subdural hematoma
Right frontal Subaracnoid
Discharge Condition:
Neurologically stable
Discharge Instructions:
Please call with any neurologic symtoms that may be concerning,
increased headache, weakness, numbness or thingling.
Continue dilantin until seen in the office by Dr [**Last Name (STitle) **].
[**Month (only) 116**] start to resume coumadin [**2108-7-3**]. No bolus/loading dose.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) **] in 8 weeks in the office with a
non-contrast head CT. Call office for an appointment at
[**Telephone/Fax (1) 2731**].
Follow up with your PCP in one week regarding restarting
coumadin and dosing. Please check dilantin level at the PCP
office at the time of follow up; goal dilantin level [**11-30**].
Completed by:[**2108-8-16**]
|
[
"425.4",
"430",
"443.0",
"V12.59",
"135",
"999.8",
"E879.8",
"496",
"427.31",
"244.9",
"V58.61",
"E934.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
12194, 12200
|
7000, 8884
|
344, 365
|
12298, 12322
|
3395, 3812
|
12651, 13028
|
1729, 2008
|
9348, 12171
|
6321, 6487
|
12221, 12277
|
8910, 9325
|
12346, 12628
|
2023, 2287
|
285, 306
|
6516, 6977
|
393, 825
|
2580, 3376
|
2302, 2564
|
847, 1313
|
1329, 1713
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,470
| 167,006
|
4206+55561
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-3-1**] Discharge Date: [**2181-3-5**]
Date of Birth: [**2100-6-30**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80 year old female transferred from NH to [**Hospital1 18**] ED for
evaluation of hypoxia and dyspnea, found to have bilateral
pulmonary emboli, and is admitted to ICU due to ?right heart
strain. Per, report she had a peripheral saturation of 64% at
her NH. She was put on 4L NC and sats increased to 80s.
.
In the ED, initial VS were: 109/69, hr 62, rr20, sat 88 RA. bp
range 102-130/41-64. HR 65-94. 84-95% 3-4L NC. A CTA confirmed
bilateral pulmonary emboli. Heparin gtt and bolus were started.
She also got a less than full dose of vancomycin (stopped as ct
showed no e/o pna) and a dose of ctx. Also ASA 325mg once. She
was given benadryl due to itching at the iv site during the
vancomycin infusion.
.
Transfer vitals af, hr 72, bp 102/61, rr 18, 94% 3L NC. On
arrival to the MICU, she looked comfortable. She is demented.
Oriented to person only. She has no specific complaints but is
an unreliable historian.
.
Review of systems: unable to obtain
Past Medical History:
-Frontal-temporal dementia: Neurocognitive decline has been
tested at least three times consistent findings with frontal
lobe "dementia."
-Spinal stenosis: arthritis of lumbar spine with sciatica
diagnosed in [**2172**].
-Depression: currently on Fluoxetine
-Mild sleep apnea, although patient refuses to use equipment.
-Hypertension in past: subsequently had "low blood pressure"
treated with Florinef.
-Bilateral cataract surgeries in [**2170**].
-Surgery on both feet foot for bunions. Chronic foot pain.
Social History:
In the past, the patient lived [**Street Address(1) 18292**] Senior Living
Center (adult
[**Doctor Last Name **] day care) in [**Location (un) 18293**] - currently lives in [**First Name4 (NamePattern1) 1188**]
[**Last Name (NamePattern1) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the program
director at Bishop St., knows the patient well (contact #:
[**Telephone/Fax (1) 18294**]; [**Telephone/Fax (1) 18295**]). Continues to smoke less than one
pack per week. Began
smoking in her 20's. Previously drank alcohol, but none
currently.
Patient has a master's in music. She has had multiple
occupations in the past, including professional violinist at the
[**Location (un) 18296**] Symphony Orchestra, piano and violin teacher, and
caretaker. She is divorced and has no children. Reports that she
attends church regularly and has a community of friends in the
area. Hcp/[**Location (un) 18297**] [**First Name4 (NamePattern1) **] [**Name (NI) 18298**] [**Telephone/Fax (1) 18299**] home,
[**Telephone/Fax (1) 18300**] cell
Family History:
NC
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
On discharge,
A&Ox1, pleasant
Lungs: CTA anteriorly
CV: RRR, no murmurs
Abd: soft, normoactive bs
Ext: warm and well-perfused, no edema
Neuro: EOMI, full strength in UE/LE bilaterally
Pertinent Results:
[**2181-3-1**] 06:29PM PT-12.1 PTT-132.4* INR(PT)-1.1
[**2181-3-1**] 05:36PM COMMENTS-GREEN TOP
[**2181-3-1**] 05:36PM LACTATE-1.8
[**2181-3-1**] 11:25AM D-DIMER-2898*
[**2181-3-1**] 09:04AM LACTATE-3.8*
[**2181-3-1**] 09:00AM GLUCOSE-138* UREA N-33* CREAT-0.9 SODIUM-142
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18
[**2181-3-1**] 09:00AM estGFR-Using this
[**2181-3-1**] 09:00AM cTropnT-<0.01
[**2181-3-1**] 09:00AM CALCIUM-8.9 PHOSPHATE-4.1 MAGNESIUM-1.7
[**2181-3-1**] 09:00AM WBC-12.8*# RBC-3.50* HGB-11.2* HCT-33.0*
MCV-94# MCH-31.9 MCHC-33.9 RDW-12.6
[**2181-3-1**] 09:00AM NEUTS-80.9* LYMPHS-11.1* MONOS-5.8 EOS-1.7
BASOS-0.5
[**2181-3-1**] 09:00AM PLT COUNT-338
[**2181-3-1**] 09:00AM PT-11.7 PTT-27.9 INR(PT)-1.1
.
INR:
[**3-2**]: 1.1
[**3-3**]: 1.2
[**3-4**]: 1.3
[**3-5**]: 1.7
.
MICROBIOLOGY:
- [**2181-3-1**] MRSA screen: No MRSA isolated
- [**2181-3-1**] Blood culture: Pending at the time of discahrge (NGTD)
- [**2181-3-1**] Blood culture: Pending at the time of discahrge (NGTD)
- [**2181-3-4**] Urine culture: Pending at the time of discharge
CTA CHEST [**2181-3-1**]:
IMPRESSION: 1. Bilateral pulmonary emboli, the largest of which
is in the right main pulmonary artery with findings suggestive
of early right heart strain. Recommended correlation with
echocardiography. 2. Bilateral ground-glass opacities in the
upper lobes are nonspecific. 3. Small hiatal hernia. 4. 12-mm
subcarinal lymph node, likely reactive. 5. 8 mm subcutaneous
nodule within the left anterior chest wall, possibly a sebaceous
cyst, for which clinical correlation is recommended. 6.
Cholelithiasis.
CXR [**2181-3-1**]:
IMPRESSION: Low lung volumes with blunting of the left
costophrenic angle
suggestive of a small effusion.
TRANSTHORACIC ECHOCARDIOGRAM [**2181-3-1**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is moderately
dilated with moderate global 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 mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. IMPRESSION: Moderately dilated right
ventricle with moderate systolic dysfunction. Normal global and
regional left ventricular systolic functino. Moderate pulmonary
hypertension.
Brief Hospital Course:
HOSPITAL SUMMARY: Ms. [**Known lastname **] is an 80F who was transferred from
her care facility to [**Hospital1 18**] for evaluation of hypoxia and
shortness of breath. CTA demonstrated bilateral submassive
pulmonary emboli, and echocardiogram showed evidence of right
heart strain as above, so she was admitted to the medical ICU.
There, she remained hemodynamically stable and was started on
anticoagulation (initially with heparin gtt, then transitioned
to Lovenox therapeutic dosing; she was started on warfarin as
well for planned bridge). She was transferred to the general
medical [**Hospital1 **] on hospital day 2, where her breathing continued to
improve. She will likely require minimum of 6 months of
anticoagulation. Further work up for prothrombotic state
(malignancy, etc.) will be deferred to the outpatient setting.
She was discharged on a lovenox bridge (70 mg twice per day) to
be continued for 2 days after therapeutic INR. She was
discharged on coumadin 7.5 mg per day with instructions that
this is not a determined stable dose and will note close
monitoring - INR on discharge was 1.7. She did have a new oxygen
requirement upon discharge (84% on RA with ambulation).
.
CHRONIC ISSUES:
.
# DEPRESSION, FRONTOTEMPORAL DEMENTIA: Patient was alert and
pleasant but oriented only to self during this admission. She
was continued on her home doses of citalopram, divalproex,
buspirone, and risperdal.
.
# SLEEP APNEA: Patient unable to tolerate CPAP. No significant
complications were noted during this admission.
.
# HYPERTENSION: Hydrochlorothiazide was held during this
admission given concern for possible hemodynamic instability.
She remained normotensive throughout this admission so
hydrochlorothiazide was discontinued on discharge.
.
#GERD: Continued home dose of omeprazole.
.
TRANSITIONAL CARE:
- Patient will require overlap of warfarin and lovenox (70 mg
[**Hospital1 **]) for 2 days once an INR goal of [**3-16**] (measured twice at least
24 hrs apart) is reached
- Recommend 6-12 months minimum of anticoagulation therapy
- daily INRs until stable coumadin dose is established
- Thrombophilia workup will be deferred to the outpatient
setting; this may include age-appropriate cancer screening and
smoking cessation counselling depending on goals of care
- 12-mm subcarinal lymph node was noted on CTA imaging (likley
reactive); decision regarding follow up will be deferred to
outpatient providers
- Blood cultures x 2 sets from [**2181-3-1**] were pending at the time
of discharge (NGTD) as was urine culture (NGTD)
- Code status: DNR/DNI (confirmed with [**Month/Day/Year 18297**])
- [**Name (NI) **]: [**First Name5 (NamePattern1) **] [**Name (NI) 18298**] ([**Telephone/Fax (1) 18299**] home,
[**Telephone/Fax (1) 18300**] cell, fax [**Telephone/Fax (1) 18301**])
Medications on Admission:
house diet pureed foods
omeprazole 20mg daily
citalopram 10mg daily
hctz 12.5mg daily
mv daily
risperidone .5mg daily
glucosamine/chondroitin
ibuprofen 600mg [**Hospital1 **]
buspirone 10mg [**Hospital1 **]
divalproex 125mg [**Hospital1 **]
senna
acetaminophen prn
bisacodyl prn
milk of mag prn
.
Allergies: nkda
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. multivitamin Tablet Sig: One (1) Tablet PO once a day.
4. risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. glucosamine-chondroitin Oral
6. buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO once a day as needed for constipation.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for fever or pain.
11. bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for constipation.
12. enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours): Please give lovenox twice
per day until INR is therapeutic for 2 days. Then discontinue
lovenox. .
13. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM: This is not a stable dose of warfarin for this patient.
Please check daily INR until appropriate daily dose is
confirmed. .
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
PRIMARY:
- Pulmonary emboli
- Right heart strain
SECONDARY:
- Frontotemporal dementia
Discharge Condition:
Mental Status: Confused - always (oriented only to self at
baseline)
Level of Consciousness: Alert and interactive.
Ambulates with a walker.
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted to [**Hospital1 18**] with shortness of
breath and low oxygen levels. Imaging studies showed blood clots
in your lungs (pulmonary emboli) that were affecting your
heart's ability to pump blood. You were treated with blood
thinners and your breathing improved. You will need to continue
to use blood thinners until directed to stop by your physician.
[**Name10 (NameIs) **] will also need oxygen until the blood clots are stabilized
and absorbed by your body.
We have made the following changes to your medication regimen:
- BEGIN TAKING Lovenox injections (70 mg) twice daily until your
INR (blood test) is > 2 for 2 days. Then discontinue lovenox.
- BEGIN TAKING warfarin 7.5 mg by mouth daily (goal INR is [**3-16**]).
We have not yet determine what your final dose will be so you
will require frequent blood tests (INR monitoring) until we know
your proper long-term dose.
- STOP taking hydrochlorathiazide as your blood pressure was
normal
- STOP taking ibuprofen as this can increase your bleeding risk
while on anticoagulation
.
Please take your medications as prescribed and follow up with
your doctors as recommended below.
Followup Instructions:
Please follow up with your PCP ([**Last Name (LF) 251**],[**First Name3 (LF) **] G. [**Telephone/Fax (1) 608**]) or
the doctor at your extended care facility. You will need to have
your INR checked daily until your stable coumadin dose is known.
Name: [**Known lastname **],[**Known firstname 3006**] Unit No: [**Numeric Identifier 3007**]
Admission Date: [**2181-3-1**] Discharge Date: [**2181-3-5**]
Date of Birth: [**2100-6-30**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1824**]
Addendum:
Blood cultures - 1/4 bottles (anaerobic bottle) from [**3-1**] grew
gram-positive rods (corynebacterium or propionibacterium) on
[**3-6**] (5 days after culture) drawn. Patient was afebrile during
admission. This almost certainly represents a contaminant.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3008**] [**Last Name (NamePattern1) **] - [**Location (un) 164**]
[**First Name11 (Name Pattern1) 634**] [**Last Name (NamePattern4) 1837**] MD [**MD Number(2) 1838**]
Completed by:[**2181-3-7**]
|
[
"530.81",
"331.19",
"V49.86",
"401.9",
"429.9",
"311",
"415.19",
"294.10",
"724.02",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13383, 13664
|
6325, 7519
|
310, 317
|
11076, 11076
|
3747, 6302
|
12479, 13360
|
2929, 2933
|
9495, 10800
|
10966, 11055
|
9156, 9472
|
11243, 12456
|
2948, 3728
|
1287, 1306
|
263, 272
|
345, 1267
|
11091, 11219
|
7535, 9130
|
1328, 1839
|
1855, 2913
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,976
| 151,798
|
35280
|
Discharge summary
|
report
|
Admission Date: [**2202-2-15**] Discharge Date: [**2202-2-19**]
Date of Birth: [**2136-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
hypotension
Major [**First Name3 (LF) 2947**] or Invasive Procedure:
none this hospitalization
History of Present Illness:
Mr. [**Known lastname 8182**] is a Spanish-comprehending 65M with complicated
PMH including CVA (nonverbal and does not move arms/legs at
baseline), AF on warfarin, h/o chronic aspiration and multiple
PNA (s/p trach/PEG [**3-/2200**]), multiple prior episodes of
UTI/urosepsis with drug-resistant organisms (VRE), C diff s/p
colectomy, DM2, PVD, and several recent admissions for
UTI/sepsis, who presented to ED with blocked foley and elevated
WBC, and became hypotensive.
.
The patient was discharged on [**2-14**] after an admission for PEG
tube replacement. During this admission his foley catheter was
replaced and proteus not treated as this was felt to be due to
colonization.
.
In the ED, initial VS: T 97.6 HR 80 BP 96/76 RR 20 Sat 94% 4L
trach mask. WBC was 30, Na 146, Cr 1.6 from baseline of 0.4 and
UA was markedly positive. However, he dropped his SBPs to 70s,
maps to 50s, improved with IVF. MAP 65, HR 69, O2 95% trach on
4L breathing on his own at 16. has a 20g in EJ. DNR ok to vent.
.
In ICU, initial BP in 130/70 but pt became hypotensive to 60-70s
again. Started on IVF and dopamine. Additional PIVs obtained.
Abx broadened to linezolid and cefepime.
Past Medical History:
* Hypertension
* Hypothyroidism
* H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**])
* Type 2 Diabetes mellitus
* Peripheral neuropathy
* Depression
* h/o DVT (? - no [**Hospital1 18**] records)
* Atrial fibrillation (on coumadin)
* Peripheral vascular disease
* Hyperlipidemia
* Tracheostomy and GJ tube for chronic aspiration
([**3-/2200**])-Portex Bivono, Size 6.0
* C.diff colitis in [**1-29**] requiring total abdominal colectomy
with end ileostomy [**1-29**], repeat positive C diff toxin
[**2200-5-20**](outside facility, [**12/2198**] here)
Social History:
Resident of [**Hospital 16662**] Nursing Home, previously at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
Family very involved in care. Patient does not take anything by
mouth due to history of aspiration. Spanish-speaking. Patient is
a former 60 pack year smoker but quit in [**2183**].
Family History:
Patient has a mother with diabetes and brother with heart
disease.
Physical Exam:
ADMISSION EXAM:
.
Vitals: T: 97.7 (Axillary) BP: 125/64 P: 58 R: 17 O2: 97% on
trach 4L
General: awake, non-verbal, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear. Eyes looking
up, pupils R>L but reactive to light bilaterally
NECK: trach in place with thick white secretions
LUNGS: Coarse breath sounds bilaterally, +scattered wheezing
bilaterally, good air movement, respirations unlabored, no
accessory muscle use
HEART: distant heart sounds but RRR, nl S1-S2, no r/m/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, PEG and ostomy bags in place.
GU: foley draining cloudy urine.
Ext: cold, palpable pulse on L DP, dopplerable PT on R, no
edema.
NEURO: awake, non-verbal. No spontaneous movement of
extremities. Contracted arms bilaterally.
.
DISCHARGE EXAM:
VS - T- Afebrile, HR- 67-86 , BP- 120-130s/70s-80s , RR-20 ,
SaO2- 96-99% RA
GENERAL: non-verbal but can nod/shake head in response to
questions
HEENT: EOMI and making good eye
contact, sclera anicteric
NECK: [**Year (4 digits) **], trach in place
LUNGS: Coarse breath sounds bilaterally, no wheezing, good air
movement, respirations unlabored, no accessory muscle use
HEART: distant heart sounds but Reg nl S1-S2,
ABDOMEN: Soft but scar tissue palpated, non-tender,
non-distended. PEG in place. Midline scar. no guarding or
rebound tenderness or suprapubic tenderness
EXTREMITIES: warm, well-perfused, no edema, contractions. Some
mild bleeding at midline insertion site with pressure dressing
placed.
NEURO: awake, non-verbal but can nod or shake head in response
to Y/N questions. Cannot move legs or feet/toes; can move both
arms slightly L>R (contracted hands b/l).
Pertinent Results:
ADMISSION LABS:
[**2202-2-15**] 06:10PM BLOOD WBC-30.2*# RBC-5.64 Hgb-13.4*# Hct-40.0
MCV-71* MCH-23.8* MCHC-33.5 RDW-16.0* Plt Ct-222
[**2202-2-15**] 06:10PM BLOOD Neuts-84.7* Lymphs-10.9* Monos-3.6
Eos-0.2 Baso-0.4
[**2202-2-16**] 02:10AM BLOOD PT-29.0* INR(PT)-2.8*
[**2202-2-15**] 06:10PM BLOOD Glucose-134* UreaN-50* Creat-1.6*#
Na-146* K-4.9 Cl-107 HCO3-29 AnGap-15
.
[**2202-2-15**] 07:01PM BLOOD Lactate-2.3*
[**2202-2-15**] 10:47PM BLOOD Lactate-1.1
.
[**2202-2-15**] 06:10PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.012
[**2202-2-15**] 06:10PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
[**2202-2-15**] 06:10PM URINE RBC-28* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
.
Microbiology:
UCx [**2202-2-15**]: URINE CULTURE (Final [**2202-2-13**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
BCx [**2202-2-15**]: no growth to date
Sputum cx:
[**2202-2-16**] 10:00 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2202-2-16**]**
GRAM STAIN (Final [**2202-2-16**]):
>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 [**2202-2-16**]):
TEST CANCELLED, PATIENT CREDITED.
.
IMAGING STUDIES:
[**2202-2-15**] CHEST (PORTABLE AP) - In comparison with study of [**2-11**],
there may be some mild engorgement with poor definition of lower
lung vessels, suggesting some elevated pulmonary venous
pressure. The right hemidiaphragm is more sharply seen,
suggesting some improved aeration at the right base. Patchy
opacifications at the bases most likely reflect atelectasis,
though in the appropriate clinical setting, supervening
pneumonia would have to be considered.
Discharge Labs/Notable Studies:
[**2202-2-19**] 06:25AM BLOOD WBC-8.3 RBC-4.71 Hgb-10.1* Hct-32.3*
MCV-69* MCH-21.4* MCHC-31.3 RDW-16.1* Plt Ct-183
[**2202-2-19**] 06:25AM BLOOD PT-17.6* INR(PT)-1.7*
[**2202-2-19**] 06:25AM BLOOD Glucose-157* UreaN-15 Creat-0.4* Na-140
K-3.3 Cl-104 HCO3-28 AnGap-11
Studies pending on discharge:
None
Brief Hospital Course:
65 yo M with history CVA c/b anoxic brain injury now nonverbal,
paraplegic, bedbound, able to shake head and move upper
extremities slightly, s/p trach/PEG admitted with septic shock
due to Proteus urinary tract infection.
#Urinary tract infection/Septic shock:
Patient was admitted with septic shock initially to the
Intensive Care Unit and was treated with broad spectrum abx
including Linezolid (for h/o VRE) and Cefepime and required
dopamine for vasopressor support along with IVF rescucitation.
His symptoms improved and he was transferred to the floor. His
urine cultures grew proteus sensitive to Ceftriaxone and his
antibiotics were narrowed to Ceftriaxone alone to be continued
for a 2 week course for complicated UTI.
# Trach/respiratory: Patient had some thick secretions but CXR
showed no pneumonia and he did not have hypoxia. Duonebs were
given prn.
#Acute renal failure: Patient found to have elevated creatinine
to 1.6 which improved to baseline 0.4-0.7 with treatment of
sepsis.
# Hypernatremia: mild, likely in setting of
hypovolemia/dehydration, improved with hydration/free water.
.
#Type 2 Diabetes mellitus: Patient on insulin as outpatient. his
blood blood glucose was monitored and he was continued on home
[**Year/Month/Day **] and humalog SSI.
.
# Depression/Leg pain:
Duloxetine and mirtazapine were initially held due to concern of
interaction with Linezolid. Patient did experience increased leg
pain with these held. These were restarted when renal function
improved and linezolid was discontinued and pain symptoms
improved.
.
# Atrial fibrillation: Patient was continued on Coumadin. INR
was therapeutic except for day of discharge (1.7). This should
be followed by NH.
.
Chronic Issues:
# Hypothyroidism: continue levothyroxine 25 mcg daily by NG tube
.
# Spasticity: continue baclofen 15 mg QID
.
# C.diff colitis in [**1-29**] requiring total abdominal colectomy
with end ileostomy [**1-29**]
- colostomy care
.
# Peripheral neuropathy: continued gabapentin 300 mg q8hrs
.
# FEN: NPO. Tube feeds
# Prophylaxis: systemic anticoagulation with coumadin
# Access: midline Left upper extremity
# Communication: [**First Name8 (NamePattern2) **] [**Known lastname 8182**] ([**Telephone/Fax (1) 79725**] (cell);
[**Telephone/Fax (1) 79726**] (day); [**Telephone/Fax (1) 79727**] (eve), son/HCP
# Code: DNR, ok to use trach (discussed with the HCP)
# Disposition: Patient was discharged to his NH to complete
treatment for proteus UTI to end [**2202-2-24**]. INR should be monitored
as INR was 1.7 on day of discharge.
Medications on Admission:
- acetaminophen 650 mg/20.3 mL Solution, [**12-21**] by mouth every six
(6) hours as needed for pain.
- ascorbic acid 500 mg/5 mL Syrup, Five (5) mL by mouth twice a
day.
- baclofen 10 mg Tablet 1.5 Tablets by mouth four times a day.
- bisacodyl 10 mg Suppository, One (1) Suppository Rectal HS (at
bedtime) as needed for constipation.
- docusate sodium 50 mg/5 mL Liquid, Ten (10) mL by mouth twice
a day as needed for constipation.
- duloxetine 30 mg Capsule, Delayed Release(E.C.) One (1)
Capsule, Delayed Release(E.C.) by mouth DAILY (Daily).
- fentanyl 100 mcg/hr Patch 72 hr One (1) Patch 72 hr
Transdermal every seventy-two (72) hours.
- furosemide 20 mg Tablet One (1) Tablet by mouth DAILY (Daily).
- gabapentin 300 mg Capsule One (1) Capsule by mouth every eight
(8) hours.
- insulin aspart 100 unit/mL Solution sliding scale Subcutaneous
four times a day.
- insulin glargine 100 unit/mL Solution Thirty Two (32) Units
Subcutaneous at bedtime.
- ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization One (1) Inhalation every 4-6 hours as needed
for shortness of breath or wheezing.
- lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] mouth once a day.
- levothyroxine 25 mcg Tablet One (1) Tablet by mouth DAILY
(Daily).
- magnesium hydroxide 400 mg/5 mL Suspension Thirty (30) mL by
mouth once a day.
- mirtazapine 15 mg Tablet One (1) Tablet by mouth HS (at
bedtime).
- morphine 10 mg/5 mL Solution Ten (10) mg by mouth every six
(6) hours as needed for pain.
- sennosides [senna] 8.6 mg Tablet One (1) Tablet by mouth twice
a day as needed for constipation.
- therapeutic multivitamin Liquid One (1) Tablet by mouth DAILY
(Daily).
- warfarin 2 mg Tablet Two (2) Tablet by mouth Once Daily at 4
PM.
- zinc sulfate 220 mg Capsule One (1) Capsule by mouth DAILY
(Daily).
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: One (1) PO Q6H
(every 6 hours) as needed for pain/fever.
2. ascorbic acid 500 mg/5 mL Syrup [**Last Name (STitle) **]: One (1) PO BID (2 times
a day).
3. baclofen 10 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO QID (4 times a
day).
4. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) suppository Rectal
twice a day as needed for constipation.
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Last Name (STitle) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): please give via
GT.
6. fentanyl 100 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
7. gabapentin 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID (3
times a day).
8. insulin aspart 100 unit/mL Solution [**Last Name (STitle) **]: as directe
Subcutaneous every six (6) hours: according to sliding scale.
9. insulin glargine 100 unit/mL Solution [**Last Name (STitle) **]: Thirty Two (32)
units Subcutaneous at bedtime.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) nebs Inhalation Q6H (every 6 hours) as
needed for wheezing/shortness of breath.
11. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) nebs
Inhalation Q6H (every 6 hours) as needed for wheezing/shortness
of breath.
12. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
15. morphine 10 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) mL PO Q6H (every
6 hours) as needed for pain.
16. warfarin 2 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Once Daily at 4
PM.
17. zinc sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily): continue until [**2202-2-20**].
18. nystatin 100,000 unit/mL Suspension [**Month/Day/Year **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
19. levothyroxine 25 mcg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
20. 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.
21. CeftriaXONE 1 gm IV Q24H Duration: 7 Days
To end [**2202-2-24**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **]
Discharge Diagnosis:
Primary:
Sepsis
Urinary tract infection
Secondary:
Prior stroke
Type 2 Diabetes Mellitus
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent. (nonverbal but understands
and able to communicate with head nodding)
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted for sepsis due to a urinary tract infection.
You improved with antibiotics and are being discharged on a two
week total course of antibiotics to end [**2202-2-24**].
Your pain medications were initially held, but were restarted
prior to discharge once your renal function and blood pressure
returned to [**Location 213**].
Followup Instructions:
Department: [**Location **] SPECIALTIES
When: THURSDAY [**2202-3-11**] at 12:00 PM
With: PELVIC FLOOR UNIT [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name 706**] CARE UNIT
When: FRIDAY [**2202-3-12**] at 8:30 AM [**Telephone/Fax (1) 446**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Street Address(1) 706**]
When: FRIDAY [**2202-3-12**] at 10:00 AM
With: [**Year (4 digits) 6122**] WEST [**Telephone/Fax (1) 8243**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"276.0",
"250.62",
"438.10",
"V44.0",
"427.31",
"V58.61",
"584.9",
"707.03",
"244.9",
"038.49",
"785.52",
"995.92",
"707.22",
"401.9",
"311",
"357.2",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14228, 14327
|
7254, 8964
|
14481, 14481
|
4329, 4329
|
15053, 15882
|
2520, 2588
|
11740, 14205
|
14348, 14460
|
9834, 11717
|
14686, 15030
|
2603, 3421
|
3437, 4310
|
7225, 7231
|
264, 361
|
389, 1563
|
4345, 6405
|
14496, 14662
|
8980, 9808
|
1585, 2172
|
2188, 2504
|
6422, 7211
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,759
| 156,383
|
14794+56583
|
Discharge summary
|
report+addendum
|
Admission Date: [**2123-8-28**] Discharge Date: [**2123-8-31**]
Date of Birth: [**2103-8-28**] Sex: F
Service:
ADMISSION DIAGNOSIS:
Status post motor vehicle accident.
DISCHARGE DIAGNOSIS:
Status post motor vehicle accident.
HISTORY OF PRESENT ILLNESS: The [**Known firstname **] is a 25 year-old
female who was a restrained passenger in a head on motor
vehicle accident with significant damage to the vehicle. The
[**Known firstname **] was found initially completely unresponsive at the
scene and had to be cut from the vehicle. She did respond to
pain shortly thereafter. On arrival the [**Known firstname **] was
unresponsive to pain and had a GCS of 3. She was intubated
and underwent a fast examination, which was negative.
PAST MEDICAL HISTORY: None.
ALLERGIES: No known drug allergies.
MEDICATIONS: None.
PHYSICAL EXAMINATION: Her temperature was 35. Pulse 108.
Blood pressure 120/palp. She was sating 100%. Neurological
she was unresponsive to painful stimuli in all four
extremities. HEENT no signs of trauma. Pupils 3 to 2
bilaterally. Tympanic membranes clear. Chest is clear to
auscultation bilaterally. Cardiac regular rate and rhythm.
S1 and S2. Abdomen soft, nontender. Rectal normal tone.
Guaiac negative. Extremities no trauma. No deformities. 2+
dorsalis pedis pulses bilaterally.
LABORATORIES ON ADMISSION: Hematocrit 36, blood gas of 7.23,
58, 127, 26 and negative 4. Urinalysis was negative. Tox
screen was negative.
FILMS: Her chest x-ray was negative. Her pelvis is
negative. Her head CT was negative. Her CT of the abdomen
was negative. Her TLSO films were negative. The repeat
chest x-ray, however, revealed a right upper lobe
contusion/aspiration. CT of her C spine was negative.
HOSPITAL COURSE: The [**Known firstname **] was admitted on [**2123-8-28**] and
taken to the Intensive Care Unit. She was loaded with
Dilantin. Neurological was consulted. MRI of the head and C
spine were done. The [**Known firstname **] was lightened from sedation and
followed commands. She seemed to be alert and oriented times
three. Given her negative workup for injuries and clearance
by neurology the [**Known firstname **] was extubated. She did well post
extubation. She was transferred to the floor. She was also
started on Ceftriaxone for presumed aspiration pneumonia,
which was seen on a sputum culture growing gram positive
coxae and gram negative rods. The [**Known firstname **] underwent an MRI
of her C spine. This was negative. Thus her C spine was
cleared and her white blood cell count was rechecked prior to
discharge and pending a stable white count she will be
discharged to home in stable condition and ten days of
Levofloxacin.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 4985**]
MEDQUIST36
D: [**2123-8-31**] 09:33
T: [**2123-8-31**] 09:54
JOB#: [**Job Number 43492**]
Name: [**Doctor Last Name 7595**], DELMI Unit No: [**Numeric Identifier 7956**]
Admission Date: [**2123-8-28**] Discharge Date: [**2123-8-31**]
Date of Birth: [**2103-8-28**] Sex: F
Service:
ADDENDUM: Note that on re-review of the magnetic resonance
imaging scan of the cervical spine, some increased cord
signal was noted. Per the neuroradiologist this could be
artifact, thus a neurosurgical spine consult was obtained.
The films were reviewed and it was decided that
flex/extension films should be ordered. These were ordered
and also reviewed by the neurosurgery team although a C5, C6
light listhesis was noted this was though not to be acute and
the [**Known firstname **] was discharged home with a soft collar in stable
condition and told to follow up in the trauma clinic next
Thursday, if there were any concerns for continued pain,
there was no need per Neurosurgery for neurosurgical follow
up.
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern1) 3595**], M.D. [**MD Number(1) 3596**]
Dictated By:[**Last Name (NamePattern1) 3831**]
MEDQUIST36
D: [**2123-8-31**] 18:49
T: [**2123-8-31**] 19:59
JOB#: [**Job Number 7957**]
|
[
"786.51",
"E812.1",
"850.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
210, 247
|
1786, 4250
|
870, 1362
|
152, 189
|
276, 758
|
1377, 1768
|
781, 847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,655
| 120,724
|
10899
|
Discharge summary
|
report
|
Admission Date: [**2202-8-5**] Discharge Date: [**2202-10-13**]
Date of Birth: [**2163-8-26**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
CC: fever, mutism
Major Surgical or Invasive Procedure:
Paracentesis [**2202-8-6**]
Lumbar puncture [**2202-8-10**]
Cardiac catheter [**2202-8-31**]
Paracardiocentesis [**2202-9-1**]
History of Present Illness:
38yo M w/ ESRD on HD, h/o PTLD, bipolar disorder, and recent
bout of sepsis and Cdiff, p/w fevers and altered mental status.
The patient is minimally interactive, though awake and [**Last Name (LF) 3584**], [**First Name3 (LF) **]
her husband [**Name (NI) **] provides the majority of her history. Prior to
her last hospitalization, her husband noticed that she was more
weak and had more of a flat affect. That was noted by both her
husband and the primary team throughout her last
hospitalization, but it was attributed to her illness. Upon
discharge, her husband noted that her affect continued to be
flat and her mentation was slow. She was verbalizing irrational
fears to her family. Several days later she became
nonresponsive, rigid, and reluctant to walk/move. Husband notes
that she was exhibiting "fleeting clarity", as if she were
delirious with changed sleep patterns and increasing anorexia.
On the day prior to admit, she saw her psychiatrist who
recommended admission given changing psychiatric picture and
continued low grade fevers. The family favored waiting to see
if stopping ativan and initiating zyprexa would help. She then
went to HD and was noted to be minimally responsive after HD.
Overnight she had fever to 100.6 and the morning or admit she
states that she felt SOB and had a cough. At the ED she
complained of abdominal pain, but denied nausea.
.
Pt presented to the ED with VS: T 99.9, BP 114/84, HR 100, RR
20, sats of 97% on 2L. She was noted to be awake, [**Name (NI) 3584**], but
nonverbal. She was following commands and denied any pain.
Work-up revealed a new LLL infiltrate on CXR and resolving
colitis on CT abdomen/pelvis. She was given CTX and vancomycin.
On return from the radiology suite, she had a desaturation event
to 89% on RA but recovered with supplemental oxygen. On arrival
to the floor, she was minimally interactive answering few
questions and responding to a few commands. She specifically
denies pain everywhere, except for her stomach.
.
Of note, pt was just discharged on [**2202-7-28**] after a week long
hospital course that was notable for sepsis, requiring a central
line, fluid resuscitation and IV pressors in the ICU and
complicated by C.Dif colitis.
Past Medical History:
# Post-tx lymphoproliferative disorder, NHL of transplant kidney
and GI tract
# ESRD [**2-19**] lithium toxicity
- s/p failed renal transplant [**2-19**] PTLD, tx kidney removed in
[**2196**]
- now on HD through R sided tunnelled line
# Myelofibrosis
# Thrombocytopenia
- s/p IVIG and rituxan for ? ITP
- heme consult felt multifactorial, mostly consumptive due to
meds/bleeding
# Anxiety
# Bipolar disorder
# s/p exlap, LOA, drainage of intraabdominal fluid collections,
subtotal gastrectomy and repair of incisional hernia w/ mesh
[**2202-5-21**]
# h/o hypothyroidism
Social History:
Married and lives with her husband, [**Name (NI) **], who is a [**Hospital1 18**]
employee. Parents are very involved. No children. No etoh, no
tobacco. She enjoys [**Location (un) 1131**].
Family History:
Non-contributory
Physical Exam:
VS: T 99.2, BP 89/67, HR 86, RR 16, sats 98% on 2L
GEN: Middle aged female, lying in bed, in NAD.
HEENT: PERRL, EOMI appear intact by observation but not able to
be formally tested. Sclera anicteric. OP clear. MM dry.
CV: Regular, normal S1, S2. III/VI systolic murmur throughout
the precordium.
PULM: Crackles at bases bilaterally, L>R. No wheezing or
rhonchi.
ABD: Soft, ND, but ? LLQ tenderness. No rebound or guarding.
Minimal BS. No appreciable hepatomegaly. Scars appear well
healed.
EXT: Warm, 2+ DP/radial pulses BL. 2+ pitting edema up to mid
shin bilaterally.
NEURO: AAO x 3. CN II-XII not able to be formally tested. [**5-22**]
strength on grip bilaterally. Began to comply with strength
testing, but then stopped, raising question of whether or not
her lack of response to questions/commands may be volitional.
Moving all 4 extremities spontaneously. Blinking frequently.
Face is symmetric.
Pertinent Results:
[**2202-8-5**] 08:00PM GLUCOSE-74 UREA N-10 CREAT-4.0* SODIUM-142
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-32 ANION GAP-13
.
[**2202-8-5**] 08:05PM LACTATE-1.1
.
[**2202-8-5**] 06:00PM WBC-5.3 RBC-3.55*# HGB-13.1# HCT-38.3#
MCV-108* MCH-36.9* MCHC-33.4 RDW-22.8*
.
[**2202-8-5**] 06:00PM NEUTS-60.5 BANDS-0 LYMPHS-30.8 MONOS-8.3
EOS-0.2 BASOS-0.3
.
[**2202-8-5**] 06:00PM PLT SMR-LOW PLT COUNT-99*
.
[**2202-8-5**] 08:00PM VALPROATE-56
[**2202-8-5**] 08:00PM TSH-5.3*
.
.
MICRO:
[**2202-8-5**] blood cx x2 pending
[**2202-8-6**] urine cx pending
.
Review of recent micro:
[**2202-7-21**] stool + Cdiff
[**2202-4-30**] blood + enterococcus, [**Last Name (un) 36**] to linezolid and daptomycin
.
STUDIES:
CHEST (PA & LAT) Study Date of [**2202-8-5**] 9:10 PM
There is a posterior segment left lower lobe infiltrate
consistent with pneumonia. The remainder of the lungs is clear.
Dual-lumen dialysis catheter is stable in course and position.
No effusion or pneumothorax is appreciated.
.
CT HEAD W/O CONTRAST Study Date of [**2202-8-5**] 9:50 PM
Advanced global parenchymal atrophy related to patient's stated
age. Differential diagnostic considerations are broad.
Nonetheless, finding is consistent with remote head MRI dated
[**2196-11-12**].
.
CT ABDOMEN/PELVIS W/O CONTRAST; Study Date of [**2202-8-5**] 9:50 PM
As best can be determined due to limitations in technique, no
significant interval change with the exception of likely
improved wall edema suggesting healing colitis. There is
relatively stable amount of ascites,
predominantly in the upper abdomen, particularly in the
perihepatic distribution. Given lack of source for fever,
spontaneous bacterial
peritonitis cannot be excluded. There has been interval
worsening of body wall edema and anasarca.
.
CHEST (PA & LAT) Study Date of [**2202-8-22**] 1:17 PM
1. Improvement of left retrocardiac atelectasis.
2. Subpulmonic effusion vs ascites.
.
CT Abdomen/PELVIS W/CONTRAST Study Date of [**2202-8-30**] 12:43 PM
1. Moderate to large pericardial effusion with thickened and
questionably
hyperenhancing pericardium as detailed above.
2. Slight increase in size in right-sided pleural effusion.
3. Stable volume of ascites with areas suggestive of
loculation.
4. Significant improvement in the patient's previously
described colitis.
.
ECHO Study Date of [**2202-8-30**]
Compared with the prior study (images reviewed) of [**2202-8-12**],
the pericardial effusion is much larger and the heart rate is
higher.
.
C.CATH Study Date of [**2202-8-31**]
1. Pericardial tamponade.
2. Successful pericardiocentesis with aspiration of 480 cc of
bloody
fluid.
.
CHEST (PA & LAT) Study Date of [**2202-9-6**] 6:01 PM
Interval increase in size of left pleural effusion and decrease
in the right pleural effusion. Right lower lobe atelectasis and
left retrocardiac opacity.
.
MR HEAD W/O CONTRAST Study Date of [**2202-9-7**] 9:29 AM
No acute intracranial abnormalities, although the evaluation is
limited due to the lack of gadolinium.
.
ECHO Study Date of [**2202-9-9**]
Small echodense pericardial effusion. Compared with the prior
study (images reviewed) of [**2202-9-1**], the effusion is smaller,
with less free pericardial fluid. The other findings are
similar.
.
CXR [**2202-9-21**]:
IMPRESSION:
No acute cardiopulmonary process with near complete resolution
of previously
identified effusions.
.
U/S Lower extremities [**2202-9-24**]:
IMPRESSION:
1. No DVT.
2. Diffuse soft tissue swelling.
.
Cardiac transthroacic echo [**2202-9-22**]:
Conclusions:
No atrial septal defect is seen by 2D or color Doppler. The
estimated right
atrial pressure is 5-10 mmHg. Left ventricular wall thickness,
cavity size,
and systolic function are normal (LVEF>55%). Due to suboptimal
technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right
ventricular systolic function is normal. The ascending aorta is
mildly
dilated. There is no aortic valve stenosis. The mitral valve
leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic
pressure is normal. There is no pericardial effusion.
Brief Hospital Course:
Patient is a 38 year old female w ESRD on HD, history of PTLD,
bipolar disorder, and recent hospitlaziation with of sepsis and
C difficile, now presented fevers and altered mental status.
.
# Altered mental status: Patient presented to the hospital with
a slow mental decline since the previous admission. There were
not focal findings on neurological examination. CT head showed
advanced global parenchymal atrophy related to patient's stated
age, findings were consistent with remote head MRI dated [**11-13**], [**2196**]. Psychiatry was consulted who believed that initial
differential was broad. They suggested returning her
psychiatric medications to baseline and obtaining an EEG. EEG
was read as normal. LP performed on the patient was also
unrevealing for a source of her mental decline. After [**Hospital 35455**]
medical work up was completed, psychiatry again came to evaluate
patient. They suggested the use of IV ativan might help a
patient with catatonic depression. A trial of 1mg of IV ativan
showed great results - the patient began speaking, having
conversations with the medical team and her family. Ativan was
titrated to 1 mg po TID with great improvement in speaking,
however she continued to be confused and agitated. Repeat MRI
on [**2202-9-7**] confirmed global atrophy inconsistent with age, but
no other identifiable abnormality. Psychiatry then proposed
possible use of ECT, but on [**2202-9-10**] the family refused this
option so further EEG analysis was not pursued. Patient
continued to have waxing and [**Doctor Last Name 688**] mental status, although
overall greatly improved. She remained withdrawn and slow to
respond to questions, and would easily fixate on certain
concepts. Psychiatry followed closely, and recommended inpatient
psychiatric stay, although her family did not feel she would
benefit from this.
Several family meetings were held to discuss the goals of care
and develop a team approach. A behavoiral plan was put in place
and all members of the care team attempted to follow it.
At time of discharge her medication regimen included ativan,
risperidone, and lamotrigine.
.
# Atrial fibrillation - During the patients hospitalization, she
had an episode of tachycardia to 180s on [**2202-8-12**] [**2-19**] Afib with
RVR. She remained hemodynamically stable during the episode.
She was given IV metoprolol and her heart rate improved greatly.
An echo performed after the episode was normal and did not show
any structural heart disease. She had no further episodes until
[**2202-8-30**] when she went into atrial fibrillation while being
evaluated for large pericardial effusion and concern for
tamponade. She was transferred to the MICU for hypotension and
started on amiodarone and spontaenously converted to sinus
tachycardia. Amiodarone was continued for three days then
discontinued. Since that time she has been hemodynamically
stable and in sinus rhythm without further episodes of atrial
fibrillation. She was given 325 mg of aspirin but no
anticoagulated given her low risk of embolic event. Aspirin was
discontinued after she had no further episodes of atrial
fibrillation for one month, and the reason for her atrial
fibrillation appeared clear, due to the effusion, which had
resolved upon repeat echo on [**2202-9-24**].
.
# Hemorrhagic pericardial effusion - on [**2202-8-31**] pt referred for
pericardiocentesis of a large pericardial effusion in the
setting of rapid atrial fibrillation and hypotension. TTE
[**2202-8-30**] showed echo evidence of tamponade; a large,
circumferential effusionwith stranding was appreciated. On [**8-31**]
the patient became progressively hypotensive requiring pressors
and urgent pericardiocentesis. Pt had a successful
pericardiocentesis with aspiration of 480 cc of bloody fluid.
Work-up failed to reveal a cause for the pericardial tamponade.
She was followed with serial echos, which showed continued
resolution of effusion.
.
# Fevers - Upon admission to the hospital, the patient reported
a history of fevers. A large workup for the source of her
fevers was completed in house. A chest xray performed on
admission, showed a left lower lobe pneumonia. She was started
on Vancomycin and Flagyl with the addition of cefepime when
fevers did not resolve. All antibiotics were discontinued after
a 14 day course. Despite obvious source, she intermittently had
low fevers during her admission. Blood cultures were
persistently negative prompting discontinuation of repeat
cultures. Paracentesis performed on [**8-6**] was unrevealing for
source of fevers. LP also did not show any evidence of
infection. TTE performed did not show any vegitations. There
were no localizing findings on physical exam and the patient did
not complain of any specific symptoms. An exhaustive search for
oncologic, rheumatic, and infectious causes were all
unremarkable.
Hematology and oncology was consulted to evaluate for evidence
of a return of her lymphoproliferative disease. They believed
that this was a highly unlikely source of her fevers. On
[**2202-9-8**] she did have a positive C. difficile culture and was
treated with an extended course of flagyl.Patient continued to
have low grade fevers, usually post-dialysis, however developed
a higher fever on [**2202-9-21**], with lower than usual blood pressures.
She was transferred to the MICU and her urine cultures grew
citrobacter freundii complex at that time. She was treated for
14 days with negative cultures after that date. Cultures off of
her dialysis catheter were negative, and her PICC line was
pulled. Erythema noted on one leg was thought to be possibly
cellulitis, so she was also treated for cellulitis with a course
of vancomycin. At time of discharge, after returning from HD pt
had a transient temperature to 100.4 which resolved without
intervention. Since these fevers had occured throughout the
admission an did not seem to have a clear cause she was
discharged with VNA services to check vital signs.
.
#Pneumonia - Seen on inital chest xray. Treated with
vancomycin, cefepime, and flagyl. Infiltrate was seen to be
improved on follow up chest xray. All antibiotics were
discontinued after a 14 day course without return of pulmonary
infiltrates on repeat CXR.
.
# C. Difficle: Patient had been on treatment for Cdiff with
flagyl since previous hospital admission. She was not having
diarrhea upon admission but the flagyl was continued as
originally prescribed at last discharge. Her stool was serially
monitored for C.dif given intermittent diarrhea and she did have
a positive c. difficile culture on [**2202-9-8**] and was again started
on flagyl. Given her difficulty with repeated infections, and
recent antibiotic use, she will continue on flagyl until
[**2202-10-26**]. Her bowel movements slowed to 1-2 times per day at the
time of discharge.
.
# Hypothyroidism: Continued levothyroxine at 125mcg PO QD (new
dose per endocrinologist). TSH was mildly elevated at admit at
5.3, but given recent change in medication, she was continued on
her outpatient dose and TSH was monitored. On last check on
[**2202-8-31**] it was normal at 3.9.
.
# ESRD: Pt has history of ESDR [**2-19**] lithium toxicity, with
history of failed renal transplant. Patient is on Monday,
Wednesday, Friday hemodialysis. She was continued on this
schedule during admission. At times during dialysis, the were
unable to remove fluid from her because of low pressures,
thought to be secondary to continued poor oral intake. For
several sessions she was run euvolemic. Ultimately her
pressures improved and she was hemodynamically stable on
discharge. On discharge, pt is to continue on HD MWF and
nephrocaps 1 CAP PO DAILY. On [**2202-10-8**] transplant surgery placed
an AV fistula in the right upper extremity. After the procedure
the pt some overlying erythema which resolved with elevation.
Pt has outpatient follow up scheduled in the transplant surgery
clinic where they will determine when the fistula can be
accessed.
.
# POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER: Discussed with
hematology and oncology team during admission as a possible
source for her fevers and new onset pericardial effusion. They
believed it was highly unlikely that her lymphoproliferative
disease was recurring.
.
# THROMBOCYTOPENIA: Stable. Known history of ITP, as well as
on several psychoactive medications and a PPI with possible
contribution of platelet suppression. All medications were
continued given that the potential harm of discontinuation did
not outweigh the benefit of increased platelets given she was
never low enough to require transfusion or be at risk for
spontaneous bleeding.
.
# Elevated PTT: Pt was noted to have an isolated elevation in
PTT in the week prior to discharge. Mixing studies, lupus
anticoagulant, anti-cardiolipin were sent, and will need to be
followed up in the outpatient clinic.
.
# ANEMIA: Stable and chronic. Consistent with anemia of
chronic disease, and complicated by ESRD status. During her
hospital stay ([**2202-9-10**]), her TIBC, iron and ferritin were
evaluated and were consistent with anemia of chronic disease.
Her hematocrit was chronically depressed, yet never to the point
requiring transfusion. She was noted to have guaiac positive
stools occasionally which was attributed to small ammount of
blood loss with chonic diarrhea of C. Diff colitis. On
discharge she was hemodynamically stable with stable hematocrit.
.
# Anorexia: The patient had relatively poor intake of meals
during her hospital stay, however with encouragement, she
improved greatly. She was supplemented with nutritional shakes.
.
# Leg edema: Patient had marked leg edema secondary to large
amounts of fluid given while in MICU and CCU to support
pressure, in addition to poor nutritional state with low
albumin. The edema was improving at time of discharge, and
patient wore compression stocking and kept legs elevated when
possible.
.
# Mobility and conditioning: Physical therapy worked with
patient to increase her mobility and maintain and increase her
endurance. She ambulated with assitance and Podus boots were
placed while she was in bed to avoid contractures. Physical
therapy recommended rehabilitation, however the patient's family
desired to bring her home with services.
Medications on Admission:
lamotrigine 50mg PO QHS
divalproex 750mg PO QHS
quetiapine 25mg PO QHS
zyprexa 5mg PO QHS
cholestyramine 4gm PO BID
omeprazole 20mg PO QD
metronidazole 500mg PO TID - last dose to be [**8-11**]
levothyroxine 125mcg PO QD
nephrocaps 1tab PO QHS
.
ALLERGIES: Codeine
Discharge Medications:
1. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Divalproex 250 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO QHS (once a day (at
bedtime)).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
9. Risperidone 0.25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO q4hours PRN
as needed for anxiety.
11. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO QMWF ().
Disp:*12 Tablet(s)* Refills:*2*
12. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary Diagnosis:
1. Cardiac Tamponade c/b Shock
2. Hemorrhagic Pericardial Effusion.
3. Atrial Fibrillation with Rapid Ventricular Response.
4. Catatonia and Mutism
5. Chronic Hypotension
6. Citrobacter Freundii Urinary Tract Infection
7. Difficile Colitis.
8. Ascites
9. Malnutrition
Invasive Procedures:
1. RUE AV Fistula Placement
2. Pericardiocentesis
3. Lumbar Puncture
4. Endotracheal Intubation
5. Paracentesis.
Secondary Diagnosis:
1. Bipolar Disorder
2. Lithium Induced ESRD
3. Failed Cadaveric Renal Transplant (CMV and EBV Positive)
4. Disseminated CMV Infection
5. Post-Transplant Lymphoproliferative Disorder of allograft
kidney,gastric fundus, bowel; s/p Rituximab
6. Immune Thrombocytopenic Purpura treated with IVIG
7. Hypothyroidism
8. Mild diffuse myelofibrosis (Grade [**2-21**])
9. PTLD related Small Bowel perforation, jejunum resection
with primary anastomosis.
10. Subtotal gastrectomy and repair of incisional hernia.
11. Status post appendectomy
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted for fever and mental status changes. A number
of tests were completed, including imaging, lumbar puncture,
blood, and urine tests. You were treated for a pneumonia,
diarrhea, and an urinary tract infection, as well as for your
bipolar disorder, as it was thought to cause some symptoms as
well.
.
Please follow up closely with your primary care physician, [**Name10 (NameIs) **]
psychiatrist, physical therapy, and other services to continue
to working back at reaching your optimal health.
.
Please contact your primary care physician or go to the
emergency room if you experience fevers, chills, chest pain,
difficulty breathing, abdominal pain, worsening diarrhea,
increasing muscle stiffness, or any other symptoms that concern
you or your family.
.
Please take all medications as prescribed.
Followup Instructions:
Please follow up closely with your primary care physician, [**Name10 (NameIs) 3**]
well as your outpatient psychiatrist.
.
Please follow up closely with your outpatient psychiatrist, Dr.
[**Last Name (STitle) **] [**Name (STitle) 35456**] at ([**Telephone/Fax (1) 35457**]. Your appointment is made
for [**2202-10-14**] 9:30 AM.
.
Please follow up with [**First Name11 (Name Pattern1) 819**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] of transplant surgery, MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2202-10-21**] 10:40
.
Please follow up with Dr. [**Last Name (STitle) 16308**] on [**2202-10-20**] at 10:30 AM
([**Telephone/Fax (1) 22245**])
|
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
[]
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20568, 20619
|
8640, 8840
|
284, 413
|
21669, 21679
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4439, 8617
|
22542, 23216
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3482, 3501
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19270, 20545
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18981, 19247
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21703, 22519
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3516, 4420
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227, 246
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441, 2661
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21098, 21648
|
20659, 21077
|
8855, 18955
|
2683, 3255
|
3271, 3466
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,271
| 135,408
|
20013
|
Discharge summary
|
report
|
Admission Date: [**2181-10-14**] Discharge Date: [**2181-10-14**]
Date of Birth: Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: This is a [**Hospital1 346**] admission for this 17-year-old man
was occasioned by his being unrestrained in the back seat of
a high-speed crash. He was found outside the car, having
been ejected. His GCS was 3 at the scene and he was found to
have a subdural left femur fracture, right tib-fib fracture
and right-left shift to the brain at an outside hospital, [**Hospital6 22198**] Center.
PAST MEDICAL HISTORY: Unknown.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
33.5, heart rate 94, blood pressure 140/89. There was a
hematoma on the right forehead with bleeding from the left
nares. He had blood in both ears. His chest was clear. He
had a left thigh hematoma.
LABORATORY/RADIOLOGIC DATA: His pH was 7.2 with a base
deficit of -8. Hematocrit 49.
HOSPITAL COURSE: He had a severe head injury. He was
admitted to the Trauma SICU and was seen by Neurosurgery who
felt that he had no brain stem reflexes with local edema and
diffuse injury. A herniation was anticipated. His family
was contact[**Name (NI) **] as it was thought that he was inoperable and
the patient became bradycardiac and asystolic and expired on
[**2181-10-14**].
DISCHARGE DIAGNOSIS:
1. Severe head injury.
2. Multiple trauma.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern4) 12891**]
MEDQUIST36
D: [**2182-1-2**] 08:57
T: [**2182-1-2**] 09:20
JOB#: [**Job Number 53920**]
|
[
"821.00",
"557.0",
"348.4",
"801.35",
"E819.1",
"958.4",
"518.5",
"584.9",
"331.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.07",
"99.04",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
1350, 1653
|
958, 1329
|
621, 940
|
575, 606
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,654
| 117,687
|
36334+58074
|
Discharge summary
|
report+addendum
|
Admission Date: [**2153-6-15**] Discharge Date: [**2153-6-20**]
Date of Birth: [**2074-12-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9415**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 22305**] is a 78 yo M with CAD, CHF, afib not
anticoagulation, h/o CVA with aphasia, as well as UTI/urosepsis
in the past who presents from [**Hospital1 **] [**Location (un) 620**] with urosepsis and
delirium. Of note, the patient was admitted to [**Hospital1 **] [**Location (un) **] from
[**Date range (1) 56565**] with delirium related to Proteus mirabilis UTI, treated
with Cipro x7 days.
.
Patient was found to have altered mental status at [**Hospital 1036**]
nursing home today. He was found to be less responsive taking
decreased POs. Per report, had not been seen by NP in 1 week.
According to the staff, he has been declining functionally for
the last few weeks, being less energetic, and eating less. At
baseline his is not oriented, is pleasantly demented, and can
interact in simple terms. His gaze deviates to the right. His
son verifies this description, and the family has been moving
towards comfort care. The nursing home staff denies any focal
symptoms otherwise.
.
At [**Hospital1 **] [**Location (un) 620**], initial VS T 101.9, HR 130s, SBP 80s, RR 20s,
99% FM. EKG with afib with RVR at 150bpm. CXR with ? bilat
patchy infiltrates. The patient was given Tylenol 650mg, ASA
300mg PR, Vanco 1g x1, CTX 2g x1 and transferred to [**Hospital1 18**].
.
On arrival, he is awake and answers simple questions, though
appears agitated.
.
ROS: Cannot obtain given patient's mental status
Past Medical History:
Afib -> not anticoagulation due to GIB
CAD
CVA with aphasia
CHF
h/o urinary tract infection
Hypertension
h/o urosepsis
Esophageal ulcer [**2152**]
? history of seizure
Dementia
h/o behavioral disorder
Social History:
He lives at the nursing home. He is dependent in his ADLs,
IADLs.
Family History:
NC
Physical Exam:
VS: T 97.6, HR 114, BP 136/120, RR 21, 2L nc
Gen: awake, responds to name with brief answers, contracted,
deviates to the right, cachectic
HEENT: anicteric sclera, MM dry, parched
Neck: thin, supple
Heart: Tachy, irregular, no m/r/g
Lung: Poor inspiratory effort, no obvious crackles
Abd: thin soft, ND, NT + BS no rebound or guarding
Ext: thin, no pitting edema, warm
Skin: no rashes appreciated
Neuro: awake, answers to name, not oriented, moderately
agitated, deviates to the right, moving all extremities. Does
not cooperate with rest of exam.
Pertinent Results:
[**2153-6-15**] 11:19PM BLOOD WBC-15.5* RBC-4.28* Hgb-12.8* Hct-40.7
MCV-95 MCH-29.9 MCHC-31.4 RDW-14.6 Plt Ct-167
[**2153-6-16**] 05:10AM BLOOD WBC-15.7* RBC-4.00* Hgb-11.8* Hct-37.8*
MCV-95 MCH-29.4 MCHC-31.1 RDW-14.7 Plt Ct-145*
[**2153-6-17**] 04:03AM BLOOD WBC-10.3 RBC-3.32* Hgb-9.9* Hct-30.5*
MCV-92 MCH-29.8 MCHC-32.5 RDW-14.8 Plt Ct-122*
[**2153-6-15**] 11:19PM BLOOD Neuts-82.7* Lymphs-13.7* Monos-3.0
Eos-0.4 Baso-0.2
[**2153-6-15**] 11:19PM BLOOD Glucose-94 UreaN-74* Creat-2.7* Na-169*
K-3.8 Cl-139* HCO3-18* AnGap-16
[**2153-6-16**] 05:10AM BLOOD Glucose-148* UreaN-66* Creat-2.3* Na-165*
K-3.4 Cl-137* HCO3-19* AnGap-12
[**2153-6-16**] 10:23AM BLOOD Na-163*
[**2153-6-16**] 05:15PM BLOOD Glucose-270* UreaN-38* Creat-1.5* Na-148*
K-3.3 Cl-122* HCO3-14* AnGap-15
[**2153-6-16**] 10:22PM BLOOD Glucose-99 UreaN-32* Creat-1.3* Na-156*
K-3.1* Cl-126* HCO3-20* AnGap-13
[**2153-6-17**] 04:03AM BLOOD Glucose-122* UreaN-27* Creat-1.2 Na-152*
K-3.3 Cl-124* HCO3-20* AnGap-11
[**2153-6-17**] 11:46AM BLOOD Na-146*
[**2153-6-15**] 11:19PM BLOOD CK(CPK)-1341*
[**2153-6-16**] 05:10AM BLOOD CK(CPK)-1361*
[**2153-6-17**] 04:03AM BLOOD CK(CPK)-768*
[**2153-6-15**] 11:19PM BLOOD CK-MB-20* MB Indx-1.5 cTropnT-0.09*
[**2153-6-16**] 05:10AM BLOOD CK-MB-16* MB Indx-1.2 cTropnT-0.10*
[**2153-6-17**] 04:03AM BLOOD CK-MB-7 cTropnT-0.08*
[**2153-6-15**] 11:19PM BLOOD Calcium-7.4* Phos-3.7 Mg-2.6
[**2153-6-16**] 05:10AM BLOOD Albumin-2.6* Calcium-7.3* Phos-2.3*
Mg-2.5
[**2153-6-16**] 10:22PM BLOOD Calcium-7.2* Phos-1.9* Mg-1.9
[**2153-6-17**] 04:03AM BLOOD Calcium-6.9* Phos-1.9* Mg-2.5
[**2153-6-16**] 05:10AM BLOOD Valproa-4*
.
[**6-16**] Port CXR
Portable AP chest radiograph was reviewed with no prior studies
available for
comparison.
The patient's heart obscures the lung apices. Cardiomediastinal
silhouette is
normal in size, position and contours. Left retrocardiac opacity
and right
bibasilar opacities are present that might represent areas of
atelectasis,
aspiration or developing infection. The rest of the lungs are
unremarkable.
There is no evidence of failure. There is no appreciable pleural
effusion or
pneumothorax.
Brief Hospital Course:
In short, Mr. [**Known lastname 22305**] is a 78M nursing home resident w CAD,
CHF, A-fib (not on AC), h/o CVA with aphasia, prior UTIs, who
originally presented to [**Hospital1 18**] [**Location (un) 620**] w fever/delirium, was
found to have Proteus urosepsis, hypernatremia, and AF/RVR, and
was subsequently transferred to the [**Hospital1 18**] MICU, where pt was
treated w CTX (d1=[**6-15**]), free water (Na improved from 163 to
146), and supportive measures. Pt required intermittent NS
boluses for hypotension, but was not on pressors. AF/RVR
converted to sinus rhythm without intervetion. Pt was also found
to have ARF and elevated CK, which resolved. Given pt's very
poor baseline functioning and multipe admissions to the hospital
without reasonable hope for improvement, family discussion was
held regarding goals of care in the presence of palliative
specialists. Family agreed that patient would have preferred the
avoidance of further hospitalizations/invasive measures at this
point and pursue comfort measures only.
.
# DNR/DNI
# Comfort measures only:
- zydis SL for agitation
- morphine concentrate for pain PRN
- may use conc haldol
- no IVs, no labs, no vitals, no abx
# Do not hospitalize
# HCP: [**Name (NI) **] [**Name (NI) 122**] ([**Telephone/Fax (1) 82319**], Dtr [**Name (NI) **] ([**Telephone/Fax (1) 82320**]
Medications on Admission:
Medications (transfer):
Ferrous sulfate 325mg daily
Prilosec 20mg daily
MVI daily
Thiamine 100mg daily
Metoprolol 12.5mg [**Hospital1 **]
Depakote ER 250mg ER q24
Tylenol prn
Mg Hydroxide unknown
Biscodyl 10mg PR prn
Lipitor 80mg qHS
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO bid:prn as needed for
constipation.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO daily:prn as needed for
constipation.
4. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO tid:prn as needed for agitation.
5. Morphine Concentrate 5 mg/0.25 mL Solution Sig: [**1-26**] PO prn
as needed for pain/SOB.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Proteus urosepsis
Hypernatremia
Altered mental status
Acute renal failure
Atrial fibrillation w rapid ventricular response
.
Coronary artery disease
Chronic congestive heart failure
History of seizures
s/p Stroke
Discharge Condition:
at baseline
Discharge Instructions:
Mr [**Known lastname 22305**] was admitted to the hospital for urinary tract
infection. Given his poor baseline function (AOx0, s/p stroke,
multiple comorbidities), family discussion was held with the
decision to provide comfort measures only.
Followup Instructions:
As needed for comfort measures
Completed by:[**2153-6-20**] Name: [**Known lastname 13171**],[**Known firstname 1198**] Unit No: [**Numeric Identifier 13172**]
Admission Date: [**2153-6-15**] Discharge Date: [**2153-6-20**]
Date of Birth: [**2074-12-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13173**]
Addendum:
Pt admitted to ICU for sepsis secondary to urinary tract
infection from Proteus.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1132**] - [**Location (un) 407**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13174**] MD [**MD Number(2) 13175**]
Completed by:[**2153-6-30**]
|
[
"427.31",
"276.0",
"414.01",
"438.11",
"345.90",
"995.91",
"584.9",
"428.0",
"V66.7",
"038.49",
"293.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8214, 8450
|
4853, 6194
|
321, 327
|
7351, 7365
|
2691, 4830
|
7657, 8191
|
2103, 2107
|
6479, 6994
|
7115, 7330
|
6220, 6456
|
7389, 7634
|
2122, 2672
|
276, 283
|
355, 1779
|
1801, 2004
|
2020, 2087
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,225
| 168,057
|
33994
|
Discharge summary
|
report
|
Admission Date: [**2116-4-8**] Discharge Date: [**2116-4-17**]
Date of Birth: [**2075-12-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hemoptysis
.
Major Surgical or Invasive Procedure:
Bronchoscopy
.
History of Present Illness:
40 year-old woman with CHF, HTN, COPD, morbid obesity, sleep
apnea, hypoventilation presented with bleed around the trach
called out of MICU. Pt had PNA in [**2-15**] and was trached at
OSH. She had been weaned off of ventilator and transferred to
rehab, then readmitted to OSH ICU on [**4-7**] for desaturations. Had
fevers to 102.6, blood-tinged sputum, no leukocytosis. CXR with
? R perihilar left basilar infiltrate. Bronchoscopy revealed
granulation tissue causing 40% occlusion of the trachea and the
trach was replaced on [**4-3**]. She was started on vanco/zosyn for
empiric HAP coverage. She was noted to have bleed around the
trach. She was transferred to [**Hospital1 18**] for further mgmt and
possible opening of her tracheal occlusion with laser technique.
Pt was initially admitted to [**Hospital1 18**] ICU on [**4-8**]. CT Chest done
here (results below) with ?aspiration pneumonia. Bronch
performed by IP on [**2116-4-9**] showing diffuse nodular lesions
involving the mid/distal trachea suggestive of an bacterial or
viral infection, bloody secretions and tracheomalacia. During
admission, patient also noted to be in acute renal failure
likely from pre-renal etiology (Cr peaked at 2.5 on [**4-9**] from 0.6
at OSH). Anti-hypertensives were held (including ACEI), lasix
was held and creatinine now improvement with good urine output
in past 24 hours.
.
Pt remained stable in the ICU. Continued to have hemoptysis of
dark colored bloody sputum, no frank red blood. Hct 34.7-->
30.7. Pt denies any SOB or difficulty breathing. She is still
producing copious secreations that are blood-tinged. She is
asking repeatedly to go back to [**Hospital6 6689**].
.
Past Medical History:
Recent pneumonia c/b prolonged intubation and trach
Obesity
Sleep apnea
Obesity hypoventilation
HTN
CHF
?COPD
Depression
.
Social History:
Was at inpatient rehab prior to OSH asmission. Previously lived
alone. Smokes 1.5 ppd, no etoh or drug use. Has 2 kids who are
in DSS custody.
.
.
Family History:
Non-contributory.
.
Physical Exam:
T 98.3 78 110/60 18 95%/10L trach collar
NAD. AAO x 3. unable to talk due to the trach. communicated via
writing, obese, NAD
HEENT: PERRL, EOMI, OP clear, MMM, trach in place. minimal blood
tinged secretions on dressing around trach
Chest: mild expiratory wheeze bilaterally anteriorly, lungs
clear to auscultation posteriorly
Heart: distant heart sounds, RRR, no M/R/G, ml S1 S2
Abd: (+) BS, soft, obese, NT
Extr: 1+ RLE edema, no calf tenderness or cord palpated, chronic
venous stasis changes in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]
Neuro: CN II-XII intact, no focal motor or sensory deficit
.
Pertinent Results:
PERTINENT LABS:
[**2116-4-8**] 11:39PM BLOOD WBC-10.4 RBC-3.85* Hgb-11.6* Hct-34.7*
MCV-90 MCH-30.2 MCHC-33.5 RDW-19.3* Plt Ct-294
[**2116-4-8**] 11:39PM BLOOD Neuts-79* Bands-7* Lymphs-2* Monos-7
Eos-5* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2116-4-8**] PT-16.0* PTT-25.7 INR(PT)-1.4*
[**2116-4-8**] Glucose-109* UreaN-20 Creat-2.0* Na-137 K-4.4 Cl-97
HCO3-29
[**2116-4-9**] Creat-2.5
[**2116-4-16**] Creat-1.1
[**2116-4-9**] [**Doctor First Name **]-NEGATIVE
[**2116-4-9**] ANCA-NEGATIVE B
[**2116-4-9**] ANTI-GBM-NEGATIVE
.
[**2116-4-9**] URINALYSIS: Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.030
[**2116-4-9**] 03:56AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-4* pH-6.5 Leuks-NEG
RBC-<1 WBC-[**5-19**]* Bacteri-MOD Yeast-NONE Epi-[**2-12**]
[**2116-4-9**] URINE ELECTROLYTES: Osmolal-311 UreaN-359 Creat-130
Na-39
.
MICRO DATA:
[**4-8**] BLOOD CX: no growth
[**4-9**] URINE CX: no growth
[**4-9**] GRAM STAIN (Final [**2116-4-9**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2116-4-13**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
CEFTAZIDIME sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
STAPH AUREUS COAG +. SPARSE 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.
Please contact the Microbiology Laboratory ([**6-/2414**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 4 S <=0.5 S
LEVOFLOXACIN---------- <=0.12 S
MEROPENEM------------- =>16 R
OXACILLIN------------- 0.5 S
PENICILLIN G---------- =>0.5 R
PIPERACILLIN---------- 32 S
PIPERACILLIN/TAZO----- 64 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2116-4-10**]): NEGATIVE for Pneumocystis jirvovecii
(carinii).
FUNGAL CULTURE (Preliminary):
YEAST.
[**4-11**] STOOL C DIFF: negative
.
STUDIES:
CXR ([**2116-4-8**]): Moderate cardiomegaly. The mediastinum shows
bilateral enlargement. In the left lung apex, a rounded
parenchymal opacity with apparent spiculations is seen. The core
of the lesion has about 1.5 cm in diameter. This lesion requires
CT for exclusion of malignancy. No signs of overhydration,
relatively low bilateral lung volumes. No evidence of pleural
effusion. Tracheal tube in situ.
.
CT CHEST: 1. Multifocal paramediastinal high attenuation
consolidations in both upper and lower lobes suspicious for
aspiration of blood given the provided clinical history. There
is no intracavitary lung lesion. 2. Findings suggestive of
tracheo- bronchomalacia, especially of the left main bronchus.
.
Bronch w/ BAL [**2116-4-9**]: A small amount of bloody secretions were
noted at the distal end of the tracheostomy tube which were all
suctioned clean. Evaluation of the airways revealed diffuse
nodular lesions involving the trachea suggestive of an infection
of either bacterial or viral etiology. Bloody secretions were
seen in the entire length of the trachea. Also, tracheomalacia
was evident with normal respiration.
.
RLE US with dopplers ([**2116-4-11**]): No evidence of DVT of the right
lower extremity.
.
Brief Hospital Course:
Ms. [**Known lastname 23239**] is a 40 year-old woman with history of CHF, HTN,
obesity, sleep apnea who presented from an OSH with
hospital-acquired pneumonia, hemoptysis, and tracheomalacia.
.
# Hemoptysis: Bronchoscopy revealed diffusely friable tissue in
the trachea with diffuse nodular lesions, oozing blood, and
diffuse bronchitis. This was felt to be most like a viral
tracheitis with concern specifically for HSV given the nodular
appearance. She was initially in the ICU and quickly transferred
to the floor. Hematocrit remained stable. On the day after
transfer to the medical floor she had several episodes of
hemoptysis and desaturations, felt due to mucus plugging. The
increased hemoptysis was attributed to aggressive endotracheal
suctioning. With less suctioning, the hemoptysis completely
resolved. Repeat bronchoscopy on [**4-14**] showed one blister in the
trachea, no bleeding. She was treated with acyclovir for
possible HSV tracheitis. She will continue to complete a 14 day
course on [**2116-4-23**].
.
# Hospital-acquired pneumonia- She initially presented to the
OSH with fevers and productive cough. The patient was started on
antibiotics for hospital-acquired pneumonia at the OSH. Here,
she had a CXR showing RUL infiltrate that was confirmed by CT
scan. Sputum culture grew pseudomonas and MSSA. She was
initially treated with vancomycin and piperacillin/tazobactam.
The vancomycin was discontinued when the staph aureus was found
to be MSSA. She will continue on pip/tazo to complete a 14 day
course on [**2116-4-21**].
.
# Acute renal failure - She has no known history of kidney
disease. Creatinine at the OSH was 0.6. On day 2 of admission at
[**Hospital1 18**] her creatinine peaked at 2.5. By the time of discharge it
has stabilized at 1.1. Etiology of her renal failure was likely
pre-renal and the patient admitted to decreased PO intake over
the weeks prior to admission. FENa was 0.5%. Her creatinine
improved with IVF but has not returned to her baseline.
Lisinopril and lasix were held. Preliminary work-up for
intrarenal causes, specifically vasculitis, was unremarkable,
including ANCA, [**Doctor First Name **], and anti-GBM which were all negative. This
should be followed as an outpatient.
.
# RLE swelling: She has asymmetric swelling of her lower
extremities, R > L. This is not new according to the patient and
she reports she has been evaluated for clots at least twice at
the OSH. She had no calf tenderness or cord palpated on exam.
RLE ultrasound was negative for DVT.
.
# Hypertension: Her lisinopril and lasix were held during this
admission given her acute renal failure and initial hypovolemia.
She remained normotensive off of medications and appeared
euvolemic so lasix was not felt necessary. [**Month (only) 116**] consider
re-starting as an outpatient.
.
# Diabetes: On insulin and metformin as an outpatient. FS well
controlled here and she has not required correction with
insulin. Metformin was held given her acute renal failure. Would
continue to monitor as an outpatient and consider adding back
insulin and metformin if needed.
.
Code: full
.
Medications on Admission:
vanc 1 q12
zosyn 4.5 qd
lasix 20 [**Hospital1 **]
Lantus
RISS
Lexapro 20
Lisinopril 40 qd
Nicotine patch
ventolin neb
.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Piperacillin-Tazobactam 4.5 gram Recon Soln Sig: One (1)
Intravenous every eight (8) hours for 3 days: last dose on [**4-20**].
10. Acyclovir Sodium 1,000 mg Recon Soln Sig: Eight Hundred
(800) mg Intravenous every twelve (12) hours for 5 days: last
dose on [**4-22**].
11. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush: PICC,
heparin dependent: Flush with 10mL Normal Saline followed by
Heparin as above daily and PRN per lumen. .
12. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
15. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): apply to affected area for 1 week.
16. Insulin Regular Human 100 unit/mL Solution Sig: as per
sliding scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Commons [**Location (un) 6691**]
Discharge Diagnosis:
Primary: Tracheitis (likely viral), hospital acquired pneumonia
Secondary: CHF, HTN, morbid obesity, OSA, obesity
hypoventilation
Discharge Condition:
Vital signs stable. No hemoptysis.
Discharge Instructions:
You were transferred to [**Hospital1 18**] for evaluation of bleeding from
your tracheostomy. You had 2 bronchoscopies while you were here
and it is felt that you have a viral infection of the trachea or
upper airway that caused the lining of your airways to become
irritated and bleed. You were started on 2 antibiotics for this.
If you develop fevers > 101, shortness of breath, hemoptysis
(coughing up blood), or chest pain, you should return to the
emergency room.
Followup Instructions:
You should follow-up with your primary care provider [**Name Initial (PRE) 176**] 2
weeks of being discharged from rehab. Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 37713**].
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"041.7",
"780.57",
"041.11",
"428.32",
"786.09",
"486",
"933.1",
"276.52",
"054.9",
"584.9",
"401.9",
"428.0",
"285.29",
"464.10",
"519.19",
"729.81",
"496",
"278.01",
"E915",
"250.00",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"33.24",
"33.21"
] |
icd9pcs
|
[
[
[]
]
] |
12464, 12540
|
7272, 10387
|
326, 342
|
12714, 12751
|
3052, 3052
|
13269, 13577
|
2373, 2394
|
10558, 12441
|
12561, 12693
|
10413, 10535
|
12775, 13246
|
2409, 3033
|
5968, 7249
|
274, 288
|
370, 2046
|
3068, 5932
|
2068, 2193
|
2209, 2357
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,839
| 134,351
|
48338
|
Discharge summary
|
report
|
Admission Date: [**2102-5-15**] Discharge Date: [**2102-5-26**]
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male
status post Foley placement on [**5-9**] tolerating it well
initially, but was started on Cipro for prophylaxis for
urinary tract infection. He developed pelvic pain and spasm
on [**5-11**]. Additionally developed diarrhea and had decreased
po intake. He describes chills and increased confusion the
last day prior to admission. He then developed hematuria.
He was status post BCG and interferon two weeks prior. Four
episodes of diarrhea yesterday and they were nonbloody.
In the Emergency Room, he was given 3 liters of normal saline
IV fluid, 500 mg of IV Flagyl, gentamicin, and pancultured.
A three-way Foley was placed and demonstrated blood clots,
and the bladder was irrigated.
REVIEW OF SYSTEMS: No chest pain, no shortness of breath.
Positive fatigue. Positive sweats. No nausea or vomiting.
Positive diarrhea. Weight at baseline with mild assistance
for activities of daily living.
PAST MEDICAL HISTORY:
1. Transitional bladder cancer: Status post right
nephrectomy, BCG, and interferon.
2. Atrial fibrillation on Coumadin.
3. Hypertension.
4. Hypercholesterolemia.
5. V-paced.
6. Benign prostatic hypertrophy.
7. Pericardial window in [**9-9**].
8. Coronary artery disease.
9. Dementia.
10. Depression.
11. Low thyroid.
12. Transient ischemic attack.
ALLERGIES: Sulfa, Bactrim, penicillin, and Lasix.
OUTPATIENT MEDICINES:
1. Coumadin.
2. Aricept.
3. Bumex.
4. Celexa.
5. Lipitor.
6. K-Dur.
7. Multivitamin.
8. Prevacid.
9. Proscar.
10. Provigil.
11. Synthroid.
12. Wellbutrin.
SOCIAL HISTORY: He is a World War II concentration camp
survivor with a 100 pack year history. He is a retired
dentist.
EXAMINATION ON ADMISSION: Temperature 99.4, blood pressure
160/61, heart rate 78, respiratory rate 19, and 100% on 2
liters. Generally, he is in no acute distress. Extraocular
muscles are intact. Sclerae were anicteric. Mucous membranes
are dry. Regular, rate, and rhythm, no murmurs, rubs, or
gallops. Lungs are clear to auscultation bilaterally. Had
decreased breath sounds bibasilarly, no wheezes. Soft,
nontender, nondistended abdomen. Extremities showed no
clubbing, cyanosis, or edema. He had [**2-9**]+ bilateral lower
extremity, no rash or no lesions. His cranial nerves II
through XII are intact. Strength 4/5 in the lower
extremities bilateral, [**6-12**] upper bilateral.
LABORATORIES: White count of 25.4 with 80% neutrophils, 2
bands, 5 lymphocytes. Sodium 139, potassium 4.4, chloride
104, bicarb 24, BUN 39, creatinine 2.5, glucose 153. PT
26.7, PTT 29, INR 4.7.
Electrocardiogram showed V-paced at 86 beats per minute.
Chest x-ray showed a right IJ in place with a ...............
cardiac silhouette. Stable bilateral pleural effusions.
His urinalysis was cloudy with large leukocytes, positive
nitrates, large blood, greater than 50 red blood cells, 0
white blood cells, and few bacteria.
HOSPITAL COURSE: He was admitted to the [**Company 191**] Service for
workup of confusion and hypotension. After fluid
resuscitation in the Emergency Room, he appeared to be
mentating well, and he was hemodynamically stable. However,
he was observed overnight in the Intensive Care Unit. MICU
course was complicated by 1) a drop in hematocrit from 47 to
33. This is thought to be secondary to hemodilution and
hematuria. His hematocrit remains stable, only slowly dipped
from downward during his hospitalization. Upon discharge it
was around his baseline of 31.
2. Elevated INR. This was thought to be secondary to
ciprofloxacin and Coumadin. His Coumadin was held and his
INR reversed.
3. Acute renal failure. He presented with a creatinine well
above baseline at 2.5. This resolved with IV fluids and was
thought to be secondary to dehydration in the setting of
fever and diarrhea. This improved with hydration. However,
later in his hospital course when patient's mental status was
not alert enough for him to maintain adequate po, his acute
renal failure recurred. This was thought to be
multifactorial secondary to obstruction which was relieved by
the placement of the Foley catheter as well as dehydration.
He was aggressively hydrated, and his creatinine began to
return to normal.
A Renal consult was obtained and the urine was not consistent
with a glomerulonephritis and suggested starting Flomax which
was begun.
4. Infectious Disease: The patient presented with fever and
mental status changes. Initially, this was thought to be
urinary tract infection, however, several blood cultures came
back positive for MRSA bacteremia. It was unclear as to the
source of this. A transthoracic echocardiogram was attained
and revealed no vegetations, however, a followup
transesophageal echocardiogram was then performed and
additionally no vegetations were found, thus making
endocarditis less likely.
CT scan of the abdomen was attained, which did not
demonstrate any focal finding of infection, but only
hydroureter and distention of the bladder when the Foley was
not in place. He was started on Vancomycin; in a few days
his fevers resolved. His blood cultures cleared. A PICC
line was placed. Although no definite source was found, this
was thought to be in the vascular source to have such high
grade bacteremia. He was continued on Vancomycin for six
weeks.
Infectious Disease was consulted throughout hospitalization,
and additional recommendations were given, however, still no
clear source was found. There was concern for a possible
prostatitis or abscess. However, per the Genitourinary team,
his rectal examination was nontender making prostatitis less
likely, therefore this is not pursued.
5. Genitourinary: He had extensive hematuria during his
hospital stay likely secondary to his transitional cell
carcinoma and subsequent treatment with BCG and interferon.
Urology followed him throughout his hospitalization.
The patient tried a voiding trial. The Foley was removed,
although he did have urine output, it dropped off, and his
renal failure increased. It was noted by the Renal team that
his creatinine began to rise upon discontinuation of the
Foley. It was therefore replaced, and dehydration
normalized. CT was performed in-house, although lacked,
Infectious Disease focus did demonstrate a mildly tortuous
hydroureter and mild hydronephrosis that was present on
retrograde pyelogram three months prior, therefore this is
not a new finding. This was discussed with the Renal team,
however, they felt that in the set with such an improved
creatinine with replacement, it would be best to leave the
Foley in x2 weeks to allow total decompression at that point
to give a voiding trial.
The patient's mental status cleared. He became more alert
and began to maintain adequate po, and ask questions
appropriately which was much closer to his baseline mental
status. It was thought at this time that he would be
suitable for discharge. He was screened and accepted at
[**Hospital **] Rehabilitation to complete a total six week course of
Vancomycin for the high grade bacteremia.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Warfarin 10 mg po q hs.
2. Carvedilol 6.25 mg po bid.
3. Vancomycin .......... 4.5 weeks.
4. Senna one tablet po bid.
5. Docusate sodium 100 mg po bid.
6. Wellbutrin 150 mg po bid.
7. Levothyroxine 75 mcg po q day.
8. Finasteride 5 mg po q day.
9. Pantoprazole 40 mg po q24h.
10. Multivitamins one cap po q day.
11. Atorvastatin 20 mg po q hs.
12. Celexa 40 mg po q day.
13. Donepezil 10 mg po q hs.
Initially, it was suggested that Flomax be started, however,
patient had allergy to Lasix, which has a crossology with
Flomax, therefore it was begun.
FOLLOW-UP INSTRUCTIONS: He had followup with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) 101824**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) 198**] 11-841
Dictated By:[**Last Name (NamePattern1) 20150**]
MEDQUIST36
D: [**2102-5-25**] 16:07
T: [**2102-5-26**] 06:12
JOB#: [**Job Number **]
|
[
"427.31",
"041.11",
"591",
"276.5",
"038.11",
"599.0",
"599.7",
"584.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
7182, 7189
|
7212, 7768
|
3034, 7160
|
872, 1064
|
132, 852
|
1816, 3016
|
7793, 8117
|
1086, 1666
|
1683, 1801
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,239
| 134,869
|
43213
|
Discharge summary
|
report
|
Admission Date: [**2183-7-4**] Discharge Date: [**2183-7-9**]
Date of Birth: [**2108-7-9**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
ovarian ca
Major Surgical or Invasive Procedure:
[**2183-7-4**] ExLap, Subtotal Hysterectomy, Bilateral
Salpingoophorectomy, Low Posterior Resection, and Removal of
Tumor at Umbilicus
History of Present Illness:
75 yo G2P2 presented with RLQ pain of several months duration.
CT guided bx of paracolic mass was consistent with
adenocarcinoma concerning for ovarian ca.
Past Medical History:
fibromyalgia
soinal stenosis
vulvodynia
macular degeneration
b/l hip replacement
tubal ligation
Social History:
no tobacco, occ etoh
Family History:
negative for malignancy
Physical Exam:
wn, wd
sclerae anicteric, LN survey negative
cta b
rrr
palpable periumbilical nodule approx 2 cm
vague firm fullness in RLQ
ext without edema
Pertinent Results:
pathology pending at time of discharge
Brief Hospital Course:
Pt was admitted for surgery which was uncomplicated - please see
op note for full details. Because of low posterior resection,
her diet was restricted to liquids until patient passed flatus.
At this time,. diet was advanced and pt tolerated without
nausea/vomiting. She had mild blood loss anemia, post op hct
was stable. Pain was well controlled with po pain meds. Social
work was consulted for high anxiety surrounding discharge. She
was sent home on POD 5 in good condition.
Medications on Admission:
atorvostatin
Discharge Medications:
1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*1*
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q8H (every 8 hours) as needed.
5. Nexium Oral
6. Senna Oral
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Ovarian carcinoma
2. Anxiety
Discharge Condition:
Stable: tolerating regular diet, having bowel movements,
ambulating well, voiding without difficulty, and pain controlled
with medications.
Discharge Instructions:
VNA for home safety evaluation.
Refrain from heavy lifting, sexual intercourse, or exercise for
6 weeks. Walking is encouraged. You may shower.
Call Dr.[**Name (NI) 2989**] office at [**Telephone/Fax (1) 5777**] if you have fever/chills,
unable to eat/drink, vomiting, increased pain not improved with
pain meds, or any other symptoms that concern you.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. GYN ONC PPS (SB) Where: GYN ONC PPS (SB)
Date/Time:[**2183-7-16**] 1:00 pm for wound check and staple removal.
**Please call to confirm the appointment tomorrow**
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. GYN ONC PPS (SB) Where: GYN ONC PPS (SB)
Date/Time:[**2183-8-7**] 11:00
Pathology results will be back within 7 days. Dr. [**First Name (STitle) 1022**] will
review these with you at your next visit and will discuss any
referrals you will need for future treatments.
|
[
"197.5",
"197.4",
"198.2",
"280.0",
"196.2",
"183.0",
"197.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"47.09",
"54.3",
"45.72",
"54.4",
"40.3",
"48.63",
"68.39",
"65.61"
] |
icd9pcs
|
[
[
[]
]
] |
2119, 2177
|
1096, 1579
|
336, 473
|
2253, 2394
|
1033, 1073
|
2799, 3355
|
831, 856
|
1642, 2096
|
2198, 2232
|
1605, 1619
|
2418, 2776
|
871, 1014
|
286, 298
|
501, 658
|
680, 777
|
793, 815
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,278
| 118,625
|
36502
|
Discharge summary
|
report
|
Admission Date: [**2158-2-28**] Discharge Date: [**2158-3-13**]
Date of Birth: [**2133-11-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
s/p Fall from cliff
Major Surgical or Invasive Procedure:
[**2158-2-28**] T4-T10 fusion
[**2158-3-3**] IVC filter placement
History of Present Illness:
24 yo male found down at bottom of 30ft cliff; he was awake and
alert but completely amnesic re: the event and unable to move or
feel his legs. he was taken to an area hospital where he
received Solumedrol protocol. He was then transferred to [**Hospital1 18**]
for further.
Past Medical History:
None
Social History:
pt liveswith father & both she and father have re-married; pt
has 13
yr-old half-brother to whom he is very close per mother. history
of polysubstance use starting in his teens,
including LSD, narcotics (opiate pills and IN heroin) with
resultant legal difficulties (arrests for drug trafficing,
possession).
Family History:
Noncontributory
Physical Exam:
Upon admission:
148/90 96 16 100
Awake, alert, Ox3, cooperative with exam, normal
affect
Perla, eomi
Face symetric
Tongue midline
Motor:
D B T Grip IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 0 0 0 0 0 0
L 5 5 5 5 0 0 0 0 0 0
Sensation: T4 sensory level on R, T5 on left to LT;
Reflexes: B T Pa Ac
Right 0 0
Left 0 0
[**Last Name (un) **]: equivocal bilat though toes [**12-29**] upgoing bilat.
Decreased tone, no clonus in LE
Rectal exam: no tone per trauma team eval
Pertinent Results:
[**2158-2-28**] 06:10PM GLUCOSE-134* UREA N-15 CREAT-0.9 SODIUM-144
POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-25 ANION GAP-12
[**2158-2-28**] 06:10PM CALCIUM-8.4 PHOSPHATE-3.5 MAGNESIUM-1.9
[**2158-2-28**] 06:10PM WBC-18.7* RBC-3.93* HGB-11.2* HCT-31.7*
MCV-81* MCH-28.5 MCHC-35.4* RDW-13.6
[**2158-2-28**] 06:10PM PLT COUNT-208
[**2158-2-28**] 12:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2158-2-27**] 11:57PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2158-3-8**] CHEST (PA & LAT)
The current study demonstrates improved aeration of the lung
bases
bilaterally. Still present at least moderate layering right
pleural effusion
is seen on both PA and lateral views with bibasilar retrocardiac
atelectasis
still seen. There is no pneumothorax. There is no evidence of
pneumomediastinum. The hardware rods are seen in the thoracic
spine. The
patient is after insertion of the IVC filter.
ECHO report
Findings
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal mitral valve supporting structures. Normal LV inflow
pattern for age.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
Conclusions
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal study as patient was not able to
cooperate. The right ventricle may be mildly dilated and
hypokinetic but this cannot be said for certain. There is mild
pulmonary artery systolic hypertension. Normal regional and
global left ventricular systolic function. No significant
valvular abnormality seen.
CT T spine [**2158-3-1**]
IMPRESSION:
1. Interval posterior fixation of the mid-thoracic spine, with
improved
anatomic alignment of extensively comminuted fracture at T7.
Persistent mild
anterolisthesis of the superior portion of L7 upon the inferior
portion, of
approximately 6 mm. Persistent small degree of retropulsion of
fracture
fragments by approximately 3 mm into the spinal canal. Limited
evaluation of
spinal canal and its contents due to hardware artifact.
2. Post-surgical changes including subcutaneous air and foci of
air within
the spinal canal.
3. High-attenuation fluid within the pleural space bilaterally
consistent
with blood within the pleural space and hematoma adjacent to the
fractured
vertebral body.
4. Consolidative foci in the left posteromedial lung consistent
with
atelectasis versus contusion. Dedicated chest CT can be obtained
for further
evaluation.
5. Persistent pneumomediastinum.
NOTE ON ATTENDING REVIEW:
The numbering used above is based on prior MR report dated
[**2158-2-28**]
There is a tiny fracture without displacement noted at the
antero-superior
aspect of the T3 body ( series 400b, im 23).
The right pedicle screws are noted coursing outside the anterior
cortical
margin of the vertebral bodies at T4, T5 and T6 levels.
Brief Hospital Course:
He was admitted to the Trauma service. Neurosurgery was
consulted given his spine fracture; he was transferred to the
Trauma ICU. He became hypotensive and started on Neosynephrine
drip. There was concern for esophageal injury and he underwent
a Gastrographin study which ruled this out. [**3-1**]: to OR for
epidural hematoma drainage.
.
On [**2158-3-1**] he was taken to the operating for:
1. Posterior laminectomy, full bilateral T6, T7, T8.
2. Transpedicular corpectomy C7 with adjacent diskectomy T6-
7 and T7-1.
3. Open reduction third anterior interbody cage placement
with autograft and allograft.
4. Posterior instrumented fusion using pedicle screws T4-
T10 bilaterally.
5. Autograft from right-sided iliac crest.
6. Allograft.
7. BMP, closure of dural rent for primary closure of CSF
leak.
There were no intraoperative complications. Postoperatively he
was taken to the Trauma ICU where he remained for several days.
He was eventually extubated and transferred to the regular
nursing unit.
An IVC filter was placed as prophylaxis.
Psychiatry was consulted for acute change in his mental status;
he was placed on a 1:1 sitter for a short period and was treated
with low dose antipsychotic for multifactorial delirium. He
became stabilized on these medications and the sitters were
stopped. He is alert, oriented x3 and is cooperative with his
care. Social work has also been following closely.
He was evaluated early on by Physical and Occupational therapy
and is being recommended for acute spinal cord injury rehab. The
screening process was initiated by case management.
By the time of discharge on [**2158-3-13**], patient was doing well,
pain controlled, tolerating regular diet. He will be going to
[**Hospital3 **] today.
Medications on Admission:
None
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
EVERY OTHER DAY (Every Other Day): hold for loose stools.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
10. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
GM Intravenous Q 12H (Every 12 Hours) for 14 days.
12. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 Grams Intravenous Q8H (every 8 hours) for 14 days.
13. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
14. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall
T7 burst fracture
Grade III antherlisthesis of T6 on T7
Severe cord compression at the T6-T7 level with paraplegia
9th rib fracture
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
The TLSO brace must be worn when out of bed at all times.
Followup Instructions:
Follow Up Instructions/Appointments
?????? Please return to the office on [**2158-3-15**] for removal of
your staples/sutures and a wound check. This appointment can be
made with the Neurosurgery Nurse Practitioner. Please make this
appointment by calling [**Telephone/Fax (1) 1669**].
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 3 months You will need CT-scan of your
thoracic spine prior to your appointment.
Completed by:[**2158-3-13**]
|
[
"349.31",
"991.6",
"807.01",
"806.20",
"486",
"958.7",
"V62.84",
"805.4",
"275.41",
"287.5",
"293.0",
"806.29",
"790.92",
"E884.1",
"305.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"84.52",
"80.51",
"38.7",
"84.51",
"03.53",
"81.63",
"03.59",
"81.05"
] |
icd9pcs
|
[
[
[]
]
] |
8731, 8801
|
5622, 7385
|
335, 403
|
8986, 9066
|
1739, 5599
|
9172, 9697
|
1078, 1095
|
7440, 8708
|
8822, 8965
|
7411, 7417
|
9090, 9149
|
1110, 1112
|
276, 297
|
431, 708
|
1126, 1720
|
730, 736
|
752, 1062
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,337
| 156,743
|
18295
|
Discharge summary
|
report
|
Admission Date: [**2113-7-14**] Discharge Date: [**2113-7-25**]
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
SBO
difficulty breathing
Major Surgical or Invasive Procedure:
Placement of L PICC
History of Present Illness:
This is an 88 y.o. female with history of schizoaffective
disorder and COPD who initially presented to the hospital with
tachypnea to the 50's. She had been in her usual state of
health at her nursing facility until the day of admission until
she was noted to have a respiratory rate of 50 during a yoga
class. The patient denied any chest pain or SOB. No fevers,
chills, or night sweats.
In the ED, initial VS were 96.8, 110, 107/68, 40, 100% 4L Nasal
Cannula. Initial concern was for PE but CTA did not reveal any
embolism or acute pulmonary process. Given abdominal distension
and mild tenderness she had an abdominal CT that showed dilated
colon and small bowel with fluid filled loops but was initially
read as being without clear transition point of evidence of SBO.
An NGT was placed and she was admitted to the floor.
Past Medical History:
COPD
Hypertension.
Schizo-affective disorder.
Chronic pancreatitis
Depression. Anxiety.
Chronic back pain
Social History:
Occupation: Unemployed. Lives in rest home ([**Doctor Last Name **] House)
Drugs: None
Tobacco: Remote social use
Alcohol: None
Family History:
NC
Physical Exam:
On Admission:
VS: T-96.3, HR=108, BP=110/68, RR=28, POx=95% RA
GENERAL: Elderly female in NAD.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear.
NECK: Supple, no JVD.
HEART: tachycardic.
LUNGS: tachypneic, wheezy.
ABDOMEN: Soft, distended, not focally tender except mildly to
deep
palpation in the LLQ, no rebound or guarding, hypoactive bowel
sounds, no palpable masses, periumbilical and RUQ subcostal
surgical scars.
EXTREMITIES: WWP, no c/c/e.
NEURO: Awake, A&Ox1-2, CNs II-XII grossly intact, moving all
extremities.
On Discharge:
VS: T 95.5, P 90, BP 98/52, RR 19, O2 96% on RA
Pulm: Lungs CTAB, no W/R/R
Abd: Soft, NT, slightly distended, BS+
Pertinent Results:
Initial Labs
[**2113-7-14**] 09:20AM LIPASE-41
[**2113-7-14**] 09:20AM CALCIUM-7.9* PHOSPHATE-3.7 MAGNESIUM-1.6
[**2113-7-14**] 12:20AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]->1.050*
[**2113-7-14**] 12:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR
[**2113-7-14**] 12:20AM URINE RBC-2 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-3
[**2113-7-13**] 08:23PM TYPE-ART TEMP-36.8 PO2-166* PCO2-32* PH-7.38
TOTAL CO2-20* BASE XS--4 INTUBATED-NOT INTUBA
[**2113-7-13**] 06:40PM GLUCOSE-101* UREA N-27* CREAT-1.1 SODIUM-143
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-20* ANION GAP-20
[**2113-7-13**] 06:40PM ALT(SGPT)-16 AST(SGOT)-37 ALK PHOS-78 TOT
BILI-0.2
[**2113-7-13**] 06:40PM cTropnT-<0.01
[**2113-7-13**] 06:40PM WBC-6.2 RBC-4.84# HGB-13.6 HCT-42.1 MCV-87#
MCH-28.0# MCHC-32.2 RDW-16.3*
[**2113-7-13**] 06:40PM NEUTS-69.3 LYMPHS-22.2 MONOS-7.0 EOS-1.2
BASOS-0.3
[**2113-7-13**] 06:40PM PLT COUNT-253
[**2113-7-13**] 06:40PM PT-12.5 PTT-23.0 INR(PT)-1.1
[**2113-7-13**] 06:38PM LACTATE-1.6
Brief Hospital Course:
Ms. [**Known lastname 24344**] is an 88 year old female with past medical history of
HTN, schizoaffective disorder, and COPD who presented with
tachypnea and was found to have SBO, and NSTEMI vs Takotsubo's
cardiomyopathy.
Active Issues:
1) Small Bowel Obstruction: After PE was ruled out in the ED
the focus shifted to the patient's abdomen. Exam was notable
for distension and mild tenderness with hypoactive bowel sounds.
KUB and CT abdomen both showed dilated loops of small bowel and
initial read was for diffuse dilation without clear transition
point. She was admitted to medicine with presumed ileus. The
following day read was more suggestive of SBO so she was
transferred to the surgical service. After return to the
medicine service in the context of SVT and NSTEMI attempts were
made to better evaluate the patient's obstructive process. She
did begin to have some bowel movements. Radiology thought most
likely source of obstruction was an obstructing lesion in the
proximal descending colon and surgery thought should be
evaluated by gastrograffin enema and/or endoscopic evaluation
prior to refeeding. Eventually the patient had a sigmoidoscopy,
which showed no clear obstruction but a narrowing at what
appeared to be an ileocolonic anastamosis. The area after this
was patent. After this result it was considered safe to attempt
refeeding as ileus was thought to be primary etiology of
distension. At time of discharge patient has been started on
solids but during period of presumed obstruction she was started
on TPN and given poor PO intake this is being continued at time
of discharge.
2) NSTEMI vs Takotsubo's cardiomyopathy: While on surgery on
[**7-15**] the patient had an episode of SVT to the 200's that was
terminated by IV metoprolol. The following morning labs
revealed positive cardiac biomarkers so MICU consult was called.
MICU team noted evolving EKG changes and significant enzyme
elevations concerning for infarction. She was started on
aspirin and beta blocker but anticoagulation was deferred as by
the time of transfer to the MICU team a second set of labs
already showed downtrending cardiac enzymes and mechanism of
injury thought more likely to be demand ischemia than ACS.
Echocardiogram was obtained that showed severe akinesis of the
entire mid to distal LV with an EF of 20-25%. In this context
BNP was markedly elevated and exam was consistent with acute
exacerbation of systolic CHF. Therefore, she was started on
furosemide drip with total diuresis of approximately six liters
from [**7-16**] to [**7-25**]. She was transitioned from furosemide drip to
bolus on [**2113-7-22**] with good effect. Attempts were made at
afterload reduction with captopril but blood pressures did not
tolerate this so this was deferred in favor of diuresis. This
should be readdressed during her time at the MACU. Pt has
cardiology follow up scheduled for *****
3) SVT, likely AVRT: Starting on the evening of [**7-15**] the patient
had multiple episodes of tachycardia to the 200's. In these
contexts her SBP's dropped to the 80s. The first of these
reverted with nodal agents but the second did now respond and
she required adenosine 6 mg IV *1. She had one additional
episode on [**7-23**] that also required adenosine. Final noted
episode was on [**7-24**] but this reverted on its own. Pt continues
on beta blocker.
4) Complicated Urinary Tract Infection: On [**7-20**] patient was
noted to have lower blood pressures. UA was grossly positive
and she was started on cefepime empirically given risk of
hospital acquired pathogens. UA grew pan-sensitive E coli and
she was transitioned to ceftriaxone and then oral TMP/Sulfa.
Last day of therapy will be on [**2113-7-27**].
5) Schizoaffective disorder: Pt has a history of schizoaffective
disorder on mirtazapine and risperidone at baseline. These were
held at presentation as it was thought they could contribute to
her constipation and bowel obstruction. Pt appeared
undistressed off these and no behavioral issues therefore they
continued to be held. Discussion of whether to restart should
be had with patient and her guardian.
6) Goals of Care: Health Care proxy/Guardian established patient
as DNR/I and reported patient had expressed no interest in
surgery or other very aggressive treatment measures given age
and comorbidities. Guardian requested palliative care eval who
saw the patient and would like continued palliative care input
on goals of care and decisions regarding hospitalization in the
future. This can be provided at her receiving facility.
7) Diarrhea: As SBO resolved pt began to have copious liquid
stool. C diff checked and was negative and patient had no pain,
leukocytosis, or signs suggestive of infectious colitis. Likely
due to functional diarrhea as SBO resolved and patient only
eating liquid diet. Will monitor as increases intake of solid
food.
Inactive Issues:
- COPD: Pt with history of COPD, continued on Beta Agonist and
anticholinergic inhalers
- Chronic pancreatitis: No issues during hospitalization.
Lipase initially mildly elevated but then normalized.
-Hypertension: Pt no longer hypertensive, likely due to CHF.
-Left shoulder pain: Chronic for years, continued acetaminophen
and lidocaine patch
Transitional Issues:
Pt has EF of 20-25% and thus should ideally be afterload reduced
with ACEi. She did not tolerate this in the hospital due to
hypotension but if pressures improve with some cardiac repair or
recovery this should be initiated.
Pt currently on TPN as has just restarted full diet and not
eating much. Pt should be weaned off TPN as she takes and
tolerates a more full PO diet.
Code Status: Patient is DNR/DNI
Contact/Guardian: [**Name (NI) 1692**] [**Name (NI) **] [**Telephone/Fax (1) 50445**]
Medications on Admission:
Medications On Transfer:
-Heparin 5000 UNIT SC TID
-Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
-Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
-Insulin SC
-Acetaminophen 650 mg PO/NG Q6H:PRN pain, fever
-Lidocaine 5% Patch 1 PTCH TD DAILY
-Omeprazole 20 mg PO DAILY
-Metoprolol 5 mg IV Q6hrs
Discharge Medications:
1. ipratropium bromide 0.02 % Solution Sig: [**1-29**] Inhalation Q6H
(every 6 hours) as needed for wheezing.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. senna 8.6 mg Tablet Sig: Two (2) 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. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
10. furosemide 10 mg/mL Solution Sig: Ten (10) mg Injection [**Hospital1 **]
(2 times a day).
11. metoclopramide 5 mg Tablet Sig: One (1) Tablet PO four times
a day.
12. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 days: Last day [**7-27**].
13. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO once a day: hold for loose stools.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary Diagnsosis:
-Acute on chronic small bowel obstruction
-NSTEMI vs Takutsubo's cardiomyopathy
-SVT, likely AVRT
-Acute systolic CHF
-Complicated Urinary Tract Infection
Secondary Diagnoses:
Hypertensions
Chronic Obstructive Pulmonary Disease
Schizoaffective disorder
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital due to a temporary and partial
obstruction of your small bowel that made you unable to eat.
Youw ere treated conservatively and your bowel obstruction
improved. Nevertheless, you had not advancd to a pont where we
felt you ccould get enough nutrition from eating alone.
Therefore nutrition by vein was continued with plan to
discontinue this as you can tolerate more by mouth.
You also had difficulties with a condition causing stress and
damage to the heart. You were started on medicines to help
prevent further damage. You were also started on medications to
help keep the weakened heart from leading to fluid build up in
your lungs.
Followup Instructions:
You should have follow up with your PCP through your facility
when you can leave acute rehab and hopefully go back to [**Doctor Last Name **]
House
Department: CARDIAC SERVICES
When: THURSDAY [**2113-8-10**] at 3:40 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"410.71",
"295.70",
"496",
"V49.86",
"427.89",
"560.1",
"300.4",
"041.4",
"724.5",
"518.81",
"276.4",
"401.9",
"428.0",
"599.0",
"428.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"48.23",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10622, 10687
|
3230, 3454
|
247, 269
|
11006, 11006
|
2128, 3207
|
11887, 12517
|
1422, 1426
|
9376, 10599
|
10708, 10885
|
9047, 9047
|
11188, 11864
|
1441, 1441
|
10906, 10985
|
1994, 2109
|
8522, 9021
|
183, 209
|
3469, 8135
|
297, 1130
|
8152, 8501
|
1455, 1980
|
11021, 11164
|
9072, 9353
|
1152, 1260
|
1276, 1406
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,234
| 185,480
|
35040
|
Discharge summary
|
report
|
Admission Date: [**2184-11-8**] Discharge Date: [**2184-11-12**]
Date of Birth: [**2122-12-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine / Niaspan
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
[**2184-11-8**] AVR (21 mm CE pericardial)/aortic root
enlargement/resect. subaortic membrane
History of Present Illness:
61 year old woman with known coronary
artery disease s/p LAD-stent([**11/2182**]) and aortic stenosis that
has progressed by echo over past year. She denies symptoms- but
notes that she would likely become dyspneic and fatigued if
activity level increased. Recent cath reveals patent LAD stent
and otherwise non-obstructive coronary lesions. [**Location (un) 109**] is 0.9cm2
and peak gradient is 94mmHg. She is referred for surgical
evaluation.
Past Medical History:
coronary artery disease s/p LAD [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] [**11/2182**]
Aortic Stenosis
Hypertension
Diabetes mellitus
Hyperlipidemia
Nephrolithiasis (remotely)
Anemia- capsule endoscopy revealed AVM and gastric ulceration.
Required 5 transfusions over past year-most recent [**Month (only) 205**]
Past Surgical History:back surgery
total abdominal hysterectomy
cholecysectomy
bladder suspension surgery x 2
lumbar discectomy
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Pulse: 60 Resp: 16 O2 sat:
B/P Right: 138/80 Left:
Height: 5'1" Weight: 97.5 kg
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 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] obese
Extremities: Warm [x], well-perfused [x]
Edema-trace pedal edema
Varicosities: None [x] spider veins
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: - Left: NP [**2-17**] edema
Radial Right: 2_ Left: 2+
Carotid Bruit Right: Left:
no bruits appreciated, +thrill on left
Pertinent Results:
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are severely thickened/deformed.
There is severe aortic valve stenosis (valve area 0.8-1.0cm2).
Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results on Mrs.[**Known lastname **]
before surgical incision.
There was no ascending/arch or desceding aortic dilatation.
During surgery, the surgeon noted presence of a subaortic
membrane extending from the anterior septum to the junction of
non and right coronary cusp. This was noted during our pre CPB
study and the images were shown to another experienced
echocardiographer to verify and that was not impressive. The
calcified aortic valve seem to be the origin for the gradients
across the valve. The surgeon noted the valve was calcified and
bad as well.
Post_CPB.
Normal biventricular systolic function. LVEF 55%.
The aortic bioprosthesis is well seated and functioning well
with no regurgitant jets.
The thoracic aortic contour is intact.
There is mild to moderate TR and mild MR.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2184-11-8**] 17:17
[**2184-11-10**] 05:44AM BLOOD WBC-8.8 RBC-3.21* Hgb-9.1* Hct-26.9*
MCV-84 MCH-28.2 MCHC-33.8 RDW-14.4 Plt Ct-133*
[**2184-11-10**] 05:44AM BLOOD Glucose-171* UreaN-19 Creat-0.8 Na-137
K-4.4 Cl-104 HCO3-28 AnGap-9
Brief Hospital Course:
Admitted [**11-8**] and underwent surgery with Dr. [**Last Name (STitle) **].
Transferred to the CVICU in stable condition on titrated
phenylephrine and propofol drips. Extubated later that day and
trasnferred to the step down unit on POD #1 to begin increasing
her activity level. Chest tubes and pacing wires were removed
per protocol. Gently diuresed toward her preop weight. Continued
to make good progress and was cleared for discharge to home with
VNA on POD #4 by Dr. [**Last Name (STitle) **]. All follow-up appointments were
advised.
Medications on Admission:
Metformin ER 1000 [**Hospital1 **]
Simvastatin 80 QHS
Atenolol 50 daily
Glyburide 10 [**Hospital1 **]
Tricor 145 daily
Fosamax 70 Qwk
Plavix 75 daily (LD [**11-2**])
Oxybutynin ER 5 daily
HCTZ 12.5 daily
Diovan 320mg daily
Ferrous Sulfate 300 TID
Carafate hs
Ranitidine 300mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*1*
4. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*1*
5. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
6. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*1*
7. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
10. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*1*
11. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
13. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease s/p LAD [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] [**11/2182**]
Aortic Stenosis s/p AVR/root enlargement
Hypertension
Diabetes mellitus
Hyperlipidemia
Nephrolithiasis (remotely)
Anemia- capsule endoscopy revealed AVM and gastric ulceration.
Required 5 transfusions over past year-most recent [**Month (only) 205**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
edema - 1+ LLE, trace-RLE
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) **] at [**Hospital1 **] [**12-2**] @ 9:00 AM
Cardiologist:Dr. [**Last Name (STitle) 20222**] [**12-13**] @ 4:30 PM
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) **] in [**1-17**] weeks [**Telephone/Fax (1) 77271**]
**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:[**2184-11-12**]
|
[
"272.4",
"V70.7",
"276.69",
"250.00",
"V45.89",
"414.01",
"401.9",
"285.9",
"V45.82",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"35.99"
] |
icd9pcs
|
[
[
[]
]
] |
6732, 6791
|
4298, 4842
|
300, 397
|
7190, 7381
|
2326, 4275
|
8305, 8843
|
1501, 1583
|
5175, 6709
|
6812, 7169
|
4868, 5152
|
7405, 8282
|
1251, 1359
|
1598, 2307
|
248, 262
|
425, 877
|
899, 1229
|
1375, 1485
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,014
| 180,505
|
43568
|
Discharge summary
|
report
|
Admission Date: [**2165-6-21**] Discharge Date: [**2165-7-25**]
Date of Birth: [**2098-2-18**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 67 year-old
male who at 12:30 a.m. on [**2165-6-21**] presented with the worse
headache of his life at an outside hospital. He complained
of positive nausea, vomiting, and was diaphoretic, and felt cool
and clammy. The patient was awake, alert and oriented times three
at presentation. He became obtunded and apneic episode at that
point. He was sedated and intubated at 2:17 a.m. on arrival.
The patient's CT showed a large intracranial hemorrhage
around the circle of [**Location (un) 431**] going both posteriorly and
anteriorly. He was then transferred to [**Hospital1 190**].
MEDICATIONS ON ADMISSION:
1. Protonix.
2. Coreg.
3. Lipitor.
4. Zestril.
5. Aspirin.
6. Lisinopril.
7. Prilosec.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Coronary artery disease.
Myocardial infarction.
Hypertension.
He has an automatic internal defibrillator in place.
PAST SURGICAL HISTORY: Positive for a coronary artery bypass
graft and pacemaker placement.
PHYSICAL EXAMINATION: The patient was afebrile. Pulse of
60. Blood pressure 133/94. Respirations 20. 100 percent.
He is intubated. The patient is heavily sedated and
intubated upon arrival. No response to painful stimulating.
He had a positive gag, positive corneal and negative
Babinski. He flexed arms to pain bilaterally and localized
pain to his lower extremities. He had increased tone in his
lower extremities and decreased tone in his arms. CT showed
blood from a bibasilar hemorrhage, blood in the basilar
cistern, lateral ventricles, posterior [**Doctor Last Name 534**] of the right
frontal [**Doctor Last Name 534**] with third and fourth ventricle dilation.
LABORATORIES ON ADMISSION: White blood cell count was 10.8,
hematocrit 39.6, platelets 151, INR 1.2, PT 13.6, PTT 21.2,
sodium was 138, 3.9, 108 for his chloride, sugar was 167. CK
was 207, CKMB was 5, troponin was less then .001, amylase was
75.
HOSPITAL COURSE: The patient was admitted to the
Neurosurgery Service under Dr.[**Name (NI) 9224**] service. Blood pressure
was to be kept at less then 130. He was started on Dilantin 100
mg q 8 and head of bed was kept greater then 30 degrees.
Neuro checks were done q one hour and placed on strict I and
O. A CTA was performed, which showed a vertebral artery
aneurysm. On [**2165-6-21**] at 11:30 in the morning Mr. [**Known lastname 93727**] went
to the neuro interventional angio suite where he underwent a
cerebral angiogram. He was found to have wide neck aneurysm
of a heavily calcified left intracranial vertebral artery
proximal to the vertebral basilar junction. He found that there
was no right vertebral flow and his bilaterally ICAs did not have
an aneurysm. He is brought back to the Intensive Care Unit.
His blood pressures kept less then 130 and Dr. [**Last Name (STitle) 1132**]
discussed possible coiling options with the [**Known lastname 93727**] family at
that time. Postoperatively after his diagnostic angio Mr.
[**Known lastname 93727**] was found not to open his eyes to sternal rub or
following commands. His pupils were 4 mm, sluggish,
reactive. He had a positive corneal and gag reflex. No
blink to visual threat. He had increased tone in his lower
extremities. He localized to pain in all four extremities
moving his legs spontaneously. At 8:30 p.m. on [**6-21**] he was
brought back to the interventional neuro angio suite where he
had a stent deployment times two and coil-through-
stent embolization of his left vertebral artery aneurysm. Before
the procedure he had a ventriculostomy drain placed without any
complications. Postoperatively, his blood pressure is kept in the
less then 120 range. His drain is open at 15. He is started on
Plavix 75 mg q day and aspirin 325 mg po q day. On [**2165-6-22**] his
intracranial pressures were ranging from 9 to 11. He had
been sedated at that point. His pupils were bilateral at 2
with a conjugate gaze, moving spontaneously on the right,
following commands in his upper and his lower extremities.
He continued to receive intravenous Dilantin. His Dilantin
was 8.3 that day. His drain was kept at 15 cm.
Later in the day on [**6-22**] he had his AICD interrogated and it
was found to be functioning normally. It is a single lead
ICD. After his coiling procedure Mr. [**Known lastname 93727**] was placed on
heparin. On [**6-23**] Mr. [**Known lastname 93727**] was weaned from the ventilator
and extubated. He tolerated his extubation without
difficulty. CAT scan on [**6-23**] showed a large amount of
subarachnoid hemorrhage within the basilar cistern and third
and fourth ventricles as well as the posterior [**Doctor Last Name 534**]. It
appeared stable from previous CAT scans. There was a small
amount of subarachnoid hemorrhage overlying the sulci
bilaterally. The ventricular size appeared decreased compared
with previous studies. Also on [**6-24**] Mr. [**Known lastname 93727**] had periods of
congestive heart failure. Chest x-ray showed failure. He
was given Lasix and pan cultured and did better post
receiving Lasix. He was started on tube feeds. He continued
to have Nipride to keep his blood pressure in the below 130
range and he continued to receive heparin at 700 units an
hour. At this point he had no positive cultures. On [**6-25**]
Mr. [**Known lastname 93728**] eyes would open spontaneously to stimulation. He
showed his thumbs bilaterally, wiggled his toes bilaterally.
He was receiving Lasix prn. He received Dilantin to have his
Dilantin level greater then 10. He continued to have a drain
in at 15 mm. Cerebral spinal fluid showed no microorganisms.
He had been ruled out for an myocardial infarction. On [**6-25**]
his heparin drip was stopped and his femoral sheath was
discontinued per Dr. [**Last Name (STitle) 1132**]. Cardiology also saw Mr. [**Known lastname 93727**]
for his continuing problems with congestive heart failure and
they felt that he was volume overloaded and they agreed to
keep his volume status balanced and to aim for negative fluid
balance. The patient had an echocardiogram and it showed his
ejection fraction was 30 percent. At this point his cardiac
medications included Coreg, Lipitor, Lisinopril, Nimodipine,
Lopressor, Hydralazine, Lisinopril and Carvedilol. He was on
a Nipride drip. During the evening of [**6-25**] Mr. [**Known lastname 93727**]
became more tachypneic and was reintubated at that time. His
failure was unable to be controlled with Lasix and his CO2
was becoming very low and he ended up being reintubated
without any problems. A head CT on [**2165-6-26**] showed stable
appearance of his brain since his previous study. His
examination on [**6-26**] his left pupil was 2.5 to 2. His right
pupil was the same. His ICTs were 8 to 11. He was wiggling
his toes, would stick out his tongue, grasps were 4 to 6.
His sodium was up from 145 to 148, which was felt to be due
to his strict fluid balance. His cultures from [**6-25**] showed a
sputum with gram positive cocci in pairs. The only
antibiotics he had been on at that point were Kefzol for his
drain prophylaxis.
On [**6-27**] Mr. [**Known lastname 93727**] went back to the diagnostic angio suite and
had a diagnostic cerebral angiogram, which showed no evidence
of aneurysm, that his stent was patent and his coils were
intact. On [**6-27**] Levaquin was started due to continued fevers
that Mr. [**Known lastname 93727**] has had since [**6-25**]. On [**6-27**] he was started and
Levaquin due to gram positive cocci in his sputum. On [**6-28**]
his blood cultures showed 1 out of 2 gram positive cocci. He
continued to have a fever without definitive cause. He had
bilateral lower extremity ultrasounds, which were negative.
Chest x-ray showed bilateral small effusion. His antibiotics
were changed from Kefzol to Vancomycin to cover positive
blood culture that he had. His Dilantin was changed to
Depakote also trying to see if the source of the fever could
be from Dilantin. He was started on Depakote 750 mg t.i.d.
On the [**6-30**] Mr. [**Known lastname 93727**] continued to spike fevers up as high as
101.7. At this point he would show his thumbs bilaterally.
He would localize his right upper extremity, localized to 50
percent in his left upper extremity, withdrew both of his
lower extremities. He seemed to be intermittently following
commands somewhat more unresponsive. His drain was lowered
to 8 to see if that would help with his alertness. An ID
consult was obtained to see if the source of the fever could
be obtained, which they recommended a chest CT and possible
change of lines. They also added Ceftazidine and Flagyl to
cover possible C-diff. He had an abdominal CT, which was
negative and he had a chest CT on [**2165-7-2**] which showed a left
sided pulmonary embolism and small to moderate bilateral
pleural effusion. Also at this point on the 9th his mental
status was slightly worsened. A pulmonary consult was
obtained and it was recommended to start Mr. [**Known lastname 93727**] on a
heparin drip with goal PTT of 50 to 60. We felt that the
possible mortality of this pulmonary embolism was higher then
the risks of intracranial bleeding so he was started on a
drip at that point.
On [**2165-7-8**] Mr. [**Known lastname 93727**] was only intermittently following
commands. He squeezed weakly on the right. Attempt to
squeeze on the left localized in his bilateral lower
extremities. He continued to have the ventriculostomy drain
at 15. We wanted to obtain an MRI of his head and C spine
just to rule out a stroke or any problems with his cord that
could be causing his decreased weakness and changes in mental
status, however, given his AICD placement he was never able
to have an MRI. Later it was felt to be more toxometabolic
given his fevers and his pulmonary embolism and the severity
of his subarachnoid hemorrhage all added together to cause
him to have more of a decreased mental status later in his
hospital course. He had periods of low sodiums. He had been
placed on a sodium drip during the week of [**7-8**] through [**7-14**]
intermittently. He had periods of CPAP and pressure support
in attempt to wean his ventilator during this week also. He
continued on empiric antibiotics of the Vancomycin,
Ceftazidine and Flagyl. The Vanco was for his
ventriculostomy drain for prophylaxis. His cultures from the
week of [**7-2**] through [**7-8**] showed no growth. His C-diff was
negative. Also during the week of [**7-9**] he had periods of
recurrent tachycardia and bigeminy and trigeminy at different
points. On [**7-9**] he had a percutaneous tracheostomy placed
without any difficulty. At this point his fevers,
temperature maximum was 99.4. He was withdrawing to pain.
He would stick out his tongue. He had a weak grip on the
right. Cardiology saw him regarding the tachycardia which
they felt was related to high catecholamine state and to
treat with beta blocker doses as tolerated. He continued to
be on aspirin and beta blockers. CAT scan from [**7-10**] showed
interval decrease in the intraventricular and subarachnoid
blood. He was continued to be attempted to wean from his
ventilator. His heparin drip continued at a rate of 1800
units an hour for a goal PTT of 60 to 80.
On [**7-13**] Mr. [**Known lastname 93727**] was found not to really respond to noxious
stimuli. He did not follow commands. His pupils were
reactive. He did withdraw his right upper extremity. He did
not withdraw his left upper extremity. He did withdraw both
lower extremities. We got a stat head CT and we opened up
his drain at 12 mm above the tragus and his head CT showed
that it was stable, no new bleeding. Again we felt that his
mental status changes are related to toxometabolic issues
from his pulmonary embolisms, his fevers, which have now
resolved and an electroencephalogram showed encephalopathy.
On [**7-16**] his intravenous antibiotics were discontinued and
later in the day a lumbar puncture was performed. In order
to check an opening pressure we felt that this current ICD
monitor did not show an accurate reflection of his ICD given
the amount of hydrocephalus that appeared on his CAT scan.
However, his opening pressure was 12 and he was found to have
normal pressure. On [**7-17**] Mr. [**Known lastname 93728**] eyes opened to voice.
He grimaced to noxious stimulus. He did not follow command
localized in his right upper extremity, slight movement in
his left upper extremity. He had slight withdraw with his
left leg and was felt to have a left hemiparesis. On [**7-17**]
Mr. [**Known lastname 93727**] had a PEG tube placed without any difficulty. He
had a normal gastric mucosa. No abnormalities were
identified. On [**7-18**] he had a head CT. There was persistent
ventricular dilation not significantly changed from his prior
studies. The week of [**7-18**] Mr. [**Known lastname 93727**] was successfully weaned
from the ventilator and tolerating a trach mask without any
difficulty. On [**2165-7-22**] a repeat head CT showed stable
appearance of his ventricular dilation. No change. On [**7-23**]
a repeat lumbar puncture was performed with an opening
pressure of 10. Neurologically Mr. [**Known lastname 93727**] would open his eyes
to stimulation. He would move his right side spontaneously.
His toes were upgoing. He was not really following commands.
DISCHARGE INSTRUCTIONS: Mr. [**Known lastname 93727**] receives the following
care, he has a trach collar at 70 percent, which most likely
can be weaned as tolerated. He receives Impact with fiber at
80 cc an hour. He has tolerated that without difficulty. He
does have a central line in place. We will leave that in
place upon discharge. He has been afebrile. His last fever
was on [**7-18**]. He is not currently on any antibiotics. His
current medications include a heparin drip at a rate of 1250
units per hour. That may change prior to his discharge. His
goal PTT is 40 to 50 that was lowered due to some increased
hematuria. He is receiving Epoietin 4000 units sq two times
a week on Tuesday and Saturday. Panadol 40 mg intravenous q
24, Indocin 2.5 mg po t.i.d., Metoprolol 25 mg po b.i.d.,
Valproic acid 100 mg po t.i.d. He should be weaned off the
valporic acid over the next two weeks to off unless he shows
any signs of seizure activity. Nystatin oral solution 5 ml
po q.i.d., aspirin 325 mg po q day, Plavix 75 mg po q day.
He should follow up with Dr.[**Name (NI) 9224**] office in two weeks. He
will call [**Telephone/Fax (1) 2992**] if you have any questions. He will be
provided an appointment prior to his discharge. Under no
circumstances should his heparin be stopped. He needs to
continue on heparin, Plavix and aspirin until follow up with
Dr. [**Last Name (STitle) 1132**]. He needs acute neuro rehab and physical therapy
and occupational therapy. Mr. [**Known lastname 93727**] was discharged
neurologically in stable condition, mentally responsive upon
discharge. Mr. [**Known lastname 93727**] is positive VRE from one rectal swab so
he has been on VRE precautions.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 23079**]
MEDQUIST36
D: [**2165-7-24**] 12:39:26
T: [**2165-7-24**] 14:56:18
Job#: [**Job Number 67582**]
|
[
"428.0",
"430",
"331.4",
"V45.02",
"415.11",
"412",
"401.9",
"790.7",
"707.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.04",
"38.91",
"96.71",
"38.93",
"02.2",
"99.04",
"43.11",
"88.41",
"96.6",
"39.72",
"96.72",
"89.59",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
794, 921
|
2105, 13538
|
13563, 15504
|
1087, 1157
|
1180, 1850
|
165, 768
|
1865, 2087
|
944, 1063
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,144
| 102,899
|
51594
|
Discharge summary
|
report
|
Admission Date: [**2187-3-5**] Discharge Date: [**2187-3-10**]
Date of Birth: [**2109-8-16**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT: Symptomatic carotid stenosis.
HISTORY OF PRESENT ILLNESS: This is a 77-year-old white male
with coronary artery disease (status post coronary artery
bypass graft), history of congestive heart failure, diabetes,
and hypertension who presented to the Emergency Department on
[**2187-3-5**] with a 3-hour to 4-hour history of left
hand weakness.
The patient's family also noticed that he was having
difficulty with expressing his thoughts. The patient's
family brought him to the Emergency Room for further
evaluation.
By the time he came to the Emergency Department, most of the
patient's speech symptoms had returned to [**Location 213**] and he had
very little weakness remaining in his left hand.
A head computed tomography scan was negative for an acute
bleed. A magnetic resonance imaging showed a small lacunar
infarction of the right internal capsule. A carotid
ultrasound showed 70% to 79% right internal carotid artery
stenosis.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post coronary artery
bypass graft times four in [**2174**].
2. Congestive heart failure.
3. Hypercholesterolemia.
4. Peripheral vascular disease.
5. Shrapnel in the right.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft times four in [**2174-2-17**].
2. Cholecystectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lopressor 100 mg p.o. b.i.d.
2. Captopril 50 mg p.o. t.i.d.
3. Lasix 40 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Aspirin 325 mg p.o. q.d.
6. Ditropan 5 mg p.o. b.i.d.
7. NPH insulin 70 units subcutaneously q.a.m.
8. Regular insulin 6 units subcutaneously q.a.m.
9. NPH insulin 30 units subcutaneously q.p.m.
10. Regular insulin 8 units subcutaneously q.p.m.
11. Timoptic 0.25% one drop b.i.d.
12. Alphagan 0.15% two drops q.h.s.
13. Pilopine gel q.d.
SOCIAL HISTORY: The patient is married and lives with his
wife. [**Name (NI) **] worked as a road builder. He does not smoke
cigarettes or use alcohol. He has two sons.
FAMILY HISTORY: Mother died at the age of 83 with diabetes.
Father died at the age of 83 of unknown cause. The patient
has four brothers and one sister and is unaware of any
illnesses of his siblings.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
heart rate was 88, respiratory rate was 22, blood pressure
was 160/90. In general, an alert and cooperative while male
in no acute distress. Head, eyes, ears, nose, and throat
examination revealed normocephalic. Sclerae were anicteric.
The neck was supple. No bruits. The lungs were clear
bilaterally. Heart was regular in rate and rhythm and
without murmurs. The abdomen was obese and soft. Bowel
sounds were present. No hepatosplenomegaly or masses.
Extremity examination revealed mild edema at the ankles.
Feet were equally warm. No ulcerations of the feet. Pulse
examination revealed carotid and radial pulses were palpable
bilaterally. The femoral and distal pulses were all
dopplerable bilaterally. On neurologic examination, speech
was clear. There was a slight left lower facial droop. The
tongue was midline with good movement. Sensation was intact
to touch and pinprick. Slight left pronator drift. Motor
function was intact except for a mild decrease in left hand
grip.
PERTINENT LABORATORY VALUES ON PRESENTATION: Admission
laboratories revealed white blood cell count was 9.2,
hematocrit was 44.8, and platelets were 220,000. Prothrombin
time was 14.6 and partial thromboplastin time was 28.3.
Sodium was 140, potassium was 4, chloride was 103,
bicarbonate was 23, blood urea nitrogen was 16, creatinine
was 1, and blood glucose was 133. Creatine kinases were 271
and 246. CK/MB were 4 and 5. Troponin was less than 0.3.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no acute
pulmonary disease.
Electrocardiogram showed sinus bradycardia with a rate of 52.
Possible old anterior myocardial infarction. No acute
ischemic changes.
HOSPITAL COURSE: The patient was admitted to the Neurology
Service on [**2187-3-5**]. The patient's symptoms
remained stable.
Vascular Surgery was consulted. After evaluating all the
studies on admission, Dr. [**Last Name (STitle) 1476**] recommended doing a right
carotid endarterectomy during this hospitalization.
The Cardiology Service was consulted for preoperative
clearance. Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (the patient's cardiologist)
cleared the patient for surgery.
On [**2187-3-9**] the patient underwent an uneventful
right carotid endarterectomy. Possibility, overnight, the
patient did well. He was discharged on [**2187-3-10**].
He was instructed to follow up with Dr. [**Last Name (STitle) 1476**] in the
office in one week for staple removal from his right neck
incision.
Aggrenox was started by the Neurology Service, and the
patient was to continue this medication per their
instruction.
MEDICATIONS ON DISCHARGE:
1. Lopressor 100 mg p.o. b.i.d.
2. Captopril 50 mg p.o. t.i.d.
3. Lasix 40 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Aspirin 325 mg p.o. q.d.
6. Ditropan 5 mg p.o. b.i.d.
7. NPH insulin 70 units subcutaneously q.a.m.
8. Regular insulin 6 units subcutaneously q.a.m.
9. NPH insulin 30 units subcutaneously q.p.m.
10. Regular insulin 8 units subcutaneously q.p.m.
11. Timoptic 0.25% one drop b.i.d.
12. Alphagan 0.15% two drops q.h.s.
13. Pilopine gel q.d.
14. Aggrenox one capsule p.o. b.i.d.
CONDITION AT DISCHARGE: Condition on discharge was
satisfactory.
DISCHARGE STATUS: Discharge status was to home.
PRIMARY DISCHARGE DIAGNOSES: Symptomatic right internal
carotid artery stenosis.
SECONDARY DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Diabetes.
3. Hypertension.
4. Hypercholesterolemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2187-4-11**] 13:56
T: [**2187-4-11**] 14:02
JOB#: [**Job Number **]
|
[
"250.80",
"401.9",
"433.11",
"428.0",
"V45.81",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.12"
] |
icd9pcs
|
[
[
[]
]
] |
2189, 4111
|
5832, 6194
|
5084, 5610
|
1520, 1998
|
4130, 5057
|
1369, 1493
|
5625, 5725
|
166, 197
|
226, 1111
|
1133, 1346
|
2015, 2172
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,803
| 165,032
|
13769
|
Discharge summary
|
report
|
Admission Date: [**2136-3-24**] Discharge Date: [**2136-3-26**]
Date of Birth: [**2054-2-16**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Demerol
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
ERCP [**2136-3-25**]
History of Present Illness:
82 y/o woman with a history of hypertension, who is admitted to
the [**Hospital Unit Name 153**] after being transfered from [**Hospital3 4107**] where she
presented with abdominal pain. She reportedly had abrupt onset
of nausea, belching, sweating, epigastric/chest discomfot and
pallor on the morning of admission and was transported to [**Hospital1 **] by EMS. There, she was found to have elevated liver
enzymes and a 1cm common bile duct stone, and was transferred to
the [**Hospital1 18**] emergency department for evaluation for ERCP.
.
In the [**Hospital1 18**] ED, initial VS were 100.9 159/72 102 18 98%2L. A
marked increase in her transaminases was noted. They moved from
AST 707, ALT 1174 at [**Hospital3 4107**], to ALT 2848, AST 3939. Her
Alk phos was 306 and bilirubin 2.4.
.
The ERCP team was contact[**Name (NI) **]. She was hemodynamically stable in
the emergency department and a procedure was planned for the
morning.
Past Medical History:
Hypertension
Coronary artery disease
Diabetes mellitus
Gout
Glaucoma
Polymyalgia rheumatica
Chronic renal insufficiency
Glaucoma
Cholecystectomy ([**2125**])
Hysterectomy
Social History:
Lives outside of [**Last Name (un) 21037**], MA with daughter, her husband, and
their children. No alcohol or past or present tobacco.
Family History:
noncontributory
Physical Exam:
Vitals: 96.1 114/62 74 16 100%RA
Pain: denies
Access: PIV
Gen: nad
HEENT: o/p clear, mmm
CV: RRR, no m
Resp: CTAB, no crackles or wheezing
Abd; soft, nontender, +BS
Ext; no edema
Neuro: A&OX3, nonfocal
Skin: no changes
psych: appropriate
Pertinent Results:
wbc 8-->6.7
hgb 12.5->10.6 stable (s/p IVFs)
Chem panel: BUN 13, creat 1.0
AST 707->3939-->2354-->494
ALT 1174->2848->2447-->1269
alk phos 306->261-->233
Tbili 2.2
INR 1.1
albumin 3.5
.
Hep serologies A/B/C negative
UA: small LE, 6-10wbc, mod bacteria
Ucx negative
blood cx X2 pending
.
.
Imaging/results:
EKG: NSR, no acute ST/Twave changes
.
CXR: no acute infiltrates
.
OSH US per report: 1cm CBD stone
.
Brief Hospital Course:
82year old female with h/o CAD, DM, HTN, Gout, PMR, s/p CCY
admitted [**3-24**] with acute abdominal pain/nausea. Imaging with 1cm
CBD stone/choledocholithiasis. . Also low grade temp concerning
for cholangitis, started zosyn. Transiently in ICU, but remained
very stable and transfered to Gen MEd. Underwent ERCP [**3-25**] with
sphincterotomy/stone retrieval, did very well post procedure. On
admission, significantly elevated transaminases likely [**3-12**]
passed stone, and these were rapidly improving by time of
discharge and can be f/u 1 week. Hep serologies negative.
Post procedure, diet advanced without problem, resumed all home
meds. Plan to complete cipro/flagyl X5more days, total 7days.
.
Cholangitis/Choledocholithiasis: s/p ERCP [**3-25**],
sphincterotomy/stone retrieval. Low fevers,
leukocytosis/neutraphilia c/w cholangitis
-s/p zosyn X2days, will Rx cipro/flagyl X5days (total 7days)
-no evidence of post-ERCP pancreatitis
-tolerating full diet
.
.
Transaminitis: Significantly elevated AST/ALT can be seen with
passed stone-->rapid improvement as expected. Low suspicion for
any other process causing liver injury.
-follow LFTs trend
-hep serology, serum acetominophen all negative
.
.
Chest pain, h/o CAD and stable angina: likely related to GI
process above. Trops/EKG unremarkable. Currently asymptomatic.
pt not on ASA due to h/o GIB? will defer to PCP but [**Name9 (PRE) **]
baby ASA [**Name2 (NI) 41412**]. not on statin at home (wouldnt start now,
defer to PCP). sl NTG prn
.
.
Medications on Admission:
Prednisone 2mg [**Hospital1 **]
sl NTG prn
Lotrel 10/40 qd
Allopurinol 300 qd
Protonix 40 qd
Centrum MVI 1 tab qd
Trospium 60 qd
Tylenol 1 gram [**Hospital1 **]
Timoptic 1 gtt both eyes qd
Optive 1 gtt ou qid
Xalatan .25 1 gtt both eyes qd
Discharge Medications:
1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Prednisone 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
8. Lotrel 10-40 mg Capsule Sig: One (1) Capsule PO once a day.
9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
11. Trospium 60 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
12. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every [**5-14**]
hours: DO NOT take this until your liver enzymes have improved.
.
13. Optive Sensitive (PF) 0.5-0.9 % Dropperette Sig: One (1)
Ophthalmic once a day: use as previously directed.
Discharge Disposition:
Home
Discharge Diagnosis:
Choledocholithiasis and cholangitis
Discharge Condition:
GOOD
Discharge Instructions:
you were admitted with abdominal pain and nausea related to gall
stones. You underwent ERCP to remove these stones and did well
after. Since you had a mild infection, you will take 5more days
of antibiotics (cipro and flagyl). Y
Your liver enzymes were very elevated due to a passed stone but
they are improving nicely. You can follow up with your doctor to
repeat these in one week.
Return if you have fevers or similar abdominal pain
You can resume all your previous meds, with the two new
antibiotics as above
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 31187**] in 1week for repeat blood tests
|
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2,473
| 139,570
|
8736
|
Discharge summary
|
report
|
Admission Date: [**2151-9-3**] Discharge Date: [**2151-9-15**]
Date of Birth: [**2101-10-26**] Sex: M
Service: Liver Transplant Service
ADMITTING DIAGNOSES: Hepatic encephalopathy with increasing
lethargy.
HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old
male with a history of alcoholic cirrhosis with history of
hematuresis, varices, ascites, multiple admissions for
hepatic encephalopathy plus increasing lethargy over two
weeks, increase in severity over the course of last summer.
The patient denies recent hematuresis, melena, bright red
blood per rectum. Also denies any recent fevers, chills,
cough, pain or dysuria. The patient had a prior admission to
[**Hospital1 69**] for hepatic
encephalopathy and was placed on the transplant waiting list.
Prior esophagogastroduodenoscopy demonstrated grade 3
varices. So patient was admitted to [**Hospital1 190**] for a possible liver transplant.
PAST MEDICAL HISTORY: End stage liver disease, alcoholic
cirrhosis, coronary artery disease, status post stent on
aspirin, Imdur, diabetes type 2 with poor glucose control,
pancytopenia, grade 3 esophageal varices, hypertension,
polypectomy for adenomatous polyp.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin 325 mg q day, nadolol 20
mg q day, NPH 100 units twice a day, isosorbide 60 mg q day,
rifaximin 200 mg b.i.d., spirolactone 100 mg q.d., Lasix 80
mg q.d., trazodone 100 mg p.o. q.h.s., Protonix 40 mg q day,
iron tablets 375 b.i.d., lactulose 10 mg q day, Caltrate,
nitroglycerine sublingual p.r.n.
SOCIAL HISTORY: Works as a cook. On disability. Smoking [**12-20**]
pack per day. Patient has 6 to 7 beers a day for 20 years,
cocaine in [**2135**].
FAMILY HISTORY: Father died at age 42 of myocardial
infarction. Mother history of coronary artery disease.
PHYSICAL EXAMINATION: Temperature 97.9, blood pressure
119/70, heart rate 56, 98% on room air. In general in no
acute distress, comfortable. Pupils equal, round, reactive to
light. Mildly icteric sclerae. Neck: No palpable nodes, no
thyromegaly. Lungs clear to auscultation. CV: II/VI systolic
ejection murmur at left upper sternal border and right upper
sternal border. Abdomen: Distended abdomen, nontender. Liver
span 9 to 10 cm percussion and fluid wave noted. No masses.
Extremities: Trace edema to knees bilaterally, dorsalis pedis
pulses intact. Neurologic: Asterixis. Rectal within normal
limits.
Preoperative electrocardiogram demonstrated sinus
bradycardia, fresh T wave changes. Chest x-ray: Clear, mild
pulmonary edema.
LABORATORY ON ADMISSION: From [**2151-9-3**] when he was
admitted WBC of 4.4, hematocrit of 36.0, platelets 61. Given
platelets prior to operating room. PT 15.4, 38.7, INR 1.6.
Sodium 132, 4.6, 95, bicarb 30, BUN/creatinine 10/0.7,
glucose 230. ALT 30, AST 48, alk phos 171, total bilirubin
10.8.
Patient went to the operating room on [**2151-9-3**] in
which patient had a preoperative diagnosis of Laennec's
cirrhosis, portal hypertension, ascites, hepatic
encephalopathy, splenomegaly. Postoperative patient had an
orthotropic deceased donor liver transplant (piggyback-portal
vein anastomosis-common bile duct. No T tube). Replaced right
hepatic artery from the superior mesenteric artery recipient
(common hepatic artery donor) performed by Drs. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and [**First Name8 (NamePattern2) 30564**] [**Last Name (NamePattern1) 30565**]. Please see details of
operative note from [**2151-9-3**]. Postoperatively
patient went to the Intensive Care Unit intubated, sedated.
Patient had an internal jugular Swan-Ganz catheter placed. X-
ray was obtained demonstrating no pneumothorax interval
development of mild congestive heart failure/fluid overload.
Ultrasound was performed on [**2151-9-4**], postoperative
day 1, demonstrating normal color flow and wave forms within
the vasculature of the transplanted liver. No biliary
dilatations. No perihepatic fluid collections. Questionable
slight heterogenicity of the architecture of the liver
posteriorly within the right lobe. Finding may be artificial
and could be re-evaluated. Repeat ultrasonography with
radiologist present.
Postoperative day 2 patient intubated on CPAP. Good ins and
outs. [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains intact. Minimal trace peripheral
edema. Patient was on MMF, Solu-Medrol 150 q day and
tacrolimus 2 and 2. On [**2151-9-6**] patient had a line
change. Chest x-ray was obtained worsening mild congestive
heart failure with new moderate size right sided pleural
effusion. Patient was status post extubation. Central venous
line in appropriate position. No pneumothorax. On [**2151-9-6**] patient continued to be in surgical intensive care
unit, extubated. Vital signs stable. CVP was 14. Ins and
outs. Lungs were mildly coarse. Abdomen distended, hypoactive
bowel sounds. [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains which were both
serosanguineous. Laboratories on [**2151-9-6**]: WBC 5.8,
hematocrit of 32.2, platelets 75. PT 13.2, INR 1.2, PTT 24.9.
Sodium 137, 3.8, 102, 29, 16, 0.8, blood sugar 172, total
bilirubin 4.1, AST 251, ALT 471, alkaline phosphatase 78,
amylase 16. Finger sticks have been in the range of 90s to
150s. [**Last Name (un) **] was consulted and they made appropriate
recommendations.
Physical therapy, occupational therapy were consulted.
Patient transferred from the unit to Far 10 on [**2151-9-9**]. Blood sugars were elevated. Afebrile, vital signs
stable. Liver function tests were slightly elevated.
Ultrasound was performed demonstrating that there was patent
hepatic and portal veins. Patency of the hepatic arteries are
identified and the resistive indices appear slightly
increased in comparison to the previous examination. Because
the ultrasound from [**2151-9-9**] was indefinite in
diagnosis and endoscopic retrograde cholangiopancreatography
was obtained to evaluate for biliary leak and with impression
demonstrated mild narrowing at the biliary anastomosis
without evidence of biliary duct dilatation. No evidence of
biliary leak. Successful placement of plastic stent in the
common bile duct across the anastomosis. On [**2151-9-9**] an ultrasound was done that evening demonstrating stable
Doppler ultrasound examination of the liver with patent
hepatic and portal veins. Hepatic arteries again show
slightly increased resistive indices.
On [**2151-9-12**] it was discussed and decided to have CT
of abdomen and pelvis because of resistive arterial indices
on ultrasound. Findings state that there was patent hepatic
arterial flow without evidence for focal stenosis. The portal
venous and hepatic venous flows unremarkable. 2) Presence of
splenomegaly and extensive collaterals consistent with portal
hypertension. Inflammatory stranding in the right
subcutaneous tissue of uncertain clinical significance which
was related by telephone to Dr. [**Last Name (STitle) 30566**]. On [**2151-9-13**] overnight the patient complained of chest pressure.
Electrocardiogram was obtained. Enzymes were obtained.
Electrocardiogram demonstrated sinus rhythm, prolonged QT
interval. Troponin levels were less than 0.01. Chest pressure
improved. Patient was ruled out for a myocardial infarction.
Patient was discontinued on telemetry.
Patient has been eating well, ambulating well without chest
pain. Patient continued on tacrolimus, MMF and patient was
weaned to prednisone 20 mg q day. On [**2151-9-15**]
patient was doing well, WBC of 4.5, hematocrit 29.4,
platelets 94. PT 13.1, PTT 23.1, INR 1.1. Sodium 136, 3.6,
97, 31, BUN/creatinine 27/1.6, glucose 107, ALT 88, AST 16,
alkaline phosphatase 106, total bilirubin 1.4. Patient's FTA
level on [**2151-9-15**] was 12.4 on 5 and 5. Patient is
being discharged home with [**Hospital6 407**] with no
[**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains. Both [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains were removed
in the last two days that patient was hospitalized. Patient
will be discharged on the following medications.
DISCHARGE MEDICATIONS: Aspirin 325 mg q day, trazodone 100
mg q.h.s., Nystatin Swish and Swallow 5 ml p.o. q.i.d.,
isosorbide 60 mg sustained release 1 tablet q day, nicotine
patch transdermal, change q day, prednisone 20 mg q day,
Protonix 40 mg 1 tablet q 12, tacrolimus 5 mg b.i.d.,
Dilaudid 2 mg 1 to 2 tablets q 4 to 6 hours p.r.n., Lasix 20
mg q day, Valcyte 900 mg q day, Lopressor 12.5 b.i.d.,
fluconazole 400 mg q 24 hours, MMF 1,000 b.i.d., Bactrim SS 1
tablet q day and also insulin sliding scale fixed dose NPH 40
units at breakfast and then a sliding scale.
The transplant coordinator has made the follow up appointment
with transplant surgery next week. For an appointment if
patient cannot make it call [**Telephone/Fax (1) 30567**]. Patient was to have
laboratories every Monday and Thursday and wishes to be chem-
10, AST, ALT, alkaline phosphatase, albumin, total bilirubin
and Prograf level to be obtained. Laboratory results should
be faxed to [**Telephone/Fax (1) 697**]. Patient should call transplant
service immediately 24 hours a day at [**Telephone/Fax (1) 673**] if any
fevers, chills, nausea, vomiting, abdominal pain, any
increased swelling in the lower extremities, any change in
skin color, any change in color, size in surgery site, any
discharge from surgery site, any problems with eating,
drinking fluids. If there are any problems with urinating or
with bowel movements please call transplant surgery
immediately.
FINAL DIAGNOSES: Alcoholic cirrhosis.
SECONDARY DIAGNOSIS: Coronary artery disease.
Diabetes mellitus type 2.
Major surgical invasive procedure, status post liver surgery
on [**2151-9-3**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD, PhD [**Numeric Identifier 8353**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2151-9-16**] 15:51:01
T: [**2151-9-16**] 17:47:35
Job#: [**Job Number 30568**]
|
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80,262
| 126,729
|
51268
|
Discharge summary
|
report
|
Admission Date: [**2152-1-19**] Discharge Date: [**2152-1-24**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Bright Red Blood Per Rectum
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
This is an 86 year old male with a medical history significant
for CAD s/p CABG over ten years ago who started having BRBPR at
9pm on the evening prior to admit. He has been having
increasing fatigue and reports being more pale. He also reports
a mild weight loss (4lbs) as well as straining with bowel
movements that started aprox 3 weeks ago. Per his PCP his heart
rate is elevated for him.
.
In the ED, initial vs were: 98.0 90 104/66 16 100. Patient had
blood on rectal exam. He refused an NGT in the ED. Patient was
given one unit of PRBC. At the time of transfer his vitals were
68, 120/57, 15, 100 RA. 97.9. He was transferred to the ICU
given the fact that he had ongoing bleeding in the ED.
.
On the floor, he complained of being fatigued but no other
complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, or congestion. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
CAD s/p CABG [**51**] years ago
echo was done in [**2147**] and showed normal LVEF and no evidence of
exercise-induced ischemia
BPH
HTN
HLD
Hypothyroid
Social History:
- Tobacco: Never
- Alcohol: None now, social in past
- Illicits: Never
Family History:
Father with prostate cancer.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: conjunctiva pale, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Rhales at bases b/l. some coarse breath sounds on right
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur best heard over the pulmonic area and radiating to the
carotids.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, bo abdominal
bruits
Rectal: No external leions, no bleeding, internal exam deffered.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
CN II-XII intact. Motor in upper and lower extremities symmetric
Pertinent Results:
Labs on Admission:
WBC-8.1 RBC-2.25*# Hgb-7.0*# Hct-21.2*# MCV-94 MCH-30.9
MCHC-32.8 RDW-16.2* Plt Ct-273
Glucose-151* UreaN-18 Creat-0.9 Na-141 K-4.1 Cl-106 HCO3-26
AnGap-13
[**2152-1-19**] 03:46PM BLOOD ALT-14 AST-16 LD(LDH)-131 CK(CPK)-83
AlkPhos-66 TotBili-0.2
Lipase-29
Albumin-3.5 Calcium-8.8 Phos-3.2 Mg-2.0 Iron-14*
calTIBC-252* Ferritn-22* TRF-194*
[**2152-1-19**] 03:46PM CK-MB-NotDone cTropnT-<0.01
[**2152-1-20**] 04:37AM CK-MB-4 cTropnT-<0.01
[**2152-1-24**] 05:45AM BLOOD IgA-183
[**2152-1-24**] 12:13PM BLOOD tTG-IgA-PND
Labs on Discharge:
WBC-7.4 RBC-3.36* Hgb-10.1* Hct-30.3* MCV-90 MCH-30.0 MCHC-33.3
RDW-15.3 Plt Ct-242
Glucose-67* UreaN-7 Creat-0.7 Na-147* K-3.5 Cl-111* HCO3-26
AnGap-14
Calcium-8.1* Phos-3.6 Mg-1.8
Microbiology: MRSA screen negative
Studies:
CT Head w/o Contrast [**2152-1-19**]: 17 mm in transverse diameter
collection adjacent to the left cerebral hemisphere compatible
with subdural hemorrhage with acute on chronic component with
layering more acute hemorrhage seen posteriorly and areas of
high attenuation seen within the hemorrhage. Associated 5-mm
rightward midline shift. No other foci of hemorrhage.
CT Head [**2152-1-20**]: Stable size of left hemispheric extra-axial
collection.
CT Head [**2152-1-21**]: Slight increase in size of acute on chronic
left subdural hematoma along frontal and parietal lobe without
increase in associated mass effect.
Colonoscopy [**2152-1-24**]:
Findings:
Excavated Lesions Multiple diverticula were seen throught the
colon. Diverticulosis appeared to be of moderate severity.
Other Prominent veins in the rectum
Impression: Diverticulosis of the throught the colon
Prominent veins in the rectum Otherwise normal colonoscopy to
cecum
Recommendations: No evidence of active bleeding
Brief Hospital Course:
This is an 86 year old male with a history of CAD s/p CABG who
presents with BRBPR in the setting of increasing fatigue.
.
# BRBPR: On arrival to the ICU, patient was asymptomatic and
hemodynamically stable. In the emergecy department and in the
ICU, the patient received a total of 6 units of blood, and his
hematocrit increased to 31.2. Gastroenterology was consulted and
recommended colonoscopy. He was given a prep with golytely, but
the following day colonoscopy was not performed secondary to
bradycardia. He had no further episodes of bleeding and his
hematocrit remained stable throughout the remainder of his
hospitalization. On [**2152-1-22**] he was transferred to the medical
floor. Colonoscopy was performed on [**2152-1-24**], and demonstrated
diverticulosis. Follow up was arranged with Dr. [**First Name (STitle) **] [**Name (STitle) **] of
gastroenterology.
.
# Subdural hematoma: Patient had a mechanical fall at home
around the holidays. Head CT demonstrated an acute on chronic
left subdural hemorrhage with associated 5mm rightward midline
shift. Neurosurgery was consulted. His neurologic exam was
followed closely, aspirin was held and keppra 500mg [**Hospital1 **] was
started for seizure prophylaxis. Repeat head CT showed no
interval change. He had no headaches, change in mental status
or change in neurologic exam throughout his hospitalization.
Follow up was arranged with neurosurgery with a repeat head CT
in four weeks.
.
# Bradycardia: Patient was noted to have bradycardia with rates
as low as 30, without any symptoms. EKGs showed sinus
bradycardia, with no changes from prior. Electrophysiology was
consulted, and felt that this did not require any immediate
intervention as long at the patient remained asymptomatic.
Follow up was arranged with his outpatient cardiologist, Dr.
[**Last Name (STitle) 911**] on discharge.
.
# ECG changes. On intitial EKG, mild ST elevations were noted in
aVR, with some T wave flattening. Myocardial infarction was
ruled out by serial cardiac enzymes and troponins. Patient
experienced no chest pain or shortness of breath throughout his
hospitalization.
.
# HTN: Antihypertensives were held in the setting of GI bleed.
As he remained normotensive throughout his stay, his amlodipine
was held on discharge.
.
# HLD: His statin was held initially, but he was restarted on
his home dose of statin on discharge.
.
# Hypothyroid: Patient was continued on his home dose of
levothyroxine.
.
# Delirium: Patient had an episode of delirium while in the
ICU. His neurologic exam was unchanged and he was given ativan
0.125 mg once. This resolved and did not recur throughout his
hospitalization.
Medications on Admission:
Terazosin 2 mg 2 pills daily
Finasteride 5 mg daily
lisinopril 10 mg daily
Amlodipine 10 mg daily
Aspirin 325 mg daily
Levothyroxine 0.075 mg daily
Simvastatin 10 mg daily
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
4. Terazosin 2 mg Capsule Sig: Two (2) Capsule PO once a day.
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulosis
Chronic Subdural Hematoma
Sinus Bradycardia
Discharge Condition:
Stable, alert and oriented to person, place and time.
Ambulating without assistance.
Discharge Instructions:
You were admitted for a bloody bowel movement. While you were
here colonoscopy was performed, which revealed diverticulosis,
bleeding from an outpouching in your colon. This is a common
condition and no intervention was performed. You had no further
bleeding while you were here. We have arranged a follow-up
appointment with gastroenterology to discuss this finding.
While here, a CAT scan of your head revealed blood between your
brain and skull called a subdural hematoma. Neurosurgery was
consulted, and felt that no intevention was necessary. This
will likely resolve on its own over time. We have arranged an
appointment with neurosurgery and a repeat CAT scan of the head
in 4 wks.
While here you also had a low heart rate. Cardiac
electrophysiology was consulted and felt that no intervention
was necessary. We have arranged follow up with your
cardiologist, Dr. [**Last Name (STitle) 911**].
Please note the following changes in your medications:
- Please START Keppra (Levetiracetam) 500mg by mouth, twice
daily. This medicine to to prevent seizures. Please continue
this medication until your visit with Dr. [**Last Name (STitle) 548**] of neurosurgery.
- Please STOP taking amlodipine. Your blood pressure was low in
the hospital, so we held this medication. Please discuss
restarting this medication with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2204**] on [**2152-2-8**].
Followup Instructions:
Please follow up the following appointments:
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**]
Specialty: Internal Medicine
Date/ Time: Tuesday [**2152-2-8**] at 3:20 PM
Location: BIDHC [**State **], [**Apartment Address(1) **], [**Location (un) **], [**Numeric Identifier 106375**]
Phone number: ([**Telephone/Fax (1) 2941**]
Appointment #2
MD: Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]
Specialty: Cardiology
Date/ Time: Thursday [**2152-2-22**] at 3 PM
Location: [**Hospital1 18**] [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) **]
Phone number: ([**Telephone/Fax (1) 2037**]
Appointment #3
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**]
Specialty: Neurosurgery
Date/ Time: Tuesday [**2152-2-8**] at 10:30 AM for the Head CT
scan, [**Hospital Unit Name 1825**] [**Location (un) **] and at 11:45 AM to see Dr. [**Last Name (STitle) 548**]
in the [**Hospital Ward Name 23**] Building [**Location (un) 551**] in the Spine Center.
Location: CT- [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Unit Name 1825**] [**Location (un) **] and Dr.
[**Last Name (STitle) 548**] in the [**Hospital Ward Name 23**] Building [**Location (un) 551**]
Phone number: ([**Telephone/Fax (1) 88**]
Special instructions for patient: Please have nothing to eat or
drink for 3 hours prior to your head CT.
Appointment #4
Dr. [**First Name (STitle) **] [**Name (STitle) **]
Gastroenterology
[**Hospital Unit Name 1825**], [**Location (un) **] - [**Hospital1 18**] [**Hospital Ward Name 516**]
[**2152-3-14**] at 1:00pm
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"401.9",
"427.89",
"600.00",
"562.12",
"293.0",
"285.1",
"244.9",
"272.4",
"E885.9",
"562.11",
"852.21",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
7778, 7784
|
4334, 7009
|
289, 302
|
7887, 7974
|
2533, 2538
|
9446, 11210
|
1765, 1795
|
7231, 7755
|
7805, 7866
|
7035, 7208
|
7998, 9423
|
1810, 2514
|
1133, 1484
|
222, 251
|
3092, 4311
|
330, 1114
|
2552, 3073
|
1506, 1660
|
1676, 1749
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,966
| 113,483
|
10175
|
Discharge summary
|
report
|
Admission Date: [**2174-9-5**] Discharge Date: [**2174-10-4**]
Date of Birth: [**2121-3-15**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
Hispanic female was last admitted on [**2174-3-31**] with
chest pain and shortness of breath. She ruled out for a
myocardial infarction and had a normal exercise MIBI. She
had medical management and has had intermittent substernal
chest pain with exertion since that time. Her pain radiates
to the right arm and can last for one hour. She is now
admitted for chest pain lasting more than one hour on [**9-5**]. She also has a history of nephrotic syndrome with an
increased creatinine, and cardiac catheterization was trying
to be avoided.
An echocardiogram on [**9-8**] revealed an ejection fraction
of 60%, mild left ventricular hypertrophy, 1 to 2+ mitral
regurgitation, and 1+ tricuspid regurgitation. A
catheterization on [**9-8**] revealed the left anterior
descending artery had a 70% mid stenosis and a 70% first
diagonal stenosis. The left circumflex had a 90% small
obtuse marginal stenosis. The right coronary artery had an
80% stenosis at the origin, 80% proximal stenosis, and 90%
distal stenosis.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. History of angina.
2. History of hypertension.
3. History of nephrotic syndrome with a baseline creatinine
of 1.9.
4. History of hypercholesterolemia.
5. Status post total abdominal hysterectomy and bilateral
salpingo-oophorectomy.
6. Status post appendectomy.
MEDICATIONS ON ADMISSION:
1. Lopressor 75 mg by mouth twice per day.
2. Hydrochlorothiazide 50 mg by mouth once per day.
3. Lipitor 20 mg by mouth once per day.
4. Norvasc 5 mg by mouth once per day.
5. Lisinopril 40 mg by mouth once per day.
6. Glipizide 10 mg by mouth once per day.
7. Nitroglycerin as needed.
8. Ciprofloxacin 250 mg by mouth twice per day (started on
[**9-8**]).
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: She does not smoke cigarettes. She does not
drink alcohol.
FAMILY HISTORY: Family history is significant for diabetes.
REVIEW OF SYSTEMS: Review of systems was unremarkable.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient was a well-developed Hispanic female
in no apparent distress. Vital signs were stable. The
patient was afebrile. Head, eyes, ears, nose, and throat
examination revealed normocephalic and atraumatic.
Extraocular movements were intact. Pupils were equal, round,
and reactive to light and accommodation. The oropharynx was
benign. The neck was supple. Full range of motion. No
lymphadenopathy or thyromegaly. Carotids were 1+ in the
ankles bilaterally and without bruits. The lungs were clear
to auscultation and percussion. Cardiovascular examination
revealed a regular rate and rhythm. No murmurs, rubs, or
gallops. The abdomen was soft and nontender. Positive bowel
sounds. No masses or hepatosplenomegaly. Extremity
examination revealed no clubbing, cyanosis, or edema. Pulses
were 2+ and equal bilaterally except for the bilateral
posterior tibialis pulses which were 1+. Neurologic
examination was nonfocal.
PERTINENT LABORATORY VALUES ON PRESENTATION:
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was seen by Dr. [**Last Name (STitle) 1537**], and she had an elevated
creatinine following catheterization, so her coronary artery
bypass graft was delayed. She continued to have chest pain
while in the hospital. Her creatinine went up to 2.8
following the catheterization and then eventually came back
down to 2.4.
On [**9-15**], she underwent a coronary artery bypass graft
times two with left internal mammary artery to the left
anterior descending artery and saphenous vein graft to
posterior descending artery.
The patient tolerated the procedure well and was transferred
to the Cardiothoracic Surgery Recovery Unit in stable
condition. She was extubated. Her creatinine did continue
to rise postoperatively; up to 3.3. She still continued to
be diuresed with Lasix. Her chest tubes were discontinued on
postoperative day one. Her creatinine continued to rise and
3.9 and then went to as high as 5.4 on [**9-19**], and then
she eventually started to trend down to her baseline. She
did have hemodialysis on [**9-19**] and tolerated this well.
On [**9-19**], she had a left effusion, and she had a
pleurocentesis from which 400 cc of serosanguineous fluid was
obtained. She was then started on continuous venovenous
hemofiltration and tolerated this well and then went back to
hemodialysis.
On [**9-23**], the patient was transferred to [**Hospital Ward Name 121**] Two. She
did not require dialysis at that point anymore. She
continued to improve. She had her epicardial pacing wires
discontinued.
On [**9-26**], she was noted to have a large left pleural
effusion which had reaccumulated. She underwent a
pleurocentesis again, and 800 cc of serosanguineous fluid was
obtained, and the patient had been oxygen dependent and after
that was not oxygen dependent and had symptomatic relief.
She continued to have a sizeable left effusion at that point.
On [**9-28**], she had a chest tube placed, and 700 cc of
serosanguineous fluid was obtained.
On [**9-29**], the chest tube was discontinued, and she had a
small pneumothorax following that. She had another chest
tube placed that had a slight air leak and still had a
pneumothorax following this placement. She also underwent a
bronchoscopy which did not reveal anything.
She had the chest tube discontinued on [**10-3**]. There
was a small bilateral pleural effusion on the final x-ray,
slightly elevated hemidiaphragm, and a small left apical
pneumothorax.
She also had an issue urinary retention. She had a Foley
catheter in for several days. Eventually, this was
discontinued. Then she had to have it put back in again
three days prior to discharge. She had it discontinued on
the night prior to discharge and voided well following that.
DISCHARGE DISPOSITION: On postoperative day 19, she was
discharged to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
PERTINENT LABORATORY VALUES ON DISCHARGE: Her laboratories
on discharge revealed her white blood cell count was 6800,
her hematocrit was 31.3, and her platelets were 502,000. Her
sodium was 130, potassium was 4.7, chloride was 97,
bicarbonate was 16, blood urea nitrogen was 27, creatinine
was 2.1, and her blood glucose was 203.
MEDICATIONS ON DISCHARGE: (Her medications on discharge
were)
1. Colace 100 mg by mouth twice per day.
2. Glipizide 10 mg by mouth twice per day.
3. Atenolol 50 mg by mouth twice per day.
4. Ecotrin 325 mg by mouth once per day.
5. Protonix 40 mg by mouth once per day.
6. Norvasc 10 mg by mouth once per day.
7. Lasix 20 mg by mouth once per day.
8. Vioxx 25 mg by mouth once per day.
9. Tylenol No. 3 one to two tablets by mouth q.4-6h. as
needed (for pain).
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**Last Name (STitle) 33950**] in one to two weeks and by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2174-10-4**] 17:00
T: [**2174-10-4**] 17:02
JOB#: [**Job Number 33951**]
|
[
"276.7",
"584.9",
"585",
"414.01",
"511.9",
"599.0",
"512.1",
"788.20",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"34.91",
"39.61",
"36.15",
"33.23",
"38.95",
"96.71",
"34.04",
"88.56",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
6052, 6116
|
2079, 2124
|
6527, 6972
|
1571, 1984
|
7006, 7495
|
3288, 6028
|
6131, 6195
|
6210, 6500
|
2145, 3254
|
159, 1209
|
1232, 1545
|
2001, 2062
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,987
| 164,106
|
15986
|
Discharge summary
|
report
|
Admission Date: [**2167-7-20**] Discharge Date: [**2167-7-24**]
Date of Birth: [**2123-12-7**] Sex: F
Service: MEDICINE
CHIEF COMPLAINT: Dyspnea.
HISTORY OF THE PRESENT ILLNESS: This is a 43-year-old female
with a past medical history remarkable for primary pulmonary
hypertension diagnosed in [**2167**] now with dyspnea. The patient
was well until she developed a herniated disk in [**3-8**], had
conservative therapy including physical therapy but then
noticed shortness of breath with exertion. Over the next
month, these symptoms got worse. She found it progressively
harder to walk up any incline and one to two flights of
stairs which made her extremely short of breath. As she was
diagnosed with asthma 14 years ago, she was treated with beta
agonists and corticosteroids without improvement in her
symptoms. She quit smoking on [**11-5**] after 28 year history of
one pack per day. She gained 16 pounds and felt palpitations
that she at that time attributed to her smoking cessation.
The symptoms did not get any better and she developed
heaviness in her chest, so she was referred to Cardiology in
[**2167-2-4**]. EKG at that time showed a sinus tachycardia in
the 120s with evidence of right ventricular hypertrophy. A
Holter monitor showed no arrhythmias. A chest echocardiogram was
performed. The patient was only able to go 4 minutes, 8 seconds
without signs of ischemia. TTE showed normal LVEF and ejection
fraction of 60%, but dilated hypertrophied RV, and Doppler
showed pulmonary hypertension with RVSP of 60. Bubble study
suggested a small amount of bubbles crossing to the left
heart consistent with ASD or PFO.
Cardiac catheterization was notable for primary hypertension
with PA of 71/33 and mean of 50, PCWP of 8, heart rate 110,
cardiac index of 2.55 liters per minute per metered square.
No shunting was noted. Pulmonary function tests and chest CT
showed no evidence of underlying disease. On a six minute
walk test, the patient had a desat down to 83%. She was
started on Bosentan, oxygen, Coumadin, and Lasix. She had
some elevated LFTs on Bosentan as well as incomplete
resolution of her symptoms. She has been following with
physicians at [**Hospital6 1708**] for lung
transplant.
She now comes in with progressing shortness of breath, worse
with exertion, left-sided chest heaviness and palpitations
that are present and yet worse on exertion. This is an
elective admission for starting intravenous Flolan therapy
and placement of a permanent catheter. At this point, she is
on 4 liters of oxygen with regular exertion and 6 liters with
maximal exertion.
PAST MEDICAL HISTORY:
1. Primary pulmonary hypertension, as described in the HPI.
2. Asthma.
3. Herniated disk at L4-5 in [**3-8**].
4. Rosacea.
5. Status post exploratory laparoscopy two years ago to
evaluate abdominal pain.
ADMISSION MEDICATIONS:
1. Bosentan 125 b.i.d.
2. Coumadin 10 q.h.s.
3. Lasix 40 b.i.d.
4. Elavil 50 q.h.s.
ALLERGIES: The patient is allergic to penicillin which
causes hives.
SOCIAL HISTORY: She lives with her husband and has two
children. She is a nurse [**First Name (Titles) **] [**Hospital3 **]. She smoked
times 28 years, one pack per day; quit smoking in the fall of
[**2166**]. Occasional alcohol use. No IV drug use.
FAMILY HISTORY: Not significant for any history of primary
pulmonary hypertension or lung disease. Her father died at
the age of 75 after pneumonia and Alzheimer's disease. The
patient's mother is still living and well.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
afebrile, heart rate 120s, blood pressure 115/73, respiratory
rate 32, saturating 96% on 4 liters nasal cannula. General:
This is a 43-year-old female in no acute distress. HEENT:
Normocephalic, atraumatic. The extraocular muscles were
intact. Neck: Supple. JVD 10 cm. Lungs: Clear. Cardiac:
Normal S1, pronounced S2, regular rate. Abdomen: Soft,
nontender, nondistended. Extremities: She has positive
clubbing and 1+ edema bilaterally. Neurologic: Alert and
oriented. She has some left-sided cheek erythema consistent
with rosacea.
LABORATORY/RADIOLOGIC DATA: White blood cell count 10.2,
hematocrit 37.1, platelets 244,000, INR 1.0. Sodium 140,
potassium 3.9, chloride 107, bicarbonate 19, BUN 19,
creatinine 0.9, glucose 87, total bilirubin 0.2, AST 17, ALT
18, alkaline phosphatase 70. Calcium 9.2, magnesium 2.3,
phosphorus 3.0. PFTs showed normal spirometry and lung
volumes but decreased DLCO.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit in order to have a Swan-Ganz catheter placed in
order to measure wedge pressures and began Flolan
administration. The patient tolerated the Swan-Ganz
placement without any complication. She was started on the
Flolan, had some flushing and nausea with advancement of
dose, was titrated back. She was started on Compazine as
well as Tylenol for her symptoms. She was noted to be mildly
hypotensive but asymptomatic. This is apparently her
baseline. It was felt that she was stable for transfer to
the floor. A Hickman catheter was placed by the Surgical
Service without any complication.
The patient was titrated up to 6 nanograms per kilogram per
minute of Flolan. Her Coumadin was restarted. She was
monitored while ambulating on 6 liters of oxygen without any
dyspnea. She had Flolan teaching in order to educate the
patient on administration at home. At this point, it was
felt that the patient was stable for discharge with follow-up
with Dr. [**First Name (STitle) **].
DISCHARGE DIAGNOSIS:
1. Primary pulmonary hypertension.
2. Status post Hickman catheter placement.
DISCHARGE MEDICATIONS:
1. Flolan.
2. Coumadin 10 mg q.h.s., adjust as per INR.
3. Lasix 80 mg p.o. b.i.d.
4. Compazine 10 mg p.o. q. six hours p.r.n.
5. Acetaminophen 325 mg p.o. q. four to six hours p.r.n.
6. Amitriptyline 50 mg p.o. q.h.s.
CONDITION ON DISCHARGE: Good.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 9296**]
MEDQUIST36
D: [**2167-7-25**] 12:54
T: [**2167-7-25**] 13:11
JOB#: [**Job Number 45781**]
|
[
"493.90",
"799.0",
"722.10",
"416.0",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"89.64",
"89.68"
] |
icd9pcs
|
[
[
[]
]
] |
3320, 3548
|
5694, 5920
|
5590, 5671
|
4530, 5569
|
2886, 3047
|
159, 2631
|
3563, 4512
|
2653, 2863
|
3064, 3303
|
5945, 6211
|
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