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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
58,237
| 180,761
|
40488
|
Discharge summary
|
report
|
Admission Date: [**2156-8-14**] Discharge Date: [**2156-8-22**]
Date of Birth: [**2084-4-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
confusion, left visual field vision loss
Major Surgical or Invasive Procedure:
Right occipital craniotomy for tumor resection
History of Present Illness:
72yp RH white man with history of CAD (2 MIs 20years ago), HTN
and CKD who was in his usual state of health until 9am this
morning when suddenly developed "confusion".
He woke up and performed his usual activities, and at 9am sat
down to read his newspaper and realized that he could not fold
his newspaper, and could not correct the upside-down disposition
of the pages. He called for his wife and tried to walk; however,
he had difficulty in turning left despite being able to ambulate
with no unsteadiness. He described being "confused" to his wife,
and walked by himself back to the chair seating down.
The EMS was activated, and the patient was taken to [**Hospital3 85745**] Hospital, where a CT scan was reported to demonstrate an
ischemic stroke in the right parietal lobe with an area of
subarachnoid hemorrhage superimposed. Upon arrival at the [**Hospital1 18**]
ER a stroke code was activated
Past Medical History:
HTN
CAD - MI x 2 in approximately 20 years ago
HLP
Social History:
No tobacco; quit 27 years ago
No alcohol
No drugs
Family History:
No family hx of CNS malignancy
Physical Exam:
Gen - NAD, calm, comfortable, appropriate affect
Neck - no bruits to auscultation
CV - RRR, no murmurs or gallops
Lungs - Clear
Neurological exam:
MS: AAOx3
Language: repetition intact, naming intact, follows 2 step
commands
Speech: no dysarthria
CN: PERRL, left homonimous hemianopsia, EMOI, no nystagmus,
V1-V3
intact, face symmetric, palate elevates symmetrically, tongue
protrudes in midline.
Motor:
Strength: [**6-10**] throughout
No drift
Finger tapping symmetric
Tone normal
Sensory: LT/PP/vib/JPS intact; tactile extinction to the right
in
the initial exam.
DTR: 3+ throughout, symmetrically
Coordination: FTN and HTS intact
Plantar response: flexor bilaterally
Station: deferred
Gait: deferred
Pertinent Results:
Labs on admission:
[**2156-8-14**] 12:34PM PT-12.8 PTT-34.2 INR(PT)-1.1
[**2156-8-14**] 12:34PM PLT COUNT-269
[**2156-8-14**] 12:34PM WBC-9.1 RBC-4.41* HGB-13.6* HCT-39.7* MCV-90
MCH-30.9 MCHC-34.3 RDW-13.4
[**2156-8-14**] 12:34PM estGFR-Using this
[**2156-8-14**] 12:34PM GLUCOSE-125* UREA N-28* CREAT-1.7* SODIUM-137
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
[**2156-8-14**] 01:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2156-8-14**] 01:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2156-8-14**] 01:05PM URINE GR HOLD-HOLD
[**2156-8-14**] 01:05PM URINE HOURS-RANDOM
Imaging:
CT 7//11
FINDINGS:
CT HEAD: There is an area of vasogenic edema in the right
parietal lobe with
a small approximately 1-cm hypodense area peripherally located.
CT ANGIOGRAPHY NECK: CT angiography of the neck demonstrates
atherosclerotic
disease and calcification at both carotid bifurcations without
high-grade
stenosis. The vertebral arteries are patent without stenosis or
occlusion.
In the visualized upper lungs, there is a parenchymal
abnormality seen in the
left upper lung as well as a partially visualized left lower
lobe abnormality
identified. Correlation with chest CT recommended.
CT ANGIOGRAPHY HEAD: CT angiography of the head demonstrates no
evidence of
vascular stenosis or occlusion. The arteries of anterior and
posterior
circulation demonstrate normal flow signal. Mild atherosclerotic
disease is
seen.
IMPRESSION:
1. Head CT shows vasogenic edema with a 1-cm hypodense area
which could be
suggestive of a hemorrhagic metastasis. The appearance does not
suggest an
infarct.
2. CT angiography of the head and neck demonstrates patent
vascular
structures with mild atherosclerotic disease.
MR HEAD [**2156-8-15**]
IMPRESSION:
1. Two enhancing lesions are identified on the right parietal
lobe, the
largest is noted on the inferior aspect of the right parietal
lobe, with
significant vasogenic edema. A punctate focus of enhancement is
demonstrated in the post-central sulcus on the right, measuring
approximately 3 x 4 mm in size. These lesions are concerning for
metastatic disease. Multiple foci of T2 and FLAIR signal are
demonstrated in the subcortical white matter, likely reflecting
chronic microvascular ischemic disease.
.
.
CT-ABD/CHEST/PELVIS [**2156-8-16**]
IMPRESSION:
1. 3 cm rounded solid mass in the left upper lobe, with
peripheral
ground-glass opacity, concerning for a primary lung malignancy.
Predominantly
ground-glass nodules in the left upper lobe and right upper
lobe, concerning
for regional metastases.
2. No pleural effusions. No mediastinal or hilar
lymphadenopathy.
3. Numerous small hypodense hepatic lesions, with the largest
one measuring 17 mm in segment V, incompletely assessed in this
single-phase study but could potentially represent biliary
hamartomas and/or small hepatic cysts.
4. Bilateral duplex kidneys, with severe upper moiety
hydroureter, right
worse than left. No renal tissue or excretion is identified in
the obstructed upper pole moieties. Ectopic insertion of
dilated/obstructed upper pole ureters into the prostatic
urethra. Lower moiety appears normal bilaterally.
5. Colonic diverticulosis without acute diverticulitis.
6. No suspicious osteolytic or sclerotic lesions.
Post op CT Head [**8-20**]
1. Recent right occipital craniotomy with small amount of blood
present
within the surgical cavity and expected pneumocephalus.
2. Vasogenic edema, unchanged with negligible shift of the
midline structures and no evidence of central herniation
Brief Hospital Course:
72yo RHM with HTN, HLD and gout here after confusion found to
have R parietal bleed with significant edema and enhancing mass
concerning for malignancy.
#Neuro:
Further imaging revealed a significant mass in lung concerning
for primary CA. Several services were consulted including
Neuro-oncology, Oncology, Neurosurgery, Radiation Oncology. The
best course of action for tackling this presentation was deemed
to be a tumor resection of the malignancy, and then - depending
on type of CA- further chemo/radiation with possible pulmonary
biopy.
On exam, he continued to have L hemineglect that improve to a
left upper quarantanopsia. He did not have a repeat episode of
confusion or "staring spell" during this admission and did not
developed new symptoms.
He was started on keppra 1000mg [**Hospital1 **] prophylactically. He was
also started on Decadron 4mg, PPI, ISS
.
# Cards: On admission, given possibility of stroke, he was
restarted on on atenolol and his BP was permitted to rise to
160. After 2 days, he was restarted on lisinopril
.
#. Renal failure: chronic and stable. We avoided nephrotoxins
and started NS IVFs
Operative course and onward
on 7.15 patient udnerwent a right sided occipitalc raniotomy for
tumor resection, patient tolerated the procedure well, was
extubated in the oeprating room, and brought to the ICU
post-operatively for further management. preliminary pathology
was consistent with metastatic carcinoma. His post-op CT was
stable and showed expected post-op changes, his post-op check
was significant only for a slight left upper quadrantanopia.
He was transferred to the floor in stable condition on POD#1.
He was seen by PT and cleared for home with family support. His
pain was well controlled with PO medications. His decadron was
tapered from 4mg q6 to goal of 2mg [**Hospital1 **]. He will follow up in
brain tumor clinic in 1 week.
Medications on Admission:
Crestor (discontinued 2 weeks ago [**3-10**] myalgias)
Hydralazine
Atenolol 50 daily
Allopurinol 300 daily
Diltiazem 75mg daily
Lisinopril 30 [**Hospital1 **]
ASA 81qd, last used [**8-15**] am
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain or T>100.4.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q6 () for 1
days.
9. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q8 () for 1
days.
10. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q12 () for
30 days.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Brain tumor
Discharge Condition:
AOx3. Activity as tolerated. No lifting greater than 10 pounds.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**11-19**] days (from your 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**].
??????You will have an appointment in the Brain [**Hospital 341**] Clinic. The
brain tumor clinic staff will contact you with your appt time
and date. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain with/ or without
gadolinium contrast. If you are required to have a MRI, you may
also require a blood test to measure your BUN and Cr within 30
days of your MRI. This can be measured by your PCP, [**Name10 (NameIs) **]
please make sure to have these results with you, when you come
in for your appointment.
Completed by:[**2156-8-22**]
|
[
"403.90",
"348.5",
"272.4",
"414.01",
"274.9",
"162.8",
"198.3",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
8916, 8922
|
5883, 7766
|
313, 362
|
8978, 9044
|
2227, 2232
|
11244, 12359
|
1455, 1487
|
8010, 8893
|
8943, 8957
|
7792, 7987
|
9068, 11221
|
1502, 1631
|
1650, 2208
|
233, 275
|
390, 1296
|
2960, 5860
|
2247, 2951
|
1318, 1371
|
1387, 1439
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,465
| 190,175
|
38983
|
Discharge summary
|
report
|
Admission Date: [**2127-4-4**] Discharge Date: [**2127-4-30**]
Date of Birth: [**2059-10-3**] Sex: M
Service: MEDICINE
Allergies:
Metformin / Celexa / Trazodone Hcl
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
CC:[**CC Contact Info 86475**]
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
67 yo male with PMH of [**Hospital 23051**] transferred from [**Hospital 1474**] hospital
for fall with new femoral/popliteal DVT. Of note, he was
recently hospitalized at [**Hospital1 1474**] until [**3-27**] for new onset
hematuria in which large abdominal lymph nodes were noted. Bone
marrow biopsy was nondiagnostic & lymph node biopsy was pending
upon discharge. Initial [**Hospital1 18**] ED VS 150/86, 113, 18, 100/RA.
Physical exam with 2+ LE edema to pelvis with rash over [**Hospital1 **] that
has been there for weeks which is attributed to Metformin, [**Hospital1 **]
with decreased sensation. Labs notable for leukocytosis,
thrombocytopenia and AG = 19. Patient was given Zofran 8mg,
Morphine 4mg, Protonix 40 mg and heparin gtt. Imaging with
occlusive left femoral thrombus. CT head without acute bleed
and CT abdomen with lymphadenopathy and concern for splenic
infarct. Has 20 x 2g for access. Patient reportedly had coffee
ground emesis x 1 and the heparin gtt was stopped. This was
resumed per recomendation of Vascular. EKG with SR, rate 102,
normal axis and intervals with sligtly peaked / enlarged T-waves
in V2-V3. VS on transfer 97, 103, 148/79, 18, 98/RA.
Upon initial MICU evaluation, patient is alert and oriented. He
can relay his history somewhat and complains of LE pain/swelling
(weeks)and abdnormal neurological findings (2 days). He states
he is nervous at baseline and very concerned about his new blood
clot.
Lymphnode biopsy from [**Hospital1 1474**] [**Telephone/Fax (1) 62332**] with diagnosis of
Difffuse large B-Cell lymphoma.
Past Medical History:
Diabetes Mellitus
OSA
Nephrolithiasis
Thrombocytopenia: New
Hematuria: New
Depression
DLBCL - diagnosed at [**Hospital1 1474**] in last several days
History of remote cocaine use
Social History:
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Remote cocaine use
Family History:
Unclear malignancy history
Physical Exam:
Vitals: T: 97 BP: 155/73 P: 105 R: 23 97/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, anteriorly without
appreciable ronchi or wheezing
CV: Regular rhythm, mildly tachycardic, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, mildly tender in LLQ, distended, bowel sounds
present, no rebound tenderness or guarding
GU: Foley with reddish urine, sediment
Ext: warm, [**Hospital1 **] with erythema, swollen, dopplerable pulses
Pertinent Results:
[**2127-4-4**] 11:58AM TYPE-[**Last Name (un) **] TEMP-36.7 O2-23 PO2-39* PCO2-45
PH-7.38 TOTAL CO2-28 BASE XS-0 INTUBATED-NOT INTUBA
[**2127-4-4**] 11:58AM LACTATE-2.4*
[**2127-4-4**] 11:50AM GLUCOSE-240* UREA N-27* CREAT-1.3* SODIUM-142
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18
[**2127-4-4**] 11:50AM ALT(SGPT)-85* AST(SGOT)-137* CK(CPK)-40* ALK
PHOS-141* TOT BILI-0.4
[**2127-4-4**] 02:15AM WBC-21.0* RBC-4.83 HGB-13.9* HCT-40.4 MCV-84
MCH-28.8 MCHC-34.4 RDW-14.5
[**2127-4-4**] 02:15AM PLT SMR-VERY LOW PLT COUNT-52*
[**4-4**]: CT abd/ pelvis w/ contrast:
1. Massive retroperitoneal lymphadenopathy predominantly on the
left
extending down to the common iliac chain and pelvic side wall.
2. Findings compatible with known DVT in the left lower
extremity and
extensive subcutaneous edema in the left proximal thigh.
3. Several small wedge-shaped hypodensities within the spleen
which are of uncertain significance but may represent small
infarcts.
.
CT head w/o Contrast: No acute intracranial abnormality.
.
TTE: Normal global biventricular systolic function.
.
LENIs: Occlusive thrombus in the left deep venous system
extending to
the most superiorly visualized portion of the common femoral
vein. No
evidence of DVT in the right lower extremity. Bilateral inguinal
lymphadenopathy. & DVT
[**4-4**]: OSH Pathology review pending
.
IMPRESSION:
1. Bulky lymphadenopathy abutting greater sciatic foramen and
sciatic nerve on the left side without apparent direct
infiltration of the nerve. Imaging characteristics are unusual
for lymphoma (diagnosis provided in the history) and if this is
the diagnosis then the imaging findings would suggest an
aggressive form of lymphoma. Other possibilities include
metastatic disease including melanoma and sarcomatous origin.
2. Left iliopsoas bursitiis.
.
PART I:
SPECIMEN: BONE MARROW CORE BIOPSY (SLIDE CONSULT RECEIVED FROM
[**Hospital **] HOSPITAL, [**Hospital1 **], [**Numeric Identifier 60185**], CONSISTING OF 9 SLIDES
ALL LABELED "10-1782" FROM PROCEDURE DATE [**2127-3-24**])
DIAGNOSIS
NORMOCELLULAR MARROW FOR AGE WITH TRILINEAGE MATURING
HEMATOPOIESIS AND MEGAKARYOCYTIC HYPERPLASIA. THERE IS NO
MORPHOLOGIC EVIDENCE OF LYMPHOMA.
Aspirate Smear: Not submitted.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation, and consists of
a 2.1 cm core biopsy of trabecular bone. The marrow cellularity
is variable, and ranges from 30% to 60% with an overall
cellularity of 50%. The M:E ratio estimate is normal.
Erythroid precursors are normal in number and exhibit full
spectrum maturation. Myeloid elements are normal in number and
exhibit full spectrum maturation. Eosinophils are increased.
Megakaryocytes are present in increased numbers, and several
tight clusters are seen. Hypolobated forms are present.
Special Stains:
An iron stain performed on the core biopsy shows the presence of
storage iron. By outside report, a reticulin stain shows a mild
increase in reticulin fibrosis. Giemsa and PAS stains were
reviewed.
PART II:
SPECIMEN: LYMPH NODE, LEFT INGUINAL, EXCISIONAL BIOPSY (SLIDE
CONSULT RECEIVED FROM [**Hospital **] HOSPITAL, [**Hospital1 **], [**Numeric Identifier 60185**],
CONSISTING OF 9 SLIDES ALL LABELED "S10-1782" FROM PROCEDURE
DATE [**2127-3-24**])
DIAGNOSIS:
DIFFUSE LARGE B-CELL LYMPHOMA, SEE NOTE.
Note: Sections are of an enlarged lymph node with complete
architectural effacement by a diffuse infiltrate. Rare
scattered residual germinal centers are seen. The cellular
infiltrate consists of sheets of large cells with moderate
amount of eosinophilic cytoplasm, irregular nuclear contour, and
vesicular nuclei. The majority of the cells contain a single,
centrally located, prominent nucleolus. Intermixed with these
cells are scattered small lymphocytes and eosinophils.
Occasional mitotic figures are seen, but no necrosis is present.
Immunohistochemical stain performed at [**Hospital6 13185**] on an additional piece of tissue from the same
procedure date, shows that the large cells are strongly
immunoreactive for pan B-cell marker CD20, are Lambda light
chain restricted and co-express MUM-1 and BCL-2, but are
negative for BCL-6 and CD10. A CD3 stain highlights scattered
background T-cells. MIB-1 staining shows a proliferation index
of 60%, consistent with a large cell lymphoma. The above
morphologic and immunophenotypic findings are those of a diffuse
large B-cell lymphoma.
Brief Hospital Course:
Assessment and Plan: 67 yo M with newly diagnosed DLBCL
compressing vasculature and nerves to [**Hospital6 **] with [**Hospital6 **] DVT now Dwith
continued elevation LDH, trending down. Course c/b DVT,
initially on heparin gtt but then discontinued given L thigh
hematoma as well as fever and neutropenia.
1. Diffuse large B cell lymphoma: Lymph node pathology at OSH
with diagnosis of DLBCL, confirmed by pathology here. Pt HIV
negative. Pt had MRI to further eval extension of lymphoma into
sacral nerve plexus which showed extensive bulky lymphadenopathy
suggesting aggressive lymphoma. Pt had CT scan which did not
show any apparent disease in the chest. Pt had LP to eval for
malignancy within the CNS which was negative for malignant
cells. He did also get cytarabine IT during the LP. Pt also had
testicular ultrasound to eval for extension of lymphoma into
testicle which was reviewed by urology and felt to be unlikely
to represent extension into testicle, however, urology felt that
ultrasound could be repeated if there is concern in the future
about extension into the testicle. Pt initially treated with
RCHOP as he initially refused PICC placement. After PICC placed,
pt got [**Hospital1 **] 3 wks after RCHOP infusion. Tumor lysis labs were
monitored and were negative except for elevated LDH (pt did
recieve allopurinol throughout C1). Maintained on atovaquone
for PCP prophylaxis, which was switched to bactrim on discharge.
Tolerated chemotherapy well without dose limiting toxicities.
24 hours following completion [**Hospital1 **], patient was started on
neupogen. Cell counts were monitored throughout hospital stay
and will need to be followed after discharge. Further
chemotherapy will be determined according to primary oncologist,
Dr.[**Name (NI) 3588**], input.
-CONSIDER REPEAT TESTICULAR ULTRASOUND
-PT WILL REQUIRE SECOND DOSE OF RITUXAN DURING 2ND CYCLE, DID
NOT RECIEVE AS INPATIENT
2. LE weakness and left foot drop: Likely [**3-4**] mass effect from
tumor burden. Remained stable through hospital stay. Pt seen by
PT and OT and was able to walk with a walker.
3. [**Name (NI) **] DVT - Pt noted to have DVT on admission to felt to be
secondary to venous stasis from lymphatic obstruction and
malignancy. IVC filter placed due to extensive clot burden and
limitations in anticoagulation given hematemesis and
thrombocytopenia on admission. Pt also placed on heparin gtt
which was continued until pt developed L thigh hematoma on [**4-18**]
at which time heparin was discontinued.
-OUTPT TEAM WILL NEED TO EVAL IF ANTICOAGULATION CAN BE
RESTARTED, ALSO SHOULD CONSIDER WHETHER IVC FILTER SHOULD BE
REMOVED
4. Large L thigh bleed and small R psoas bleed on [**2127-4-18**]:
Developed in setting of heparin gtt. Pt recieved 3U prbc and
heparin gtt was discontinued. Vascular surgery was consulted and
did not recommend any intervention. Hct remained stable after
heparin gtt off.
5. fever and neutropenia: pt developed fever and neutropenia
after cycle 1 of CHOP. Source felt to be potentially pulmonary
and pt recieved 10d course of vancomycina and cefepime. Pt also
recieved 2d of micafungin while febrile. Pt recieved neupogen as
well. Patient defervesced and remained stable on discharge.
6. UTI: on admission pt found to have pan-sensitive enterococcal
UTI. He completed 14d course of antibiotics (initially
ampicillin, then switched to vanc/cefepime during period of
febrile neutropenia.
7. subacute lacunar infarct: Pt noted to have subacute lacunar
infarct. Neurology evaluated pt and felt that pt should be on
asa if not on heparin or coumadin.
-CONSIDER START ASA IF NOT RESTARTING SYSTEMIC ANTICOAGULATION
8. GIB: 1 episode hematemesis in ED while on heparin gtt.
Initially started on protonix [**Hospital1 **] and GI was consulted but pt
refused EGD. Patient had no further symptoms of abdominal pain
or evidence of bleed. Discharged on home dose of PPI,
omeprazole 40mg daily
-COULD CONSIDER OUTPT EGD, PER GI RECOMMENDATION ON ADMISSION
9. thrombocytopenia: noted on admission. Improved s/p
chemotherapy.
10. DM: [**Last Name (un) **] was consulted for help in controlling sugars on
varying steroid doses. By time of discharge, the patient's
blood sugars were at target on lantus and humalog dosing
regimen. Patient was restarted on home glipizid. Recommend
close surveillance at rehab facility. Of note, hospital insulin
dosing included with discharge paperwork.
11. anxiety/depression: Per pt and his pcp, [**Name10 (NameIs) 86476**] was recent
med addition in setting of wt loss and ? depression. [**Name10 (NameIs) **]
was discontinued per pt's request. This was discussed with pt's
PCP who felt this was appropriate given wt loss likely was [**3-4**]
cancer. SW visited pt throughout his stay as well for a
complicated home situation.
12. Elevated LFTs on admission- most likely from Lymphoma,
hepatitis viral loads negative and LFTs trended back to wnl
after first cycle of chemotherapy.
Medications on Admission:
(Obtained from [**Hospital1 1474**] d/c summary; patient unsure of meds)
Lisinopril 5mg QD
Glipiizide 10
Omeprazole 40
Prednisone 80 mg po with breakfast
[**Hospital1 **] 2mg qHS, 1mg qAM.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Outpatient Lab Work
Please get CBC with differential on [**2127-5-2**] and [**2127-5-7**]. Fax
results to Dr.[**Name (NI) 3588**] office:([**Telephone/Fax (1) 43297**]
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
9. Neupogen 480 mcg/0.8 mL Syringe Sig: One (1) syringe
Injection once a day: take until your oncologist tells you to
stop.
10. Insulin Lispro 100 unit/mL Insulin Pen Sig: varies units
Subcutaneous QACHS: administer according to sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
primary:
diffuse large b cell lymphoma
[**Location (un) **] DVT
Left thigh hematoma
UTI
neutropenia
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**] for large b cell lymphoma and a blood
clot in your leg. We placed a filter to try to prevent the blood
clot from going to your lungs and started you on a blood
thinner. Unfortuantely you had a bleed into your leg so the
blood thinner was stopped.
The lymphoma and blood clot caused weakness in your left leg.
You were seen by physical therapy who recommended a soft collar
on your leg to help you walk.
Your hospital course was complicated by a pneumonia and a
urinary tract infection for which we treated you with
antibiotics.
We also gave you chemotherapy for your lymphoma. You tolerated
this medication well without any major toxicities. We will need
to watch your blood counts carefully once you have left the
hospital. You will need yo follow closely with your oncologist
for further treatment guidance.
Please make the following changes to your medications:
1. Please take Neupogen 5mg/kg/day until your oncologist tells
you to stop
2. Please take Bactrim SS daily to help prevent lung infections
3. You can take tramadol 50 mg every 4- 6 hours as needed for
pain
4. You can take senna and colace for any constipation
Followup Instructions:
Please go to the following appointments that we have arranged
for you:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 23551**], MD Phone:[**Telephone/Fax (1) 447**]
Date/Time:[**2127-5-8**] 10:00
|
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icd9cm
|
[
[
[]
]
] |
[
"88.51",
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"38.7"
] |
icd9pcs
|
[
[
[]
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13549, 13620
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13764, 13764
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12338, 12528
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13944, 14824
|
2303, 2865
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255, 286
|
374, 1958
|
13779, 13920
|
1980, 2160
|
2176, 2244
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,425
| 195,552
|
48324
|
Discharge summary
|
report
|
Admission Date: [**2201-1-22**] Discharge Date: [**2201-1-30**]
Date of Birth: [**2138-9-5**] Sex: M
Service: MEDICINE
Allergies:
Captopril / Prednisone / infed
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Nephrostomy tube placement
Central venous catheterization placement
History of Present Illness:
Pt is a 62 yo with history of LURT in [**2192**] and
pancreas-after-kidney transplant in [**2193**], complicated by
rejection and subsequently a transplant pancreatic artery-small
bowel fistula and massive GI bleed in [**2198**] necessitating
explantation of the pancreas and R iliac covered stent. Patient
awoke with sudden onset sharp RLQ pain awakening him from sleep
overnight, which radiates to his back. He also has non-bloody,
non-bilious vomiting associated with the pain. Denies hematuria,
hematochezia, chest pain, shortness of breath, or dysuria. He
had a colonoscopy one week ago to evaluate the etiology of 6
weeks of diarrhea, which was unrevealing.
.
In the ED, initial VS: 99.5 87 143/55 16 100% ra. Patient had UA
without evidence of UTI, CT abdomen and pelvis showing
mod-severe hydronephrosis and hydroureter of the R native kidney
w/ perinephric stranding w/o obvious stones. Transplant surgery
saw patient in ED and felt pt had pyelonephritis on right native
kidney - recommended admission to medicine for antibiotics and
percutaneous nephrostomy tube by IR. In the ED patient spiked
fever to 101.7, received 2L NS, tylenol 1000 mg PO x1, and
unasyn 3 g IV x1. He also got 8 mg IV morphine. He took his long
acting insulin last night and was not eating so he was started
on D5NS in the ED for downtrending fingerstick. Vitals on
transfer are 100.0 116 130/66 18 95% 3L.
.
Currently, pt complains of 5 - [**5-17**] RLQ abdominal pain. He is
sleepy and falls asleep during interview. He denies chest
pain/shortness of breath.
.
On floor he was noted to be hypoxic at 1:30 in the AM to 80% on
2 L. he triggered for that, and at that time his BP was fine. He
was broadened to Zosyn. However, later his BP dropped to
80s/doppler. He subsequently got 1.5 L fluid.
Past Medical History:
Celiac sprue
depression
diabetes s/p failed pancreas transplant
renal failure s/p LURT
diabetic retinopathy
OA
osteoporosis
diabetic neuropathy
CAD
hx TIA [**2190**]
hx Afib
.
PSH:
Tonsillectomy
removal bladder tumor [**2183**]
lap chole [**2184**]
B/L cataracts [**2192**]
LURT [**2192**]
PAK [**2192**]
ex lap/pancreatic graft explantation/SBR/bl chest tubes [**8-/2199**]
abdominal closure [**8-/2199**]
Social History:
Lives with his wife. [**Name (NI) **] ETOH, tobacco or illicit drug use
Family History:
Father with bleeding stomach ulcer
Physical Exam:
VS - Temp 103.5 F, BP 132/60 , HR 116, R , 85% on 2L, improved
to 94% on 4L
GENERAL - Sleepy, but arousable to voice, A&Ox3, appears
uncomfortable
HEENT - PERRLA, EOMI, sclerae anicteric, MMM
NECK - Supple, no thyromegaly, no LAD
HEART - Tachy, S1, S2, AV fistula heard throughout the
precordium
LUNGS - Tachypnic, bibasilar crackles
ABDOMEN - NABS, mildly distended, soft, moderate RLQ tenderness
to deep palpation, no rebound tenderness or guarding
BACK - Right sided CVA tenderness
EXTREMITIES - WWP, no c/c/e
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Labs on admission:
[**2201-1-22**] 01:35PM WBC-10.7 RBC-3.88* HGB-10.7* HCT-33.7* MCV-87
MCH-27.6 MCHC-31.8 RDW-15.4
[**2201-1-22**] 01:35PM NEUTS-91.1* LYMPHS-3.6* MONOS-3.5 EOS-1.4
BASOS-0.3
[**2201-1-22**] 01:35PM PLT COUNT-159
[**2201-1-22**] 01:35PM GLUCOSE-146* UREA N-38* CREAT-1.9* SODIUM-141
POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-23 ANION GAP-14
[**2201-1-22**] 02:06PM LACTATE-1.2
[**2201-1-22**] 01:35PM CK(CPK)-50
[**2201-1-22**] 01:35PM CK-MB-3 cTropnT-0.01
[**2201-1-22**] 09:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2201-1-22**] 09:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2201-1-22**] 09:15PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2201-1-22**] 09:15PM URINE HYALINE-3*
[**2201-1-22**] 09:15PM URINE MUCOUS-RARE
CXR [**2201-1-22**]:
FINDINGS: Removal of central venous catheter and nasogastric
tube. Stable cardiomediastinal contours. Mild pulmonary vascular
congestion accompanied by interstitial edema and a small amount
of fluid within the minor fissure. Patchy bibasilar retrocardiac
opacities are present, and likely reflect atelectasis.
.
CT abdomen pelvis [**2201-1-22**]
1. New moderate-to-severe hydronephrosis and hydroureter of the
native right kidney. Dilated ureter can be seen to the level of
small soft tissue density at the site of previously removed
pancreas transplant.
2. Locule of gas within the right lower quadrant may be within a
tethered
loop of small bowel or a contained locule of intra-abdominal
gas; a small
gas/fluid collection cannot be entirely excluded or potentially
fistulization. If clinically indicated, a repeat CT with oral
and/or IV contrast or enhancement may be considered.
.
Liver US [**2201-1-23**]
IMPRESSION:
Normal appearance of the liver parenchyma. No focal lesions.
Pulsatility in
the main portal vein is suggestive of right heart dysfunction
.
TTE [**2201-1-24**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 65%). The right ventricular free wall is hypertrophied.
Right ventricular chamber size is normal. with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened (the
noncoronary cusp is moderately thickened and displays reduced
systolic excursion). There is a minimally increased gradient
consistent with minimal aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is borderline/mild
posterior leaflet mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
.
Renal transplant US [**2201-1-25**]
1. Left lower quadrant renal transplant without hydronephrosis.
2. Perinephritic fluid is present, although may be confounded by
presence of a small ascites as seen on prior ultrasound dated
[**2201-1-23**].
3. Intraparenchymal arterial resistive indices of 0.84-0.9,
previously
0.71-0.74 in [**2192**].
4. Thickened bladder wall may be accentuated by underdistension.
.
Nephrostogram [**2201-1-27**]
IMPRESSION: Complete obstruction at the mid right native ureter.
.
MICROBIOLOGY
C. difficile Toxin PCR-Negative
.
[**2201-1-22**] 10:00 pm BLOOD CULTURE #2.
**FINAL REPORT [**2201-1-25**]**
Blood Culture, Routine (Final [**2201-1-25**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final [**2201-1-23**]):
Reported to and read back by DR. [**First Name (STitle) **] [**2201-1-23**], 10:25AM.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2201-1-23**]): GRAM
NEGATIVE ROD(S).
Blood cultures (- No growth to date [**1-23**], [**1-24**], [**1-25**], [**1-26**],
[**1-27**])
.
CMV Viral Load (Final [**2201-1-26**]):
CMV DNA not detected
.
[**2201-1-23**] 10:05 am URINE Source: Kidney.
GRAM STAIN ADD-ON REQUESTED BY FAX PER DR. [**Known firstname **] [**Doctor Last Name **] ON
[**2201-1-24**] AT
11:27AM.
URINE-GRAM STAIN - UNSPUN (Final [**2201-1-24**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
= or >1 per 1000x field GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final [**2201-1-26**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Final [**2201-1-27**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final [**2201-1-26**]): NO YEAST ISOLATED.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
.
C diff toxin [**1-24**], [**1-25**], [**1-27**]
.
MICROSPORIDIA STAIN (Final [**2201-1-29**]): NO MICROSPORIDIUM SEEN.
CYCLOSPORA STAIN (Final [**2201-1-28**]): NO CYCLOSPORA SEEN.
FECAL CULTURE (Final [**2201-1-29**]):
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Preliminary):
OVA + PARASITES (Final [**2201-1-28**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
Cryptosporidium/Giardia (DFA) (Final [**2201-1-28**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2201-1-28**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
This is a 62 year old with PMH of LURT in [**2192**] and
pancreas-after-kidney transplant in [**2193**] who presented with RLQ
abd pain, N/V, diarrhea, and found to have urosepsis with a
dilated hydroureter of the native right kidney which drained
frank pus.
.
#. Septic Shock: Patient presented with acute onset RLQ
abdominal pain and was found to have hydronephrosis and
hyrodureter of his native right kidney without evidence of
obstruction. Transplant surgery evaluated him and recommended
percutaneous nephrostomy which drained frank pus. He was
covered for pyelonephritis with vanco/Zosyn/Cipro given his
fever and fat stranding seen around his native right kidney. He
was narrowed to just ceftriaxone when his blood and urine
cultures grew out pansensitive Klebsiella. Subsequent blood
cultures were negative. His blood pressure was initially
supported on Levophed which was quickly weaned off. MAPs were
kept above 65 and CVPs between [**7-19**]. ID was consulted and
recommended continuation of ceftriaxone for a total of 14 days
from his first negative blood culture (last dose [**2201-2-5**]) with
transition to oral ciprofloxacin 500 mg [**Hospital1 **] until definitive
procedure is completed.
.
# Respiratory Failure: Likely secondary to sepsis and resultant
leaky capiliaries. He was intubated on arrival and vented via
ARDSNET protocol to support his respiratory distress. He was
extubated within 48 hours. Oxygen saturations remained stable on
room air.
.
# Pyelonephritis- As above the patient was initially treated
with broad spectrum antibiotics for pyelonephritis of his native
R kidney. A nephrostomy tube was placed by IR. Attempts were
made to place a ureteral stent but were unsuccessful. The
patient will ultimately need embolization of the renal artery or
a nephrectomy of the native kidney. His nephrostomy tube will
need to stay in place until a definitive procedure is completed.
He will follow-up with transplant surgery as an outpatient
regarding this procedure.
.
# Acute on chronic kidney injury, ESRD s/p LURT: Baseline
creatinine is around 2 s/p renal transplant. His creatinine
peaked at 3.5 in the setting of sepsis, likely prerenal vs. ATN.
Creatine was improving to 3.1 upon transfer to the floor.
Creatinine continued to trend downward and was 1.7 on discharge.
Transplant nephrology was consulted and his home tacrolimus,
prednisone, doxercalciferol, and Bactrim prophylaxis were all
continued. His tacrolimus levels were running high in his home
dose therefore his dose was decreased to 3 mg [**Hospital1 **] with
appropriate levels.
.
# Elevated transaminitis: Transaminitis to the 300s on admission
likely secondary to the beginnings of shock liver.
Transaminitis improved with IVFs, pressors, and improved blood
pressures. RUQ U/S showed normal appearance of the liver
parenchyma with patent portal vasculature. LFTs trended downward
and were normal at the time of discharge.
.
# Diarrhea- Patient noted a 6 week history of diarrhea of
unclear etiology. Stool studies were performed. C diff was
negative x 3. Cyclospora and microsporidium were negative.
Salmonella and shigella were negative. Cryptosporidium and
giardia were also negative. The patient was started on
loperamide.
.
#. Coronary artery disease s/p stenting: Held home ASA, Plavix,
and Simvastatin. ASA and simvastain were restarted but plavix
was held at the time of discharge.
.
#. Hypertension: Home Diovan was held throughout the admission
and at the time of discharge. Patient will follow-up as an
outpatient regarding restarting this medication.
.
#. Thrombocytopenia: Platelets fell from peak of 188 to 103 upon
transition to the floor. Possibly reflective of low grade DIC in
the setting of sepsis. Patients platelet count trended upward
and were normal at the time of discharge.
.
#. Anemia: Hct trended downward from 33.7 to 25.4 upon
transition to the floor likely in the setting of fluid
resuscitation. HCT remained labile (23-25) but was relatively
stable. His LDH was elevated by haptoglobin and bilirubin were
normal, making hemolysis unlikely. Output from nephrostomy tube
was bloody however only put out approxmately 50 mL per day
making this an unlikely source of HCT drop.
.
#. Diabetes Mellitus: Continued home insulin regimen
.
#. Hypothyroidism: Continued home levothyroxine 100 mcg daily.
.
#. Depression: Continued home sertraline 150 mg daily.
.
TRANSITIONAL ISSUES
- Blood cultures were pending at the time of discharge
- Patient will follow-up with transplant nephrology
- Patient was full code throughout this hospitalization
-Plavix stopped during this admission as patient had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
placed in [**2192**] and no coronary events since, full dose ASA
continued
Medications on Admission:
Clopidogrel 75 mg daily
Doxercalciferol 0.5 mcg daily
Lantus 9 in AM 18 in PM
Regular insulin sliding scale
Levothyroxine 100 mcg daily
Pantoprazole 40 mg daily
Prednisone 5 mg daily
Sertraline 150 mg daily
Simvastatin 20 mg daily
Bactrim SS daily
Tacrolimus 4 mg [**Hospital1 **]
Diovan 320 mg daily
Aspirin 325 mg daily
Ferrous sulfate 325 mg daily
MVI
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Primary Diagnosis
Pyelonephrosis
Respiratory failure
septic shock
bacteremia
Secondary
Diabetes
Coronary artery disease
Celiac sprue
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:
Mr [**Known lastname 7324**],
It was a pleasure participating in your care while you were
admitted to [**Hospital1 69**]. As you know
you were admitted because you were having abdominal pain. It was
ultimately determined that you had an infection in your kidney.
A drain was placed to drain the infection. You were given
antibiotics through the IV which you will need to continue for 6
more days. You will need to continue oral antibiotic pills until
you are instructed to stop by your doctors. You will also need
to have a procedure in the future to solve this problem. [**Name (NI) **]
will therefore need to follow-up with the surgeons to have this
done.
We made the following changes to your medications.
1. STOP Plavix
2. DECREASE tacolimus to 3 mg twice a day
3. START loperamide 2 mg twice a day
4. START Ceftriaxone 1 gram daily for 6 more days
5. START ciprofloxacin 500 mg by mouth twice a day once you
finish the IV antibiotics until instructed to stop by your
doctor
6. Stop Diovan, and please measure your Blood pressure at home.
If your blood pressure is more than 160/80 call your primary
care physician and restart this medication
You should continue to take all other medications as instructed.
Please feel free to call with any questions or concerns.
.
Please check CBC with differential, Chemistry panel,tacrolimus
level, LFTs and coagulation studies on Monday [**2201-2-2**] and fax
results to renal transplant clinic at [**Telephone/Fax (1) 21335**]
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] E
Address: [**State **], [**Apartment Address(1) 101800**], [**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 98031**]
*Please call your primary care physician to book [**Name Initial (PRE) **] follow up
appointment for your hospitalization. You need to book an
appointment within 1 week of discharge.
Department: TRANSPLANT CENTER
When: TUESDAY [**2201-2-17**] at 9:00 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
|
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|
[
[
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[
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icd9pcs
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,249
| 175,360
|
2708
|
Discharge summary
|
report
|
Admission Date: [**2149-2-6**] Discharge Date: [**2149-2-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6994**]
Chief Complaint:
cc:[**CC Contact Info 13460**]
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
hpi: [**Age over 90 **] M with a h/o CHF, CRI, CAD who was found unresponsive at
home and in agonal breathing. Per the daughter he was normal
one moment then started clenching jaw, clutching left arm and
not responding. The family immediately called EMS. Of note he
has had a cough and upper respiratory symptoms for three days
per family report. He has had no GI symptoms however he had
some diarrhea after arrival to the ED. He has been having a
steady decline in mental status and functioning for the last
several months for which he has been evaluated extensively by
his primary care doctor.
On arrival to the ED he was immediately intubated. VBG on
arrival pH 7.09 and K 8.0, glucose 157, lactate 4.1. Pt had EKG
changes consistent with hyperkalemia and was given calcium
gluconate, D50, insulin. Repeat K 4.6. Also given vancomyin 1
gm IV and levoquin 500 mg IV x1 empirically for sepsis of
unknown source. He had episode of hypotension to SBP's 70
responding to 1L NS but otherwise has not required pressors. CT
scan head without ICH, CT abd poor study but no free air or
peritonitis. Abdominal U/S with no cholecystitis. Seen by
cardiology for NSTEMI and felt that not candidate for cath.
Aspirin given but asked to defer heparin gtt as he was guiaic
positive.
Past Medical History:
1. h/o MI in 93'--> refused treatment
MI [**46**]' --> s/p LAD stent
Stress MIBI ([**2-5**])
-3 min on modified [**Doctor Last Name 4001**] protocol
-no EKG changes
-ischemic dilation; mod fixed apical defect; mod revers septal
defect
-global HK; EF 22%
2. BPH
3. dementia
4. HTN
5. GERD
6. hiatal hernia
7. zenker's diverticulum
8. hypercholesterolemia
9. anemia, transfusion dependent, unclear etiology
10.CRI- baseline cr 2.0-2.5
11.CHF
-echo [**10-5**]: EF 30-35%, PASP 49, +1TR, +1 MR,
apical/anteroseptal AK
12.
Social History:
-lives at home with daughter and son-in-law, not drinker, no
Smoking
-retired dentist
Family History:
not contributory
Physical Exam:
Tc 101.6 Tm 101.6 BP 150/61 HR 75 spO2 100%
A/C: 500/20 PEEP 5 FiO2 40% PIP 29
ABG: 7.31/53/241 Lactate 4.1
Gen: sedated on prop; not responsive to pain; intubated
HEENT: intubated
Neck: low JVD although lying flat
CV: RRR, nl S1S2, difficult to assess murmers secondary to
respiratory sounds
Pulm: crackles at bases b/l; secretions
Abd: scaphoid, thin, nd, hyperactive bowel sounds
ext: +2 pitt edema to mid thighs b/l; left arm infiltrated
Pertinent Results:
[**2149-2-5**] 08:30PM FIBRINOGE-355
[**2149-2-5**] 08:30PM PLT COUNT-328
[**2149-2-5**] 08:30PM PT-15.6* PTT-26.8 INR(PT)-1.7
[**2149-2-5**] 08:30PM WBC-6.2 RBC-3.74*# HGB-12.6* HCT-39.0*#
MCV-105* MCH-33.7* MCHC-32.3 RDW-14.0
[**2149-2-5**] 08:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2149-2-5**] 08:30PM CK-MB-14* MB INDX-7.5* cTropnT-0.54*
[**2149-2-5**] 08:30PM CK(CPK)-187* AMYLASE-60
[**2149-2-5**] 08:30PM UREA N-69* CREAT-2.3*
[**2149-2-5**] 08:34PM freeCa-1.18
[**2149-2-5**] 08:57PM URINE GRANULAR-0-2
[**2149-2-5**] 08:57PM URINE RBC->50 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-[**4-6**]
Brief Hospital Course:
Pt was intubated for respiratory distress and found to be RSV
postitive. In addition, he was felt to have aspirated in
setting of alter mental status. He was quickly weaned off the
ventilator and extubated. Pt continued to be lethargic and
unable to control his secretions. Blood gas showed 7.13/75/85.
He was placed on BiPAP to improve his minute ventilation.
Repeat ABG several hours later did not show significant
improvement. Subsequently, family meeting was held to discuss
his poor prognosis. Family decided to make him CMO. He was
taken off BiPAP and on morphine gtt. He expired on [**2149-2-10**] at
12:25 AM.
Medications on Admission:
Plavix 75 mg Daily
Metoprolol 50mg [**Hospital1 **]
Aspirin 325 mg Daily
MVI
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Dehydration
RSV
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
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"585.9",
"600.00",
"424.0",
"584.9",
"285.9",
"412",
"410.71",
"276.51",
"995.92",
"401.9",
"276.7"
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
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icd9pcs
|
[
[
[]
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] |
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|
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|
290, 302
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4111, 4189
|
4344, 4349
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|
221, 252
|
330, 1616
|
1638, 2158
|
2174, 2261
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,492
| 101,068
|
27980
|
Discharge summary
|
report
|
Admission Date: [**2122-1-26**] [**Year/Month/Day **] Date: [**2122-2-2**]
Date of Birth: [**2056-2-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
paracentesis (10L removed)
History of Present Illness:
This is a 65 year old male with a history of end-stage renal
disease (on HD), cirrhosis secondary to alcohol with multiple
complications (see below) and insulin dependant diabetes who
presents with abdominal pain and malaise. For the past couple
days, his wife noted that he was increasingly lethargic and that
he was complaining of abdominal pain. 4 days prior to
presentation, he had been tapped therapeutically and 12 L of
fluid was drained; he does get weekly paracenteses for recurrent
ascites following a failed TIPS. He was initiated on HD in
[**2121-9-20**] for hepatorenal syndrome, the hemodialysis being
a bridge until he gets a transplant. Initially he was getting
tapped twice a week; the frequency of his taps has decreased to
once a week. In the emergency department, diagnostic
paracentesis revealed > 4000 WBCs in para fluid suggestive of
spontaneous bacterial peritonitis. Vancomycin and zosyn were
administered. Nephrology and hepatology were consulted.
Lactate was noted to be 6. At time of transfer to the MICU,
vitals were: 98.2 105/74 18.
Past Medical History:
-Alcohol-related cirrhosis complicated by esophageal varices,
encephalopathy, refractory ascites s/p TIPS which is likely no
longer patent, h/o hepato-renal syndrome requiring admission to
[**Hospital1 18**] from [**2121-4-18**] to [**2121-4-30**], and h/o SBP on Cipro ppx. Sober
since [**2117**]. On transplant list for combined liver-kidney.
-IDDM
-Hypothyroid
-Pituitary mass
-h/o nephrolithiasis
-h/o +PPD
-ESRD on HD MWF, initiated [**2121-9-20**]
Social History:
Lives w/ wife at home. Independent in ADLs and ambulation. Quit
smoking [**2121-6-20**]. No alcohol since [**2118-10-22**]. Denies IVDU.
Family History:
Mother deceased, age 50, CVA. Father deceased, age 62, stomach
problems. One brother living and in good health. Two sisters,
both living and in good health.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: SBP 93/55, HR 99, SpO2 99% RA, temp 98, RR 12
Gen: Portuguese-speaking male, dark-skinned, drowsy, but
otherwise arousable and oriented, in no apparent distress
Cardiac: Nl s1/s2 RRR, no murmurs appreciable
Pulm: clear bilaterally, no accessory muscle use
Abd: grossly distended with dullness to percussion throughout
consistent with significant ascites
Ext: 1+ edema bilaterally, warm
[**Year (4 digits) 894**] PHYSICAL EXAM
General Appearance: Thin, with protuberant abdomen. Moaning.
Eyes / Conjunctiva: scleral icterus
Head, Ears, Nose, Throat: Normocephalic, NG tube
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bibasilar)
Abdominal: Bowel sounds present, extremely Distended,
Tender-diffusely
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+
Musculoskeletal: Muscle wasting
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): self, place, year, month not
date, Movement: Purposeful, Tone: Normal
Pertinent Results:
ADMISSION LABS
[**2122-1-26**] 03:15PM BLOOD WBC-7.4 RBC-3.12* Hgb-8.7* Hct-28.1*
MCV-90 MCH-28.0 MCHC-31.1 RDW-17.0* Plt Ct-223
[**2122-1-26**] 03:15PM BLOOD Neuts-92.5* Lymphs-3.7* Monos-3.3 Eos-0.3
Baso-0.2
[**2122-1-26**] 03:15PM BLOOD PT-14.6* PTT-25.7 INR(PT)-1.4*
[**2122-1-26**] 03:50PM BLOOD Glucose-294* UreaN-75* Creat-6.1*#
Na-125* K-4.6 Cl-86* HCO3-17* AnGap-27*
[**2122-1-26**] 03:50PM BLOOD ALT-17 AST-32 CK(CPK)-48 AlkPhos-231*
TotBili-0.9
[**2122-1-26**] 03:50PM BLOOD Lipase-42
[**2122-1-26**] 03:50PM BLOOD CK-MB-6 cTropnT-0.28*
[**2122-1-26**] 03:50PM BLOOD Albumin-2.9* Calcium-8.2* Phos-7.7*#
Mg-2.9*
[**2122-1-26**] 03:34PM BLOOD Glucose-294* Lactate-6.4* Na-126* K-4.4
Cl-89* calHCO3-16*
CXR [**2122-1-26**] Portable AP upright chest radiograph obtained. A left
IJ tunneled dialysis catheter is again noted with its tip
residing in the expected location of the right atrium. Lung
volumes are low. Previously noted right PICC line has been
removed. Given the low lung volumes, evaluation of the lung
bases is limited. There is linear opacity in the left
retrocardiac space, likely representing atelectasis. No definite
signs of pneumonia or CHF. No pleural effusion or pneumothorax.
The heart size cannot be readily assessed. Mediastinal contour
appears stable with atherosclerotic calcifications along the
aortic knob. Bony structures are intact. IMPRESSION: Basilar
atelectasis without definite signs of pneumonia.
CT ABD/PELVIS [**2122-1-27**] 1. No evidence of perforation, abscess
formation or hemorrhage.
2. Severe liver cirrhosis with splenomegaly and large amount of
ascites.
3. Filling defect is seen in the distal SMV, at the portal
confluence, the
proximal portal vein, and the TIPS stent, representing
thrombosis or flow
artifact. Evaluation is limited due to lack of multiphase
imaging.
Further workup with Doppler liver vascular ultrasound should be
considered.
TIPS [**2122-1-28**] 1. Occluded TIPS shunt. This is a change from the
ultrasound of [**2121-11-19**]. The portal veins and hepatic veins are patent.
2. Massive ascites.
3. Cirrhotic appearing liver with splenomegaly.
PORTABLE ABDOMEN [**2122-1-29**]
1. Technically limited study, demonstrating diffuse gaseous
distention of the large and small bowel, most consistent with
ileus.
2. Apparent nasogastric tube should be advanced for optimal
positioning.
CXR [**2122-1-29**]
The patient is severely rotated, distorting anatomical
landmarks. The
examination was performed at near expiration, which crowds and
dilates
pulmonary vasculature and is responsible for severe left lower
lobe
atelectasis. The upper lungs are probably clear. Cardiac size
cannot be
assessed. Left subclavian dialysis catheter ends in the right
atrium.
Nasogastric tube passes to the lower esophagus and out of view.
There is no pneumothorax.
PERITONEAL FLUID [**2122-1-26**] AND [**2122-1-27**]
ESCHERICHIA COLI
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
65 year old male with a history of EtOh-cirrhosis, on transplant
list, complicated by hepato-renal syndrome on HD, presenting
with worsening abdominal pain and fatigue.
.
# Transition to Comfort Care: the patient's TIPS was found to be
not patent and the patient was not considered a transplant
candidate in the near future. The family opted to focus on
comfort. He was transitioned to CMO and passed away at 6:30 am
on [**2122-2-2**].
.
# Sepsis - Abdominal pain is present on review of systems;
diagnostic paracentesis reveals a WBC count of >4000 with >90%
polys consistent with either SBP or secondary bacterial
peritonitis (given repeated taps), but no perforation or abscess
seen on CT abdomen. Lipase and LFTs are within normal limits
making other abdominal sources unlikely. Alkaline phosphatase
is elevated which could be secondary to TIPS. There is concern
that a clot in the TIPS could be infected. He was treated
empirically initially with vanc and zosyn, the vancomycin was
changed to daptomycin for VRE given hx of VRE in peritoneal
fluid in [**2119**] and chronic thrombocytopenia (so avoid linezolid).
The fluid culture revealed GNRs. He did receive albumin for SBP
despite already having HRS and being on HD. The fluid culture
grew e.coli which was resistant to zosyn, which he had been
treated with, and he was transitioned to ceftriaxone, which the
e.coli was sensitive to.
.
# Hypotension: blood pressure was in the range of SBP 80s at
night; then increased during the day to the 100s. He was started
on midodrine but was unable to take this secondary to his ileus,
which was causing him not to absorb PO medications. At time of
transition to CMO, the patient's blood pressure was 60/40.
.
# Ileus: the patient developed a severe ileus, which was thought
to be [**1-22**] his peritonitis and his ascites. An NGT was placed
with relief of nausea and vomiting, and he was discharged with
this tube to hospice for intermittent suctioning. At time of
[**Month/Day (2) **], less than 500cc per day was being aspirated, which
was mostly the food that he was eating for comfort. He did stool
very small amounts even with lactulose.
.
# Anemia: the patient has had an acute hematocrit drop from 28
to 21. The patient has baseline anemia, likely secondary to
kidney disease and liver disease; prior iron studies consistent
with anemia of chronic disease. In the setting of acute
hematocrit drop, concern for bleed; no signs of acute bleeding
despite history of varices. No signs of hemorrhage on CT abd.
.
# Cirrhosis - Secondary to EtOH. He is no longer drinking.
Listed for transplant. Complicated by esophageal varices,
hepatic encephalopathy, and refractory ascites s/p TIPS that is
no longer patent. Continued lactulose and rifaximin. On
prophylactic bactrim for SBP, which was held during his
treatment of SBP. He did receive a therapeutic paracentesis with
removal of 10L of fluid on [**2122-1-28**]. After that point, although he
was in pain with his distension, the patient could not have
another paracentesis as his hypotension was preventative.
.
# End stage renal disease - Hemodialysis for hepatorenal
syndrome in setting of cirrhosis. The patient missed HD on day
of admission (Monday, [**1-27**]) so recieved an extra session on [**1-28**],
in which 1L was removed. Sevelamer and calcium acetate were
continued.
.
#IDDM - continue home lantus and sliding scale.
.
#. Ventral Hernia: Per records this is not reducible but not
changed from prior. No evidence of incarceration/strangulation.
This has been one of the patient's most significant sources of
discomfort and embarassment for several years however he has
been told that he is not a candidate for surgical repair until
after he has a liver transplant.
.
#. Hypothyroidism: Chronic. Continue Levothyroxine at home dose.
.
# CONTACT: WIFE : [**Telephone/Fax (1) 68125**], [**Telephone/Fax (1) 68133**]; sister
[**Telephone/Fax (1) 68134**]
Medications on Admission:
1. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. lactulose 10 gram/15 mL Syrup Sig: One (1) ML PO three times
a day: take as needed to maintain [**2-22**] Bowel Movements per day.
8. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime: please follow your sugars closely, you
may need this dose to be increased if your sugars are high.
9. insulin lispro 100 unit/mL Solution Sig: please see below
units Subcutaneous four times a day: as directed 4 times a day
per sliding scale sliding scale: (<70) no insulin. (71-100)8
units before meals.(101-150)10 units before meals.(151-200) 12
units before meals.(201-250)14 units before meals, 2 at
HS.(251-300)16 units before meals, 3 units @HS. (301-350)18
units before meals, 4 units @HS. (351-400)20 units before
meals,5 units @HS. (>401) give 22 units before meals, 6 units
@HS and [**Name8 (MD) 138**] MD. .
10. VITAMIN D2 Sig: 50,000 units once a week.
11. B-complex with vitamin C Tablet Sig: One (1) Tablet PO
once a day.
12. CALCIUM CARBONATE [TUMS] - (OTC) - 200 mg calcium (500 mg)
Sig: One (1) tablet once a day.
13. CLOTRIMAZOLE Sig: Ten (10) troche PO dissolve in mouth
5x/day.
[**Name8 (MD) **] Medications:
1. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
2. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: One
(1) bottle PO Q1H (every hour) as needed for pain: Use for
breakthrough pain. Hold for sedation. Hold for respiratory rate
less than 12.
Disp:*2 bottle* Refills:*0*
[**Name8 (MD) **] Disposition:
Home with Service
[**Name8 (MD) **] Diagnosis:
patient expired
Primary Diagnosis:
alcoholic cirrhosis
hepatorenal syndrome on hemodialysis
hepatic encephalopathy
Secondary diagnosis:
hypothyroidism
insulin dependent diabetes
[**Name8 (MD) **] Condition:
patient expired.
[**Name8 (MD) **] Instructions:
patient expired
Dear Mr. [**Known lastname 16651**],
You were admitted to the hospital for your liver and kidney
disease. We wish you all the best. It was a pleasure taking care
of you.
Please note to stop taking all of your medications except the
following:
- Morphine by mouth 5-10mg every one hour as needed for pain.
- Fentanyl patch every 72 hours.
You will have a nurse to help you with your general care at home
as well as the following:
- Suction your nasogastric tube as needed.
Followup Instructions:
None.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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icd9cm
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[
[
[]
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[
"39.95",
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icd9pcs
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[
[
[]
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3523, 6787
|
13685, 13830
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2113, 2272
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2287, 3504
|
283, 299
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393, 1464
|
13047, 13662
|
12945, 13026
|
1486, 1942
|
1958, 2097
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,952
| 184,554
|
38591
|
Discharge summary
|
report
|
Admission Date: [**2134-5-17**] Discharge Date: [**2134-6-4**]
Date of Birth: [**2108-10-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p ~20 ft Fall
Major Surgical or Invasive Procedure:
Right fronto parietal Craniectomy
T8-L2 spine fusion
History of Present Illness:
25M transfer from scene after ~25 foot fall, hypotensive in
field. Unknown down time. On arrival to [**Hospital1 18**] ED was bradycardic
and intubated with succinylcholine, etomidate and lidocaine for
combative behavior.
Past Medical History:
Unknown
Family History:
Noncontributory
Physical Exam:
T:96.7 BP: 115/51 HR: 69 R:14 O2Sats 100%intubated
Ventilator CMV 100% Fio2 500x18,
Gen: intubated GCS-6T
HEENT: Pupils:2.5-2mm perrl EOMs:eyes bilaterally deviated
upwards and laterally right eye to right and left eye to left
Neck: in hard cervical collar
Lungs: CTA bilat
Extrem: Warm and well-perfused.
Neuro:
Mental status/Orientation:GCS:6T-no eye opening, intubated,
minimal flex/withdrawal in all 4 extremities.
Recall/Language: unable to test
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields not tested Extraocular movements
eye fixed-upward gaze right gaze to right , left gaze to left
nystagmus.
V, VII: Facial strength-grossly symmetric
VIII: Hearing intact unable to test
IX, X: Palatal elevation unable to test
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius unable to test
XII: Tongue midline unable to test
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength-withdraws minimally in all 4 extremities.
Pronator drift-unable to test
Sensation: unable to test
Reflexes: Corneal reflex present, pt biting on anything placed
in
mouth unable to test gag/cough at this time
Toes downgoing bilaterally
Coordination: unable to test
Pertinent Results:
[**2134-5-17**] 08:14PM TYPE-ART PO2-185* PCO2-38 PH-7.43 TOTAL
CO2-26 BASE XS-1
[**2134-5-17**] 12:17PM GLUCOSE-108* UREA N-8 CREAT-0.7 SODIUM-143
POTASSIUM-3.3 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14
[**2134-5-17**] 12:17PM CALCIUM-7.5* PHOSPHATE-1.3* MAGNESIUM-1.3*
[**2134-5-17**] 12:17PM WBC-12.8* RBC-3.74* HGB-12.2* HCT-34.1*
MCV-91 MCH-32.8* MCHC-35.9* RDW-13.1
[**2134-5-17**] 12:17PM PLT COUNT-192
[**2134-5-17**] 12:17PM PT-12.8 PTT-26.4 INR(PT)-1.1
[**2134-5-17**] 06:50AM ASA-NEG ETHANOL-122* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Imaging:
CT head: Multifocal intraparenchymal contusion/hemorrhages in
the right frontal lobe. Small right-sided SAH. Small SDH along
the right convexity. Partial effacement of the right lateral
ventricle. No significant midline shift. Small right frontal
subgaleal hematoma, Large left occipital subgaleal hematoma.
Acute left occipital fracture. Acute mild comminuted left skull
base fracture, concerning for overall stability. AFLs in the
left sphenoid sinus.
CT c-spine: no fx, but skull base fx ?stability
CT torso: Multiple L rib fx [**4-4**], T11 compression fracture w 4mm
retropulsion, corner fx T12, L shoulder/scapular fx into [**Hospital1 **]
joint, sliver pneumomediastinum or PTX. Bilateral atelectasis
FAST; negative
CT facial: No definite acute facial bone fx
CXR: no ptx
MR: [**5-17**]:
1.Compression fx at T11 with minimal repulsion to the spinal
canal. Small corner fx at T12. Bone marrow edema in these two VB
extending to the posterior element. Mild perispinal fluid at
these two levels. No definite cord signal abnormality.
2. Fluid-to-fluid level in the most dependent portion at the
sacral thecal sac, could represent small intrathecal hemorrhage
(image 9:9 and image 12:20).
Brief Hospital Course:
He was admitted to the Trauma service:
Neurosurgery was consulted for his traumatic brain injuries; a
[**Last Name (un) **] Bolt was placed to monitor his ICP which was high. The
decision was mad to take him to the operating room for right
hemicraniectomy and evacuation of subdural hematoma.
Postoperatively he was taken to the Trauma ICU where he remained
sedated and intubated. He was fitted with a helmet for
protection of his skull; this needs to be worn at all times when
out of bed. It was several days before his sedation was weaned
and he was noted to follow some commands. He was eventually
extubated. Seizure prophylaxis was initiated early on and would
later be changed to Depakote which will need to continue until
follow up as an outpatient. The plan after discharge is for him
to follow up with a repeat head CT scan and possible surgery to
replace the portion of skull that is being preserved at [**Hospital1 18**].
He is currently awake, alert and oriented to self; ambulates
independently with supervision for safety.
Orthopedic spine was consulted for his spine fractures and he
was taken ot the operating room on [**5-21**] for:
1. T8-L2 fusion.
2. Multiple thoracic laminotomies.
3. Multiple lumbar laminotomies.
4. Instrumentation T8-L2.
5. Iliac crest bone graft.
6. Epidural catheter placement
He did require some packed red blood cells several days
postoperatively.
The epidural catheter was removed after a couple of days and his
pain is currently being managed with prn Percocet. He will
follow up in 4 weeks in Ortho Spine clinic.
He was evaluated by Orthopedics for the scapula glenoid
fracture; non operative treatment with a sling for comfort.
Follow up in 4 weeks as an outpatient for repeat films.
Psychiatry was consulted for the delirium associated with his
head injuries and for a comment re: suicidal ideation made by
patients. He remained on 1:1 supervision during his stay and
there were no observed or reported suicidal behaviors. He has
been intermittently agitated for which standing Zyprexa was
started.
A swallowing evaluation was done and his diet was upgraded to
regular. He was also evaluated by Physical and Occupational
therapy and is being recommended for brain injury rehab after
his acute hospital stay.
Medications on Admission:
Unknown
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
5. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Three (3)
Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)).
12. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
13. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO BID (2 times a day):
please give second dose at hs.
14. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic
three times a day as needed for dry eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 4339**]
Discharge Diagnosis:
s/p ~20 ft Fall
Injuries:
Multiple intraparenchymal hemorrhage
Small right subarachnoid/subdural hemorrhages
Multiple subgaleal hematomas
Left occipital fracture
Left comminuted skull base fracture
Left 3rd-7th rib fractures
T11 compression fracture, T12 corner fracture
Left scapular fracture
Right 1st distal phalanx foot fracture
Right 5th proximal phalanx foot fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Your helmet and TLSO brace must be worn at all when out of bed.
Continue with the Depakote until follow up with Dr. [**First Name (STitle) **],
Neurosurgery.
Followup Instructions:
Follow up in 4 weeks with Dr. [**First Name (STitle) **], Neurosurgery for your
brain injuries, call [**Telephone/Fax (1) 1669**] for an appointment. Inform the
office that a repeat non contrast head CT is needed for this
appointment.
Follow up in 4 weeks with Dr. [**Last Name (STitle) 363**] for your spine, call
[**Telephone/Fax (1) 3573**] for an appointment.
Follow up in Orthopedics clinis with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for your
scapula fracture, call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 4 weeks with Podiatry for your foot fractures, call
[**Telephone/Fax (1) 85795**] for an appointment.
Completed by:[**2134-6-4**]
|
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icd9cm
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[
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icd9pcs
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[
[
[]
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7520, 7567
|
3795, 6059
|
329, 385
|
7985, 7985
|
1994, 2578
|
8321, 9018
|
683, 700
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6117, 7497
|
7588, 7964
|
6085, 6094
|
8137, 8298
|
715, 1175
|
274, 291
|
413, 636
|
1191, 1975
|
2587, 3772
|
8000, 8113
|
658, 667
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,104
| 139,180
|
6704
|
Discharge summary
|
report
|
Admission Date: [**2179-10-22**] Discharge Date: [**2179-10-26**]
Date of Birth: [**2113-10-8**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
dyspnea, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66 yo male with history of hypertension, hyperlipidemia,
congestive heart failure with EF 30-40% in [**2177**] by recent
evaluation NYHA Class I, presents with acute onset dyspnea this
AM. The patient reports the last few days he has awoken with
some dyspnea at rest. This has resolved through the course of
the day prior to today. Today, his symptoms progressed to being
unable to speak in full sentences. He denies any associated
chest pain, palpitations, diaphoresis, abd pain, or nausea. He
does report over the same amount of time he was experiencing
left leg pain, around his left knee which he attributed to gout.
He reports bilateral leg swelling, to which he normally takes
lasix PRN for.
.
In the ED, initial vitals were T 98.6 HR 78 BP 120/75 RR 35
O2Sat 94% on BiPAP. He had a chest x-ray showed marginal
evidence of volume overload. He was given lasix 40mg IV X1 and
levaquin 750mg IV X1. The patient has had 800ccs of urine output
since the lasix. As he was grossly hypoxic, he was placed on
BiPap with decreased work of breathing and increased O2 sat.
Attempts to remove BiPap resulted in increased work of breathing
and hypoxia down to 82% on RA. An ABG was sent off Bipap which
showed marked hypoxia and non-anion gap metabolic acidosis and
respiratory alkalosis.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
# EtOH cirrhosis
- Abd U/S [**8-31**]: small liver, large amt of ascites
- HAV(+). HBV(-). HCV(-).
# Hypertension
# Cardiomyopathy ([**8-31**] EF 35-40%)
# h/o pancreatitis in 10/00 and [**2-/2172**]
# h/o left thalamic cerebrovascular accident
- no residual symptoms
# EtOH abuse (currently 1 pint vodka/day; 40+ years)
# Gout (not on PPx therapy)
# Glucose Intolerance
# s/p appy
Social History:
Mr. [**Known lastname 25559**] lives with his girlfriend. [**Name (NI) **] is not currently
working.
-Tobacco history: 10 cigarettes per day.
-ETOH: One half to one pint per day.
-Illicit drugs: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Brother alive
and well. Sister with breast cancer. Other brother died of
unknown cause. Father with prostate cancer in his 70s. Mother
alive and well.
Physical Exam:
GENERAL: Unable to speak in full sentences, on BiPAP. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not elevated.
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. Crackles bilaterally to
the mid lung fields, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ bilateral pitting edema, No c/c. No femoral
bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2179-10-26**] 06:30AM BLOOD WBC-12.4* RBC-2.54* Hgb-8.2* Hct-24.9*
MCV-98 MCH-32.3* MCHC-33.1 RDW-13.2 Plt Ct-325
[**2179-10-26**] 06:30AM BLOOD PT-14.6* PTT-32.3 INR(PT)-1.3*
[**2179-10-26**] 06:30AM BLOOD Glucose-126* UreaN-47* Creat-1.3* Na-138
K-4.0 Cl-107 HCO3-20* AnGap-15
[**2179-10-22**] 06:13PM BLOOD ALT-15 AST-32 LD(LDH)-281* CK(CPK)-125
AlkPhos-136* TotBili-0.5
[**2179-10-22**] 12:00PM BLOOD CK(CPK)-222*
[**2179-10-22**] 12:00PM BLOOD cTropnT-<0.01
[**2179-10-22**] 03:30PM BLOOD CK(CPK)-130
[**2179-10-22**] 03:30PM BLOOD CK-MB-6 cTropnT-<0.01
[**2179-10-22**] 06:13PM BLOOD ALT-15 AST-32 LD(LDH)-281* CK(CPK)-125
AlkPhos-136* TotBili-0.5
[**2179-10-22**] 06:13PM BLOOD CK-MB-6 cTropnT-<0.01
[**2179-10-26**] 06:30AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.1
[**2179-10-22**] 03:36PM BLOOD D-Dimer-2829*
[**2179-10-23**] 07:45AM BLOOD Type-ART pO2-67* pCO2-24* pH-7.48*
calTCO2-18* Base XS--2
.
[**2179-10-23**] 10:39PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2179-10-23**] 10:39PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018
.
[**2179-10-23**] 11:07 am Influenza A/B by DFA
Source: Nasopharyngeal swab.
**FINAL REPORT [**2179-10-23**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2179-10-23**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2179-10-23**]):
Negative for Influenza B.
[**2179-10-22**] 8:45 pm URINE Source: Catheter.
**FINAL REPORT [**2179-10-23**]**
Legionella Urinary Antigen (Final [**2179-10-23**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
[**2179-10-22**] 12:30 pm BLOOD CULTURE SET #2.
**FINAL REPORT [**2179-10-28**]**
Blood Culture, Routine (Final [**2179-10-28**]): NO GROWTH.
TTE [**10-22**]:
Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is severe regional
left ventricular systolic dysfunction with severe inferior and
inferolateral hypokinesis and extensive distal LV akinesis (LVEF
25-30%). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with normal free wall
contractility. There are three aortic valve leaflets. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Dilated left ventricle with severe regional systolic
dysfunction, c/w multivessel CAD. Mild mitral regurgitation.
Moderate pulmonary hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2178-8-27**], LV systolic function may have slightly
deteriorated. Pulmonary pressures are higher today. The other
findings appear similar.
CTA chest [**10-22**]:
IMPRESSION:
1. No pulmonary embolus. No aortic dissection.
2. Diffuse central perihilar ground-glass opacification,
bilateral pleural
effusions, non-bulky mediastinal lymphadenopathy and pulmonary
artery
hypertension is most consistent with cardiogenic pulmonary
edema.
Differential diagnosis, however, does include interstitial
pneumonia such as
PCP, [**Name10 (NameIs) 3**] well as pulmonary hemorrhage, drug hypersensitivity,
sarcoid and
alveolar proteinosis although these seem less likely. Recommend
rescan after
treatment to ensure no underlying process.
3. Vascular including dense coronary artery calcifications.
4. Appparent thickening of left atrial appendage may artifactual
due to wall
apposition or could represent thrombus. Correlation with
clinical history and
echocardiogram suggested.
EKG [**10-22**]:
Normal sinus rhythm with ventricular premature beats. RSR'
pattern in
lead V2. Non-specific T wave changes. Compared to the previous
tracing
of [**2178-11-5**] there are now frequent ventricular premature beats.
The
non-specific T wave changes were also present at that time. No
other
diagnostic interval change.
LLE U/S:
IMPRESSION: No deep venous thrombosis in the left lower
extremity.
Brief Hospital Course:
# Acute on chronic systolic heart failure, EF 25%
History of dilated cardiomyopathy thought [**1-25**] EtOH abuse, now
worse from 1 year ago. Initial concern for respiratory distress
was pulmonary embolism given LLE swelling and elevated D-dimer,
but chest CTA was negative. CXR consistent with pulmonary
edema. Patient improved on BIPAP in unit and with diuresis.
Total weight lost approx. 2 kg. Eventually he was weaned off
his oxygen requirement and transitioned to PO lasix. Alcohol
counseling was provided and the patient agreed to visit an
outpatient rehabilitation center to help with cessation. CHF
and smoking cessation teaching was provided as well.
- transitioned to carvedilol from metoprolol. Continued home
[**Last Name (un) **].
# Coronaries
Cath [**2170**] showed minimal CAD. Has mult CD RF including HTN,
smoking and HLD.
- cont statin and ASA
# Hyperglycemia
Random BG= 268, fasting (likely) glucose 130. Hx of glucose
intolerance, A1C's running in mid 5's as outpatient. Patient
was covered with sliding scale insulin in house.
# Leukocytosis
Trended down since hospitalization with no obvious source; all
cultures negative. No bandemia noted. No evidence of
infiltrate on CXR although chronic lung changes are noted.
Patient spiked low level temps ~100.x inhouse suppressed by
Tylenol. Did not c/o symptoms of URI/infection.
- Treated with outpatient course of azithromycin for possible
bronchitis.
# Macrocytic Anemia
Baseline hct 31. Decreased during hospital stay possibly [**1-25**]
phlebotomy, fluid shifts. LIkely [**1-25**] ETOH and nutritional
deficiences. On B 12/folate at home and here, level high last
month. No evidence of bleeding.
# ETOH abuse
Was placed on CIWA scale in house, did not require BZD coverage.
As above, agreed to outpatient rehabilitation per SWer [**First Name8 (NamePattern2) 2411**]
[**Last Name (NamePattern1) 2412**].
Medications on Admission:
FOLIC ACID 1 mg [**Hospital1 **]
FUROSEMIDE 40 mg PRN weight gain (takes 2 times per week)
INDOMETHACIN 25 mg PRN gout
METOPROLOL SUCCINATE 100 mg QD
NIFEDIPINE 90 mg QD
POTASSIUM CHLORIDE 20 mEq PRN when taking lasix
SIMVASTATIN 20 mg QD
VALSARTAN 80 mg [**Hospital1 **]
ASPIRIN 325 mg QD
CYANOCOBALAMIN 1,000 mcg QD
MAGNESIUM OXIDE 400 mg TID
Discharge Medications:
1. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Indomethacin 25 mg Capsule Sig: [**12-25**] Capsules PO three times a
day as needed for gout pain: stop taking as soon as possible.
10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO three
times a day.
11. 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*
12. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
three times a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute on Chronic Systolic Congestive Heart Failure
Discharge Condition:
stable
Discharge Instructions:
You had an acute exacerbation of your congestive heart failure.
WE believe that your heart is weak because of your alcohol
intake. We strongly suggest that you stop drinking any more
alcohol and go to the program at [**Hospital1 **]. Information was given
to you about this by [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 2412**] and she will call you at home
tomorrow. We have adjusted your medicines to prevent fluid
accumulation and keep you out of the hospital. It is very
important that you take all of your medicines every day.
Medication changes:
1. Stop taking Metoprolol
2. Start Carvedilol to lower your heart rate and blood pressure
3. Increase your lasix (furosemide) to 40 mg twice daily
4. Stop taking Procardia (Nifedipine)
5. Take your potassium every day
6. Start taking 1000mg of Tylenol three times a day to treat
your knee pain.
.
You have some stiffness and pain in your knees and will need a
walker for now. Please take Tylenol three times a day to help
with the pain. You can talk to Dr. [**First Name (STitle) 1022**] on thursday if the knee
pain is not better.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes
up more than 3 lbs in 1 day or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 Liters or about 8 cups of fluid per day
.
Call Dr. [**Last Name (STitle) **] if you notice swelling in your legs, trouble
breathing, trouble walking up stairs, chest pain, increasing
cough or any other concerning symptoms.
Followup Instructions:
Primary Care:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:
Thursday [**10-28**] at 10:40am.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2179-12-30**] 9:40
.
Cardiology:
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: Wednesday [**12-15**] at 9:20pm. Office will call you with an earlier appt.
.
Completed by:[**2179-11-2**]
|
[
"571.2",
"403.90",
"593.9",
"425.5",
"585.9",
"428.0",
"414.01",
"790.29",
"276.2",
"305.00",
"274.9",
"486",
"416.8",
"428.23",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11735, 11792
|
8278, 10172
|
288, 295
|
11886, 11895
|
3948, 8255
|
13455, 14013
|
2751, 3017
|
10567, 11712
|
11813, 11865
|
10198, 10544
|
11919, 12475
|
3032, 3929
|
12495, 13432
|
234, 250
|
323, 2113
|
2135, 2518
|
2534, 2735
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,685
| 183,521
|
2511
|
Discharge summary
|
report
|
Admission Date: [**2129-1-26**] Discharge Date: [**2129-1-31**]
Date of Birth: [**2078-7-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
abdominal pain, bacteremia, fevers; concern for possible hepatic
abscess and/or cholangitis
Major Surgical or Invasive Procedure:
Drainage of liver abscess [**2129-1-28**]
History of Present Illness:
50 yo female with hx of gastric bypass ([**2125**]), spinal fusion,
anxiety, GERD, presents in transfer from [**Hospital3 **] Hospital for
concern of possible hepatic abscess.
3 days ago, pt began to develop abdominal discomfort, for which
she took Gas-x, as she has a hx of gas pains s/p gastric bypass,
although the nature of the pain seemed different. Pain was
located in RUQ and radiated around R side to R back. Pain
progressively worsened to [**10-23**], and began to develop fevers
which started off mild, but progressed to 104+. She was noted
to have mild elevation of LFT's with AST to 103, ALT 106, alk
phos 75. Bili 0.8. WBC on [**1-25**] showed WBC 7.7 and bandemia
40%. Pt was treated with IV Unasyn, and Ertapenem was later
added last night. Pt feels that she has continued to clinically
worsen with increased pain, fevers, rigors, worst at night.
.
She had multiple imaging studies, which revealed 4.4 cm mass in
lateral segment of of L lobe of the liver, and a 2.7 cm lesion
in medial segment of L lobe of liver. MRCP was performed to
further evaluate, however the report is currently pending
(awaiting fax).
Pt had blood cultures drawn, and micro showed e.coli, with some
resistances.
Pt was subsequently transferred for furhter evaluation and
treatment with concern of possible liver abscess and/or
cholangitis.
.
.
ROS:
+: as per HPI, plus: fevers, chills, rigors, night sweats,
nausea, vomiting (x1), abdominal distention (subjective),
constipation.
.
Denies:
10 point ROS otherwise negative.
Past Medical History:
Migraines
GERD
Anxiety
Chronic back pain
Hx hysterectomy, [**2119**]
Hx gastric bypass surgery, [**2125**]. No complications.
Hx spinal fusion, [**2116**]
Social History:
Lives in [**Location **], MA. On disability d/t back pain. Married,
children.
Tobacco: quit [**2129-1-14**]; previously 1 pack/wk x 1yr
ETOH: occasional
Drugs: denies
Family History:
Family hx of colon cancer.
DM
Father: lung cancer, smoker
Physical Exam:
VS: 99.3 103/61 63 20 96RA
GEN: AAOx3. non-toxic.
HEENT: eomi, perrl, MMM.
Neck: No LAD. JVP WNL. No cervial or supraclavicular LAD.
RESP: CTA B. No WRR.
CV: RRR. No mrg.
ABD: +BS. Soft, ND. Mildly uncomfortable on palp of RUQ.
Ext: No CEE.
Neuro: CN 2-12 grossly intact.
on discharge
98.0 112/72 61 20 100RA
well appearing
exam as above
Pertinent Results:
[**2129-1-26**] 06:10PM GLUCOSE-105* UREA N-7 CREAT-0.4 SODIUM-139
POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-29 ANION GAP-10
[**2129-1-26**] 06:10PM estGFR-Using this
[**2129-1-26**] 06:10PM ALT(SGPT)-136* AST(SGOT)-66* LD(LDH)-172 ALK
PHOS-104 TOT BILI-0.6
[**2129-1-26**] 06:10PM LIPASE-20
[**2129-1-26**] 06:10PM CALCIUM-8.3* PHOSPHATE-1.8* MAGNESIUM-1.8
[**2129-1-26**] 06:10PM WBC-5.2 RBC-3.21* HGB-9.8* HCT-28.7* MCV-89
MCH-30.5 MCHC-34.2 RDW-12.4
[**2129-1-26**] 06:10PM NEUTS-79.2* BANDS-0 LYMPHS-13.2* MONOS-6.9
EOS-0.6 BASOS-0.2
[**2129-1-26**] 06:10PM PLT COUNT-176
[**2129-1-26**] 06:10PM PT-12.2 PTT-23.7 INR(PT)-1.0
Peak Cr: 3.0 ([**1-29**])
Discharge Cr is 2.6 ([**1-31**])
Blood culture
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
MRCP: [**2129-1-27**]
IMPRESSION:
1. 4.2 x 2.7 cm rim-enhancing hepatic lesion containing fluid
and debris
concerning for abscess. This has increased in size from recent
outside
hospital CT [**2129-1-23**].
2. Periportal edema, small amount of pericholecystic and
retroperitoneal
fluid, and small bilateral pleural effusions probably related to
third
spacing.
3. Dependent atelectasis of the right lower lobe overlying the
hepatic dome.
4. Convex contour abnormality of the left hepatic lobe has
similar imaging
characteristics to normal hepatic parenchyma and is not
concerning. This may
be related to prior trauma or could be congenital.
Brief Hospital Course:
50 yo female with hx of gastric bypass [**2125**], hysterectomy [**2119**],
lumbar fusion [**2116**], presents in transfer from OSH with e.coli
bacteremia, high fevers, RUQ pain, and concern for liver abscess
and/or cholangitis.
.
Primary Diagnosis: 790.7 BACTEREMIA
Secondary Diagnosis: 572.0 ABSCESS, LIVER
Patient had high fevers and RUQ pain in setting of E. coli
bacteremia at OSH. OSH MRCP had showed probable liver abscess.
ERCP and ID team was consulted. Patient was covered with vanco
initially, Zosyn and cipro. Vanco was D/Ced after blood cx grew
GNR. Given persistant bacteremia and probable liver abscess,
patient underwent U/S guided drainage of liver lesion on
[**2129-1-28**]. 8cc was aspirated and sent for culture, no drain was
left in place. Hepatology believes that the patient had a
hepatic cyst that became secondarily infected. She was
discharged on cipro and flagyl and will remain on these
medications until directed to stop by the ID team. ID followup
was arranged [**2129-2-23**]; she will require repeat abd imaging (CT or
MRI, pending renal status) prior to her ID appt. She will
follow up with hepatology (Dr [**Last Name (STitle) 696**] within a week of
discharge.
.
.
# Hypoxemic respiratory distress- Patient developed respiratory
distress and hypoxemia in setting of fevers to 104. A-a gradient
of 136. Corrected with oxygen. Suspect V/Q mismatch as
etiology, likely pulmonary edema. TTE showed mild to moderate
MR and normal LVEF. Trop reflected demand, and trended down. TTE
and trop leak suggested component of flash pulmonary edema in
setting of fever, tachypnea, and transient bacteremia. Hypoxia
resolved quickly and she thereafter remained stable on room air
following this initial decompensation.
.
Secondary Diagnosis: 584.9 ACUTE RENAL FAILURE
FENA high, BUN low. no cast in UA. renal u/s wnl. Likely from
combination of sepsis and contrast nephropathy. Cr peaked at 3.0
[**1-29**] and improved to [**2-19**] on [**1-31**]. Renal was consulted (Dr
[**Last Name (STitle) 118**], and agreed with diagnosis. She is to have her Cr
checked as outpatient; expect normalization within 2 weeks per
renal. She will not need renal f/u unless Creatinine fails to
rapidly improve.
.
Secondary Diagnosis: 724.2 PAIN, BACK LUMBAR
Stable, continued on home narcotic regimen
.
# Anxiety: continue home paroxetine
.
# GERD: continued PPI
.
# Lung nodule- The CT scan of the abdomen done at [**Hospital3 **]
hospital noted a 0.5 cm right lower lobe lung nodule. The OSH
radiologists did not state a follow up duration, but given her
low risk a CT scan at 3-6 months seem reasonable. The patient
and PCP were notified about this finding.
Medications on Admission:
Transfer Medications:
tylenol 650 mg po q 4hr prn
dilaudid 0.5 mg IV q 2 hr prn
dilaudid 2 mg IM q 4hr prn
serax 10 mg po qHS prn insomnia (did not receive)
nexium 40 mg IV q day
trazodone 50 mg po q hs
propranolol 60 mg po q hs
paroxetine 40 mg po q hs
fentanyl 25 mcg/hr patch q 3 days (placed 9 am [**1-25**])
docusate 100 mg po BID prn
.
Ampicillin/Sulbactam 3gm IV q 6hr (last dose 1/13 8am)
Ertapenem (dose?) IV q 24 hrs (las dose 11pm [**1-25**])
.
D5 1/2 NS +KCl @ 125 cc/hr
Home Medications:
Fentanyl patch 25 mcg/hr q 72 hr
Paroxetine 40 mg po q day
Prilosec 40 mg po q day
Propranolol 60 mg po q day
Trazodone 50 mg po q day
Vicodin 10/325 mg po bid prn
Discharge Medications:
1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Propranolol 40 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Vicodin ES Oral
7. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day: ?DURATION OF THERAPY.
8. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day: NEEDS
DURATION AND DOSE ADJUSTED.
9. Outpatient Lab Work
Check Chem 7 and CBC on Thursday, [**2128-2-4**].
Fax results to: [**Last Name (LF) 12832**], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**Hospital1 18**], ONE PEARL ST, [**Apartment Address(1) 12833**], [**Hospital1 **],[**Numeric Identifier 8728**] Phone: [**Telephone/Fax (1) 12834**], Fax: [**Telephone/Fax (1) 12835**]
10. Outpatient Imaging
MRI Abdomen to be done at [**Hospital1 18**] by [**2129-2-21**].
11. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: 790.7 BACTEREMIA
Secondary Diagnosis: 530.11 GASTROESOPHAGEAL REFLUX DISEASE
(GERD)
Secondary Diagnosis: 584.9 ACUTE RENAL FAILURE
Secondary Diagnosis: 572.0 ABSCESS, LIVER
Secondary Diagnosis: 724.2 PAIN, BACK LUMBAR
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
As we discussed, you were admitted with an infection in your
liver that entered your blood stream. Please make sure to
complete the entire antibiotic course. You were also found to
have injury to your kidneys. This will improve with time but
will need to be followed after you leave. If it does not improve
you will need to see a kidney specialist as an outpatient.
As we discussed, the CT scan done at the outside hospital showed
a nodule in your right lung which will need to be rechecked with
a CT scan in the future. Please discuss this with your PCP to
arrange the appropriate followup.
You will be discharged on two antibiotics (Ciprofloxacin and
Flagyl). Please continue taking these medications until your
follow up appointment with Infectious Disease.
Followup Instructions:
1. Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12832**] to schedule follow up
within a week of your discharge. We expect your kidney function
will return to normal within 10 days and that you will NOT need
to follow up with the kidney doctors. However, if your primary
doctor finds that your kidney function has not returned to
[**Location 213**], he will help you arrange follow up with a kidney
specialist.
.
Name: [**Last Name (LF) 12832**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] HEALTHCARE - [**Hospital1 **]
Address: ONE PEARL ST, [**Apartment Address(1) 12836**], [**Hospital1 **],[**Numeric Identifier 8728**]
Phone: [**Telephone/Fax (1) 12834**]
Fax: [**Telephone/Fax (1) 12835**]
.
2. You need to follow up with Dr [**Last Name (STitle) 696**] (Hepatology/Liver
Clinic) within 1 week of discharge. Call ([**Telephone/Fax (1) 1582**] to
schedule this appointment. His office is located in the [**Hospital Ward Name 12837**] in the [**Hospital **] Medical Office Building.
.
3. You need to follow up with Dr [**Last Name (STitle) 12838**] in the Infectious
Disease Clinic on [**2-23**] at 2:00 PM. Call ([**Telephone/Fax (1) 4170**]
with questions. This clinic is located in the [**Hospital Ward Name 517**] in the
[**Hospital **] Medical Office Building. ** You need to have an MRI of
your abdomen here at [**Hospital1 **] before this visit (ie, by [**2-21**])** Your
PCP will help you arrange this test if it has not already been
done by Dr [**Last Name (STitle) 696**].
|
[
"995.92",
"584.5",
"V45.86",
"572.0",
"793.1",
"300.00",
"573.8",
"338.29",
"V45.4",
"346.90",
"530.81",
"518.4",
"038.42",
"724.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.91"
] |
icd9pcs
|
[
[
[]
]
] |
9522, 9528
|
4780, 5011
|
406, 449
|
9809, 9809
|
2826, 3543
|
10742, 12348
|
2381, 2441
|
8169, 9499
|
9549, 9549
|
7479, 7479
|
9953, 10719
|
2456, 2807
|
7981, 8146
|
3587, 4757
|
275, 368
|
7501, 7963
|
477, 2000
|
9762, 9788
|
9568, 9585
|
9823, 9929
|
2022, 2179
|
2195, 2365
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,136
| 162,522
|
28510
|
Discharge summary
|
report
|
Admission Date: [**2179-2-22**] Discharge Date: [**2179-2-28**]
Date of Birth: [**2106-1-8**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
EGD
Blood transfusion
History of Present Illness:
72 year-old Portuguese-speaking female with history of chronic
thoracic aneurysm s/p stent graft [**12-14**] for type B dissection
with penetrating ulcer, hypertension who presented to [**Hospital **]
with back pain similar to initial presentation with TAA. SBP at
OSH in 200s and CTA showed small dissection, resulting in
transfer to [**Hospital1 18**] [**2179-2-22**]. Here, CTA showed: No new
abnormalities, focal dissection 2 cm from the superior portion
of the thoracic stent unchanged from [**2178-12-21**].
.
The patient was initially admitted to CT surgery but once the
graft was acknowledged to be stable she was transferred to the
MICU for blood pressure management. BP controlled with labetalol
and nipride gtt. NGT was placed for nausea/vomiting soon after
admission showing dark maroon drainage. 2U transfused around
midnight the night of admission following difficult T&C. GI
consulted for GIB and performed EGD which showed gastritis.
Patient was placed on PPI and serial hematocrits were monitored;
hematocrit stable at 28 prior to transfer. The patient's blood
pressure regimen was transitioned to oral regimen of
hydralazine, isosorbide, and nifedipine.
.
On review of systems, the patient complains of recent chills.
She denies any chest pain, back pain, shortness of breath,
fevers, weight loss, fatigue, headaches, dizziness, blurred
vision, nausea, vomiting, abdominal pain, dysuria, hematuria,
increased urgency, diarrhea, hematochezia, melena. All other
systems reviewed in detail and negative except for what has been
mentioned above.
Past Medical History:
1. Chronic thoracic aneurysm s/p stent graft [**12-14**] for type B
dissection with penetrating ulcer
2. Hypertension
3. Aortic abdominal aneursym 4.2 x 3.9 cm on CTA [**2179-2-22**]
4. Left iliac aneursym 1.8 cm in diameter on CTA [**2179-2-22**]
5. Diastolic CHF (EF 55% by TTE in [**2178**])
6. Hypercholesterolemia
7. Rheumatoid arthritis
8. Osteoporosis
9. Anemia of chronic inflammation
10. Right lower lobe nodules, CTA [**2179-2-22**] showed unchanged from
previous
Social History:
Patient is originally from [**Country 3587**]. Lived previously in
[**Country 6171**] and [**Country 480**] approx 30yr ago. Retired; used to work in
factories. No hx of blood transfusions. 3 children from 3 men,
now currently married. Denies EtOH, ciggs, IV drug use.
Family History:
DM
CVA
History of aneurysms in sister and [**Name2 (NI) 12232**]
Physical Exam:
On arrival to the MICU:
Tm/c 99 71 147/75 (120/147/58/75) 17 100RA
NAD
MMM, NGT in place, no LAD
CTAB
Nl S1/S2; [**3-16**] HSM @ LUSB and apex, I/VI diastolic murmur @ LUSB
Soft, nt, nd, +BS
WWP X 4 w/o c/c/e
.
On arrival to the floor:
VS: T: 96.3 HR: 66 BP: 133/72 RR: 22 Sat: 99% on RA
Gen: Elderly woman breathing comfortably, in no acute distress
HEENT: NCAT, PERRL, Sclera anicteric, No ulcers, oropharynx
otherwise clear, throat with no erythema or exudates, no thrush,
no cervical lymphadenopathy, no JVD
CV: Normal S1/S2, RRR, +S4, no tenderness to palpation of
precordium,
Lungs: Crackles at bases, R>L
Abdomen: Soft, nontender, nondistended, normoactive bowel
sounds, no hepatosplenomegaly, no ascites
Ext: 1+ peripheral edema bilaterally, no clubbing, cyanosis, no
calf pain, DP pulses are palpable bilaterally
Neuro: A + O x 3, moving all extremities well
Skin: Pink, warm, no rashes
Pertinent Results:
Labwork on admission:
[**2179-2-22**] 01:28PM WBC-3.7* RBC-2.48* HGB-8.6* HCT-25.5*
MCV-103*# MCH-34.9* MCHC-34.0 RDW-16.7*
[**2179-2-22**] 01:28PM PLT COUNT-145*
[**2179-2-22**] 01:28PM NEUTS-82.4* LYMPHS-11.9* MONOS-3.3 EOS-2.1
BASOS-0.3
[**2179-2-22**] 01:28PM PT-11.8 PTT-28.0 INR(PT)-1.0
[**2179-2-22**] 01:28PM GLUCOSE-168* UREA N-23* CREAT-1.2* SODIUM-133
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-21* ANION GAP-16
[**2179-2-22**] 01:28PM ALT(SGPT)-8 AST(SGOT)-22 LD(LDH)-306*
CK(CPK)-31 ALK PHOS-68 AMYLASE-98 TOT BILI-0.5
[**2179-2-22**] 01:28PM LIPASE-20
[**2179-2-22**] 01:28PM CK-MB-NotDone cTropnT-<0.01
.
CTA THORAX W&W/O C & RECONS [**2179-2-22**]
There is an endovascular stent graft within the descending
thoracic aorta. There is no endoleak identified. Superior to the
aortic stent graft, at the level of the carina (series 3, image
17), there is a small plaque ulceration unchanged from the prior
study of [**2179-1-20**]. It measures approximately 4 x 11 mm.
This finding is confirmed on the sagittal images as well. The
small previously seen superior type 1 endoleak is stable
compared to [**2178-12-21**]. As mentioned on the prior report,
this could represent a focal dissection or ulceration at the
superior end of the stent. However this is unchanged from
[**2178-12-21**].
IMPRESSION:
1. No new abnormalities. Focal dissection 2cm from the superior
portion of the thoracic stent is unchanged from [**2178-12-21**].
.
ECG Study Date of [**2179-2-22**] 1:49:26 PM
Sinus rhythm. First degree A-V block. Left ventricular
hypertrophy with
secondary ST-T wave changes. Anterolateral ST-T wave
abnormalities most likely related to left ventricular
hypertrophy, but cannot rule out myocardial ischemia. Compared
to the previous tracing of [**2178-12-18**] anterolateral ST-T wave
abnormalities and voltage criteria for left ventricular
hypertrophy are new. Clinical correlation is suggested.
.
Labwork on discharge:
[**2179-2-28**] 07:03AM BLOOD WBC-2.2* RBC-3.33* Hgb-10.9* Hct-31.6*
MCV-95 MCH-32.7* MCHC-34.4 RDW-19.1* Plt Ct-158
[**2179-2-28**] 07:03AM BLOOD Glucose-82 UreaN-18 Creat-1.5* Na-135
K-4.2 Cl-103 HCO3-20* AnGap-16
Brief Hospital Course:
73 year-old with chronic thoracic aortic aneurysm status post
stent transferred from OSH with back pain, resolved soon after
admission, but ongoing hypertension, upper GI bleed secondary to
gastritis s/p two units PRBC, and acute renal failure likely
contrast-induced. CTA showed stable graft.
.
1. Thoracic aorta aneurysm: Here, her CTA showed stable
appearance of her stent graft. CT surgery initially managed the
patient; however, once her graft was assessed to be stable, she
was transferred to the MICU for blood pressure control. The
patient's blood pressure was initially controlled with labetalol
and nipride gtt in MICU with goal SBP 120-140. The patient was
then transitioned to oral medications for blood pressure
control. The patient's aneurysm is believed secondary to
atherosclerotic disease; extensive rheumatologic and infectious
work-up on previous admission was negative. The patient's blood
pressure was controlled with isosorbile, nifedipine, and
metoprolol prior to discharge. The patient was scheduled for
repeat CTA torso scheduled in [**4-14**] with cardiac surgery
follow-up
.
2. Acute renal failure: Baseline creatinine 0.7. The patient's
creatinine peaked at 1.6 and trended down to 1.5 prior to
discharge. The acute renal failure was likely secondary to
contrast administration. FeNa 0.20 consistent with pre-renal
etiology, although the patient was not oliguric. The patient did
not respond to fluid challenge and was 6 liters positive for
length of stay. Urine eosinophils negative. Kidneys appeared
normal on CT abdomen. The patient's medications were renally
dosed. The patient will follow-up with her primary care doctor
for resolution.
.
3. Nausea/vomiting/gastritis: NGT on admission following
episodes of nausea/vomiting revealed dark maroon drainage.
Etiology of nausea unclear but resolved soon after. The patient
has history of gastritis likely secondary to rheumatoid
arthritis. The patient denies any prior BRBPR, melena or prior
hematemesis/coffee ground emesis. She received 2 units PRBC on
admission for drop in hematocrit. GI consulted; EGD revealed
gastritis in body and fundus of the stomach. This duplicates EGD
from [**Hospital3 **] from [**2178-4-8**] which also showed gastritis.
The patient should schedule a follow-up endoscopy in one month.
The patient was given PPI [**Hospital1 **] for one month until follow-up.
.
4. Anemia: She received 2 units PRBC on admission for drop in
hematocrit secondary to gastritis as above. Hematocrit
subsequently remained stable at 28. The patient has anemia of
chronic disease per iron studies [**11-13**]. The patient has a
history of rheumatoid arthritis diagnosed last admission. The
patient's folate and B12 were within normal limits. The patient
should schedule a follow-up endoscopy in one month and continue
PPI [**Hospital1 **] until that time. The patient should follow-up with her
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 21339**] as necessary.
.
5. Leukopenia, thrombocytopenia: The patient has long-standing
leukopenia; she was seen by hematology and this is believed
secondary to rheumatoid arthritis. The patient had new mild
thrombocytopenia during admission, as well likely secondary to
her underlying inflammatory arthritis. The patient's platelets
were at nadir 130s and platelets improved to 150 prior to
discharge. The patient did not receive heparin on this
admission. The patient does not have splenomegaly clinically or
on imaging studies. The patient's leukopenia and
thrombocytopenia remained stable during admission. The patient
should follow-up with her primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 21339**]
as necessary.
.
6. Hypertension: Previously on regimen of metoprolol 25 mg [**Hospital1 **]
at home. In setting of aneurysm, SBP goal 120-140. She was
initially managed with labetalol and nipride drips, but was
later titrated off and started on a regimen of metoprolol,
isosorbide, and nifedipine. Of note, the patient is allergic to
ACE-inhibitors. The patient will follow-up with her primary care
doctor.
.
7. Urinary tract infection: Urinalysis [**2-24**] positive for
infection. Patient with chills but otherwise asymptomatic. The
patient remained afebrile without leukocytosis. The patient
completed a three-day course of ciprofloxacin. Urine culture was
contaminated with genital flora.
.
8. Cardiac: Age-indeterminate septal MI per OSH echocardiogram.
The patient had no complaints during admission.
a. Ischemia: Extensive coronary artery calcifications. Cardiac
enzymes negative on admission. The patient's aspirin was
initially held in the setting of gastrointestinal bleeding but
restarted prior to discharge. The patient was restarted on
metoprolol. The patient's LDL < 100 [**11-13**] off statin.
b. Pump: Diastolic CHF with EF 55%. Euvolemic. Crackles likely
secondary to RA lung disease. The patient was started on
isosorbide and nifedipine for afterload reduction.
c. Rhythm: No active issues. The patient was continued on
metoprolol.
.
9. Aortic abdominal aneurysm: 4.2 x 3.9 cm on CTA [**2179-2-22**]. The
patient should schedule follow-up with vascular surgery.
.
10. Rheumatoid arthritis: No active issues. The patient likely
has rheumatoid lung disease.
.
Code: Full
Medications on Admission:
ASA 81 mg QD
Lopressor 25 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin EC 81 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*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Primary:
1. Back pain
2. Stable chronic thoracic aortic aneursym
3. Hypertensive emergency
4. Gastritis, likely secondary to rheumatoid
5. Pancytopenia, likely secondary to rheumatoid
6. Urinary tract infection
.
Secondary:
1. Chronic thoracic aneurysm s/p stent graft [**12-14**] for type B
dissection with penetrating ulcer
2. Hypertension
3. Aortic abdominal aneursym 4.2 x 3.9 cm on CTA [**2179-2-22**]
4. Left iliac aneursym 1.8 cm in diameter on CTA [**2179-2-22**]
5. Diastolic CHF (EF 55% by TTE in [**2178**])
6. Hypercholesterolemia
7. Rheumatoid arthritis
8. Osteoporosis
9. Anemia of chronic inflammation
10. Right lower lobe nodules, CTA [**2179-2-22**] showed unchanged from
previous
Discharge Condition:
Afebrile, vital signs stable.
Discharge Instructions:
You were hospitalized with back pain. This was likely secondary
to uncontrolled blood pressure and your chronic thoracic aortic
aneursym. There was no change to the aneursym. You need to take
your blood pressure medications as prescribed to prevent future
episodes.
.
You were diagnosed with irritation of your stomach. You should
take protonix twice daily for treatment to reduce stomach acid.
.
You were diagnosed with a urinary tract infection. You finished
a course of ciprofloxacin, an antibiotic, for treatment.
.
Please contact a physician if you experience fevers, chills,
chest pain, shortness of breath, back pain, pain with urinating
or having to go more often, or any other concerning symptoms.
.
Please take your medications as prescribed.
- You should take coated aspirin to protect your stomach.
- You should continue metoprolol 25 mg twice daily for blood
pressure.
- You were started on isosorbide dintrate 20 mg three times
daily for blood pressure.
- You were started on nifedipine 90 mg daily for blood pressure.
- You were started on protonix twice daily to reduce stomach
acid and prevent bleeding.
.
Please keep your follow-up appointments as below.
Followup Instructions:
Follow-up with your primary care doctor, Dr. [**Last Name (STitle) 69079**]
[**Last Name (un) 69080**], on [**3-5**] at 10:00 am. Please call
[**Telephone/Fax (1) 9674**] if you have any questions or concerns. Talk with
her about checking your electrolytes.
.
You should call to make an appointment with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] of vascular surgery for followup of your aneurysm.
This appointment should be in about 3 months. Please call
[**Telephone/Fax (1) 2625**] to make an appointment.
.
You will also need a followup endoscopy to evaluate your stomach
irritation. This should be in about 1 month. You can call
[**Telephone/Fax (1) 1983**] to make an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**] for
this procedure.
.
Previously scheduled appointments:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2179-4-14**] 10:45
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] CARDIAC SURGERY LMOB 2A Date/Time:[**2179-4-14**]
2:15
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
] |
12100, 12156
|
5884, 11148
|
284, 307
|
12898, 12930
|
3697, 3705
|
14151, 15210
|
2696, 2762
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11244, 12077
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12177, 12877
|
11174, 11221
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12954, 14128
|
2777, 3678
|
5644, 5861
|
235, 246
|
335, 1896
|
3719, 5630
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1918, 2393
|
2409, 2680
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,145
| 175,265
|
14921
|
Discharge summary
|
report
|
Admission Date: [**2170-8-31**] Discharge Date: [**2170-9-23**]
Date of Birth: [**2102-8-29**] Sex: M
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 43735**] is a 67-year-old
male who is a resident of [**State 108**], who had been traveling to
[**State 350**] to visit his daughter. [**Name (NI) **] reports a 2-week to
3-week history of a progressive onset of jaundice. He also
denied any pruritus. He also had lower abdominal discomfort
but denied any significant upper abdominal pain. He denies
any nausea or vomiting. He states that his appetite has been
poor over the past few weeks.
The patient was initially seen at [**Hospital **] Hospital for these
symptoms and was found to have a bilirubin level of 32.4, and
He subsequently underwent an abdominal ultrasound which was
consistent with distal common bile duct obstruction and
pancreatic ductal obstruction, though no definite lesion was
seen. He also was noted to have a distended gallbladder with
evidence of gallstones.
The patient also underwent an endoscopic retrograde
cholangiopancreatography at the outside hospital which
demonstrated a markedly dilated bile duct with a distal
stricture. Attempts were also made to introduce a biliary
stent; however, one could not be successfully placed. He was
then transferred to the [**Hospital1 69**]
for further evaluation of his obstructive jaundice and
possible surgical intervention.
PAST MEDICAL HISTORY: Past medical history was unremarkable.
PAST SURGICAL HISTORY: No past surgical history.
SOCIAL HISTORY: The patient is married and has three
children. He lives in [**State 108**]. He is a former smoker who
quit 12 years ago. He states that he does drink two to three
beers per day and at least two cocktails per day.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Weight was 174 pounds,
blood pressure was 126/70, heart rate was 80. In general,
the patient was a middle-aged male in no acute distress.
Head, eyes, ears, nose, and throat revealed normocephalic and
atraumatic. Scleral were icteric. Pupils were equal, round,
and reactive to light and accommodation. Extraocular
movements were intact. Neck was supple. No jugular venous
distention. Lungs were clear to auscultation bilaterally.
Cardiovascular revealed a respiratory rate. No murmurs,
rubs or gallops. Abdomen was mildly distended, soft,
nontender. No hepatosplenomegaly. Mild ascites.
Extremities revealed no clubbing, cyanosis or edema.
Neurologically, alert and oriented times three. No
asterixis. Skin was notable for jaundice.
PERTINENT LABORATORY DATA ON PRESENTATION: Hematocrit
was 36.9, white blood cell count was 11.5. Sodium was 136,
potassium was 3.6, chloride was 103, bicarbonate was 19,
blood urea nitrogen was 26, creatinine was 1.2, blood glucose
was 91. AST was 111, ALT was 22, alkaline phosphatase
was 442, total bilirubin was 45.3. PT was 13.2, INR was 1.2,
PTT was 34.9. CA19-9 from the outside hospital was 4278.
Hepatitis A, hepatitis B, and hepatitis C serologies were
negative.
RADIOLOGY/IMAGING: Electrocardiogram revealed a normal
sinus rhythm at 85 beats per minute, and no evidence of ST
changes.
A CT of the abdomen with intravenous contrast revealed
(1) pancreatic head mass measuring 2.4 cm X 2.6 cm with
minimal small peripancreatic lymph nodes and minimal
stranding of the mesentery, grade 0 involvement of the
superior mesenteric artery and probable grade 1 or 2
involvement of the superior mesenteric vein; (2) normal
celiac access; (3) ascites; (4) findings suggestive of mild
cirrhosis.
Endoscopic retrograde cholangiopancreatography ([**2170-8-31**]) revealed (1) ampullary mass; (2) biliary dilatation
compatible with distal obstruction; (3) stent placement in
the common bile duct; (4) gastric mucosal changes consistent
with portal hypertensive gastropathy.
HOSPITAL COURSE BY SYSTEM:
1. HEPATOBILIARY: The patient initially presented to an
outside hospital with signs and symptoms consistent with
obstructive jaundice. An endoscopic retrograde
cholangiopancreatography and CT scan demonstrated a mass in
the head of the pancreas consistent with adenocarcinoma. He
was also noted to have mild ascites.
Following the patient's CT scan, he developed an elevated
creatinine to 2.4. He was therefore managed as an inpatient
with rehydration and total parenteral nutrition until he was
deemed suitable for surgery.
On [**2170-9-10**], he was taken to the operating room for
exploration, possible Whipple, and possible biliary bypass.
Intraoperatively, the patient's liver was noted to be
cirrhotic in nature and approximately 2 liters of
straw-colored ascites fluid was also noted.
In light of the patient's liver disease, the patient was
deemed not to be suitable for a Whipple; and, therefore, a
Roux-en-Y choledochal jejunostomy was performed. In
addition, he also underwent a cholecystectomy, wedge liver
biopsy, and transduodenal biopsy of the pancreas.
The liver wedge biopsy revealed chronic obstruction with
marked bile stasis and active cholangiolitis as well as mild
steatosis with prominent regeneration. Also noted was marked
portal and sinusoidal fibrosis.
The pancreatic biopsy revealed invasive adenocarcinoma which
was moderately differentiated.
The patient continued to do well postoperatively. His total
bilirubin levels came down dramatically from 45.3 to 5.5 on
the patient's day of discharge. In addition, the patient's
alkaline phosphatase levels also improved.
He was evaluated by the Medical/Oncology and
Radiology/Oncology teams for his pancreatic cancer. He was
to follow up with them as an outpatient.
The patient's liver disease was likely secondary to chronic
alcohol use. He was noted to have ascites both
intraoperatively and on his CT scan of the abdomen. He was
started on Aldactone 100 mg by mouth daily for management of
his fluid status. Urinary sodium levels were followed to
assess for adequate diuresis. He was to continue this
medication as an outpatient.
On postoperative day eight, fluid from the [**Location (un) 1661**]-[**Location (un) 1662**]
drain was sent for cell count, cytology, and cultures. The
patient was found to have a white blood cell count of 6660
and 53% polymorphonuclear leukocytes. His absolute
neutrophil count was determined to be [**2108**]; which was
consistent with spontaneous bacterial peritonitis. He was
started on intravenous Unasyn for treatment of spontaneous
bacterial peritonitis. The culture from the [**Location (un) 1661**]-[**Location (un) 1662**]
drain fluid also grew out alpha streptococcus and
Staphylococcus epidermidis. The patient was then started on
vancomycin intravenously which was subsequently dosed by
levels.
2. INFECTIOUS DISEASE: As noted above, the patient was
found to have spontaneous bacterial peritonitis as suggested
by the cell count and culture from the [**Location (un) 1661**]-[**Location (un) 1662**] drain
fluid.
He underwent a diagnostic paracentesis on [**2170-9-20**] for
further evaluation of his ascites fluid. The Gram stain
revealed no evidence of polymorphonuclear leukocytes or
microorganisms. However, his white blood cell count was
found to be 1775 with 42% polymorphonuclear leukocytes. This
also confirmed the diagnosis of spontaneous bacterial
peritonitis since the patient's absolute neutrophil count
was 911. He was continued on intravenous antibiotics until
the day of discharge. He has remained afebrile and has not
complained of any abdominal pain since that time.
3. RENAL: On admission, the patient's creatinine was within
normal limits at 1.2. However, following the patient's CT
scan with intravenous contrast, the patient developed an
increase in his creatinine to 2.4. Since that time, his
creatinine has remained stable, and on the day of discharge
his creatinine was 2.6.
4. WOUND CARE: The patient's incision was healing well, and
there was no evidence of a wound infection. The [**Initials (NamePattern4) 228**]
[**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] drain was removed on postoperative day eight.
A stitch was placed at the [**Location (un) 1661**]-[**Location (un) 1662**] drain site, and
there was no evidence of leakage for the next one to two
days. However, on postoperative day 11, the patient noted
leakage of straw-colored fluid from the [**Location (un) 1661**]-[**Location (un) 1662**] drain
site despite the stitch that was placed previously. On the
day of discharge, an additional two stitches were placed at
the [**Location (un) 1661**]-[**Location (un) 1662**] drain site; however, there were still
amounts of fluid coming out from the site.
He was discharged home with an ostomy bag for fluid
collection. He was instructed to remove the bag if he
noticed that the fluid leakage had minimized.
DISCHARGE DIAGNOSES:
1. Pancreatic adenocarcinoma.
2. Cirrhosis.
3. Status post cholecystectomy, Roux-en-Y
hepaticojejunostomy, liver biopsy, and pancreatic biopsy.
4. Chronic renal insufficiency.
5. Spontaneous bacterial peritonitis.
MEDICATIONS ON DISCHARGE:
1. Augmentin 875 mg p.o. b.i.d. (times 10 days).
2. Ciprofloxacin 500 mg p.o. b.i.d. (times 10 days).
3. Aldactone 100 mg p.o. q.d.
4. Protonix 40 mg p.o. q.d.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was good.
DISCHARGE FOLLOWUP: The patient will be followed up at
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] clinic. He was instructed to call
Dr.[**Name (NI) 1369**] office for a follow-up appointment. The patient
also had an appointment with Dr. [**Last Name (STitle) 150**] on [**9-28**]
at 3:30 p.m. at the Medical/[**Hospital **] Clinic. He was
instructed to return should he develop any fevers or
persistent abdominal pain.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Name8 (MD) 7861**]
MEDQUIST36
D: [**2170-9-23**] 16:06
T: [**2170-9-28**] 01:46
JOB#: [**Job Number 43736**]
|
[
"789.5",
"572.3",
"571.2",
"157.0",
"197.7",
"576.8",
"584.5",
"576.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"99.15",
"51.37",
"50.12",
"52.11",
"03.90",
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
8888, 9108
|
9134, 9309
|
1800, 3911
|
3939, 7904
|
1512, 1539
|
9324, 9405
|
9426, 10109
|
7917, 8867
|
147, 1425
|
1448, 1488
|
1556, 1773
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,571
| 114,180
|
24961
|
Discharge summary
|
report
|
Admission Date: [**2178-7-29**] Discharge Date: [**2178-8-17**]
Date of Birth: [**2113-1-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18369**]
Chief Complaint:
fevers/cholangitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CC: Cholangitis/fevers
.
HPI: 65 yo man with metastatic renal cell carcinoma metastatic
to abdomen and retroperitonium with a complicated history of
biliary obstruction from tumor compression who is transfered to
OMED from the [**Hospital Unit Name 153**] for further management.
.
He was seen in clinic yesterday for a regular follow up visit
and was found to be jaundiced with an elevated AP and total
bilirubin. He was evaluated in clinic and noted to have
hypotension to 97/55 and fever to 101.4. He was given zosyn and
D51/2NS and referred to the ED. In the ED VS sign for BP 99/55,
HR 72, T 96.8, sat 98% RA. He was given 2L NS and zosyn. BP
improved to 110's-140. He was sent to [**Hospital Unit Name 153**] for further
management.
.
He denies fevers, chills, chest pain, SOB, dizziness, increasing
LE edema, bloody/black tarry stools, or any other concerning
symptoms. He does state that his stools have been light/[**Male First Name (un) 1658**]
colored today and he continues to feel fatigued as he has over
the last several days. He also describes short, fleeting
episodes of abdominal pain that lasts for [**1-20**] the day and then
goes away on its own.
.
Of note, his most recent hospital stay was complicated by anemia
with episodic need of blood transfusion. He had been admitted in
[**Month (only) 116**] with GIB, however no clear source of bleeding was found. He
has a history of two recent admissions ([**Date range (1) 62721**] and [**Date range (1) 62722**])
to the ED and ICU for cholangitis and biliary obstruction s/p
ERCP with plastic and then metal stent placement. He completed
10 day course of cipro/flagyl [**7-20**].
.
Past Onc Hx:
Mr. [**Known lastname 7710**] presented in [**2176-10-19**] with urinary retention,
ultrasound revealing a mass in the right kidney, surgery was
delayed, but he underwent right nephrectomy on [**2177-3-14**], revealing a 10-cm tumor clear cell pathology, [**Last Name (un) 9951**] grade
3 to 4, with tumor extension into the perinephric issues. The
patient was staged as a T3. Two lymph nodes were involved.
However, at the time of diagnosis, there was no evidence of
distant metastatic disease. The patient was enrolled in the
ARISER clinical trial randomized phase III double blind adjuvant
study involving cG250 versus placebo, received twelve weeks of
therapy, at which point, a CAT scan demonstrating increased
retroperitoneal lymph nodes suggestive of metastatic disease. He
underwent a cardiac catheterization with stent placement for
symptoms of angina on [**2177-7-30**], to the RCA. He has been
asymptomatic since then from a cardiac standpoint. Followup CT
in mid [**Month (only) 216**] revealed slight increase in size of
retroperitoneal lymph nodes, and since then the patient has
intermittent history of abdominal pain, which has become
progressive in nature. High-dose IL-2 was initiated on the
high-dose IL-2 select trial on [**2177-12-22**]. He received 11 out of
14 doses and was stopped secondary to neurotoxicity. His last
treatment was delayed in the setting of the elevated creatinine
and urinary retention on [**2178-1-5**]. He underwent his last cycle
of therapy from [**2178-1-20**] through [**2178-1-27**]. He had been on Sutent
[**Date range (1) 62717**] when it was stopped for BRBPR. He was restarted on
Sutent at the end of [**Month (only) 116**]. He was admitted [**5-27**] and [**7-8**] for
cholangitis with CBD obstruction despite stent placement due to
large met compressing cbd.
Past Medical History:
1)Metastatic renal cell ca with known large mesenteric
metastasis, and liver mets on Sutent as below, complicated
course with biliary obstruction from tumor s/p stent placement
[**5-25**] in CBD.
2)CAD s/p RCA [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] [**7-/2177**]: Cath [**7-24**]: LCX 75% stenosis,
OM1 50% stenosis, RCA 90% stenosis
3)Diabetes
4)GERD
5)HTN
6)Hypothyroid
7)Hyperlipidemia
8)BPH retention - indwelling foley with failed voiding trial- no
turp due to hematuria. Urologist Dr. [**Last Name (STitle) 770**]
9) s/p appendectomy
10) s/p tonsillectomy
11) Extensive DVT up into the IVC to the level of compression of
the abdominal mass > an IVC filter was discussed however was not
deemed possible given the location of the compressive mass
12) CKD: baseline 1.4-1.6
13) GI bleed
Social History:
Lives with wife in [**Name (NI) 7658**], MA. He has 3 grown children. Denies
current tobacco, alcohol, or IVDA.
Family History:
Father with lung cancer.
Physical Exam:
Vitals: 96.0 116/55 83 18 97% RA
Gen: WNWD male laying in bed in NAD.
HEENT: sclera icteric, dry MM,
CV: RRR, no murmurs, rubs, gallps
Chest: limited exam due to patient's inability to sit up, though
CTAB, no wheezes, rales, rhonchi appreciated
Abd: abdomen mildly distended, +BS, no guarding or rebound,
mildly tender to deep palpation over left side of abdomen
Ext: [**2-21**]+ pitting edema in BLE
Neuro: CN 2-12 grossly intact
Pertinent Results:
Imaging:
ERCP [**2178-7-30**]: Tumor infiltration in the duodenum. Biliary
stricture compatible with malignant biliary stricture from tumor
infiltration above previously placed stent - a second covered
wall stent was placed.
.
Gallbladder US [**2178-7-29**]: The common bile duct was not visualized
due to overlying bowel gas, however, no evidence of intrahepatic
bilary ductal dilatation was noted. Pneumobilia was noted within
the left lobe of the liver most likely related to the recent
procedure. The gallbladder contains sludge. Bubbles of air are
also noted within the gallbladder lumen. No evidence of
cholecystitis is identified. The portal vein demonstrates
bidirectional flow. The portal vein branches, hepatic artery,
hepatic veins and IVC demonstrate normal flow pattern.
.
Chest PA/Lat [**2178-7-29**]: Retrocardiac opacity which may represent
vascular structures, although early infiltrate cannot be
excluded.
.
CT chest/abd/pelvis [**2178-7-8**]: Increased intrahepatic biliary
dilatation without intrabiliary gas suggests occlusion of the
common bile duct stent.
Stable disease burden with unchanged large retroperitoneal mass
and
mesenteric lymphadenopathy. Unchanged IVC thrombosis with
extension into the bilateral iliac veins as well as thrombosis
of the proximal SVC.
Unchanged appearance of the L2 lytic lesion with focal
compression. Unchanged 3 mm left lower lobe nodule. Mild
ascites and anasarca.
Brief Hospital Course:
Mr. [**Known lastname 7710**] is a 65 yo male with metastatic renal cell cancer who
present with biliary obstruction. He underwent ERCP at the time
of admission with stenting of the common bile duct. He continued
his Sutent. During the admission, he developed a rise in his
pancreatic enzymes with no clear source, as it was several days
after instrumentation. In addition, he developed worsening
guaiac positive diarrhea, with no ability to absorb; antibiotics
were started. On [**8-16**], he acutely desatted with oxygen
saturations in the low 80's. DNR/DNI status was confirmed with
the patient and with the family. The family was notified of the
change in status and came to the hospital. He was made CMO and a
morphine drip was started. He expired on [**8-17**] at 12:50 am.
Medications on Admission:
1. aspirin 325 daily
2. lisinopril 20 daily
3. atorvastatin 20 daily
4. Protonix 40 daily
5. oxycodone 5 mg one or two tabs p.o. q.4-6h.
6. Toprol-XL 50 mg daily
7. levothyroxine 125 mcg daily
8. oxycodone 20 mg b.i.d.
9. Lantus 30 units subq at bedtime
10. Lispro as directed by sliding scale.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
Expired
|
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18,794
| 194,376
|
2763
|
Discharge summary
|
report
|
Admission Date: [**2115-1-22**] Discharge Date: [**2115-1-30**]
Date of Birth: [**2086-1-19**] Sex: F
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is a 29 year old female
with a significant psychiatric history including depression
and panic disorder with multiple chronic pain syndromes who
was transferred from [**Hospital3 **] Emergency Department
secondary to mental status changes, generalized weakness and
jaundice. The patient's mother noticed increasing confusion,
forgetfulness and disorientation over ten days prior to
admission. It was worsening over the two days prior to
admission. The mother also noted unsteady gait and
difficulty walking. The morning of admission the patient
fell while getting out of bed. Her mother helped her to the
bathroom and noticed that the patient was jaundiced. The
patient has a history of chronic low back pain as well as
myofascial pain syndrome and had been taking Percocet that
she had been prescribed, however, it was also noted that she
had been receiving Percocet from a friend as well as some
other medications including blue and pink pills with no
imprintation. At the outside hospital, the patient was noted
to be progressively obtunded and was intubated for airway
protection. A head CT performed at the outside hospital was
negative. Her acetaminophen level was 44. Her urine
toxicology was positive for benzodiazepines and opiates.
Her other laboratories included liver transaminases in the
500 to 800 range as well as total bilirubin of 4.6 and an INR
of 1.5. She received Anacetylcysteine and Lactose and
bicarbonate and was transferred to [**Hospital1 190**].
PAST MEDICAL HISTORY:
1. Chronic back pain with persistent urinary incontinence
and paresthesias.
2. Irritable bowel syndrome.
3. Panic attacks.
4. Fibromyalgia.
5. Depression.
6. No history of suicidality or suicidal ideation or
attempts.
7. Iron deficiency anemia.
8. History of prescription narcotic use/abuse.
9. History of recurrent urinary tract infections and yeast
infection.
PAST SURGICAL HISTORY:
1. Gastric bypass surgery in [**2108**], for obesity after which
she lost 100 pounds.
2. Skin removal cosmetic surgery following her procedure.
ALLERGIES: Darvocet which causes swelling and Compazine
which causes a dystonic reaction.
MEDICATIONS ON ADMISSION:
1. Paxil.
2. Elavil.
3. BuSpar.
4. Ativan.
5. Skelaxin.
6. Percocet.
7. Ortho-Ever patch.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She is unemployed. She dropped out of
nursing school secondary to back pain. She lives with her
mother and sister and brother-in-law in [**Name (NI) **]. She has a
fiancee. She is a one pack per day tobacco smoker. She
denies alcohol or intravenous drug use.
REVIEW OF SYSTEMS: Positive for recurrent urinary retention
and bilateral groin pain. Negative for fever, chills,
nausea, vomiting, diarrhea, constipation, headaches, stiff
neck, chest pain, abdominal pain or recent change in
medications.
PHYSICAL EXAMINATION: On admission, temperature is 97.7,
blood pressure 132/65, heart rate 110, oxygen saturation 100%
with an FIO2 of 1 on a ventilator. In general, she was obese
female intubated and sedated in the Emergency Department.
Her head and neck showed dilated pupils, decreased reflexes
and icteric sclera. Her optic disks were sharp. She had a
nasogastric tube as well as an endotracheal tube. Her oral
mucosa was pink and dry. Her heart rate was tachycardic with
regular rhythm, S4 and a III/VI systolic murmur heard loudest
over the left lower sternal border. Her lungs were clear to
auscultation bilaterally with breath sounds transmitted from
the ventilator. Her right neck was bandaged at the site of
the removal of the right IJ. Her abdomen was soft,
nontender, and obese with positive bowel sounds and a well
healed midline scar. Her extremities had 2+ pulses
throughout, well perfused and no edema. Her right groin had
a triple lumen catheter in place. Her neurologic examination
showed hyperreflexia throughout and upgoing toes bilaterally.
Her skin had no jaundice.
LABORATORY DATA: On admission, white blood cell count was
6.0, hematocrit 30.0, platelet count 235,000. Chem7 showed
sodium 148, potassium 2.6, chloride 108, bicarbonate 26,
blood urea nitrogen 16, creatinine 1.1, glucose 195. Calcium
7.3, magnesium 1.5, phosphorus 3.0, AST 608, ALT 443,
alkaline phosphatase 163, total bilirubin 3.6, amylase 22,
lipase 66. Urinalysis showed 21-50 white blood cells. Her
toxicology screen repeated was positive for tricyclics as
well as benzodiazepines. Her acetaminophen level was 27.1.
Arterial blood gases showed a pH of 7.47, pCO2 32 and paO2 of
470.
Chest x-ray showed an endotracheal tube. Abdominal
ultrasound showed normal Doppler study. Electrocardiogram
showed sinus tachycardia with widened QRS and increased Q-Tc.
She had flat and inverted T waves in V3 through V6.
The patient was evaluated by the liver service and toxicology
in the Emergency Department and was admitted to the Medical
Intensive Care Unit for management and stabilization.
HOSPITAL COURSE:
1. Liver failure - For her acute liver failure, she received
Anacetylcysteine infusion as well as Lactulose. She was
evaluated for potential liver transplant workup including
viral hepatitis workup. She had q2hours neurologic checks as
well as liver function tests. Her INR was followed q6hours.
Her electrolytes and liver function tests were followed twice
a day. She continued to have resolving liver function tests
as well as INR and albumin values. Her scleral icterus
resolved and she was felt not to require transplant. Her
Anacetylcysteine was stopped.
2. For her possible other toxin ingestions - Her
Acetaminophen level decreased precipitously, however, it was
felt that she was likely having a PCA tricyclic
antidepressant overdose with anticholinergic side effects
including tachycardia and widened Q-Tc and hyperreflexia.
She was evaluated by neurology and psychiatry services. Her
electrolytes were followed as well as attempt to identify the
pills. At the time of dictation, the identification of the
pills is still pending. Her electrocardiograms were followed
serially and her Q-Tc resolved to within normal limits during
her hospitalization. She continued on the Lactulose for
likely hepatic encephalopathy secondary to the acetaminophen
overuse.
3. For her coagulopathy, she received Vitamin K and no fresh
frozen plasma was given. No active bleeding occurred. Her
INR trended down to 1.0.
4. For her acute renal failure, she was hydrated and her
renal function stabilized during the remainder of her
hospitalization.
5. For sterile pyuria, urine culture was drawn and the
patient received three days of Ciprofloxacin. Her urine
culture remained negative and the Ciprofloxacin was
discontinued on the third day.
6. For pain control, the patient was given Morphine Sulfate
as needed.
7. For her respiratory distress, the patient was extubated
on hospital day two, [**2115-1-24**]. She was without complication
with her respiratory function and her nasogastric tube was
pulled at the time. Her diet was advanced once the
nasogastric tube was pulled.
8. For her neurologic and psychiatric issues, the patient
had some mild agitation and anxiety with episodic
hallucinations early in her hospital course, however, by the
date of discharge and transfer from the Medical Intensive
Care Unit on her second hospital day, she was much improved
and comfortable. She was seen with the psychiatry service
who felt that she was in no acute risk of suicide and a one
to one sitter was not recommended. The patient's mother
remained attentive for the patient throughout her
hospitalization. In addition, the psychiatry service felt
that she should reconnect with her outpatient psychiatrist
for further management of her psychiatric medications.
9. Chronic pain, the patient was started on Morphine for
pain control intravenous p.r.n. Her pain in her lower back
and leg which are chronic flared occasionally requiring pain
control. The chronic pain service was consulted and
recommended the patient switch to p.o. Morphine followed by
p.o. Oxycodone for discharge. They recommended that she
follow-up with the pain service of her choice for a
comprehensive evaluation and further physical therapy as
needed.
10. Anemia - She has a history of iron deficiency anemia as
well as B12 and folate deficiency given her history of
gastric bypass surgery. She was continued on her iron and
B12 and folate regimen as well as multivitamin.
In general, the patient was called out of the Intensive Care
Unit on [**2115-1-24**], and was admitted to the general medicine
service. At that time, she was stable with stable vital
signs and stabilizing laboratory function. During her time
in the Medical Intensive Care Unit, she spiked a fever and
blood cultures were drawn. Blood cultures on the [**2115-1-22**],
and on [**2115-1-23**], were positive for Staphylococcus aureus that
was sensitive to Penicillin. To avoid liver toxicity of
Nafcillin or Oxacillin, she was started on Cefazolin. She is
to continue this for fourteen days post discharge to treat
empirically for gram positive bacteremia. Because of this, a
PICC line was placed in her left arm by the interventional
radiology service. She will go home with intravenous
antibiotic therapy on [**2115-1-30**], hospital day nine. The
patient was felt to be in stable condition for discharge to
home.
CONDITION ON DISCHARGE: Good and stable.
DISCHARGE STATUS: To home with services.
FINAL DIAGNOSES:
1. Acetaminophen overdose.
2. Amitriptyline overdose.
3. Acute liver failure.
4. Depression.
5. Anxiety.
6. Bacteremia with Staphylococcus aureus.
7. Chronic B12, folate deficiency and anemia.
MEDICATIONS ON DISCHARGE:
1. Cefazolin one gram intravenously q8hours through
[**2115-2-6**].
2. Oxycodone 5 mg one to two tablets p.o. q6hours p.r.n. for
pain. She was given a prescription for twenty doses.
3. Folic Acid 1 mg p.o. once daily.
4. Vitamin B12 100 mcg one half tablet p.o. once daily.
5. Iron 325 mg p.o. three times a day.
FOLLOW-UP PLANS: The patient is to follow-up with the [**First Name4 (NamePattern1) 1193**]
[**Last Name (NamePattern1) 1194**] Clinic. She has been given the telephone number to call
for comprehensive evaluation. The appointment was made for
[**2115-2-14**], at 12:00 p.m. with her psychiatrist, Dr. [**First Name (STitle) **].
She is also instructed to call Dr. [**First Name (STitle) **] this week to see
him at his and her availability. She is also to follow-up
with her primary care physician for management of future
medical issues.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5613**], M.D. [**MD Number(2) 5614**]
Dictated By:[**Last Name (NamePattern1) 7483**]
MEDQUIST36
D: [**2115-1-30**] 14:11
T: [**2115-1-30**] 20:07
JOB#: [**Job Number 13638**]
|
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icd9cm
|
[
[
[]
]
] |
[
"88.72",
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icd9pcs
|
[
[
[]
]
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2460, 2478
|
9844, 10164
|
2345, 2443
|
5119, 9514
|
2080, 2319
|
9617, 9818
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3025, 5102
|
10182, 10984
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2780, 3002
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15,355
| 150,494
|
10712+10713
|
Discharge summary
|
report+report
|
Admission Date: [**2181-6-17**] Discharge Date: [**2181-6-25**]
Date of Birth: [**2159-7-25**] Sex: F
Service: TRANS [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient is a 21 year old
female with end-stage renal disease of unclear etiology who
had a cadaveric renal transplant on the [**2181-6-4**].
The patient was initially discharged from that operation on
the [**5-16**]. The patient is readmitted on the 6th with
persistent nausea and vomiting and with hypertension. The
patient was seen by way of the Emergency Department by
Transplantation Surgery and the patient was seen to have a
blood pressure as high as 230/120. The patient did not have
nausea on the day prior to admission and had a bowel movement
on the date of admission. The patient denied any abdominal
pain, no nausea or vomiting, or bloody stools prior to that,
however, on the date of admission the patient noted the onset
of severe nausea and vomiting. The patient missed her
medications since Sunday, including her blood pressure
medications.
PAST MEDICAL HISTORY:
1. Hypertension.
2. End-stage renal disease.
MEDICATIONS ON ADMISSION:
1. Immunosuppressant medications of Prednisone 20 q. day.
2. CellCept [**Pager number **] four times a day.
3. Tacrolimus 8 mg p.o. twice a day.
4. Valcyte 450 mg p.o. q.o.d.
5. Bactrim Single strength one q. day.
6. Nystatin swish and swallow 5 cc four times a day.
7. Protonix 4 mg p.o. q. day.
8. Reglan 5 mg p.o. four times a day.
9. Colace 100 mg p.o. twice a day.
10. Lamivudine 100 mg q. day.
11. Norvasc 10 mg q. day.
12. Labetalol 800 mg twice a day.
13. Hydralazine 75 mg four times a day.
14. Lasix 80 mg twice a day.
15. Clonidine 0.2 mg twice a day.
16. Percocet p.r.n.
17. Tums three times a day.
18. PhosLo three times a day.
PHYSICAL EXAMINATION: The patient had vital signs of 96.9
F. Temperature; heart rate 75; blood pressure 230/100 up to
161/97. The patient was actively vomiting. The patient's
HEENT was clear. Chest had regular rate and rhythm with
clear breath sounds bilaterally; no murmurs. The abdomen was
soft, there was no guarding or rebound tenderness and no
distention.
LABORATORY: Values on admission revealed a white blood cell
count of 7.8, a hematocrit of 25.6, platelets of 216. Chem-7
with sodium of 134, potassium of 4.7, chloride of 99,
bicarbonate of 22, BUN of 82, and a creatinine of 9.0.
Calcium, magnesium and phosphorus were 10.4, 1.9 and 6.7.
Liver function tests were within normal limits. Amylase was
normal and bilirubin of 0.4, albumin of 3.9.
Urinalysis had blood but no white cells.
HOSPITAL COURSE SUMMARY: This is a patient who had chronic
renal disease complicated by delayed graft function with
persistent nausea or vomiting question secondary to uremia,
and hypertension. The patient was admitted to he Intensive
Care Unit for a Nipride drip.
For control of her hypertension, the patient is admitted to
the Intensive Care Unit, however, Nipride drip resulted in
patient developing a headache and the patient was switched to
Labetalol. The patient was given an attempt at Lasix with
some response and urinary output. Her Hydralazine was
increased to 20 q. six hours and the patient was given a
Clonidine patch.
With the nausea and vomiting the patient's CellCept was
discontinued and the patient was started on Rapamycin (which
changed to Solu-Medrol intravenously). The patient continued
to improve in the Intensive Care Unit. Creatinine decreased
to 7.8 by hospital day two.
We changed her Metoprolol to 50 twice a day and her
Hydralazine to 75 mg four times a day. We continued her on
her Norvasc. Her Clonidine was continued at 0.2, and she
also had a clonidine patch placed.
To assess her kidney's renal function, we obtained both an
MRA of her native kidneys and adrenals to rule out renal
artery stenosis or adrenal tumors, as well as an MRA of her
transplanted kidney.
The patient, for her increased phosphorus, she was continued
on Amphojel 30 cc q. eight hours.
The patient's MRI and MRA of her transplanted kidney
demonstrated good arterial flow with a slight slowing of the
venous anastomosis consistent with a small
non-hemodynamically significant stenosis. The patient's
blood pressure was better controlled with blood pressures
running systolic of 140 to 190 and diastolic of 80 to 90 and
MAPs of 110 to 130s.
We changed her clonidine to 0.2 twice a day and to a #2
clonidine patch q. week. Her labetalol was increased to 800
mg p.o. three times a day and hydralazine to 75 mg four times
a day.
Her graft function continued to improve. The patient became
slightly prerenal and so her Lasix was discontinued. The
patient was transferred from the Intensive Care Unit to the
Floor on the [**5-22**]. From the 10th until the [**5-26**], the patient improved. She had an MRI done of her
native kidneys which demonstrated no renal artery stenosis
and no evidence of tumors in the adrenals or the kidneys.
The patient's creatinine continued to improve. The patient's
nausea and vomiting became only a problem at night and then
resolved. The patient was made therapeutic on Rapamycin
after a load. On the 14th, the patient was doing well. Her
creatinine had decreased to 5.3. Her blood pressure was
better controlled from the 120s to 160s over 50s to 90s with
a heart rate in the 80s to 90s. The patient was maintained
on Norvasc 10 mg q. day, Labetalol 800 mg three times a day;
Clonidine patch #2, Hydralazine 75 mg four times a day,
Clonidine 0.2 mg twice a day.
DISPOSITION: The patient was discharged to home on those
medications as well as Rapamycin 4 mg q. day, tacrolimus 3 mg
twice a day; Prednisone 15 mg q. day; Bactrim Single strength
tablet one q. day; Valcyte 450 mg four times a day;
Chlortramizol troches; Lamivudine 100 mg q. day; Norvasc 10
mg q. day; Labetalol 800 mg three times a day; clonidine
patch #2; Hydralazine 75 mg four times a day; clonidine 0.2
mg twice a day; Protonix 40; Colace 100.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 14369**]
MEDQUIST36
D: [**2181-12-10**] 10:58
T: [**2181-12-12**] 22:49
JOB#: [**Job Number 35071**]
Admission Date: [**2181-6-17**] Discharge Date: [**2181-6-25**]
Date of Birth: [**2159-7-25**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 21-year-old
female with a history of end-stage renal disease with unclear
etiology. The patient also has a history significant for
hypertension.
The patient underwent a cadaveric renal transplant on [**6-4**]. The patient's postoperative course was prolonged and
complicated by delayed graft function, persistent nausea and
vomiting, and the arrangements for dialysis. The patient was
discharged two days prior to admission and had been doing
well until the morning of admission when she awoke with
severe nausea and vomiting times one. The patient again was
seen in the Emergency Department. The patient denied any
abdominal pain. She denied any fevers or chills. The
patient also had normal bowel movements.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. End-stage renal disease.
2. Hypertension.
MEDICATIONS ON ADMISSION: (Medications on admission
included)
1. Colace 100 mg by mouth twice per day.
2. Epivir 100 mg by mouth once per day.
3. Amlodipine 10 mg by mouth once per day.
4. Labetalol 100 mg by mouth twice per day.
5. Hydralazine 75 mg by mouth four times per day.
6. Tums.
7. Lasix 80 mg by mouth twice per day.
8. Phos-Lo.
9. Clonidine 0.2 mg by mouth twice per day.
10. Prograf 8 mg by mouth twice per day.
11. Prednisone 20 mg by mouth once per day.
12. CellCept [**Pager number **] mg by mouth four times per day.
13. Valcyte 450 mg by mouth every other day.
14. Bactrim single strength one tablet by mouth every day.
15. Nystatin 5 cc by mouth four times per day.
16. Protonix 40 mg by mouth once per day.
17. Reglan 5 mg by mouth four times per day.
18. Percocet by mouth as needed.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient's temperature was 96.9
degrees Fahrenheit, her heart rate was 76, her blood pressure
was 160/110 to 160/97, her respiratory rate was 16, and her
oxygen saturation was 100%. The sclerae were anicteric. The
patient's cardiovascular examination revealed a regular rate
and rhythm. There were normal heart sounds. Respiratory
examination revealed clear chest fields bilaterally.
Abdominal examination revealed the abdomen was soft without
tenderness. There was no rebound or guarding. The incision
was clean, dry, and intact with no discharge. Extremity
examination revealed the extremities were warm with 2+ pulses
bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory
examination on admission revealed the patient's white blood
cell count was 7.8, her hematocrit was 25.6, and her
platelets were 216. Electrolytes were within normal limits
with a blood urea nitrogen of 82 and creatinine of 9. Her
glucose was 106. Calcium, magnesium, and phosphate were
10.4, 1.9, and 6.7; respectively. Her amylase was 60. Her
bilirubin was 0.4. Her albumin was 3.9. Urinalysis revealed
blood without evidence of white blood cells.
CONCISE SUMMARY OF HOSPITAL COURSE: The patient was
therefore re-admitted two days after discharge after a
cadaveric renal transplant which was complicated by delayed
graft function. The patient had persistent nausea and
vomiting; after which she was unable to keep down her by
mouth medications including her antihypertensive medications.
The patient also presented with hypertension.
The patient was given some intravenous fluids and continued
on her immunosuppressive medications. The patient was
admitted to the Intensive Care Unit for control of her blood
pressure.
The patient was admitted to the Intensive Care Unit and was
started on a Nipride drip. Unfortunately, the patient
developed headaches, and because of her renal function the
Nipride drip was discontinued. The patient was changed to
labetalol. In the Intensive Care Unit, the patient's
creatinine decreased to 7.2. The patient's nausea and
vomiting did improve, and her blood pressure was improved.
The patient was transferred to the floor on [**6-21**]. The
patient's CellCept (which was felt also to be contributing to
her nausea and vomiting) was discontinued. The patient was
loaded with 10 mg once per day of rapamycin for three days
and then was started on a standing dose of 4 mg of rapamycin
once per day. The patient's other antihypertensive
medications were adjusted to lower her blood pressure to the
120 level.
The patient had a magnetic resonance imaging of her native
kidney and magnetic resonance angiography as well, as a
magnetic resonance imaging of her adrenals revealed no
evidence of renal artery stenosis, no evidence of adrenal or
renal masses. The patient had a magnetic resonance
angiography and magnetic resonance imaging of her
transplanted kidney which also demonstrated no evidence of
renal artery stenosis and not hemodynamically significant
stenosis of her renal vein.
The patient was advanced to a regular diet. The patient was
tolerating a regular diet and ambulating. The patient had
resolution of her nausea and vomiting.
DISCHARGE DISPOSITION: By [**6-25**], the patient was doing
well and was discharged to home.
MEDICATIONS ON DISCHARGE: (The patient's medications on
discharge included the following)
1. Rapamycin 4 mg by mouth once per day.
2. Prograf 3 mg by mouth twice per day.
3. Prednisone 15 mg by mouth once per day.
4. Bactrim single strength one tablet by mouth every day.
5. Valcyte 450 mg by mouth every other day.
6. Clotrimazole troches.
7. Lamivudine 100 mg by mouth once per day.
8. Norvasc 10 mg by mouth once per day.
9. Labetalol 800 mg by mouth three times per day.
10. Clonidine patch.
11. Hydralazine 75 mg by mouth four times per day.
12. Clonidine tablets 0.2 mg by mouth twice per day.
13. Protonix 40 mg by mouth once per day.
14. Colace 100 mg by mouth twice per day.
15. Reglan 5 mg by mouth four times per day.
16. Percocet for pain.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] as well as with Dr.
[**Last Name (STitle) **] in the [**Hospital 1326**] Clinic.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Last Name (NamePattern1) 14369**]
MEDQUIST36
D: [**2181-12-10**] 11:07
T: [**2181-12-13**] 09:13
JOB#: [**Job Number 35072**]
|
[
"285.9",
"787.01",
"E932.0",
"V42.0",
"276.5",
"251.8",
"E933.1",
"E849.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11470, 11541
|
11568, 12320
|
7299, 9409
|
12354, 12786
|
9438, 11446
|
1830, 6394
|
6423, 7159
|
7182, 7272
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,258
| 110,348
|
52585
|
Discharge summary
|
report
|
Admission Date: [**2124-12-24**] Discharge Date: [**2124-12-26**]
Date of Birth: [**2059-12-26**] Sex: M
Service: MEDICINE
Allergies:
Lithium / Erythromycin Base / Cogentin / Stelazine / Clozaril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfer from [**Hospital **] Hospital for CVVH
Major Surgical or Invasive Procedure:
HD line placement L neck, CVVH
Intubation
History of Present Illness:
The patient is a 64-year-old male with multiple medical problems
including a history of chronic kidney disease (stage IV)
secondary to presumed lithium toxicity with renal tubular
acidosis, history of endocarditis in [**2110**] and presumed
endocarditis in [**2124-7-7**], schizoaffective disorder,
who was admitted to the [**Hospital **] Hospital on [**2124-8-31**]
for treatment of MSSA bacteremia and presumed endocarditis with
a six week course of nafcillin in the context of a hip fracture
with hardware in place in the left hip. The [**Hospital 228**] hospital
course at [**Hospital1 **] was complicated by 2 major gastrointestinal
bleeds secondary to multiple duodenal erosions and ulcerations,
severe malnutrition with anasarca and weakness. In the week
preceding [**2124-12-17**], the patient was noted to be less
alert by the chronic medical service
that was following him. He had been having continued diarrhea
with a recent history of Clostridium difficile colitis for which
he was treated with Flagyl and was again found to be Clostridium
difficile positive. The patient was also found to have a
urinary tract infection with urine culture growing enterobacter
cloacae. The patient's diarrhea and urinary tract infection were
accompanied with volume depletion and metabolic acidosis. On
[**2124-12-15**], the patient became hypotensive with blood
pressures in 80s/30s, nonresponsive to aggressive fluid
hydration. He was transferred to the ICU and started on
Levophed as well as increased antibiotic coverage.
.
In the ICU, he was started on po vanc and continued on IV flagyl
for treatment of cdiff. He had an episode of afib w/ rvr and is
s/p cardioversion for hypotension. He was treated with
Vanc/Zosyn for broad coverage in the setting of septic shock and
continued on cipro for treatment of an enterobacter UTI. He was
afebrile during his ICU course and has been off pressors for
several days however his blood pressure was thought to be too
low to tolerate HD so he was transferred to [**Hospital1 18**] for CVVH.
.
On arrival, he states he feels mildly SOB. He denies cough. He
endorses R testicular pain. No f/c/n/v. He feels hungry and
thirsty.
Past Medical History:
1. Bipolar disorder versus schizoaffective disorder with history
of suicide attempts and ECT tx (Followed in the past by PACT
team [**Telephone/Fax (1) 95230**]).
2. Enterococcal endocarditis in [**2110**].
3. Questionable MSSA endocarditis, [**2124-8-7**]: TEE at [**Hospital1 **] was
negative for vegetation and abscesses, so diagnosis of
endocarditis was not clear. However, given MSSA bacteremia at
the time, and presence of hardware in the left hip, a six week
course of nafcillin dating from first negative culture on [**7-30**], [**2123**] was recommended and completed on [**2124-9-11**].
4. Noninsulin dependent diabetes.
5. Hypertension.
6. Coronary artery disease status post myocardial infarction x2.
7. Echocardiogram performed [**2124-9-6**] showing ejection
fraction to 50%, focal thickening of the mitral and aortic
valves, and mild pulmonary hypertension.
8. Gastroesophageal reflux disease.
9. Benign prostatic hypertrophy.
10. Chronic kidney disease, stage 4 with nephrotic syndrome and
renal tubular acidosis secondary to presumed lithium toxicity
with a baseline creatinine of 2.5 while at the [**Hospital **]
Hospital.
11. DVT
12. Recent h/o afib w/ RVR.
13. Hyperlipidemia
14. s/p fall w/ occipital bleed
15. Duodenal ulcers w/ 3 recent GI bleeds
16. L hip femoral neck fracture s/p hemiarthroplasty in [**6-13**]
17. L radial fx [**6-13**]
Social History:
Prior to his hospitalization for hip surgery and then transfer
to the [**Hospital **] Hospital, the patient lived in an apartment by
himself with PACT team support for psychiatric issues. He was
at [**Hospital 671**] rehab from [**2124-7-5**] until [**Month (only) **]. The patient has a
girlfriend, [**Name (NI) **], who visits him occasionally. The patient has a
sister who is also his health care proxy who lives in [**Name (NI) 4565**]
but is very involved in his health care. The patient had a
smoking history of 1.5 packs a day x30-40 years. The patient has
a rare history of alcohol use. Denies illicit drug use.
Family History:
H/o bipolar disorder and depression in the family.
Physical Exam:
Vitals: T: 98 BP: 129/51 P: 89 R: 16 O2: 92% on 2L NC
General: Groggy and slow to answer but awake, oriented, no acute
distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, RIJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, but non-tender, hyperactive bs
Ext: anasarca, wwp, able to move all extremities
Pertinent Results:
[**2124-12-24**] 03:24PM TYPE-MIX
[**2124-12-24**] 03:24PM O2 SAT-74
[**2124-12-24**] 02:13PM TYPE-ART TEMP-37.8 PO2-87 PCO2-41 PH-7.26*
TOTAL CO2-19* BASE XS--8 COMMENTS-AXILLARY
[**2124-12-24**] 02:13PM LACTATE-1.7 NA+-137 K+-3.3*
[**2124-12-24**] 02:13PM freeCa-1.10*
[**2124-12-24**] 02:00PM URINE HOURS-RANDOM UREA N-280 CREAT-74
SODIUM-52
[**2124-12-24**] 02:00PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017
[**2124-12-24**] 02:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2124-12-24**] 02:00PM URINE RBC-32* WBC->1000* BACTERIA-NONE
YEAST-MANY EPI-0
[**2124-12-24**] 02:00PM URINE WBCCLUMP-MANY
[**2124-12-24**] 01:16PM GLUCOSE-57* UREA N-95* CREAT-5.5*# SODIUM-142
POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-19* ANION GAP-16
[**2124-12-24**] 01:16PM estGFR-Using this
[**2124-12-24**] 01:16PM ALT(SGPT)-4 AST(SGOT)-13 ALK PHOS-66 TOT
BILI-0.2
[**2124-12-24**] 01:16PM TOT PROT-3.1* ALBUMIN-1.3* GLOBULIN-1.8*
CALCIUM-7.3* PHOSPHATE-7.7*# MAGNESIUM-1.8
[**2124-12-24**] 01:16PM VIT B12-1222* FOLATE-16.8
[**2124-12-24**] 01:16PM VANCO-18.1
[**2124-12-24**] 01:16PM WBC-18.0*# RBC-2.62* HGB-8.3* HCT-26.1*
MCV-100*# MCH-31.8 MCHC-31.9 RDW-18.5*
[**2124-12-24**] 01:16PM NEUTS-77* BANDS-4 LYMPHS-12* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-1*
[**2124-12-24**] 01:16PM HYPOCHROM-OCCASIONAL ANISOCYT-2+
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+
[**2124-12-24**] 01:16PM PLT SMR-NORMAL PLT COUNT-293
[**2124-12-24**] 01:16PM PT-15.6* PTT-83.1* INR(PT)-1.4*
Brief Hospital Course:
This is a 64 M w/ pmh of stage IV CK, 3 recent UGI bleeds in the
setting of duodenal ulcers, recent tx for MSSA endocarditis w/
3+ AR, recent cardioversion for afib w/ rvr, transferred to
[**Hospital1 18**] for consideration of CVVH in the setting of hypotension
and likely continuing septic physiology.
.
# Hypotension: Currently relatively hypotensive given h/o
hypertension. Vanc/Zosyn were started on [**12-16**] for empiric
broad-spectrum coverage for septic shock at OSH. Blood cx from
OSH on [**12-16**] w/ ngtd. Had been afebrile during his ICU stay at
OSH. WBC count 18 from 27 on the 14th. Given leukocytosis,
likely c/w continued sepsis.
Possibly from c diff colitis as seemed to improve with po
vancomycin. Patient was placed on continued PO vanc and IV
vanc/zosyn. His hypotension continued to progress. He was
intubated for airway protection after he became acutely less
responsive, diaphoretic and pale. His sister was called and she
decided to make him CMO. The tube was removed and the patients
blood pressure continued to drop until he passed at 855 PM.
.
# C. diff colitis: Currently being treated w/ po vanc (D1 = [**12-13**])
and IV flagyl (unknown time course). Has a history of chronic
diarrhea of unknown etiolgy.
- continue po vanc X 14 after last day of broad-spectrum
antibiotics ([**12-24**])
.
# Acute renal failure on chronic renal failure: His baseline cr
was 2.6 on admission to [**Hospital1 **]. Cr now 5.6 on transfer. ?
from ATN from hypotension. Has a h/o nephrotic syndrome w/
albumin of 0.7. Clearly has anasarca. Blood pressure on the
low side so unclear if he would tolerate HD.
- renal consult for possible CVVH-unable to place line on HD 2,
on HD 3 acutely hypotensive and L IJ line placed emergently.
CVVH never initiated as patient made CMO.
- renal diet
- nephrocaps
- phos binders given phos of 7.7
.
# Hypoxia: h/o smoking so likely has some underlying COPD.
Likely a component of volume overload/pulmonary edema given
renal failure.
- continue ipratropium nebs
- CXR
- CVVH vs HD as above
.
# Enterobacter clocae UTI: Per OSH, blood cx from [**12-16**] w/ NGTD.
- cipro started on [**12-13**] (no [**Last Name (un) 36**] data), will d/c as now s/p an
11-day course
- send UA/cx
.
# DVT: R superficial femoral vein thrombosis [**First Name8 (NamePattern2) **] [**Hospital1 **]
report. Is very high risk for recurrent GI bleed. The
risk/benefit ratio was discussed at [**Hospital1 **] and thought to
favor anticoagulation.
- heparin ggt-held given need for HD line, never re-initiated
.
# Afib: Currently in sinus. Status post cardioversion on [**12-20**]
in the setting of hypotension. Has been on heparin ggt and amio
was started to prevent recurrent afib. Likley afib occurred in
the seting of septic shock from ? cdiff.
- will discontinued amiodarone
.
# Anemia: Macrocytic. Had an upper GI bleed during his last
[**Hospital1 18**] hospitalization and 2 additional GI bleeds at [**Hospital1 **]
requiring 6 U PRBC. This may also be c/b B12 deficiency as it
appears that his B12 level was low in [**4-13**].
- guiac stools
- transfuse for hct < 21
.
# Decubitous ulcers: Stage 1 sacral decubitous ulcer.
- wound consult
.
# DM: BS well-controlled w/o insulin coverage at [**Hospital1 **].
- trend for now
- add insulin SS if needed
.
# Aortic regurgitation: 3+ on [**8-14**] ECHO thus although EF > 55%,
functionally his forward flow is not normal.
.
# Bipolar disorder/Schizophrenia: continue valproic acid,
wellbutrin, seroquel, lamictal
.
# GERD: continue pantoprazole 40 mg [**Hospital1 **] given h/o duodenal
ulcers and GI bleed during last [**Hospital1 18**] hospitalization
.
# Hyperlipidemia: continue simvastatin
.
# BPH: hold terazosin as has a foley in place
.
# FEN: No IVF, replete electrolytes, renal diet
.
# Prophylaxis: heparin ggt, VRE carrier, known cdiff +
.
# Access:
Lines:
1- Right IJ line (placed [**2124-12-16**]) - will order PICC and d/c
2- Right radial A-line (placed [**2123-12-21**]) - will d/c if not needed
.
# Code: FULL CODE
.
# Communication: Patient, sister ([**Telephone/Fax (1) 108572**]
.
# Disposition: pending above
Medications on Admission:
1. Ciprofloxacin 400 mg IV q. 24 hours.
2. Zosyn 2.25 grams IV q. 8 hours.
3. Vancomycin 1 gram IV daily (dose given daily depending on
daily a.m. vanco trough).
4. Vancomycin 250 mg p.o. t.i.d.
5. Flagyl 250 mg IV q. 8 hours.
6. Bicitra 10 mL p.o. b.i.d.
7. Valproic sodium 750 mg p.o. b.i.d.
8. Omeprazole 40 mg p.o. q. 12 hours.
9. Epogen 40,000 units subcu once weekly.
10.Lamictal 50 mg p.o. b.i.d.
11.Calcitriol 0.25 mcg p.o. daily.
12.Ipratropium bromide 0.5 mg 0.25% inhaled q. 4 hours p.r.n.
shortness of breath.
13.Tylenol 650 mg p.o. q. 6 hours p.r.n. temperature greater
than 101.
14.Atrovent inhaler q. 4 hours p.r.n. shortness of breath.
15.Folic acid 1 mg p.o. daily.
16.Cholecalciferol 400 units p.o. daily.
17.Oxycodone 5 mg p.o. q. 6 hours p.r.n. pain.
18.Wellbutrin SR 100 mg b.i.d.
19.Seroquel Extended Release 200 mg p.o. q. h.s.
20.Amiodarone 400 mg p.o. t.i.d.
21. Heparin gtt with q6 hours PTTs
22. NovaSource renal at 20 mL an hour around the clock with 250
mL normal saline flushes every 4 hours
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired secondary to cardiopulmonary compromise from sepsis
likely C.diff. Complicated by acute on chronic renal failure.
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2124-12-26**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,836
| 131,966
|
9181
|
Discharge summary
|
report
|
Admission Date: [**2164-8-31**] Discharge Date: [**2164-9-4**]
Date of Birth: [**2080-6-12**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 14689**]
Chief Complaint:
Hypoxia, altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 yo [**Location 7979**] speaking male with duodenal adenocarcinoma,
diagnosed in [**5-7**], s/p gastroenterostomy and a diversion around
the duodenal mass with recent admission to [**Hospital1 18**] from
[**Date range (3) 31547**] with a PE on lovenox who BIBA to ED for
decreased PO intake and lethargy. Per family, patient has been
lethargic since 2pm this afternoon. Patient is not mobile, has
not been out of been in months. He typically is conversant and
has not been interacting, just making eye contact. His family
notes that he seems to be getting worse at home since most
recent hospitalization. VNA this am noted a O2sat of 90% on ra
and that his breathing seemed short so recommended he be
evaluated. Daughters report pt has had no PO intake in past 24
hrs. Pt having difficulty choking on fluids in past few days.
They also noted that he has been shaking often in the past 24
hrs.
.
In the ED, initial vs were: 97.8 100 124/77 27 100% NRB. In the
ED, he was arousable to loud voice and painful stimuli. He was
noted to be tachypneic to the 30s and spiked a fever to 103.
CXR was concerning for PNA/effusion. CT Head was negative for
an acute process. CTA of the Torso was negative for PE, but did
show large effusion, ? LLL PNA vs collapse, worsening acute
pancreatitis. Lipase 209 which is stable from previous levels.
In the ED, he was given Vancomycin 1g Aspirin (Rectal) 600mg,
Acetaminophen (Rectal) 650mg PO x1, CeftriaXONE 1g, Azithromycin
500 mg IV x1 for presumed CAP. He was also given 2L of NS. His
EKG was noted to have lateral depression in V4 & V5 in the
setting of an elevated HR. Current VS are 103/71 99 20 100% FM
50%.
.
.
Review of systems: Unable to obtain as patient non-verbal.
Past Medical History:
Oncologic
# duodenal adenocarcinoma:
- [**2164-4-28**]: developed crampy abdominal pain, nausea, vomiting,
and jaundice. ERCP revealed a malignant appearing stricture and
also a duodenal mass. He had a plastic stent placed followed by
a
metal stent to relieve the jaundice. Dr. [**Last Name (STitle) **] had discussed
the potential for a Whipple procedure; however, given Mr.
[**Known lastname 12330**]' comorbidities and underlying medical problems and
delirium, he was not deemed a good candidate for Whipple's and
was deemed to be a better candidate for a less invasive
procedure. On [**2164-6-8**], Dr. [**Last Name (STitle) **] performed
gastroenterostomy and a diversion around the duodenal mass,
which
was left in place.
- [**2164-6-27**]: saw Dr. [**First Name (STitle) 11309**] and Dr. [**Last Name (STitle) **]. Given his
poor performance status, chemotherapy was not recommended.
OTHER MEDICAL HISTORY:
atrial fibrillation
history of CVA
history of an elevated PSA
status post right internal capsular CVA in [**2163-3-30**]
NSTEMI in [**2163-3-30**]
hypertension
hyperlipidemia
nephrolithiasis
PSH:
s/p ERCP with biopsy followed by repeat ERCP & CBD stent
placement [**2164-5-24**] & [**2164-6-4**]
s/p hepaticojejunostomy, gastrojejunostomy [**2164-6-7**]
Social History:
[**Location 7972**] speaking only, formerly worked as a mechanic,
now retired. Lives with multiple family members.
[**Name (NI) 1139**]: former smoker, quit ~30 yrs ago.
EtOH: Distant EtOH on weekends, not recently.
Illicits: No illicits.
Family History:
Non-contributory
Physical Exam:
Vitals: T97.3, HR 90, BP 116/66, R 22, SpO2 100%RA
General: arousable to voice, moves arms/hands, no acute
distress
HEENT: Sclera anicteric, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation on right, decreased breath sounds
and dullness on left base, no wheezes, rales, ronchi
CV: rapid rate and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, obese NABS, tender to palpation in epigastric
area, non-distended, no rebound tenderness or guarding, no
organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Arousable to voice, non-verbal, EOMI, squeezes hands
bilat.
Pertinent Results:
Admission Labs:
[**2164-8-31**] 06:10PM WBC-24.1*# RBC-3.72* HGB-8.0* HCT-27.2*
MCV-73* MCH-21.4* MCHC-29.3* RDW-17.6*
[**2164-8-31**] 06:10PM NEUTS-81.1* LYMPHS-13.6* MONOS-4.1 EOS-0.6
BASOS-0.5
[**2164-8-31**] 06:10PM PLT COUNT-1045*#
[**2164-8-31**] 06:10PM AMMONIA-3*
[**2164-8-31**] 06:10PM TOT PROT-7.5 ALBUMIN-2.5* GLOBULIN-5.0*
CALCIUM-8.5 PHOSPHATE-5.0*# MAGNESIUM-2.6
[**2164-8-31**] 06:10PM TRIGLYCER-105
[**2164-8-31**] 06:10PM ALT(SGPT)-23 AST(SGOT)-36 LD(LDH)-333* ALK
PHOS-137* TOT BILI-0.2
[**2164-8-31**] 06:10PM LIPASE-209*
[**2164-8-31**] 06:10PM GLUCOSE-137* UREA N-33* CREAT-1.0 SODIUM-143
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-25 ANION GAP-19
[**2164-8-31**] 06:25PM LACTATE-1.8
.
[**2164-8-31**] 06:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2164-8-31**] 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-TR
[**2164-8-31**] 06:30PM URINE RBC-0 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2164-8-31**] 06:30PM URINE GRANULAR-0-2 HYALINE-[**3-2**]*
[**2164-8-31**] 06:30PM URINE MUCOUS-FEW
.
Other Notable Labs:
[**2164-9-1**] 11:48AM BLOOD PT-20.3* PTT-30.6 INR(PT)-1.9*
[**2164-9-1**] 05:54AM BLOOD LD(LDH)-177
[**2164-9-1**] 05:54AM BLOOD Triglyc-109
[**2164-9-1**] 12:45AM BLOOD Type-ART Temp-37.4 Rates-/24 FiO2-35
pO2-92 pCO2-40 pH-7.49* calTCO2-31* Base XS-6 Intubat-NOT INTUBA
Comment-SIMPLE FAC
.
Discharge Labs:
[**2164-9-2**] 04:35AM BLOOD WBC-21.0* RBC-3.66* Hgb-7.8* Hct-27.2*
MCV-75* MCH-21.3* MCHC-28.6* RDW-17.9* Plt Ct-962*
[**2164-9-2**] 04:35AM BLOOD Glucose-122* UreaN-23* Creat-0.7 Na-146*
K-3.8 Cl-110* HCO3-28 AnGap-12
[**2164-9-2**] 04:35AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.3
.
[**2164-8-31**] CXR: Large left pleural effusion with retrocardiac left
lung base atelectasis. Superimposed infection cannot be
excluded.
.
[**2164-8-31**] CT Head without contrast: No acute intracranial
hemorrhage detected. Right maxillary sinus disease.
[**2164-8-31**] CT Chest/Abdomen/Pelvis with contrast:
1. No acute pulmonary embolism or thoracic aortic pathology
detected. Stable mild enlargement of the ascending thoracic
aorta measuring up to 3.9 cm.
2. Moderate-to-large left pleural effusion and associated
compressive
atelectasis of the left lower lobe, new since the prior study.
3. Interval worsening of the patient's known acute pancreatitis
with increase in size of the previously seen peripancreatic
fluid collections. Splenic subscapular simple fluid collection
is new since the prior study.
4. Hypoattenuating lesions within the head of the pancreas may
represent
dilated ducts or small fluid collections.
5. Unchanged thickened appearance of the first and second
portion of the
duodenum in this patient with known duodenal mass. Multiple
omental and
peritoneal nodules remain concerning for carcinomatosis.
6. Stable prostatomegaly.
7. Renal cysts and sigmoid diverticulosis.
.
[**2164-9-1**] ECG: Atrial flutter with ventricular premature beats.
Early precordial QRS transition. Probable left ventricular
hypertrophy. ST-T wave abnormalities. Findings are non-specific.
Since previous tracing of [**2164-8-31**] atrial wave forms now appear
more suggestive of flutter than fibrillation but there may be no
significant change.
.
[**2164-9-2**] CXR: Large left effusion with adjacent atelectasis has
markedly increased. Cardiomediastinum is midline. Moderate
cardiomegaly is stable. Right lower atelectasis is unchanged.
The cardiomediastinal silhouette is partially obscured by the
left pleural effusion.
Brief Hospital Course:
Mr. [**Known lastname 12330**] is an 84yo man with duodenal adenocarcinoma s/p
gastroenterostomy who presented with worsening lethargy and
tachypnea.
.
# Fever/Leukocytosis: Pt w persistent leukocytosis ([**10-12**]) of
unclear etiology, with acute elevation to 24 on admission.
Diagnoses considered at time of admission were: inflammatory v
infectious v malignant. Given tender abdomen and abdominal CT
findings with large fluid collections, this was felt to be the
most likely source of infection. PNA was also considered given
his pleural effusions, but it was felt that these were most
likely secondary to abdominal inflammation. The patient was
broadly covered with Vanco and Meropenem (started [**2164-9-1**]) for
intra-abdominal infection / possible PNA. Surgery felt that
drainage of fluid collections in abdomen would put the patient
at risk for bleeding or infection with minimal benefit. IR
declined to perform a therapeutic [**Female First Name (un) 576**] with pigtail placement
until a diagnostic [**Female First Name (un) 576**] had been done. His cultures remained
negative, but the patient remained intermittently febrile with
continued lethargy and poor mental status. At this time, the
patient's family made it clear that they wanted the patient to
be made DNR/DNI. Overnight patient became agitated and pulled
out peripheral IVs. At this time, patient was made comfort
measures only, and it was decided not to replace his IVs and not
to transfer the patient over to a PO antibiotic equivalent.
Patient received symptomatic control of his fevers and was
transferred out of the ICU. After arrival to the medical
oncology floor, the patient continued to receive symptomatic
treatment. He was discharged to home with hospice care.
.
# Tachypnea/Dyspnea - At time of admission, tachypnea was
thought to be secondary to pleural effusion vs PNA vs PE. No
sign of PNA on CXR or physical exam, pt w prior diagnosis of PE
and was therapeutic on lovenox, effusion more likely the cause.
Given the large abdominal fluid collection, effusion was thought
to be most likely secondary to abdominal process as discussed
above.
.
# Altered mental status - Most likely delirium related to
malignancy, likely also with infectious component. Head CT was
negative with stable neuro exam. His infection was treated as
above. Given the extent of his malignancy, patient's family
decided to make him comfort measures only with the request to
bring him home to be with his family.
.
#. Duodenal adenocarcinoma: Patient is s/p gastroenterostomy.
After decision was made to make comfort measures only the goal
of care, the patient received symptomatic treatment with
morphine (liquid) as needed for pain or dyspnea, ondansetron as
needed for nausea, acetaminophen as needed for pain, and
lorazepam as needed for anxiety or nausea. He was discharged to
home with hospice care.
.
# Hypertension: Patient was normotensive throughout admission.
He was continued on PO Metoprolol.
Medications on Admission:
Flomax 0.4 mg 24 hr Cap by mouth daily 1/2 hour after a meal
Calcium Carbonate-Vitamin D3 500 mg (1,250 mg)-200 unit Tab PO
TID
Senna 8.6 mg Tab 1 Tablet(s) by mouth twice a day
Aspirin 325 mg Tab 1 Tablet(s) by mouth DAILY (Daily)
Acetaminophen 325 mg Tab [**12-31**] Tablet(s) by mouth q 4-6 hours
Hydrochlorothiazide 12.5 mg Tab 1 Tablet(s) by mouth daily
Simvastatin 40 mg Tab by mouth daily at night
Colace 100 mg Cap by mouth twice a day as needed for
constipation
Norvasc 5 mg Tab 1 Tablet(s) by mouth daily
Multivitamin Tab 1 Tablet(s) by mouth daily
Ondansetron HCl 8 mg Tab 1 Tablet(s) PO TID PRN Nausea
Toprol XL 50 mg 24 hr Tab 1 Tablet(s) by mouth daily
Lovenox 80 mg/0.8 mL Sub-Q 70mg Syringe(s) Twice Daily
Oxycodone 5 mg Tab Oral [**12-31**] Tablet(s) Every 4-6 hrs, as needed
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Lorazepam 2 mg/mL Concentrate Sig: 0.5 - 2 mg PO Q1H (every
hour) as needed for agitation, anxiety, dyspnea.
Disp:*1 bottle (250cc)* Refills:*0*
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: [**12-31**] Tablet, Rapid
Dissolves PO TID (3 times a day) as needed for agiation,
anxiety.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
9. Morphine Concentrate 20 mg/mL Solution Sig: 10-20 mg PO every
four (4) hours as needed for pain, anxiety, dyspnea.
Disp:*1 bottle (500 cc)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice and palliative care
Discharge Diagnosis:
Pancreatitis
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital with pneumonia and
pancreatitis. You were initially in the intensive care unit, but
were transferred to the oncology care. You and your family
decided to focus on comfort. You are being discharged home with
hospice care
Followup Instructions:
Please follow up with your primary care doctors if [**Name5 (PTitle) **] [**Name5 (PTitle) 788**] fit.
[**Name6 (MD) **] [**Name8 (MD) 10341**] MD [**MD Number(2) 14690**]
|
[
"V58.61",
"600.00",
"401.9",
"272.0",
"486",
"427.31",
"285.9",
"152.0",
"V12.51",
"412",
"414.01",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13067, 13145
|
7975, 10957
|
302, 308
|
13202, 13280
|
4390, 4390
|
13582, 13786
|
3632, 3651
|
11800, 13044
|
13166, 13181
|
10983, 11777
|
13304, 13559
|
5843, 7952
|
3666, 4371
|
2024, 2065
|
232, 264
|
336, 2004
|
4406, 5827
|
2087, 3359
|
3375, 3616
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,791
| 184,036
|
14699
|
Discharge summary
|
report
|
Admission Date: [**2131-5-21**] Discharge Date: [**2131-5-24**]
Date of Birth: [**2090-9-26**] Sex: F
Service: Medicine
ADMISSION DIAGNOSIS: Respiratory failure.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 43251**] is a 41-year-old
woman with a history of depression and asthma. She was well
until [**Month (only) **] of this year when she was found unresponsive in
her kitchen.
She was transported to the [**Hospital6 1708**],
apparently in respiratory distress. She remained in that
institution for approximately seven days. The workup there
did not explain her respiratory arrest.
A few days after her discharge from [**Hospital6 15291**], Ms. [**Known lastname 43251**] was visiting her daughter at [**Hospital3 18242**]. She was undergoing a heated discussion with her
family when she developed the sudden onset of chest pain and
diaphoresis. The pain radiated to her left arm as well as to
her jaw. After a short time, Ms. [**Known lastname 43251**] [**Last Name (Titles) 43252**] and was
apparently in respiratory arrest. She was intubated at
[**Hospital3 1810**]. There were poor records around the code
that was run at [**Hospital3 1810**]. After intubation,
Ms. [**Known lastname 43251**] was transported to the Emergency Department at
[**Hospital1 69**].
PAST MEDICAL HISTORY:
1. Recent admission to [**Hospital6 1708**] from
[**5-13**] until [**5-15**] of this year with respiratory arrest of
unknown etiology. Reports obtained from the [**Hospital6 8866**] indicated that they suspected the
respiratory arrest was secondary to a drug overdose. Of
note, her toxicology screen at that institution was negative.
At the time of this dictation, the gamma hydroxybutyrate and
Rohypnol levels obtained that institution were still pending.
2. Recent urinary tract infection approximately one month
ago which was treated and resolved.
3. A long history of depression, panic attacks, and
attempted suicide.
4. Hypertension.
5. Type 1 diabetes.
6. A history of a low thyroid-stimulating hormone at the
[**Hospital6 1708**].
7. Asthma.
8. Polysubstance abuse.
MEDICATIONS ON ADMISSION: Medications taken prior to
admission included trazodone 150 mg p.o. q.h.s.,
Effexor-SR 75 mg p.o. q.h.s., Remeron 45 mg p.o. q.h.s.,
Neurontin 800 mg p.o. b.i.d., Klonopin (dose unknown),
albuterol inhalers on an as needed basis, Tylenol as needed,
Atrovent inhaler as needed.
ALLERGIES: PENICILLIN which results in a rash.
SOCIAL HISTORY: Ms. [**Known lastname 43251**] [**Last Name (Titles) 42866**] approximately one pack of
cigarettes per week. She denies alcohol use at this time.
Of note, she also denies active substance abuse.
PHYSICAL EXAMINATION ON PRESENTATION: In the Emergency
Department, Ms. [**Known lastname 43253**] physical examination was
unremarkable. Her vital signs were within normal limits.
There was nothing focal on neurologic examination.
Cardiovascular examination was unremarkable. The abdomen was
soft and nontender. Chest examination revealed good air
entry bilaterally.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory
results on admission revealed the white blood cell count
was 16.2, hematocrit was 35.9, platelets were 418. INR
was 0.9, PTT was 24.6. Glucose was 317, blood urea nitrogen
was 14, creatinine was 0.6, sodium was 134, potassium
was 5.2, chloride was 97, bicarbonate was 25. Her creatine
kinase was elevated at 285, CK/MB was 3, and troponin was
less than 0.3. Her toxicology screen in the Emergency
Department was negative for aspirin, alcohol,
benzodiazepines, barbiturates, tricyclics, and Tylenol. An
arterial blood gas obtained in the Emergency Department
showed an oxygen of 334, carbon dioxide of 56, pH of 7.31,
bicarbonate of 30. A urinalysis was negative for nitrites
and ketones. A large amount of blood was present in the
urine. Leukocyte esterase was negative.
RADIOLOGY/IMAGING: Electrocardiogram on admission was
unremarkable. There were no signs of ischemia.
An electroencephalogram was obtained which was negative for
seizure activity.
An echocardiogram was obtained which showed a trivial mitral
regurgitation and a mildly dilated left atrium.
A CT of the head was negative.
A chest x-ray showed no evidence of pneumonia of congestive
heart failure.
Subsequently, a CT of the chest was obtained. This was
negative for a pulmonary embolism. Of note, it did not an
aspiration pneumonia. It was felt that this was secondary to
a difficult intubation. There were reports that Ms. [**Known lastname 43251**]
[**Last Name (Titles) 43254**] during intubation at [**Hospital3 1810**].
HOSPITAL COURSE: Ms. [**Known lastname 43251**] was transferred to the Medical
Intensive Care Unit on [**5-21**]. She was easily weaned from
the ventilator. She ruled out for a myocardial infarction by
enzymes. Her telemetry remained unremarkable. She remained
asymptomatic in the Medical Intensive Care Unit.
On [**5-22**], she was transferred to the Medical [**Hospital1 **]. She
remained asymptomatic on the Medicine floor.
There was some discussion as to whether her episodes of
respiratory arrest could be attributed to seizure activity.
A Neurology consultation was obtained. After reviewing her
electroencephalogram and her relevant history, the Neurology
team did not feel that her symptoms could be attributable to
seizures.
The Electrophysiology Service was also consulted. Given her
unremarkable telemetry during her three day stay in the
hospital, the Electrophysiology team did not feel that
Ms. [**Known lastname 43251**] required an electrophysiology study at this
point. At this time it is unclear what the etiology of her
episodes of respiratory arrest are.
Ms. [**Known lastname 43251**] was started on levofloxacin to treat her
aspiration pneumonia. She remained afebrile throughout her
stay in the hospital. She never developed a white blood
count. As such, it was felt that the findings on the CT of
the chest were likely related to aspiration pneumonitis. Her
levofloxacin was stopped on [**5-24**].
Ms. [**Known lastname 43251**] has type 1 diabetes and is maintained on insulin
at home. On presentation, her blood sugar was noted to be in
the 300s. She was started on an insulin sliding-scale while
in the hospital. The benefits of maintaining a blood sugar
in the target range were discussed with her.
Ms. [**Known lastname 43251**] apparently had a low thyroid-stimulating hormone
during her stay at the [**Hospital6 1708**]. Repeat
studies here revealed a thyroid-stimulating hormone of 0.43
and a free T4 of 5.5; both of which were within normal
limits.
Of note, Ms. [**Known lastname 43251**] was noted to have an anemia during her
stay here. After her initial blood draw in the Emergency
Department, her hematocrit ranged from 26.5 to 29. The mean
cell volume was normal at 85 to 87. Iron studies were sent
which were normal. Of note, her ferritin was 251. Her
vitamin B12 was 294, and her folate was 11.4. The total
iron-binding capacity was 257.
At the time of this dictation, there was no clear etiology
for Ms. [**Known lastname 43253**] episode of respiratory arrest. It was
noted that she has an extensive psychiatric history. It was
also noted that she has been under a considerable amount of
stress over the past month. Her eldest daughter is getting
married this week. Apparently, there has been a great deal
of arguing amongst the family in relation to this event. Her
younger daughter was also hospitalized at [**Hospital3 18242**]. It was possible that her episodes in the past week
were related to a psychiatric problem.
DISCHARGE DIAGNOSES: Syncope/apnea of unclear etiology.
MEDICATIONS ON DISCHARGE:
1. Tylenol one to two tablets p.o. q.4-6h. as needed.
2. Trazodone 150 mg p.o. q.h.s.
3. Effexor-SR 75 mg p.o. q.h.s.
4. Klonopin 2 mg p.o. b.i.d. as needed.
5. Albuterol inhaler.
6. Atrovent inhaler.
7. Regular insulin 10 units in the morning and 5 units at
5 p.m. and 10 units q.h.s.; and NPH insulin 10 units in the
morning and 10 units at 5 p.m. and 10 units q.h.s.
DISCHARGE FOLLOWUP: Ms. [**Known lastname 43251**] was to see her primary care
physician on [**5-25**] if possible. If not, she was to see her
primary care physician on [**5-28**]. She was also instructed
to follow up with her outpatient psychiatrist.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 10451**]
Dictated By:[**Last Name (NamePattern1) 222**]
MEDQUIST36
D: [**2131-5-25**] 13:41
T: [**2131-5-28**] 08:23
JOB#: [**Job Number 43255**]
|
[
"285.9",
"518.81",
"507.0",
"401.9",
"250.01",
"305.1",
"300.00",
"311",
"305.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7642, 7678
|
7704, 8082
|
2137, 2464
|
4636, 7620
|
159, 181
|
8103, 8612
|
210, 1304
|
1326, 2110
|
2481, 4618
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,216
| 119,804
|
3602
|
Discharge summary
|
report
|
Admission Date: [**2186-11-27**] Discharge Date: [**2186-12-1**]
Date of Birth: [**2130-3-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 56 year-old female with a history of macrocytic
anemia, MDS, possible seizure disorder, multiple falls who
presents with chest pain.
.
Of note, she was just recently admitted to [**Hospital 4199**] hospital from
[**Date range (1) 16384**] for lethargy and hypoglycemia. She was found to have
elevated INR as well as elevated transaminases and severe
hypoalbuminemia, attributed to possibly underlying liver disease
as well as malnutrition. She was noted to be disoriented
initially with visual hallucinations. Her mental status cleared
with holding of psychoactive meds. Abdominal ultrasound showed
mild hepatic steatosis but no acute abnormality. She declined
rehab at discharge.
.
On the morning of this admission, she reports a general feeling
of malaise and a sense that she should go to the hospital. When
her VNA arrived, she asked her to call EMS and was brought to
the ED. In the ambulance, pt developed onset of pins and needles
sensation that started in her left hand and radiated up the arm
to her shoulder. She then noticed pleuritic chest pain starting
at the left chest and moving across to the right as well as up
her left neck. The pain also occasionally radiates in a
band-like fashion across her upper abdomen. She has had
associated nausea and diaphoresis as well as SOB. Also complains
of a migraine HA, similar to her usual. Denies fevers, chills,
vomiting.
.
In the ED, initial vitals were T98.6, HR 148, BP 100/60, RR 17,
85% on 2L. While in the ED, her BP occasionally dipped to the
80s but quickly came back up to the 90s without intervention.
She remained tachycardic in the 110-120s. EKG showed sinus tach.
Trop was elevated to 0.03 but flat. Because of risk for PE and
poor IV access it was decided to perform VQ scan. However, there
was a prolonged wait for VQ during which the patient spiked a
temp to 101.8. CVL was eventually placed for access. Pt was also
noted to have a UTI and was given ceftriaxone. In addition, she
received 1700cc NS and 1g tylenol. Admitted to the [**Hospital Unit Name 153**] for
closer monitoring.
.
On arrival to the [**Hospital Unit Name 153**], the patient is very anxious and says
that she is having a "panic attack". She feels nervous because
she does not know what is going on. She continues to have pain
at her L chest, under her breast, and L shoulder as well as
migraine HA. Also feels SOB.
.
ROS: +HA, intermittent band-like abdominal pain, CP and SOB as
above. +coughing up green-white phlegm x 1 day. The patient
denies any fevers, chills, weight change, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, orthopnea, PND,
lower extremity edema, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash or skin changes.
Past Medical History:
1. Chronic macrocytic anemia
2. Bone marrow biopsy [**2179-7-28**]-MDS v EtOH toxicity
pancytopenia > resolved and most likely attributed to ETOH
toxicity
3. Hypothyroidism
4. h/o questionable seizures, but neg 48h EEG and nL MRI in
past.
5. Migraine headaches
6. Questionable history of cardiac arrhythmias. [**Doctor Last Name **] of Hearts
in past showed some tachys to 180s. Patient denies.
7. Peptic ulcer disease status post Nissen fundoplication.
8. Status-post hemorrhoidectomy.
9. Asthma s/p intubation x 1 in past
10. Osteoarthritis
11. b/l cataracts
12. R knee surgery
Social History:
Lives with her boyfriend in [**Name (NI) 4628**]. Three daughters. [**Name (NI) **]
tobacco. No drugs/herbals. Drinks 1 glass of wine every [**12-28**]
weeks, states last drink was 2 days ago. Used to be a
photographer. Has VNA and home PT.
Family History:
Father died of CAD at age 80. Mother-alive and healthy. No
family with MDS or leukemia.
Physical Exam:
INITIAL EXAM:
Vitals: T: 98.7 BP: 104/68 HR: 106 RR: 18 O2Sat: 97% 2L
GEN: chronically ill appearing female, appears older than stated
age, tremulous, anxious
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: tachy, regular, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
RECTAL: brown, trace guiaic positive stool
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 4+/5 in upper
extremities, [**4-1**] RLE, [**3-1**] LLE (exam limited by generalized
weakness and pt's inability to continue with strength exam).
SKIN: No jaundice, cyanosis, or gross dermatitis.
Pertinent Results:
Initial labs
[**2186-11-27**] 03:00PM WBC-7.5 RBC-3.03* HGB-10.1* HCT-29.7* MCV-98
MCH-33.3* MCHC-34.0 RDW-16.6*
[**2186-11-27**] 03:00PM NEUTS-70.4* LYMPHS-21.3 MONOS-6.8 EOS-1.1
BASOS-0.4
.
[**2186-11-27**] 03:00PM PT-13.1 PTT-22.2 INR(PT)-1.1
.
[**2186-11-27**] 03:00PM GLUCOSE-81 UREA N-19 CREAT-1.2* SODIUM-141
POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-16
[**2186-11-27**] 03:00PM ALT(SGPT)-67* AST(SGOT)-82* LD(LDH)-1112*
CK(CPK)-203* ALK PHOS-128* TOT BILI-1.4
[**2186-11-27**] 03:00PM cTropnT-0.03*
[**2186-11-27**] 03:00PM CK-MB-5 proBNP-760*
.
[**2186-11-27**] 07:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-8.0
LEUK-MOD
[**2186-11-27**] 07:00PM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0-2
.
EKG: [**11-27**] Sinus tachycardia
[**11-28**] sinus tachycardia with nonspecific ST changes
.
RADIOLOGY:
VQScan [**11-27**]: Multiple bilateral areas of subsegmental defects,
indeterminate scan.
Chest CT [**11-28**]
1. Multiple acute pulmonary emboli in both main pulmonary
arteries, every
lobar artery, and multiple segmental arteries with no signs of
right
ventricular strain.
2. Trace right pleural effusion.
3. Bibasilar and lingular atelectasis. Left lateral costophrenic
angle
opacity could be atelectasis or early infarct, should be
followed in three to six months.
4. Unchanged 3 mm nodule since [**2181**], does not warrant further
followup.
Abd/pelvic CT [**11-29**]: No evidence of Retroperitoneal bleed.
Pelvic ultrasound and transvaginal: Nabothian cyst, simple
fluid in pelvis, small amount
.
ECHO [**11-28**]
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 number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal global and regional biventricular systolic
function, without echocardiographic evidence of "right heart
strain". Mild pulmonary hypertension.
Brief Hospital Course:
# Pulmonary embolus and deep vein thrombosis: CT Chest
significant for bilateral PEs. LENI revealed right common
femoral DVT. Her ECHO did not show evidence of right heart
strain, and she had only a short period of hypotension which
responded to fluids. She did have an IVC filter placed on [**11-29**]
given clot burden. She was started on heparin and coumadin. Her
Hct dropped on the day of initiation of heparin, but workup did
not reveal a GI bleed or a retroperitoneal bleed. Her
hematocrit was subsequently stable. She was transitioned to
lovenox on the day of discharge for more predictable
anticoagulation. She was also started on coumadin. She should
have a daily INR and an overlap of 48 hours with lovenox after
her INR is > 2.
.
This was an unprovoked large PE. She will require age
appropriate cancer screening, including endoscopy, colonoscopy,
and mammogram, as well as a hypercoaguable workup after 6 months
on coumadin.
.
She is a fall risk, and will need physical therapy to lower risk
of falling while on coumadin. Given her clot burden, despite
the IVC filter, she needs full anticoagulation for the next 6
months.
.
#Guaic positive stool: Her stool on admission was guaic
positive, but has subsequently been negative. Her stools should
all be guaiced, with GI referral for persistent occult blood.
She was seen by GI (Dr. [**Last Name (STitle) 6220**] and Shields) here in the
hospital, and endoscopy and colonoscopy were deferred due to the
risk of discontinuation of anticoagulation in the acute post
thrombosis period.
.
# Urinary tract infection:
Positive UA in the ED with mod leuk, 21-50 WBC, and many
bacteria. Has history of 2 E coli UTIs here over the past year
([**3-4**] and [**9-4**])-- resistant to ampicillin, otherwise sensitive.
She had 2 organisms, with again E coli, resistant only to
ampicillin, and klebsiella, susceptible to all antibiotics
except nitrofurantoin. She was initially treated with
ceftriaxone, and transitioned to vantin. She should complete a
7 day course, with last day on [**12-4**].
# Hypoalbuminemia: She was admitted with severely low albumin.
This is likely multifactorial due to poor nutrition, and
possibly protein losing enteropathy, as well as the effect of
the acute inflammatory phase of the pulmonary embolus. She had
no significant edema or protein in her urine. She had a TTG
pending at the time of discharge, and will follow up with GI for
further evaluation.
.
# Acute anemia, as well as anemia of chronic disease: Her
initial Hct was 29.7 which dropped to 24.8 while in ED. On
repeat Hct is 21.8. Her anemia workup revealed an anemia of
chronic disease. She received 2 units of blood, and her final
Hct was 30.8. Her laboratory values showed an extremely high
ferritin, with low TIBC and transferrin, likely consistent with
anemia of chronic disease.
.
# Alkalosis: She had a persistent alkalosis, improving by the
time of discharge. ABG showed this as a chronic respiratory
alkalosis, with metabolic compensation and lower bicarbonate.
.
# Weakness/Falls: She has chronic gait instability, attributed
to weakness and possibly alcohol. She worked with PT and will
continue at rehab.
.
# Acute renal failure: She was admitted with acute dehydration
and renal failure with creatinine 1.1. With hydration, her
creatinine returned to baseline, and is 0.6 at the time of
discharge.
.
# History of EtOH abuse: Pt states that she only drinks 1 drink
every 1-2 weeks however it has been documented in the past that
she has not been forthcoming about her EtOH use. Mixed picture
of tachycardia, HA, anxiety, tremulousness could all be
attributed to EtOH withdrawal. There was no conclusive evidence
of alcohol withdrawal.
.
# Anxiety: she was treated with ativan prn and lexapro.
.
# Hypothyroidism: TSH has been <0.02 on multiple occasions this
year. If she is actually hyperthyroid currently, that could also
contribute to her anxiety, tremulousness, and tachycardia. TSH
0.22 and T4 3.8 indicating she is hypothyroid. This is
difficult to interpret in the acute setting, and will need to be
repeated once she is no longer acutely ill. For now, she was
continued on her synthroid.
# Seizure disorder: continued keppra
.
# Hypokalemia, hypomagnesemia: She was admitted with
electrolyte abnormalities, which were repleted. She should have
a CMP rechecked in 3 days.
Medications on Admission:
Keppra 750mg PO BID
Folic acid 1mg PO daily
Lorazepam 1mg PO qHS
Levothyroxine 88mcg PO daily
Lexapro 10mg PO daily
Mag Oxide 400mg PO daily
Mephyton (Vitamin K1) 5mg PO daily
Omeprazole 20mg PO BID
Vitamin B-1 100mg PO daily
Vitamin D 1000 units PO daily
Protonix 40mg PO daily
Zolpidem 10mg PO qHS
Albuterol prn
Propoxyphene 65mg prn
Imitrex 50mg prn
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (4) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
2. Levetiracetam 250 mg Tablet [**Month/Day (4) **]: Three (3) Tablet PO BID (2
times a day).
3. Folic Acid 1 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
4. Lorazepam 0.5 mg Tablet [**Month/Day (4) **]: 1-2 Tablets PO HS (at bedtime)
as needed.
5. Escitalopram 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. B-Complex with Vitamin C Tablet [**Month/Day (4) **]: One (1) Tablet PO
DAILY (Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (4) **]: 2.5 Tablets
PO DAILY (Daily).
9. Acetaminophen 500 mg Tablet [**Month/Day (4) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. Levothyroxine 88 mcg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY
(Daily).
11. Warfarin 5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Once Daily at 4
PM.
12. Cefpodoxime 100 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO Q12H (every
12 hours).
13. Oxycodone-Acetaminophen 5-325 mg Tablet [**Month/Day (4) **]: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
14. Lovenox 60 mg/0.6 mL Syringe [**Month/Day (4) **]: Sixty (60) mg Subcutaneous
twice a day: Until INR > 2 for 2 days.
15. Magnesium Oxide 400 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO twice a
day for 2 days.
16. Ambien 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO at bedtime as
needed for insomnia.
17. Cepacol Sore Throat 10-2 mg Lozenge [**Month/Day (4) **]: One (1) lozenge
Mucous membrane three times a day as needed for sore throat.
18. Imitrex 50 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO once a day as
needed for headache.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4316**] Rehab & [**Hospital **] Care Center
Discharge Diagnosis:
Pulmonary embolus
Deep vein thrombosis.
Acute renal failure
Hypoalbuminemia.
Guaic positive Stool.
Respiratory alkalosis.
Positive troponin.
Urinary tract infection
Anemia of chronic disease.
Malnutrition
Discharge Condition:
Stable, satting well on room air, blood pressure stable.
Discharge Instructions:
You were admitted with a large blood clot and clot in your leg.
You were initially admitted to the ICU, and then stabilized and
transferred to the floor. You also had anemia and electrolyte
disturbances, and some blood in your stool, and it will be
important to follow up with the GI doctors.
.
Return to the emergency room with worsening shortness of breath,
swelling in your legs, chest pain, blood in your stool or black
stool.
Followup Instructions:
Provider: [**Name10 (NameIs) 16385**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2187-1-3**] 1:30
.
Call Dr. [**Last Name (STitle) 1270**] for an appointment after you leave rehab.
.
All stools should be guaiced.
CMP, CBC on Monday, [**12-4**]. Daily INR until therapeutic.
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"38.91",
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
13976, 14058
|
7286, 11663
|
327, 333
|
14307, 14365
|
4960, 7261
|
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|
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|
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4120, 4941
|
277, 289
|
361, 3138
|
3160, 3742
|
3758, 4000
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,515
| 143,372
|
46738
|
Discharge summary
|
report
|
Admission Date: [**2106-12-17**] Discharge Date: [**2107-1-3**]
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female who
comes in with a history of diabetes, end stage renal disease,
CAD, status post CABG times two, aortic valve replacement
surgery, who presented to the Emergency Room with
day and some left shoulder pain and two days prior to the
episode also having it. The patient is being ruled out for a
myocardial infarction which eventually her CKs were negative.
PAST MEDICAL HISTORY: Significant for diabetes, end stage
renal disease, CAD, status post CABG and AVR. Stent
placement to the PDA in [**8-23**] was complicated by dissection,
disease, status post fem [**Doctor Last Name **] in [**2101**], monoclonal gammopathy,
aortic stenosis status post AVR with a bovine valve in [**2102**]
and CVA in [**2092**].
MEDICATIONS: Metoprolol, Plavix, Lipitor, Amiodarone,
RenaGel, Nephrocaps, Aspirin, Folic Acid, Epogen, Albuterol,
Procrit and Heparin.
ALLERGIES: Bactrim, Sulfa, Penicillin and Cephalosporins.
PHYSICAL EXAMINATION: On admission the patient was hypotensive
and was resuscitated with some fluids. Other
vital signs were stable. HEENT: Normocephalic, atraumatic,
extraocular movements intact. Lungs with bibasilar crackles.
Cardiovascular, S1 and S2, no murmurs, rubs or gallops.
Abdomen was soft, nontender, non distended with positive
bowel sounds. Extremities, no cyanosis, no clubbing, no
edema.
HOSPITAL COURSE: The patient was admitted to the medical
cardiology team to rule out myocardial infarction. The
patient eventually ruled out for myocardial infarction. On
[**12-21**] the patient had a decompensation on the floor in which
she became hypotensive as well as spiked a temperature. The
patient was cultured which eventually grew out staph MRSA in
her blood cultures. The patient was started on Vancomycin.
The patient was then transferred over to the medical ICU in
which she became hypotensive and was admitted in respiratory
distress. The patient was then intubated. The patient was
treated with aggressive fluid resuscitation as well as
multiple pressors including Dopamine, Dobutamine,
Neo-Synephrine and Levophed. On [**12-27**] the patient had her
Hickman line pulled, femoral cath was in place for dialysis.
She continued to be hypotensive and she started on Levophed
for a better control. Respiratory status was not improving.
Her ABG was then on bi-pap and eventually had to be
intubated. The patient had a TEE for evaluation of a
questionable endocarditis which eventually was negative. The
patient, on the 8th, had a Swan Ganz catheter placed for
evaluation of her decreased blood pressure. It was
established that the patient had had a myocardial infarction
after hematocrit had dropped down to 20. The patient was
transfused, however, patient's elevated CKs and troponin
revealed that the patient had a myocardial infarction. The
patient had a repeat echocardiogram which showed severe
globally diffuse LV function compared to her previous
echocardiogram when she was admitted to the hospital on the
C-Med service. The patient continued to be hypotensive
despite multiple pressors as well as fluid resuscitation.
The patient continued with her hemodialysis despite being
hemodynamically unstable for a continuous CVVH. The patient
eventually died on [**1-4**] after it was established that patient
would not be able to tolerate any more pressors as well as
CVVH. The patient was made CMO and died comfortably with
Morphine. The patient's family was well aware and was fully
involved with the decision making process. The patient died
comfortably.
DR.[**Last Name (STitle) 2437**],[**First Name3 (LF) **] 12-664
Dictated By:[**Last Name (NamePattern1) 6234**]
MEDQUIST36
D: [**2107-1-11**] 11:24
T: [**2107-1-12**] 20:37
JOB#: [**Job Number 99208**]
1
1
1
R
|
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|
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icd9pcs
|
[
[
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1486, 3908
|
1080, 1468
|
102, 504
|
527, 1057
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,669
| 133,062
|
36333
|
Discharge summary
|
report
|
Admission Date: [**2172-6-12**] Discharge Date: [**2172-6-27**]
Date of Birth: [**2101-1-22**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Methotrexate / Tetracycline
Attending:[**Male First Name (un) 4578**]
Chief Complaint:
Question of new thoracic aneurysm disection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 71 y/o gentleman with a history of a thoracic
aortic aneurysm and now with a questionable new dissection,
found
at [**Hospital3 **]. The current non-contrast CT of the chest is
consistent with a 5.3 cm thoracic aneurysm from the proximal
arch
to the level of the pulmonary veins and small focal aortic
dissection involving the mid to distal thoracic aorta at the
level of the left inferior pulmonary vein. The patient was
admitted to [**Hospital3 6592**] from his nursing home 24 hrs prior
for
possible hemoptysis and difficulty breathing. The patient is
suffering from Alzheimer's disease and is a poor historian -
historical information is being relayed via his health care
proxy. On transfer to [**Hospital1 18**] via [**Location (un) 7622**] the patient denies
pain, however, received fentanyl, labetolol, and nipride
enroute.
The patient was bradycardic on transfer, yet hemodynamically
stable.
Past Medical History:
Known thoracic aneurysm
HTN
CAD s/p past MI
PVD
CKD
PSH: thoracic aneurysm repair '[**61**], L. fem-[**Doctor Last Name **] bypass
Social History:
Lives in a NH Forest View in [**Location (un) **], MA: [**Telephone/Fax (1) 82314**]
Patient has a Health Care Proxy: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 82315**] - Phone:
[**Telephone/Fax (1) 82316**]
Family History:
N/C
Physical Exam:
Per Vascular Surgery Team on Admission:
Vital signs: HR 90s BP 156/56 (145-162/50-67) RR 14
General: Alert w/ episodes of confusion. NAD
neck: No JVD
Cards: Irreg/Irreg no mrg
Lungs: cta , B/L
Abd: soft, NT, ND
LE w/o edema
Pulses: Rad Fem [**Doctor Last Name **] DP PT
R. palp palp palp tri tri
L. palp palp palp tri tri
pulses equal both sides
Pertinent Results:
[**2172-6-19**] 06:20AM BLOOD WBC-7.8 RBC-3.27* Hgb-9.8* Hct-29.9*
MCV-92 MCH-29.9 MCHC-32.7 RDW-16.6* Plt Ct-194
[**2172-6-14**] 02:23AM BLOOD Neuts-67.9 Lymphs-21.2 Monos-6.9 Eos-3.8
Baso-0.1
[**2172-6-19**] 06:20AM BLOOD Plt Ct-194
[**2172-6-17**] 06:30AM BLOOD PT-19.7* PTT-32.8 INR(PT)-1.8*
[**2172-6-19**] 06:20AM BLOOD Glucose-82 UreaN-42* Creat-2.0* Na-144
K-3.5 Cl-107 HCO3-24 AnGap-17
[**2172-6-17**] 06:30AM BLOOD Glucose-92 UreaN-46* Creat-2.2* Na-139
K-3.7 Cl-103 HCO3-24 AnGap-16
[**2172-6-17**] 06:30AM BLOOD CK(CPK)-49
[**2172-6-14**] 02:23AM BLOOD CK(CPK)-66
[**2172-6-13**] 03:50AM BLOOD ALT-18 AST-26 LD(LDH)-231 CK(CPK)-43
AlkPhos-100 TotBili-0.4
[**2172-6-17**] 06:30AM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2172-6-14**] 02:23AM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2172-6-19**] 06:20AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.4
[**2172-6-17**] 06:30AM BLOOD Calcium-7.6* Phos-3.3 Mg-2.6
[**2172-6-14**] 02:23AM BLOOD TSH-4.1
[**2172-6-16**] 06:20AM BLOOD Digoxin-1.5
CHEST (PORTABLE AP) Study Date of [**2172-6-17**] 1:32 PM
FINDINGS: Comparison made to [**2172-6-12**]. Enlarged
cardiomediastinal contours are unchanged. Mediastinal widening
is not significantly changed. Left basilar atelectasis not
significantly changed. Lungs otherwise clear. Minimal bilateral
pleural effusions are stable. Surgical clips in the mediastinum
are again noted. There is no pneumothorax.
CTA PELVIS/Abd/Chest W&W/O C & RECONS Study Date of [**2172-6-13**]
9:18 AM
CT OF THE CHEST WITH IV CONTRAST: Coronary artery calcifications
are present along with aortic annular calcifications. Surgical
clips are seen within the anterior mediastinum. Otherwise, the
heart and pericardium are unremarkable, without pericardial
effusion. There are scattered mediastinal lymph nodes, which are
slightly prominent, measuring up to approximately 1.2 cm in
short axis along the right paratracheal station.
Bilateral pleural effusions are present, which are moderate in
size. There is associated opacification of the adjacent lung,
likely reflecting atelectasis. Additional patchy opacities in
the upper lobes bilaterally, may reflect additional areas of
atelectasis or, alternatively, this may reflect an infection or
inflammatory changes. Small thyroid nodules are evident.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver, spleen, pancreas
and adrenal glands are unremarkable. There are numerous
gallstones, without evidence of cholecystitis. Within bilateral
kidneys are innumerable rounded hypodensities, which are
incompletely characterized, as some of these are not clearly a
simple cyst. The kidneys are otherwise unremarkable.
The stomach and small bowel are normal. There is diverticulosis
of the colon, without evidence of diverticulitis. There is no
free air or free fluid. Few scattered retroperitoneal lymph
nodes are seen, which are not pathologically enlarged by CT size
criteria.
CT PELVIS WITH IV CONTRAST: Foley catheter is in the bladder.
Prostate and
rectum are unremarkable. Incidentally noted is a small right
inguinal hernia, containing a loop of small bowel, without
evidence of obstruction. There is no free air or free fluid.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is
identified.
There are multilevel degenerative changes of the thoracolumbar
spine.
AORTA: There has been prior ascending aortic surgical repair
with a graft
seen. There is aneurysmal dilatation of the aortic arch, which
measures
approximately 4.9 cm in maximal dimensions, with an additional
aneurysm
involving the descending thoracic aorta which measures 4.9 cm
transverse x 4.8 cm AP, and spans approximately of 5 cc in
craniocaudad dimensions. Immediately inferiorly, there is a
focal thoracic aortic dissection, in an infra- subclavian level,
which spans approximately 4 cm of the thoracic aorta in
craniocaudad dimensions. The intimal flap is located along the
medial aspect of the aorta.
Additional infrarenal abdominal aortic aneurysm is evident,
measuring
approximately 4.0 cm AP x 4.3 cm transverse, with irregular
atheromatous
plaque seen throughout. This abdominal aortic aneurysm extends
into bilateral common iliacs, with the right common iliac artery
measuring up to 2.3 cm in maximum dimensions, and the left
measuring up to 2.0 cm. Extensive atherosclerotic plaque is seen
throughout the abdominal aorta as well as the takeoff of the
celiac, SMA, as well as renal arteries bilaterally.
There is thrombus of the right external iliac and right common
iliac arteries, without any contrast opacification identified.
IMPRESSION:
1. Thoracic aortic aneurysms as detailed above, with a focal
dissection seen within the distal descending thoracic aorta,
which involves a short segment.
2. Abdominal aortic aneurysm.
3. Occlusion of the right external iliac artery and common
femoral artery.
4. Post-surgical changes of the ascending aorta seen.
CHEST (PORTABLE AP) Study Date of [**2172-6-12**] 10:10 PM
The cardiomegaly is moderate to severe. The mediastinum is
widened that might be related to aortic dissection. Left basal
opacity is present that might represent area of atelectasis.
There is minimal bilateral pleural effusion. There is no
evidence of pulmonary edema. There is no pneumothorax. Three
surgical clips are projecting over the anterior mediastinum,
related to prior aortic surgery.
CARDIOLOGY:
Portable [**Date Range **] (Complete) Done [**2172-6-17**] at 11:02:13
Conclusions
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). There
is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The descending thoracic aorta is mildly dilated. The
aortic arch is not well seen. No dissection flap is seen (best
excluded by TEE or thoracic MR/CT). 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
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension.There is no pericardial effusion.
IMPRESSION: Dilated ascending and descending thoracic aorta.
Minimal aortic valve stenosis. Mild aortic regurgitation. Mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function. Mild pulmonary artery
systolic hypertension.
.
ECG Study Date of [**2172-6-14**] 5:56:36 AM
Atrial flutter with rapid ventricular response
Left anterior fascicular block Consider left ventricular
hypertrophy and possible biventricular hypertrophy Anterolateral
ST-T abnormalities - cannot exclude in part ischemia Clinical
correlation is suggested
Since previous tracing of [**2172-6-12**], atrial flutter and further
ST-T wave changes are now present
.
Cardiology Report ECG Study Date of [**2172-6-12**] 9:53:12 PM
Sinus bradycardia
Left atrial abnormality
Left anterior fascicular block
Consider left ventricular hypertrophy and biventricular
hypertrophy
Anterolateral T wave abnormalities - cannot exclude ischemia
Clinical correlation is suggested
No previous tracing available for comparison
Brief Hospital Course:
[**2172-6-12**] patient was transferred from [**Hospital3 **] for a new
disecting thoracic aneurysm.
.
# Thoracic aortic aneurysm/dissection: The current non-contrast
CT of the chest is consistent with a 5.3 cm thoracic aneurysm
from the proximal arch to the level of the pulmonary veins and
small focal aortic dissection involving the mid to distal
thoracic aorta at the level of the left inferior pulmonary vein.
The patient was admitted to [**Hospital3 6592**] from his nursing home
24 hrs prior for possible hemoptysis and difficulty breathing.
The patient is suffering from Alzheimer's disease and is a poor
historian - historical information was relayed via his health
care proxy. On transfer to [**Hospital1 18**] via [**Location (un) 7622**] the patient
denies pain, however, received fentanyl, labetolol, and nipride
enroute.
The patient was bradycardic on transfer, but hemodynamically
stable. His metoprolol was stopped for bradycardia. Patient was
treated medically w/ antihypertensives to keep his pressure
down. He initially required a Nitro drip with a clonidine patch,
PO hydralizine, and amlodipine. Home dose Lisinopril was held
in the setting of acute on chronic renal failure, but re-started
later during his admission. Carvedilol was added for rate and
pressure control.
.
# HTN: as previously stated required a combination of
medications to control his BP, and currently on Amlodipine,
Clonidine, Lisinopril, Carvedilol, and Furosemide.
.
# Arrythmias: Patient had episoded of Bradycardia,
Arial-flutter, and Atrial-fibrillation. Cardiology was consulted
and Digoxin was held due to the bradycardia - was not resumed.
After the A-flutter/A-fib episodes, patient was placed on
Diltiazem drip. He was loaded w/ Amiodarone 200 PO TID, then
switched to 200 mg daily. Also, carvedilol was started for rate
and rhythm control. Then patient had prolongued his QTc up to
580, therefore amiodarone was stopped. Patient kept rate
controlled with coreg alone.
.
# CAD: Patient had ruled out for MI. Started on baby Aspirin.
[**Name2 (NI) **]: Dilated thoracic aorta. Min AVS. Mild AR. Mild symmetric
LVH with preserved global and regional biventricular systolic
function. He will follow-up with his cardiologist Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 174**] - [**Telephone/Fax (1) 82317**]
.
# Delirium: patient had bouts of confusion requiring 1:1 sitter.
Initial episode consistent with delirium, but [**Name8 (MD) **] RN from
nursing home, sundowning has been an increasing problem
beginning in the early afternoon and continuing until midnight.
On [**2172-6-20**] he became very agitated and pulled out his foley
catheter. He required IM haldol and risperidone, which also
matched with the acute worsening of his QTc from 420s to 580.
Haldol was stopped. Infectious work up was negative, patient was
re-oriented, received lactulose to move his bowels and he
improved. He is currently at his baseline regarding his
dementia.
.
# Chronic kidney disease: Per nursing home his baseline cr is
2.2. He had a rise in Creatinine after CTA peaked at 2.4.
Lisinopril was re-started afterward. Given his volume overload,
furosemide 40 mg [**Hospital1 **] was started with good effect. Now his
creatinine has been from 2.7-3.1 after starting ACEI, which is
close to 10% decrease in eGFR. We accepted this bump given the
patient's prior difficult to control blood pressure. All
medications need to be renaly dosed.
.
# PVD- no acute issue at this time.
.
# CODE - Patient was DNR/DNI while in house, confirmed with
Health care proxy (HCP [**Name (NI) **] [**Telephone/Fax (1) 82318**]).
Medications on Admission:
trazadone 50 mg HS
allopurinol 300 mg daily
combivent q6h PRN wheezing
namenda 5 mg daily
clonidine 0.2 mg [**Hospital1 **]
lipitor 10 mg daily
lisinopril 20 mg daily
digoxin 0.25 mg daily
synthroid 50 mcg daily
asa 325 mg daily
coumadin alternating 5mg and 4mg daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Memantine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Alzheimer's Disease.
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours).
8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO NOON (At
Noon).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Insulin Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-60 mg/dL [**1-24**] amp D50
61-120 mg/dL 0 Units
121-160 mg/dL 2 Units
161-200 mg/dL 4 Units
201-240 mg/dL 6 Units
241-280 mg/dL 8 Units
> 280 mg/dL Notify M.D.
12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patches
Transdermal once a week.
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day.
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for yeast.
17. Clobetasol 0.05 % Solution Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
18. Fluocinonide 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
19. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
20. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
22. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for Constipation.
23. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) **]
Discharge Diagnosis:
Dissecting thoracic aneurysm
Delirium
HTN
Atrial fibrillation
Atrial flutter
Discharge Condition:
Hemodynamically stable, without pain
Discharge Instructions:
You were admitted for a dissecting thoracic descending aneurysm.
The vascular surgeons evaluated you and you were threated
medically, and will continue to be. We have changed many of
your medications to control your blood pressure. Additionally,
your heart rate was irregular, also known as Atrial fibrillation
(A-fib). You will need to follow-up with your cardiologist.
Your coumadin is being held because the level (INR) is too high.
Please have your level checked daily and restart coumadin only
when the level is between [**2-25**].
.
Medication changes:
- Please stop taking digoxin
- Allopurinol was decreased to 100 mg daily
- Lisinopril was changed to 20 mg daily
- Clonidine was changed to a weekly patch changed on Fridays
with dose of 0.3 mg/24hr
- Hydralizine, amlodipine, and carvedilol were added to control
blood pressure.
.
Please seek medical attention if you have chest pain, shortness
of breath, back or stomach pain, dizzyness/lightheadedness, or
other concerns.
Followup Instructions:
Please follow up with your cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] - Phone:
[**Telephone/Fax (1) 82317**], within 2 weeks.
.
You also need to follow-up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]
[**Telephone/Fax (1) 8129**], within 2-4 weeks for new medications that were
started.
.
Please follow- up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 1391**] from Vascular
surgery in 3 months for a repeat CTA for the aneurysm call his
office at [**Telephone/Fax (1) 1393**].
|
[
"294.10",
"244.9",
"996.79",
"585.9",
"427.89",
"441.02",
"331.0",
"428.0",
"428.32",
"427.32",
"E879.9",
"584.9",
"403.90",
"511.9",
"427.31",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15542, 15612
|
9619, 13245
|
370, 376
|
15733, 15772
|
2166, 9596
|
16805, 17427
|
1735, 1740
|
13563, 15519
|
15633, 15712
|
13271, 13540
|
15796, 16337
|
1755, 1781
|
16357, 16782
|
287, 332
|
404, 1319
|
1795, 2147
|
1341, 1473
|
1489, 1719
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,776
| 124,803
|
339
|
Discharge summary
|
report
|
Admission Date: [**2178-4-25**] Discharge Date: [**2178-4-30**]
Date of Birth: [**2138-6-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
etoh withdrawl, rhabdomyolysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 39 yo male with pmhx HIV (unknown cd4, viral
load)on HAART brought in by police after being found down behind
a dumpster. No records available in computer and ED thinks that
pt gets most of his care at [**Hospital1 2177**]. Neurology was initially
consulted for altered mental status which they attributed to
toxic/metabolic issues, etoh intoxication, UTI but recommended
that if he continued to have altered sensorium and not clear
appropriately to consider LP for CNS infection and MRI to r/o
toxo, PML, etc. Head CT was negative. Serum etoh was 229 and he
had an anion gap of 39 on presentation to the ED. He was going
to be admitted to the floor, but the floor team asked for
additional studies to work up his anion gap and he was found to
have a lactate of 8. He was given broad spectrum abx including
vancomycin, levaquin and ceftriaxone. Toxicology was consulted
and recommended checking an osm gap which was 79 by my
calculation. Toxicology recommended giving IVF and if the
lactate and osmolar gap improved with fluid, then it was
unlikely to be due to ethylene glycol or methanol intoxication.
After 5 liters of IV NS, lactate decreased from 8-->5. Repeat
osm pending currently. During his ED course, patient was noted
to become tremulous and taccycardic and was thought to be
undergoing withdrawl. He was given a total of 20 mg valium and 2
mg ativan. His cks were also checked and found to be
significantly elevated > 6000 and he was given approx 5 liters
ns (one of the liters was bannana bag). He was then transferred
to the ICU for further management.
.
In the ED, his initial vs were: T 97.8 P 88 BP 148/90 RR 18 O2
sat 100% RA. He was given acyclovir, ceftriaxone, levaquin,
vancomycin. Blood and urine cx were not drawn prior to these
antibiotics. He also received valium po 20 mg and 2 mg IM ativan
as well as 5 liters IV NS and bananna bag.
On presentation to the ICU, his initial vs were: T 97.2 P 124 BP
124/66 RR 17 O2 sat 99% RA. He reported feeling dehydrated,
dizzy, mild headache, whole body feels stiff including neck,
pain in legs from sunburn. Denies cp, sob, abd pain.
Past Medical History:
HIV on HAART
ETOH abuse
Social History:
Works as an accountant. Homosexual, lives with his male
partner. Drinks, but no drugs or tob. Recently got into fight
with parnter.
Family History:
NC
Physical Exam:
VS: T 97.2 P 124 BP 124/66 R 17 O2 sat 99% RA.
GEN: agitated
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MM extremely dry, Neck supple, moves in all
directions without pain, no LAD, no carotid bruits
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r, decreased at bases b/l
ABD: soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL
NEURO: alert & oriented x 2, CN II-XII grossly intact, 4-/5
strength throughout. No sensory deficits to light touch
appreciated. No asterixis
SKIN: sunburn
PSYCH: agitated, oriented to person and date, thinks he is at
[**Hospital1 **]
Pertinent Results:
Labs:
144 94 27 AGap=43
-------------< 86
3.5 11 1.4
.
most recent chem-7 3:30 am
135 98 26
--------------< 81 AGap=30
3.9 11 1.1
.
Lactate 8.0 --> 5.7
.
estGFR: 56/68 (click for details)
CK: 6061 --> 4580
.
Serum EtOH 229
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
urine tox negative
Osms:378 --> currently pending
15.9 MCV101
3.7 >< 103
47.0
N:89.7 Band:0 L:6.2 M:3.7 E:0.3 Bas:0.1
.
PT: 16.7 PTT: 27.6 INR: 1.5
.
UA: Color Yellow Appear Clear SpecGr 1.014 pH 5.0 Urobil Neg
Bili Neg Leuk Neg Bld Tr Nitr Neg Prot 30 Glu Neg Ket 50
RBC 0-2 WBC [**10-29**] Bact Mod Yeast None Epi 0-2 Other Urine
Counts
CastGr: 0-2 Fine Granular Casts
.
Imaging: No evidence of acute intracranial hemorrhage.
.
ekg: 104, nl asix, sinus, nl intervals.
.
L Thigh Ultrasound: [**2178-4-30**]: Grayscale and color flow images of
the left upper thigh was performed. The area was completely
interrogated. No hematoma, abscess was noted. There is diffuse
soft tissue swelling at the site of visualized abrasions.
IMPRESSION: No hematoma or abscess in the left upper thigh.
.
CT head [**2178-4-25**]:
FINDINGS: There is no evidence of acute intracranial hemorrhage,
shift of midline structures or hydrocephalus. [**Doctor Last Name **] and white
matter differentiation appears preserved. Visualized paranasal
sinuses are normally aerated. Mild opacification of left mastoid
air cells noted.
IMPRESSION: No evidence of acute intracranial hemorrhage.
.
Brief Hospital Course:
A/P: Pt is a 39 yo man with pmhx HIV with unknown cd4 count
admitted here with etoh intoxication, now withdrawl,
rhabdomyolysis, hepatitis, elevated anion and osmolar gap. He
was initially admitted to the MICU given his altered mental
status, and was transferred to the floor after his mentation
improved.
.
# ETOH withdrawl- Patient received total of 30mg Valium and 2mg
Ativan. On CIWA protocol. Continued on multivitamin, thiamine,
and folate. Patient was seen by social work. He did not require
any further diazepam on his last 3 days in house as his CIWAs
were [**1-11**]. At times, it was felt that the patient was
confabulating.
# Altered mental status- On admission, the differential included
toxic/metabolic causes including acidosis, urinary tract
infection, etoh withdrawl. Head ct was negative. Neurology was
consulted in the ED and recommended LP and MRI. LP was hled as
he was agitated and he was treated empirically for meningitis
with ceftriaxone, acyclovir and vanco. His mentation improved
quickly and it was eventually felt that his AMS was primarily
from EtOH intoxication. Cxr, bld/urine cx were negative
infectious source
.
# Tacchycardia- This was likely multifactorial with multiple
possible causes such as etoh withdrawl, pain, volume depletion
and anxiety although he has received 5 liters in ED.
-ekg -> sinus tachy
-treated ? UTI -> urine cx negative
- continued to be slighlty tachycardic to the 90s on discharge.
He reported that he was anxious about confronting his partner.
.
# Anion gap metabolic acidosis with osmolar gap- On admission,
his anion gap was felt likely due to etoh ketoacidosis, lactic
acidosis (? [**1-10**] [**Doctor Last Name **]) but he has osmolar gap concerning for
other toxic ingestions.
- his lactate improve, his anion and osmolal gaps returned to
[**Location 213**] with IVFs
.
# HIV- the patient citing confidentiality refused to allow me to
contact his ID specialist or PCP regarding his [**Name9 (PRE) 2775**] regimen or
other medications.
- as such he was asked to make a follow up appointment and
restart his medications.
- started on daptomycin and azithromycin for PPX
.
# UTI- Patient has positive UA.
-f/u urine culture and UA were negative
.
# [**Name (NI) 3148**] pt found down by police which is the likely
cause of his rhabdo. Tox screen otherwise negative. No evidence
of seizure activity that was witnessed.
-his CK was in the 6000 range on admission and continued to
trend down on discharge with IVFs. His Cr was 1.4 on admission
and 0.6 on discharge.
.
# Acute renal failure- thought to be prerenal - improved with
IVFs
.
# Thrombocytopenia- likey due to combination of etoh abuse and
HAART therapy and HIV infection. In addition, he was treated
with chemotherapy
- We did not know his baseline platelet count, and he refused to
give permission to me to contact his PCP/ID specialist.
- he did not require plt transfusions and his plt was in the low
30s on discharge.
.
# Transaminitis: His ALT was 279 and his AST was 376 on
admission and trended down to 95/100, respectively, on
discharge. This was felt to be from EtOH, ? underlying liver
disease and/or medication induced. Bilirubin was not elevated;
1.8 on admission -> 1.1 on discharge. He was asked to follow
this up with his PCP.
.
# L thigh contusion: He was found to have a raised L thigh
contusion/bruise. Given its raised nature, and low hematocrit,
an ultrasound was done to rule out underlying hematoma/abscess.
He did not have fevers, warmth or erythema beyond the area of
desquamation c/w cellulitis. Given his immunocompromised state,
he was given 7 days of clindamycin to prevent infection and
asked to change dressings on this area daily. Surgery was
consulted and did not feel that this was antyhing more than a
contusion/deep bruise.
.
# Discharged : to a friend's house. He did not want to go to a
shelter in lieu of going home.
Medications on Admission:
per my discussion with patient on the [**Hospital1 **]:
- 4 HAART drugs
- Dapsone
Discharge Medications:
1. Clindamycin HCl 150 mg Capsule Sig: One (1) Capsule PO three
times a day for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
2. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*21 Tablet(s)* Refills:*0*
3. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO QMON (every
Monday) for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 21 days.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Alcohol intoxication
.
Secondary Diagnosis:
Rhabdomyolysis
AIDS
thrombocytopenia
Elevated LFTs
Anemia
Discharge Condition:
AAO x 3
Afebrile
Discharge Instructions:
You were admitted for alcohol intoxication, rhabdomyolysis
(muscle breakdown) and altered mental status. These problems
have resolved.
.
We also found that your liver enzymes were elevated, that your
platelets are low. These could be from your disease, your
alcohol intake or your HAART medications. Since you did not give
us permission to contact your primary care physician or your ID
physician, [**Name10 (NameIs) **] could not corroborate how changed these were from
your baseline levels. As such, I recommend that you make an
appointment in the next week with your primary care doctor to
follow up these tests.
.
You were also found to have a L thigh contusion. Please change
the dressings daily on this and use the antibiotic provided so
that the area does not become infected.
.
Please stop drinking alcohol.
.
If you develop any headaches, cp, sob, fevers, or other
concerning symptoms, please call your primary care doctor or go
to the nearest emergency room.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3149**] to arrange for a follow up
appointment regarding your recent hospitalization. Since you did
not give us permission to contact your PCP, [**Name10 (NameIs) **] will have to do
this.
Completed by:[**2178-5-3**]
|
[
"577.0",
"202.80",
"070.32",
"276.51",
"303.00",
"518.89",
"728.88",
"291.81",
"E888.9",
"785.0",
"287.4",
"276.2",
"V08",
"599.0",
"924.00",
"571.1",
"291.2",
"284.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9589, 9595
|
4906, 8786
|
312, 319
|
9760, 9779
|
3330, 4883
|
10796, 11089
|
2680, 2684
|
8918, 9566
|
9616, 9616
|
8812, 8895
|
9803, 10773
|
2699, 3311
|
242, 274
|
347, 2465
|
9679, 9739
|
9635, 9658
|
2487, 2512
|
2528, 2664
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,217
| 164,505
|
22527
|
Discharge summary
|
report
|
Admission Date: [**2141-4-1**] Discharge Date: [**2141-4-6**]
Date of Birth: [**2056-4-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Chief Complaint: Lethargy and abnormal labs
Reason for MICU transfer: Sepsis and acute encephalopathy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 year old male with history of senile/vascular dementia
(baseline AAOx1), sick sinus/syncope s/p PPM, moderate AS (TTE
in [**2134**]), and prior MRSA pneumonia, referred to [**Hospital1 18**] ED from
her nursing home ([**Hospital **] Rehab [**Telephone/Fax (1) 41602**]) with a 1-week
history of lethargy and "abnormal labs", with only BUN slightly
elevated. He was managed with IV hydration for a few days and
initially improved, but then noted to have decreased O2 sats
(rehab unsure how low they went on room air). He is on
aspiration precautions and given nectar-thickened liquids at his
nursing home. He was placed on O2 and noted to be 88% on 2L NC
with increased RR to 24 and noted decreased PO intake. He is
normally oriented to himself, but generally confused and
tolerates PO intake well. He has a CBI catheter with irrigation
in place since last year for frequent UTI with recent change
after a malfunction last week. He is completely dependent with
ADLs.
Vital signs on transfer from nursing home were: T 98.8 BP
118/76, HR 112, RR 24, O2 sat 88% on 2L. EMS was called and
provided additional IVF given hypotension as well as
supplemental O2 en route. FSBG measured at 135.
He was recently seen by Neurology ([**2141-2-19**]) for his seizure
disorder, not having seen him for 2 years. They noted his
significant decline in mental status compared to that time and
felt his leukopenia might be attributable to the [**Last Name (LF) 13401**], [**First Name3 (LF) **] this
is being transitioned to lamotrigine. Cardiology saw him in
[**2141-1-19**] and confirmed appropriate function of his PPM.
In the ED, initial VS were: 98 70 81/52 22 96% 4L NC. Exam was
notable for complete disorientation (AAOx0), diaphoretic, opens
eyes and responds to voice and name, guiaic negative brown
stool, III-IV SEM heard throughout precordium, and a CBI
catheter. Urinalysis showed many WBCs, large leuk esterase with
significant amount of bacteriuria and CXR showed concern for a
RML/RLL infiltrate. He was subsequently covered with cefepime,
vancomycin, and Flagyl. IVFs 1.5L. BP improved to 100-120s/60s
and mental status very slightly improved. Urine output hard to
quantify given CBI. HCP was [**Name (NI) 653**] in the [**Name (NI) **] and he is a
confirmed full code.
On arrival to the MICU, patient's VS: HR 70 BP 106/45 RR 22 SpO2
97%/RA. He is lethargic and unable to answer many questions but
states that his breathing feels ok and and he denies any pain.
From speaking with his nursing home, he is normally verbal but
consused, A&Ox1. Over the past week, they note that he has been
more lethargic and eating less. Today was the first day they
noted him to be hypoxic. No fevers per their report.
Review of systems: (+) per HPI, otherwise unable to complete
given patient disorientation
After stqbilization of the patient's sepsis in the medical ICU,
the patient was transitioned to the hospital medicine service
for ongoing care.
Past Medical History:
- senile dementia
- seizure disorder likely secondary to his vascular events
(hasn't had seizure for quite awhile per nursing home reports;
witnessed tonic-clonic seizure in [**4-/2135**] and then in [**7-/2135**])
- hypertension
- abdominal aortic aneurysm
- status post pacemaker placement ([**2134-10-18**]) for sick
sinus/syncope
----[**Company 1543**] Enpulse DR E2DR31, last interrogation [**2140-7-31**]
with atrial fibrillation with vent rate of 50-80, > 90% and has
been since his clinic visit in [**Month (only) 958**]. He had no ventricular high
rates. He has been paced < 1%. DDI mode, lower rate 55 bpm, AV
delay 300 milliseconds.
- Last ECHO ([**2135-5-9**]), LVEF 60 %, moderate AS
- history of vertebral body fracture
- BPH
- history of MRSA pneumonia
- C. difficile colitis
Social History:
Unable to obtain from the patient. Currently living in a nursing
home (Stonehedge). Dependent for ADLs and IADLs.
From previous d/c summary: Former 4 pack/day smoker, quit about
50 years ago. Drinks 1 beer daily, but unclear if this is
current.
Family History:
FH: Non-contributory to this presentation with sepsis.
Physical Exam:
Admission Physical Exam:
Vitals: HR 70 BP 106/45 RR 22 SpO2 97%/RA
General: Lethargic, arousable to voice
HEENT: Dry MMM
Neck: JVP difficult to assess, appears to be 6-7cm
CV: Irregular rhythm (demand paced), [**1-24**] crescendoo-descrescndo
murmur heard through the precordium and the back
Lungs: Quiet breath sounds but otherwise clear
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: 3-way Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Patient not cooperative with full exam. Moving all 4
extremities on command.
Discharge physical exam:
Physical exam
Vital signs: Tmax afeb BP 109-127/70-85 HR 91 94% RA O2 sat
BM X 4. I/O 1120/2050.
General: lying in bed, somnolent, arousable.
HEENT: OP moist, no LAD appreciated, jvp not elevated.
Lungs no rales appreciated anteriorly, but coarse bilaterally.
CV: irregular with 3/6 systolic harsh murmur heard throughout
precordium.
Abdomen soft, NT, ND, NABS
Ext: no edema
Neuro: alert/oriented to self, in Valley forge, in hospital,
not
to date. moves all extremities, follows simple commands, eomi.
GU: foley catheter in place, yellow urine
Skin: small stage II ulcer on coccyx.
Pertinent Results:
ADMISSION LABS:
[**2141-4-1**] 10:50AM BLOOD WBC-2.5* RBC-3.86* Hgb-10.6* Hct-34.0*
MCV-88 MCH-27.5 MCHC-31.2 RDW-15.1 Plt Ct-235
[**2141-4-1**] 10:50AM BLOOD Neuts-52.8 Lymphs-35.8 Monos-5.8 Eos-4.4*
Baso-1.3
[**2141-4-1**] 11:30AM BLOOD PT-12.9* PTT-27.9 INR(PT)-1.2*
[**2141-4-1**] 10:50AM BLOOD Glucose-124* UreaN-21* Creat-0.8 Na-143
K-4.5 Cl-109* HCO3-25 AnGap-14
[**2141-4-1**] 10:50AM BLOOD ALT-19 AST-31 AlkPhos-74 TotBili-0.3
[**2141-4-1**] 10:50AM BLOOD Lipase-34
[**2141-4-1**] 10:50AM BLOOD cTropnT-<0.01
[**2141-4-1**] 10:50AM BLOOD Albumin-2.6* Calcium-8.5 Phos-2.7 Mg-2.1
[**2141-4-1**] 11:08AM BLOOD Lactate-2.8*
[**2141-4-1**] 09:15PM BLOOD Lactate-1.6
[**2141-4-1**] 10:50AM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.009
[**2141-4-1**] 10:50AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2141-4-1**] 10:50AM URINE RBC-72* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
[**2141-4-1**] 10:50AM URINE WBC Clm-MANY Mucous-OCC
.
MICROBIOLOGY:
Micro - c diff negative, urine culture from admission
contaminated, blood cultures from admission no growth to date.
ECHO [**4-3**]:
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. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF>75%). There is no ventricular
septal defect. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). 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 a
rhematic deformity of the tricuspid valve. Tricuspid
regurgitation is present but cannot be quantified. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2135-5-9**],
the degree of AS is now slightly more severe (mean gradient now
61 mmHg vs 38 mmHg on prior) with more hyperdynamic LV systolic
function.
IMAGING:
-[**4-1**] CXR:
FINDINGS: Lung volumes are low. There is a right pleural
effusion and right basilar consolidation. No pneumothorax is
detected on this view. Heart and mediastinal contours are
similar to [**2134**], but difficult to evaluate in the setting of low
lung volumes. Pacing hardware appears similarly position.
IMPRESSION: Small right pleural effusion with right lower lung
opacity, which could represent atelectasis, aspiration, or
pneumonia.
Discharge labs:
[**2141-4-6**] 08:45AM BLOOD WBC-1.9* RBC-3.67* Hgb-10.1* Hct-31.5*
MCV-86 MCH-27.6 MCHC-32.1 RDW-15.3 Plt Ct-231
[**2141-4-6**] 08:45AM BLOOD Glucose-89 UreaN-6 Creat-1.0 Na-139 K-3.7
Cl-105 HCO3-27 AnGap-11
Brief Hospital Course:
Impression: The patient is an 84 year old man with history of
dementia, sick sinus syd s/p PPM, moderate AS, prior MRSA
pneumonia and C. diff colitis, with indwelling catheter, and a
seizure disorder, presenting with sepsis secondary to likely
pulmonary sources. He was initially admitted to the ICU for
early goal-directed therapy for the sepsis, and was later
transitioned to the hospital medicine service once the sepsis
had been stabilized, and continuosly improved until discharge
back to his long term nursing home.
Acute Issues
# Sepsis: Upon admission, the most likely source was the urinary
tract given his chronic 3-way urinary catheter at rehab and his
UA with >182 WBCs. Aspiration PNA may also have played a role
given his RML/RLL infiltrates on CXR and his poor mental status
with high risk for aspiration. There was no report of fevers or
diarrhea at rehab. He was mildly hypotensive on arrival to the
[**Hospital Unit Name 153**] with SBP in the 80s on no pressors. His BP's improved to
the 100-120s after about 1L total of fluids, and he received
empiric vanc/Zosyn for presumed urosepsis as well as MRSA
covereage given the concern for aspiration PNA. Urine culture
was negative, and therefore cause of symptoms presumed due to
aspiration pneumonia. He will complete a course of augmentin at
his facility for pneumonia.
# Acute encephalopathy on admission Patient was reportedly more
lethargic than usual, per direct discussion with the [**Hospital1 1501**] staff.
His baseline MS is A&Ox1 to self, thought to be from vascular
dementia. The most likely cause for his AMS was sepsis from
UTI, but may also have been [**12-22**] to starting lamotrigine
recently, although it would not have been expected to resolve as
quickly as was noted if due to medications. We held his
seroquel and trazodone initially, but continued Celexa. He was
resumed on home trazodone and seroquel at discharge.
# Leukopenia: Unclear etiology, may be related to [**Month/Day (2) 13401**]. He
is currently being transitioned from [**Month/Day (2) 13401**] to lamotrigine in an
attempt to improve his leukopenia. His underlying
infection/sepsis may be acutely lowering his WBC, although he
has evidence of leukopenia prior to his presentation for sepsis.
ANC at admission is 1300 and he is very mildly neutropenic, so
concern for atypical infections was low. The transition off
[**Month/Day (2) **] was continued, after discussion with his neurologist, and
the [**Month/Day (2) 13401**] was decreased from 500 mg twice daily to 250/500.
The recommended plan was to continue to decrease the [**Month/Day (2) **] by
250 mg a week (ie: next dose would be 250/250) as the
lamotrigine was increased by 25/25mg each week until goal of 150
mg po bid. At this time, we increased his lamotrigine to 75/75mg
doses.
# Aortic stenosis: Valve area 0.8cm2 in [**2134**]. He appears
somewhat volume depleted on exam, he has no edema or crackles on
exam. His cardiac exam is consistent with a decreased S2,
suggestive of critical AS. Repeat TTE showed progression of his
aortic stenosis, to severe. As a result, he is likely to be
very sensitive to low blood pressures.
# Hematuria and CBI: Patient presented from rehab with a 3-way
Foley and CBI. His rehab states that he has been on this for at
least a year and plan to continue it indefinitely. He had not
been seen by urology at [**Hospital1 18**] for 2 years. Has had negative
cystoscopy and CT urogram with no clear cause for his hematuria.
We stopped the CBI, with no hematuria, and changed his foley to
a regular foley prior to discharge. CBI SHOULD NOT BE
RESTARTED. If he develops hematuria after a foley catheter
change, this should be monitored for evidence of obstruction.
If he continues to have hematuria or obstruction, CBI can be
started for 24-72 hours as needed until his urine clears again,
at which point it should be stopped. He should follow up with
urology as needed if this persists.
# Goals of care: Upon admission, the [**Hospital Unit Name 153**] team spoke with the
patient's brother, [**Name (NI) **] [**Name (NI) 23203**], who states that he is the
health care proxy and makes decisions for the patient. He
stated that the patient has expressed that he would like
everything done for him, including resuscitation, intubation,
pressors and invasive procedures. This should be re-addressed
with the brother again given severe aortic stenosis, and his
degree of cognitive dysfunction.
Chronic issues:
# Atrial fibrillation. He was rate controlled, not
anticoagulated.
# Chronic dementia. Stable.
TRANSITIONS OF CARE:
1. Antiseizure medications: continue to titrate up to goal
lamotrigine dose of 150 mg po bid, and taper off of
levatericetam over next 3 weeks.
2. Pneumonia: Complete course of augmentin on [**4-9**].
3. Blood cultures pending at discharge.
Medications on Admission:
Medications (from nursing home records):
- ASA 81 mg Po qD
- citalopram 20 mg Po qD
- MVI
- seroquel 12.5 mg PO qD
- colace/senna
- trazodone 25 mg PO BID
- calcium with Vit D
- [**Month/Year (2) **] 500 mg PO BID
- metoprolol 100 mg Po BID
- APAP 1000 mg PO q 8 hr
- lamotrigine 50 mg PO BID - being tapered up this month
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day) for 5 days: through [**4-10**], then increase by 25 mg
[**Hospital1 **] per week.
5. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO once a day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO twice a day.
8. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig:
One (1) Tablet PO twice a day.
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 3 days.
10. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: Hold for HR < 55, SBP < 100.
11. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
every eight (8) hours.
12. levetiracetam 100 mg/mL Solution Sig: Two [**Age over 90 1230**]y
(250) ML PO once a day: IN AM.
13. levetiracetam 100 mg/mL Solution Sig: 5 ML ML PO HS (at
bedtime): AND TAPER AS PER DR. [**First Name (STitle) **], 250 MG/WEEK TAPER UNTIL
OFF.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & [**Hospital **] Care Center - [**Location 1268**]
Discharge Diagnosis:
Aspiration pneumonia
Dementia
Seizure disorder
Leukopenia, possibly related to anti-seizure medication
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound or out of bed with significant
assistance.
Discharge Instructions:
It was a pleasure to care for you during this admission. You
were treated for pneumonia. Your blood pressure was low when
you were admitted, and you were sleepy. These things improved
with intravenous fluids and antibiotics. We stopped the bladder
irrigation and this should not be restarted.
Medication changes:
Augmentin 875 mg po bid for 4 more days
Lamictal increased to 75 mg po bid
[**Location 13401**] decreased to 250 mg/500 mg po bid
Followup Instructions:
Department: NEUROLOGY
When: THURSDAY [**2141-6-15**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 8222**], MD [**Telephone/Fax (1) 2928**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2141-7-25**] at 9:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
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79,051
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48809
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Discharge summary
|
report
|
Admission Date: [**2116-8-26**] Discharge Date: [**2116-8-31**]
Date of Birth: [**2061-8-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
PLIF
History of Present Illness:
53-year-old woman who presents with complaint of back pain. She
describes right lower extremity radiculopathy that proceeds down
the leg and into the big toe. It also involves the bottom of
her foot. She traces the onset to an
accident 2 years ago. She has been seen in the Pain Center
where she underwent epidural steroid injections, which have been
somewhat helpful. Physical therapy since [**2114-11-10**] has only
been helping slightly. She is unable to climb stairs. She no
longer works because she is disabled secondary to her kidney
transplant.
Past Medical History:
1) ESRD since [**2102**] - HD x 7 years s/p cadaveric renal transplant
[**2110-8-11**] at [**Hospital1 2177**]
2) Stroke [**2106**] - Sxs were L-sided hemiparesis, some residual -
uses a cane at times
3) h/o obesity
4) h/o HTN d. [**2097**]
5) R shoulder rotator cuff tear - repair [**1-13**] (Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **])now w/ recurrent tear awaiting completion of fistula
removal prior to return to OR
6) Epilepsy - since stroke in [**2106**]; last sz > 1 [**Last Name (un) **]
7) Depression/Anxiety
8) s/p multiple UTIs since transplant
9) s/p varicose vein stripping on Left
10) post-partum cardiomyopathy
11) small hiatal hernia
12) grade II hemorrhoids
13) h/o colitis [**2107**]
14) s/p CCY [**2082**]
15) L leg abscess 995 s/p I&D
16) LMP - 8 years ago (when started dialysis)
17) LGIB s/p colonoscopy on [**2107-4-19**]
18) bursitis in the knees and ankles
19) migraines
20) toxemia of pregnancy [**2095**]
21) gastroesophageal reflux disease
Social History:
lives at home with 14 yo daughter, has [**Name (NI) 269**]. also w/ 2 older
daughters. no alcohol, tobacco or drugs
Family History:
NC
Physical Exam:
On examination, her motor strength was graded at 5/5 in hip
flexors, extensors, quadriceps, hamstrings, dorsiflexion, and
plantar flexion bilaterally. Her sensory examination revealed a
decreased appreciation of light touch in the left lower
extremity, but in a nondermatomal pattern. Her reflexes were
hypoactive but symmetric in the patellar and Achilles
bilaterally. The straight leg raise was negative bilaterally as
was the [**Doctor Last Name **] maneuver. Her back was flat and nontender.
On discharge:
A&Ox3
PERRL
Motor: D B T IP [**Initials (NamePattern5) 12643**] [**Last Name (NamePattern5) **] AT [**Last Name (un) 938**]
R 5 5 5 5- 5 5 5 5 5
L 5 5 5 5- 5 5 5 5 5
Incision: c/d/i
Pertinent Results:
An MRI of the lumbosacral spine obtained on [**2114-10-11**],
demonstrates a grade 1 spondylolisthesis at L4-L5 with severe
stenosis. There are diffuse spondylitic changes at the other
levels.
Brief Hospital Course:
Pt was admitted electively to hospital, went to OR where under
general anesthesia underwent PLIF L3-4 and L4-5. She tolerated
the procedure well, was extubated, transferred to PACU and then
floor. Diet and actvity were advanced. Pain medication was
transitioned to PO. She had JP drain placed intra-op that was
monitored for output and removed on POD#2. Foley was removed
and she was voiding though required straight cath once POD#2.
here I/Os were closely monitored. Incision was clean dry and
intact with staples. Labs were followed and she recieved 1 unit
PRBC on POD#2 for hematocrit of 24. She was evaluated by PT/OT
and recommended for rehab.
On [**8-31**], foley was dicontinued and she voided once on her own.
Her strength was full when evaluated individually and incision
c/d/i. She was discharged to rehab on [**8-31**].
Medications on Admission:
fosamax, fioricet prn, keppra 750 [**Hospital1 **], Metoprolol 25 [**Hospital1 **],
Omeprazole 20 [**Hospital1 **], MVI, vit D
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
2. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
12. Topiramate 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
13. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for rash.
14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
19. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
20. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Spondylolisthesis
urinary retention
post op anemia with transfusion
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:
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ remove dressing [**2116-8-28**] / begin daily showers
[**2116-8-30**]
?????? If you have steri-strips in place ?????? keep dry x 72
hours. Do not pull them off. They will fall off on their own or
be taken off in the office
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
Followup Instructions:
PLEASE HAVE YOUR STAPLES REMOVED [**9-9**] AT REHAB.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINTMENT
Completed by:[**2116-8-31**]
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"V42.0",
"788.29",
"724.02",
"300.4",
"401.9",
"345.90",
"756.12",
"287.9",
"438.20",
"530.81",
"285.9",
"588.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"81.08",
"77.79",
"84.51",
"80.51"
] |
icd9pcs
|
[
[
[]
]
] |
5752, 5906
|
3043, 3880
|
302, 309
|
6018, 6018
|
2824, 3020
|
7202, 7455
|
2068, 2072
|
4057, 5729
|
5927, 5997
|
3906, 4034
|
6194, 7179
|
2087, 2588
|
2602, 2805
|
253, 264
|
337, 897
|
6033, 6170
|
919, 1917
|
1933, 2052
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,862
| 103,923
|
44513
|
Discharge summary
|
report
|
Admission Date: [**2173-1-4**] Discharge Date: [**2173-1-11**]
Date of Birth: [**2110-10-7**] Sex: F
Service: MEDICINE
Allergies:
Prempro / Fiorinal / Erythromycin Base / Aleve
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62 yo W w/h/o myasthenia [**Last Name (un) 2902**] on immunosuppression, htn,
hyperlipidemia, spinal compression fractures who initially
presented with tachycardia. ROS remarkable for intermittent
sinus pressure/HA, not unusual, no retroorbital pain, ear pain
or pressure, decreased hearing. On admission she was ruled out
for PE. Subsequently she developed a HA, N, V and was treated
with phenergan and lorazepam. Neurology felt symptoms could be
due to narcotic withdrawal and the pt was given Dilaudid 2x 1mg.
Subsequently she became obtunded and hypoxic.
Past Medical History:
1. Myasthenia [**Last Name (un) **]-first diagnosed in [**2163**], followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]
2. multiple spinal compression fractures s/p steroid use for MG
3. hypercholesterolemia
4. h/o migraines
5. seasonal allergies
6. HTN
7. osteoporosis
Social History:
Patient is single, lives alone. She is currently on disability.
She used to work as a histology tech a [**Hospital1 18**]. She denies
tobacco, illicit drugs, occ EToH but none since starting
narcotic medications.
Family History:
Mother: [**Name (NI) 77552**], first age 55, also CHF, deceased age 77; father
with rheumatic heart disease, deceased age 83 CVA; sister died
at age 5 of insulin dependent diabetes mellitus w/PNA.
.
Physical Exam:
VS: 102.4 120 140/85 100% on 50% FM
General: NAD, pleasant well-appering woman
HEENT: PERRL, EOMI without nystagmus, no proptosis, MMM, OP
clear, conj pink/sclera white, hirsuit
Neck: supple, no lad, JVP: 8cm, no bruits
Resp: CTA, scant left basilar crackels, no rhonchi or wheezes
CV: RRR, s1, s2 present, no murmurs, rubs, gallops
Abdomen: protuberant, soft, nontender, nondistended, +BS, no
masses, no HSM
Ext: trace edema, no c/c, 2+ radial, DP pulses bilaterally
Neuro: CN II-XII intact, A&Ox3, motor [**6-12**] UE/LE, lid lag not
tested because of photophobia, good coordination, reflexes
intact 2+ bilaterally
Pertinent Results:
[**2173-1-4**] 10:05PM CK(CPK)-27
[**2173-1-4**] 10:05PM CK-MB-NotDone cTropnT-<0.01 proBNP-<5
[**2173-1-4**] 10:05PM TSH-1.4
[**2173-1-4**] 10:05PM FREE T4-1.2
[**2173-1-4**] 10:05PM D-DIMER-783*
[**2173-1-4**] 01:40PM GLUCOSE-106* UREA N-26* CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2173-1-4**] 01:40PM estGFR-Using this
[**2173-1-4**] 01:40PM CK(CPK)-38
[**2173-1-4**] 01:40PM CK-MB-NotDone
[**2173-1-4**] 01:40PM CALCIUM-9.6 PHOSPHATE-2.6* MAGNESIUM-2.1
[**2173-1-4**] 01:40PM WBC-8.5# RBC-3.71* HGB-12.6 HCT-36.8 MCV-99*
MCH-34.0* MCHC-34.3 RDW-15.3
[**2173-1-4**] 01:40PM NEUTS-77.9* LYMPHS-16.6* MONOS-3.9 EOS-0.8
BASOS-0.9
[**2173-1-4**] 01:40PM POIKILOCY-1+ MACROCYT-2+
[**2173-1-4**] 01:40PM PLT COUNT-242#
[**2173-1-4**] 01:40PM PT-12.1 PTT-23.2 INR(PT)-1.0
Brief Hospital Course:
1. Hypoxia:
This developed in the setting of IV narcotics use; quick
development and rapid improvement was most suggestive of
aspiration in the context of sedation. Contributing could have
been chronic low ventilatory state in the context of OSA and MG,
although MG crisis thought to be unlikely given 5/5 strength
otherwise.
The patient never required intubation and did well after being
dosed with narcan. Overall, her respiratory status improved;
she was continued on BiPAP at night and NIFs/VCs were followed.
Her MG was treated as prior.
For the possible aspiration, initially treated with levo/flagyl,
then just levofloxacin. [**2173-1-12**] is day 7 of planned seven day
course.
2. Tachycardia:
Sinus, likley reactive. PE ruled out, TSH normal. Anemia
slightly worse then normal but not sufficient to explain
tachycardia. This was felt to be either related to beta-blocker
withdrawal or narcotic withdrawal. This resolved upon
resumption of narcotics (at home doses) and beta-blocker. Later
in the admission, the beta-blocker was again d/c'd as the
indication was unclear. Thereafter, the patient's HRs remained
<100.
3. [**First Name9 (NamePattern2) **] [**Last Name (un) 2902**]:
There was no evidence for current flare. Cellcept and
pyridostigmine were continued; neurology followed the patient.
4. Anemia:
Previous baseline hct mid 40's, over the last month decreased to
mid 30's. This was felt to be secondary to B12 deficiency with
the possible contribution of Cellcept. The B12 level was low
end of normal. MMA was checked and pending at d/c. Given that
the patient has no reason for nutritional deficiency, pernicious
anemia was entertained and IF antibody was sent (pending at
d/c).
5. Headache:
Thought to be secondary to possible migraine headache versus med
withdrawal headache.
Was treated with tylenol PRN.
6. Spinal compression fractures:
Narcotics were initially held, but restarted many of the
patient's symptoms were felt to be secondary to withdrawal.
7. Hypertension:
The patient's propranolol had recently been stopped prior to
admission. This was restarted, given the tachycardia. Later in
the admission, the patient was not hypertensive so the
beta-blocker was again held given the prior episodes of
hypotension. Her blood pressure and heart rate were normal on
discharge.
8. Hyperlipidemia:
Continued atorvastin.
Medications on Admission:
Pyridostigmine Bromide 30 mg PO Q8H
Atorvastatin 20 mg PO HS
Mycophenolate Mofetil 1000 mg PO BID
Raloxifene *NF* 60 mg Oral qd osteoporosis
Senna 1 TAB PO HS:PRN constipation
Heparin 5000 UNIT SC TID
Cyanocobalamin 1000 mcg PO DAILY
Docusate Sodium 100 mg PO HS
Calcium Carbonate [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN upset stomach
Dolasetron Mesylate 25 mg IV Q8H:PRN nausea
Acetaminophen 325-650 mg PO/PR Q4-6H:PRN pain
Sodium Chloride Nasal [**2-10**] SPRY NU QID:PRN
Discharge Medications:
1. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO Q8H
(every 8 hours).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO qd () as
needed for osteoporosis.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: [**2-10**] Tablet,
Chewables PO Q4H (every 4 hours) as needed for upset stomach.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-10**] Sprays Nasal
QID (4 times a day) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
13. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Sinus tachycardia
2. Narcotic withdrawal
3. Myasthenia [**Last Name (un) 2902**]
4. Anemia
5. Renal cysts
Secondary:
1. Hypertension
2. Hyperlipidemia
3. Osteoporosis
Discharge Condition:
Improved; in normal sinus rhythm.
Discharge Instructions:
You were admitted with elevated heart rates and possibly
withdrawal from narcotics. At this time, your heart rate is
normal and you do not have any symptoms of withdrawal.
If you experience worsening headaches, diarrhea, racing heart,
shortness of breath or have any other questions/concerns, please
call your PCP or go to the emergency room.
Followup Instructions:
You have the following appointments scheduled:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9899**], M.D. Phone:[**Telephone/Fax (1) 558**] Date/Time:[**2173-2-15**]
1:00
DR. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2173-2-23**]
8:00
Please be sure to schedule an appointment with your PCP to be
seen within 1-2 weeks: [**Last Name (LF) **],[**First Name3 (LF) 198**] W. [**Telephone/Fax (1) 250**]
|
[
"593.2",
"358.00",
"304.91",
"427.89",
"733.09",
"E932.0",
"518.81",
"346.90",
"733.13",
"564.00",
"787.91",
"272.4",
"281.1",
"458.0",
"799.02",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
7461, 7540
|
3179, 5546
|
318, 324
|
7763, 7799
|
2320, 3156
|
8192, 8677
|
1464, 1664
|
6073, 7438
|
7561, 7742
|
5572, 6050
|
7823, 8169
|
1679, 2301
|
267, 280
|
352, 913
|
935, 1218
|
1234, 1448
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,008
| 126,625
|
24402
|
Discharge summary
|
report
|
Admission Date: [**2122-4-22**] Discharge Date: [**2122-4-24**]
Date of Birth: [**2093-4-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / [**Year (4 digits) **] Sting Kit
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
known metastatic melanoma to the brain
Major Surgical or Invasive Procedure:
left craniotomy
History of Present Illness:
Mr. [**Known lastname 61780**] is a 29M h/o metastatic melanoma. He underwent
resection of a left lower eyelid 4.5-mm thick, polypoid melanoma
in [**2119-8-2**]. In [**2120-3-1**], he developed left neck
lymphadenopathy with fine-needle aspiration confirming
melanoma. In [**2120-5-1**], he underwent left superficial
parotidectomy and left modified radical neck dissection with
4/76 nodes positive. In [**2120-5-31**], he had a left neck
subcutaneous nodule resected with pathology revealing
melanoma. He underwent radiation therapy and began interferon
with conjunctival an eyelid recurrences, which were
surgically resected. He also underwent resection of a right
lung nodule revealing melanoma. Follow-up CTs revealed
multiple new pulmonary nodules. Screening for high-dose
interleukin-2 revealed a frontal CNS lesion, for which he
underwent craniotomy on [**2121-7-3**] and postop Cyberknife
treatment on [**2121-8-7**]. He began biochemotherapy on
[**2121-8-19**] with torso CT after 2 cycles revealing
decrease in his lung nodules with a stable brain MRI. He
tolerated cycle #3 of biochemotherapy well with the usual
nausea and vomiting noted.
Past Medical History:
Peptic ulcer disease, childhood heart
murmur, wrist and ankle fracture, melanoma.
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
Postoperatively:
V: 98.2; HR 76-97; BP 105-135/59-72; RR 15-22; O2 Sat 96-98%
Opens eyes to voice, but sleepy.
PERRL, 3.5 --> 3 mm
EOMI
Tongue midline
Speech clear
Oriented to place, person, and time
Follows commands
Motor strength full throughout
No obvious drift, but arms are tremuluous
Pertinent Results:
[**2122-4-22**] 08:23PM GLUCOSE-131* UREA N-12 CREAT-1.0 SODIUM-140
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-31 ANION GAP-12
[**2122-4-22**] 08:23PM estGFR-Using this
[**2122-4-22**] 08:23PM CALCIUM-9.9 PHOSPHATE-3.5 MAGNESIUM-2.2
[**2122-4-22**] 08:23PM PHENYTOIN-0.7*
[**2122-4-22**] 08:23PM WBC-17.5* RBC-4.07* HGB-11.9* HCT-34.5*
MCV-85 MCH-29.3 MCHC-34.6 RDW-17.0*
[**2122-4-22**] 08:23PM PLT COUNT-264
[**2122-4-22**] 08:23PM PT-10.8 PTT-23.2 INR(PT)-0.9
Brief Hospital Course:
The patient was admitted on [**2122-4-22**] for a left craniotomy for
resection of a frontal brain mass. The surgery was uncomplicated
and the patient was transferred to the floor. His wound was
healing well and his neuro exam was unchanged upon discharge.
He has chronic pain for which his oncologist is managing his
mediations. The patient was deemed ready for discharge on
[**2122-4-24**].
Medications on Admission:
Oxycodone
Methadone
Gabapentin
Celexa
Colace
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
4. Keflex 500 mg Tablet Sig: One (1) Tablet PO four times a day
for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
Disp:*120 Tablet(s)* Refills:*0*
6. Pain Meds
Please see your oncologist on [**Location (un) **] for any pain medication.
Discharge Disposition:
Home
Discharge Diagnosis:
melanoma -Metastatic brain lesion
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Appt:Dr. [**Last Name (STitle) 3929**] [**4-29**] @ 3pm and [**5-8**] 2pm
You are to get MRI on [**Location (un) 945**] prior to appt - call Dr.[**Name (NI) 12757**]
office to arrange this. [**Telephone/Fax (1) 2731**].
You need to have your sutures removed in 10 days. Please call
[**Telephone/Fax (1) 1669**] to make an appointment for this in Dr.[**Name (NI) 12757**]
office.
F/U with Dr. [**Last Name (STitle) **] (oncologist) in 3 weeks [**Telephone/Fax (1) 61789**].
Completed by:[**2122-4-24**]
|
[
"198.3",
"197.0",
"172.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.39",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
3633, 3639
|
2543, 2938
|
350, 368
|
3717, 3741
|
2048, 2520
|
5115, 5621
|
1704, 1722
|
3033, 3610
|
3660, 3696
|
2964, 3010
|
3765, 5092
|
1737, 2029
|
272, 312
|
396, 1548
|
1570, 1654
|
1670, 1688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,212
| 153,754
|
43497
|
Discharge summary
|
report
|
Admission Date: [**2146-12-11**] Discharge Date: [**2146-12-19**]
Date of Birth: [**2065-7-19**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Hypercarbic Respiratory Failure
Major Surgical or Invasive Procedure:
Mechanical Ventilation and Intubation
History of Present Illness:
This is an 81 yo female with end-stage COPD, DM2, CRF, anemia of
renal disease, diastolic CHF, h/o DVT, PMR, OA, OSA, h/o C diff
who was discharged from [**Hospital1 18**] on [**12-8**] after a COPD exacerbation,
treated with PO steroids and levofloxacin. She was discharged to
a rehab and was doing ok. Of note, she was not on several of her
home COPD meds on discharge. However, her family noted that she
was becoming progressively more lethargic and tired during her
stay. Her O2 had been increased from 2 to 3 liters. Family
denies any fevers, chills, or cough. She presented to [**Hospital 6451**] hospital early today with increasing shortness of
breath. ABG there showed 7.16/139. Intubated there at her
husbands request and transferred to [**Hospital1 18**] as her prior care was
here.
In the ED, initial VS: 88 138/100 16 97% on the ventilator. A
CXR showed a possible retrocardiac opacity so she was given
Vanc/CTX for abx and 2L NS. BPs trended down to the 80s-90s but
daughter at bedside stated she would not want a central line.
She was successfully managed with IVF and extubated. She was
then transferred to the floor for further management.
ROS: Further ROS unable to be obtained due sedation.
Past Medical History:
COPD on 2.5-3.5L O2 NC, no h/o intubation, never seen by
pulmonologist, severely disabled, chronic hypercarbia and
history of CO2 narcosis
DM2 x 50 years
diastolic CHF, last hospitalized for this 1 year ago
CRF stage 3, creatinine 2.0 in [**11-14**]
anemia of renal disease on epogen
OSA on CPAP
h/o DVT - patient states that 50 years ago she injured her left
leg, never went to the hospital for it and it might have been a
phlebitis
PMR on steroids x 50 years
OA - particularly left shoulder
osteoporosis, vertebral compression fx [**2138**]
h/o C diff per records but daughter [**Name (NI) 63582**]'t aware, patient states
it might have been 3-4 years ago
h/o fall
cognitive decline, h/o agitation and confusion at night
Social History:
former nurse, trained at [**Hospital 1474**] Hospital, lives at home with
husband, daughter lives in [**Name (NI) 3307**], quit smoking decades ago
Family History:
asked but not contributory
Physical Exam:
On arrival to the MICU
Vitals - 97.8, 83, 111/52, 96% AC 400, 16, 40%, 5:
GENERAL: Intubated and sedated, twitching
HEENT: PERRL, EOMI
CARDIAC: RRR, 2/6 SEM
LUNG: Diffuse rhonchi
ABDOMEN: Soft, NT/ND, +bS
EXT: no edema
NEURO: intubated and sedated
Pertinent Results:
URINE CULTURE (Final [**2146-12-10**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2146-12-11**] 4:30 am URINE Site: CATHETER
**FINAL REPORT [**2146-12-14**]**
URINE CULTURE (Final [**2146-12-14**]):
ESCHERICHIA COLI. PRESUMPTIVE IDENTIFICATION.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
**FINAL REPORT [**2146-12-15**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2146-12-15**]):
Feces negative for C.difficile toxin A & B by EIA.
[**2146-12-11**] 04:30AM BLOOD WBC-9.0 RBC-4.50 Hgb-11.2* Hct-36.6
MCV-81* MCH-24.9* MCHC-30.7* RDW-16.6* Plt Ct-255
[**2146-12-19**] 06:10AM BLOOD WBC-7.4 RBC-4.00* Hgb-10.0* Hct-32.2*
MCV-81* MCH-25.1* MCHC-31.2 RDW-16.7* Plt Ct-213
[**2146-12-11**] 04:30AM BLOOD Neuts-81.3* Lymphs-14.7* Monos-3.6
Eos-0.3 Baso-0.2
[**2146-12-16**] 06:25AM BLOOD Neuts-56.5 Lymphs-31.6 Monos-11.3*
Eos-0.5 Baso-0
[**2146-12-11**] 04:30AM BLOOD Glucose-119* UreaN-54* Creat-2.7* Na-145
K-6.8* Cl-98 HCO3-38* AnGap-16
[**2146-12-19**] 06:10AM BLOOD Glucose-100 UreaN-52* Creat-3.3* Na-145
K-4.3 Cl-99 HCO3-34* AnGap-16
[**2146-12-19**] 06:10AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.2
[**2146-12-11**] 07:28AM BLOOD Type-ART pO2-73* pCO2-63* pH-7.45
calTCO2-45* Base XS-16
[**2146-12-14**] 04:22AM BLOOD Type-[**Last Name (un) **] pO2-145* pCO2-63* pH-7.44
calTCO2-44* Base XS-16 Comment-GREEN TOP
[**2146-12-11**] 04:46AM BLOOD Lactate-2.4*
[**2146-12-12**] 06:23AM BLOOD Lactate-0.6
Imaging:
CXR [**2146-12-15**]
IMPRESSION: Status post extubation. Slight improved aeration at
lung bases with residual atelectasis adjacent to effusions.
ECHO [**2146-12-15**]
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The aortic root is mildly dilated at the sinus level. 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. The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved left ventricular systolic
function. Mild right ventricular dilation with probable mild
hypokinesis. Moderate pulmonary hypertension.
CXR [**2146-12-11**]
SINGLE UPRIGHT PORTABLE VIEW OF THE CHEST: An endotracheal tube
terminates approximately 2 cm from the carina. An enteric tube
extends below the diaphragm and terminates below the bottom of
the radiograph. Lung volumes are low. There is dense
retrocardiac opacity which could reflect atelectasis or
consolidation. There may be bilateral pleural effusions.
Moderate cardiomegaly is likely unchanged. Scarring at the lung
apices is again noted. Hilar fullness is likely related to low
lung volumes. Aortic arch calcifications are noted. Pulmonary
vascular structures are otherwise normal in caliber.
IMPRESSION: ETT terminates 2.1 cm from the carina. Dense
retrocardiac
opacity could reflect atelectasis, effusion or consolidation.
Brief Hospital Course:
Ms. [**Known lastname **] is an 81 year old woman with COPD, type II diabetes,
chronic renal failure, anemia of renal disease, diastolic CHF,
h/o DVT, PMR, OA, OSA, and a history of C. diff who presented to
an OSH with hypercarbic respiratory failure. She was intubated
and transfered to [**Hospital1 18**] for further care on [**12-11**]. In the MICU,
she was weaned off mechanical ventillation on [**12-12**]. She was
transferred to the medical floor on the evening of [**12-14**].
.
# Hypercarbic respiratory failure: Patient had just been
discharged from the hospital for a COPD exacerbation when she
went into hypercarbic respiratory failure. This exacerbation
seems to have been caused by increased oxygen in the setting of
her advanced COPD. She was extubated on the evening of [**12-12**]. She
received Bipap overnight. She was started on 60 mg of prednisone
daily, this was gradually decreased to a dose of 30 mg on the
day of discharge. She was continued on standing ipratropium and
albuterol. She can desaturate with minimal exertion. Her oxygen
saturation goal was 88-92%.
.
# Acute on Chronic Renal Failure: Baseline of ~2.0. Her
creatinine peaked at 3.8 after receiving heavy doses of
furosemide while in the ICU. Renal was consulted and felt the
increase in creatinine was likely due to volume depletion. She
was given a fluid bolus and continued on gentle hydration. Her
creatinine improved to 3.3 on the day of discharge to rehab.
Per renal, they felt that she should continue gentle fluids on
the day after her discharge at rehab and to continue monitoring
her I/Os. A foley catheter was inserted to accurately monitor
her urine output. This should be removed as soon as possible at
rehab. Her creatinine should be followed daily until there is a
significant improvement. S he should follow up with a
nephrologist as an outpatient once she leaves rehab, per the
renal team. If her creatinine does not improve or worsens, she
should see a nephrologist sooner. The inpatient renal team also
recommended to discontinue her alendronate given her degree of
renal insufficiency.
# Venous Insufficiency: Patient has a history of venous
insufficiency. She should wear compression stockings. Of note,
her left lower leg has chronic venous stasis changes. The area
is slightly pink, but has remained stable throughout her
hospital course. There was no sign of infection. The area was
marked and followed daily.
# UTI: She had a positive urinalysis during her previous
hospitalization and at the start of this hospitalization. She
received coverage with cefepime for three days in the ICU. On
the floor she received two days of Bactrim. This was changed to
ceftriaxone for the remaining two days out of concern for
Bactrim causing the increased creatinine. She finished 7 days of
treatment on [**12-18**].
# Diastolic CHF: She is on a home regimen of furosemide 80 mg
twice daily. This was restarted in the ICU when she appeared
volume overloaded. This was discontinued as her creatinine
increased. Patient was given back fluids. When appropriate,
please restart furosemide slowly at 40 mg daily. Titrate up to
her home dose.
# Diabetes: She was continued on a sliding scale regimen. Her
morning blood sugars were well controlled. However, she had
elevations in her afternoon and evening blood sugars coinciding
with the expected effects of her morning dose of prednisone.
# Depression: She was continued on her home dose of
escitalopram. However, this was stopped on [**12-18**] out of concern
for her renal failure. Given the long half life of the
medication, this was not tapered. She is not acutely depressed.
This medication can be restarted when renal function improves if
it is thought to be needed.
# Anemia: Patient was continued on Epoetin Alfa 10,000 unit/mL
Solution. She did not receive any injections during this
admission.
# GERD: Home omeprazole was switched to pantoprazole.
.
# Osteoporosis: She was on calcium. Her alendronate was
discontinued due to renal failure.
# PMR: She is on a home dose of 10 mg prednisone. She was on
much higher doses while in the hospital. she was placed on a
slow taper to ultimately decrease to 10mg prednisone daily
# Swallowing: She was evaluated by speech and swallow who placed
her on a diet of pureed solids and nectar thick liquids. She
should have a reevaluation as her mental status and strength
improves. She was not placed on a diabetic diet in order to
increase her desire to eat and drink.
# Delirium/Hallucinations: Ms. [**Known lastname **] was oriented x2 while on the
medical floor. Her memory and recall gradually improved. She
recalled a hallucination at night on [**12-18**]. Her medication list
was analyzed and potentially offending agents were discontinued.
Her hallucination was thought to be due to delerium or
prednisone. If it continues, she should have further follow-up
with geriatrics/psychiatry.
# Prophylaxis: She received subcutaneous heparin and
pantoprazole.
# CODE: Ms. [**Known lastname **] was a full code during this admission.
Palliative care had extensive discussions with her and her
family. She had previously expressed desires to not be
intubated. However, she and her family agreed to pursue
intubation if needed again.
Medications on Admission:
Ipratropium Bromide 1 Neb q6H PRN dyspnea
Docusate Sodium 100 mg PO BID as needed for constipation.
Calcium Carbonate 500 mg PO BID
Alendronate 70 mg PO QTHUR
Escitalopram 10 mg PO DAILY
Omeprazole 20 mg PO DAILY
Fexofenadine 60 mg Tablet PO BID
Epoetin Alfa 10,000 unit/mL qWeek
RISS
Levofloxacin 250 mg PO DAILY until [**12-14**].
Prednisone Taper from 60mg to HOME dose of 10mg daily
Albuterol Sulfate Neb Q4H as needed for dyspnea.
.
Additional home meds not on list when d/c'd [**12-8**]:
lasix 80 mg [**Hospital1 **]
KCl 20 mEq [**Hospital1 **]
Spiriva daily
flovent 220 mcg [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed for SOB/wheeze.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of
breath.
12. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. Insulin Lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous ASDIR (AS DIRECTED).
14. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
Hypercarbic respiratory failure
Acute on Chronic renal failure
Chronic Obstructive Pulmonary Disease
Secondary Diagnosis:
Urinary tract infection
Hypernatremia
Diastolic congestive heart failure
Type II diabetes mellitus
Osteoporosis
Polymyalgia Rheumatica
Swallowing difficulties
Discharge Condition:
Activity Status:Out of Bed with assistance to chair or
wheelchair
Level of Consciousness:Lethargic but arousable
Mental Status:Confused - sometimes
Discharge Instructions:
You were admitted to the hospital with respiratory failure. You
had a breathing tube placed when an ambulance brought you to
another hospital. When you came to [**Hospital1 1170**], you were taken care of in the intensive care unit. You
breathing began to improve and the breathing tube was removed.
You were also treated for a urinary tract infection while you
were at the hopsital. Your breathing and strength got better
while you were in the hospital. However, you required a
significant amount of assistance to perform activities. Because
of this you are going to a pulmonary rehabilitation facility.
We changed several of your medications while you were in the
hospital.
You are now taking 30 mg of prednisone. Your doctors [**Name5 (PTitle) **] be
slowly decreasing this amount over the next couple of days and
weeks.
We stopped your fexofenadine, alendronate, and escitalopram.
These medications may be added back as your kidney function
improves.
Followup Instructions:
You should follow up with a nephrologist when you leave rehab if
your renal function improves to baseline. If your renal function
remains poor or worsens, you should follow up with a
nephrologist sooner.
You should follow up with your primary care physician when you
leave rehab.
|
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.91",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14915, 14987
|
7517, 12755
|
312, 352
|
15332, 15445
|
2834, 7494
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2522, 2550
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241, 274
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380, 1594
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15150, 15311
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15027, 15129
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2357, 2506
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,990
| 171,034
|
49189
|
Discharge summary
|
report
|
Admission Date: [**2173-9-6**] Discharge Date: [**2173-9-8**]
Date of Birth: [**2098-6-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
Ms. [**Known lastname 103090**] is a 75F with a PMH s/f ESRD who was recently
hospitalized for surgical management of a LUE fisula
pseudoaneurysm. Her course was complicated by two unsuccessful
extubation attempts secondary to stridor. She finally required
dexamethasone and bronchoscopic guidance to be extubated on
[**2173-8-25**]. She reports new onset "throat tightness" and
difficulty breathing since this morning.
In the emergency department the patients vital signs were 99,
175/70, 86 and 100% on 2L. Labs were notable for hyperkalemia
to 5.9 and a BNP of 19,000. A CXR was largly unchanged. The
patient was given 125mg of methylprednisolone, and continous
nebulizer treatments with albuterol and ipratropium. IP was
made aware of the admission.
Past Medical History:
1. End stage renal disease
-On HD
-Recently admitted in [**8-/2173**] with pseudoaneurysm at LUE fistula
s/p excision. Complicated by intra-operative hypotension with
MC and L ACA watershed cerebral ischemia, and three intubations
(intubated for surgery, with two unsuccessful extubations
complicated by stridor). She was finally successfully extubated
with dexamethasone and bronchoscopic guidance. Bronchoscopy did
not show any evidence of airway obstruction, edema, or
compromise up to the level of the vocal chords.
-Now with a right subclavian tunneled HD line
2. Vascular dementia s/p CVA
-MRA with narrowing diffusely of BL MCA's and left A1
-A+O x1 at baseline
3. HTN
4. Type 2 Diabetes Mellitus
5. Osteoarthritis
Social History:
Lives at the [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. No tobacco, ETOH, or drug use.
Daughter is involved in care.
Family History:
NC
Physical Exam:
T=97.4 BP=166/80 HR=87 RR=18 O2=100% 2L
GENERAL: Elderly creole-speaking female, stridorous, in mild
respiratory distress.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. No JVD
LUNGS: Listening over her neck, you can hear a high pitched
inspiratory and expiratory stridor, which is transmitted to her
distal lung fields
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
Pertinent Results:
==================
ADMISSION LABS
==================
[**2173-9-6**] 01:30PM BLOOD Neuts-62.7 Lymphs-24.9 Monos-7.0 Eos-4.8*
Baso-0.5
[**2173-9-6**] 01:30PM BLOOD Glucose-71 UreaN-25* Creat-6.5* Na-137
K-5.9* Cl-94* HCO3-32 AnGap-17
[**2173-9-6**] 01:30PM BLOOD Calcium-9.3 Phos-3.9 Mg-2.2
CHEST X-RAY
FINDINGS: AP upright portable chest radiograph is obtained. A
right
subclavian dialysis catheter is again noted with its tip in the
approximate location of the SVC. There has been interval removal
of the NG tube. Vascular stents are unchanged in the mediastinum
and left axilla. Lung volumes are low which limits evaluation.
Heart size remains mildly increased. There is no evidence of
congestive heart failure. No large pleural effusions or evidence
of pneumonia is seen. Mediastinal contour is unremarkable. There
is no pneumothorax. Osseous structures are intact. There is
coarse calcification in the upper abdomen, likely corresponding
with calcifications in the pancreas seen on a prior CT abdomen
and pelvis from [**2171-5-28**].
IMPRESSION:
1. Interval removal of NG tube. Dialysis catheter unchanged in
position.
2. Mild cardiomegaly without evidence of congestive heart
failure or
pneumonia.
CT AIRWAY
FINDINGS: Since [**2173-8-16**], pulmonary edema has cleared. There
is no
residual ground-glass or interstitial thickening. Small residual
bilateral
pleural effusions and dependant atelectasis improved. Left lower
lobe aeration also improved. Diffuse soft tissue edema is
unchanged.
Right thoracic venous collaterals are extensive. Reflux in the
azygos is
significant but superior vena cava is patent. A left
brachiocephalic vein
stent is also patent. There is no pleural effusion. Heart size
is mildly
enlarged. Lymph nodes are not enlarged using CT criteria.
Coronary artery
calcifications are severe and aortic calcifications are mild.
The inspiration and the expiration images are suboptimal with
poor evaluation of the glottic and subglottic area, to be
correlated with bronchoscopy. The intrathoracic aorta and
bronchi are patent to the subsegmental level. ET tube was
removed. Tracheal secretions have cleared.
3-mm right middle lobe nodule is unchanged. 3-mm right and left
upper lobe
nodules are present. Lungs are otherwise clear. Pleurae are
normal. This
study was not tailored for subdiaphragmatic elevation except to
note small-
sized kidneys in this patient known for chronic renal failure
and left upper extremity AV fistula.
Bones are normal.
IMPRESSION:
1. Limited study demonstrating no evidence of stenosis within
the
intrathoracic airways to the subsegmental level. Glottic and
subglottic area are not well distended and should be correlated
with bronchoscopy.
2. Inability to assess for malacia due to patient's inability to
cooperate
with breathing instructions.
3. Residual small bilateral pleural effusion and dependent
atelectasis.
Improved left lower lobe aeration.
4. Diffuse soft tissue edema. Resolved pulmonary edema.
5. Extensive right thoracic collaterals and reflux in the azygos
vein. Patent SVC and stent in the left brachiocephalic vein.
6. Severe coronary artery calcifications and enlarged heart
size.
7. Sub 4-mm pulmonary nodules. Chest CT is recommended in one
year to
determine stability.
Brief Hospital Course:
Ms. [**Known lastname 103090**] is a 75F with a PMH s/f ESRD on HD, and a recent
admission with multiple intubations, who is presenting with
acute onset of SOB, wheezing and stridor.
1)Respiratory distress: The patient was transferred from her
nursing home for increasing shortness of breath. The patient has
no history of asthma or COPD and has had several recent
intubations. The initial differential diagnosis included
laryngeal injury, including edema or granulomatous inflammation;
tracheal stenosis or tracheobronchitis. She was started on IV
steroids on admission and placed on Albuterol/Atrovent nebs. She
also received racemic epinephrine with an excellent response.
The following morning she underwent a bronchoscopy which showed
mild cervical tracheomalacia, no stenosis, and the distal
airways remained patent. There appeared to be some edema of teh
arytenoids likely secondary to acid reflux. She was started on
Protonix 40mg [**Hospital1 **]. ENT was also consulted and did not recommend
any further work-up.
Because of concern regarding ACEI and [**Last Name (un) **] contributing to airway
edema, we have decided to hold these medications. Defer
re-starting them to nephrology team.
2)ESRD: On admission, renal was consulted. The patient was
dialyzed without any complications. She was continued on Phoslo
and Nephrocaps.
3)Hypertension: She was continued on home regimen of Amlodipine
and Labetolol. The ace-inhibitor and [**Last Name (un) **] were held given initial
concern for angioedema.
4)Type 2 DM: Patient was continued on outpatient regimen of NPH
and insulin sliding scale.
5)Dementia: Continued cinecalcet, namenda, risperdal, celexa
Medications on Admission:
Amlodipine 5mg daily
Valsartan 40mg qhs
Cinecalcet 30mg daily
Labetalol 200mg [**Hospital1 **]
Lisinopril 10mg daily
Simvastatin 40mg daily
Phoslo 1335 mg TID with meals
Renal caps
Namenda 5mg qhs
NPH 6units [**Hospital1 **]
Risperdal 0.25mg daily
NGT prn
Heparin ppx
Procrit 10,000 units SC 3x/week
Bowel regimen
Celexa 10mg daily
Aspiration precautions
*Pureed nectar thick liquids
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1188**] house
Discharge Diagnosis:
PRIMARY:
LARYNGEAL EDEMA
SECONDRAY:
END STAGE RENAL DISEASE
Discharge Condition:
Stable, with improved stridor
Discharge Instructions:
You were admitted to the hospital because you were having
difficulty breathing, concerning given your history of repeated
intubations. Inflammation of your airway was found on
bronchoscopy, and we have started anti-acid medication.
Please note, because of concerns of side effects, the following
medications have been held:
-- Lisinopril 10mg daily
-- Valsartan 40mg qhs
*** DO NOT RESTART THESE UNTIL YOU SEE YOUR PCP/RENAL DOCTOR***
Please keep all appointments and take all medications as
prescribed. If you develop any new difficulty breathing or
beging making a loud high pitched noise when you breathe, please
seek medical attention immediately.
Followup Instructions:
Please schedule a visit with your PCP [**Last Name (NamePattern4) **] [**2-10**] weeks.
Please follow up with your primary renal doctor [**First Name (Titles) 3**] [**Last Name (Titles) 103171**]
|
[
"250.00",
"478.6",
"585.6",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
8113, 8171
|
6010, 7678
|
290, 304
|
8276, 8308
|
2732, 5987
|
9011, 9211
|
2019, 2023
|
8192, 8255
|
7704, 8090
|
8332, 8988
|
2038, 2713
|
231, 252
|
332, 1092
|
1114, 1840
|
1856, 2003
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,961
| 148,651
|
49036
|
Discharge summary
|
report
|
Admission Date: [**2172-12-29**] Discharge Date: [**2173-2-9**]
Date of Birth: [**2105-1-30**] Sex: F
Service: MEDICINE
Allergies:
Tape
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
1. Temporary hemodyalysis line placement
2. Permanent hemodyalysis line placement
3. Endometrial Biopsy
4. Psoas abscess drainage
5. Epidural abscess resection and laminectomy
6. Central line placement
7. PICC lines placement
Patient still has Hemodyalysis line in place, not removed due to
comfort, if wanted can be removed.
History of Present Illness:
Pt is 67 y/o woman with PMH of CAD, last echo [**2172-12-22**] showing EF
60% with 13mm aortic valve with h/o aortic stenosis, HTN, Type
II DM complicated by diabetic neuropathy, retinopathy, h/o ESRD
on HD (three times per week, last dialyzed on [**2172-11-29**]), h/o L
fem-[**Doctor Last Name **] bypass s/p L BKA for severe PVD, h/o right heel foot
ulcer, h/o indwelling dialysis cathether growing MRSA recently
and subsequent left IJ placed for HD, h/o multiple line
infections and infections of dialysis catheter sites with MRSA,
who presented to [**Hospital3 **] on [**2172-12-12**] with CC of [**10-26**],
sharp, low back pain and fever. Blood cultures drawn
demonstrated gram positive cocci in pairs and clusters. A TEE
was attempted but she desatted and was felt to be 'unstable.' A
TTE was inconclusive, but given her harsh systolic murmur and
blood cultures, was presumed to have endocarditis. She was
started on Zithromax, and CTX originally on admission, and after
blood cultures came back positive on [**2172-12-20**], she was started on
IV vancomycin w/ d/c of zithromax. It appears she was in the
ICU during her stay at [**Hospital1 46**] X 1 week then transferred to
medical floor. Her back pain continued to worsen despite abx.
MRI of the spine revealed L3-L4 discitis, osteomyelitis with
epidural abscess and cauda equina compression with probable
multiple lumbar radiculopathy. She was seen by NSGY who felt
her unstable to have the procedure done at [**Hospital3 3583**],
given her PMH. Vascular surgery accepted her here at [**Hospital1 18**] for
transfer. She was admitted yesterday to vascular service, made
NPO, IVF, Vanco X1, levoflox and metonidazole started, and spine
consulted with Dr. [**Last Name (STitle) 363**] attending. Renal was also consulted,
and she was dialyzed on [**2172-12-29**].
Past Medical History:
1. DM II w/retinopathy, neuropathy
2. HTN
3. AS (1.3 cm2)
4. h/o CAD with h/o "stents" though additional info in records,
EF 60%
5. PVD s/p L fem [**Doctor Last Name **] bypass and L BKA
6. ESRD on HD (Tue, Thurs, Sat) last HD today [**2173-1-8**]
7. h/o multiple line infections and infections of dialysis
catheter sites with MRSA
8. Hypercholesterolemia
9. Hyperthyroidism
10. Glaucoma
Social History:
Married, lives with husband. Non [**Name2 (NI) 1818**], no alcohol. No IVDA.
Family History:
Non-contributory
Physical Exam:
VS: Tmax 102 T BP 159/60 HR 90 R 19 O2 sat 100% 4L
GEN: Drowsy, shivering, diaphoretic, responds to questions, eyes
closed.
HEENT: PERRL. +catarats b/l, anicteric, moist/diaphoretic.
Neck: supple, unable to assess JVP
Chest: diffuse rhonchi, poor inspiratory effort
CVS: nl S1 S2, [**3-22**] harsh ESM radiates throughout, regular
rhythm.
Abd: obese, soft NT/ND, active BS
Ext: no edema, s/p L BKA. R foot warm, +heal ulcer with purulent
drainage
Neuro: drowsy but arousable, oriented to person/place, non focal
Pertinent Results:
Upon Discharge:
[**2173-2-4**] 07:55AM BLOOD WBC-7.8 RBC-3.87* Hgb-11.5* Hct-33.9*
MCV-88 MCH-29.7 MCHC-34.0 RDW-15.6* Plt Ct-255
[**2173-2-4**] 07:55AM BLOOD Plt Ct-255
[**2173-2-4**] 07:55AM BLOOD Glucose-92 UreaN-14 Creat-3.3* Na-135
K-3.7 Cl-99 HCO3-26 AnGap-14
[**2173-2-4**] 07:55AM BLOOD Glucose-92 UreaN-14 Creat-3.3* Na-135
K-3.7 Cl-99 HCO3-26 AnGap-14
[**2173-2-4**] 07:55AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.6
.
Upon Admission/Interval Data:
[**2173-1-31**] 05:29AM BLOOD Neuts-84.4* Bands-0 Lymphs-9.8* Monos-3.0
Eos-2.5 Baso-0.3
[**2173-1-31**] 05:29AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-OCCASIONAL
Macrocy-OCCASIONAL Microcy-1+ Polychr-2+ Tear Dr[**Last Name (STitle) 833**]
[**2173-1-31**] 05:29AM BLOOD ALT-9 AST-16 LD(LDH)-173 AlkPhos-71
TotBili-0.3
[**2173-2-4**] 07:55AM BLOOD Calcium-7.9* Phos-2.9 Mg-1.6
[**2172-12-30**] 07:37PM BLOOD %HbA1c-6.6* [Hgb]-DONE [A1c]-DONE
[**2173-1-7**] 03:10AM BLOOD Triglyc-83 HDL-28 CHOL/HD-2.7 LDLcalc-31
[**2173-1-10**] 05:30AM BLOOD TSH-6.6*
[**2173-1-10**] 05:30AM BLOOD T3-54* Free T4-0.9*
[**2172-12-30**] 06:55AM BLOOD WBC-13.9*# RBC-2.91*# Hgb-8.9*#
Hct-28.2*# MCV-97 MCH-30.5 MCHC-31.4 RDW-15.2 Plt Ct-417#
[**2172-12-30**] 09:15PM BLOOD Neuts-84.0* Lymphs-9.3* Monos-3.6 Eos-2.9
Baso-0.1
[**2172-12-30**] 09:15PM BLOOD Hypochr-2+ Macrocy-1+
[**2172-12-30**] 06:55AM BLOOD PT-13.9* PTT-23.7 INR(PT)-1.3
[**2172-12-30**] 06:55AM BLOOD Glucose-164* UreaN-49* Creat-5.2* Na-137
K-4.6 Cl-93* HCO3-28 AnGap-21*
[**2172-12-30**] 09:15PM BLOOD ALT-23 AST-32 LD(LDH)-209 AlkPhos-126*
TotBili-0.3
[**2172-12-30**] 06:55AM BLOOD Calcium-8.4 Phos-5.1* Mg-1.9
[**2172-12-30**] 09:15PM BLOOD calTIBC-105* VitB12-1534* Folate-GREATER
TH Ferritn-GREATER TH TRF-81*
.
Micro Data:
[**2173-1-1**] 3:15 pm ABSCESS PSOAS MUSCLE ABSCESS.
**FINAL REPORT [**2173-1-5**]**
GRAM STAIN (Final [**2173-1-1**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2173-1-4**]):
STAPH AUREUS COAG +. SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES PERFORMED ON CULTURE # 199-8937C
[**2172-12-31**].
ANAEROBIC CULTURE (Final [**2173-1-5**]): NO ANAEROBES ISOLATED.
[**2173-2-2**] 5:07 am BLOOD CULTURE
AEROBIC BOTTLE (Final [**2173-2-6**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 102915**], RN @ FA11 [**Numeric Identifier 64343**] @
0609AM ON
[**2173-2-4**].
[**Female First Name (un) **] ALBICANS.
Imaging - see body of text (Hospital Course)
.
Recent Imaging:
CXR [**1-31**]:
1. No evidence of pulmonary edema.
2. Right middle and lower lobe opacities, which may relate to
pneumonia given the history of bacteremia. Adjacent pleural
effusion.
3. Right PICC line now terminates within the right subclavian
vein near junction with brachiocephalic vein.
.
CT head [**2083-1-29**]:
1. No evidence of intracranial hemorrhage.
2. Ongoing evolution of prior infarction in the right occipital
lobe.
3. Questionable blurring of the [**Doctor Last Name 352**]-white matter
differentiation in the posterior right sylvian fissure, which
may represent an area of new acute infarction.
4. Sinus disease
.
MRI head [**2173-1-30**]: Except for nonvisualization of the distal
portion of the right posterior cerebral artery, no other
abnormalities are seen on the MRA of the head.
Brief Hospital Course:
In summary, patient is a 67 y/o woman with hx of CAD (EF 60%),
AS (AV 1.3 cm2), HTN, DM2 c/b diabetic neuropathy, retinopathy,
h/o ESRD on HD, severe PVD s/p L BKA, admitted from OSH with
MRSA bacteremia [**2-18**] HD line infection, also with back pain and
fevers. Patient treated with Azithromycin and Ceftrixone then
changed to IV Vanco. Also ?BE given murmur on exam, TEE
inconclusive. Back pain persisted despite Antx treatment, MRI
performed which showed L3-L4 discitis, osteomyelitis w/epidural
abscess and cauda equina compression. Patient was then
transfered to [**Hospital1 18**] for further management, admitted to vascular
surgery, treated with IVF, Vanco, Levo, Flagyl, and spine
service consulted (Dr. [**Last Name (STitle) 363**]. Renal was also consulted, and
dialysis initiated. Ortho and general [**Doctor First Name **] were consulted for
her spinal abscess and psoas abscess respectively. Patient was
taken to the OR on [**12-31**] for a total laminectomy of L2, L3 and
L4, as I&D of epidural abscess, which later grew out coag
positive staph. On [**1-1**], IR drained the psoas abscess with
removal of 30cc of fluid, gram stain showing 2+PMNs, no bact,
culture growing rare gram positive cocci.
.
Patient then went into rapid a.fib on [**1-5**], HR 130-140s a/w
hypotension SBP 60s. No response to metoprolol; was bolused with
Amiodarone then started on gtt. She converted into sinus [**1-6**].
Overnight [**Date range (1) 84136**], she became confused and lethargic. Head
CT showed subacute right occipital stroke (new since [**12-30**]).
Patient was then transferred to the MICU for further management
and was continued on PO Amiodarone, Diltiazem po added for
better control. Patient remained stable and then transfered to
the medical floor.
.
On the floor, patient continued to make slow improvement, MS
improved gradually but generally drowsy but arousable. She
continued to have low grade temps, Vanco was continued for
approximately 30 days, then d/ced since multiple surveillance cx
negative, patient refusing TEE (although several prior negative
for BE), MRI showing continued resolution. Zosyn was added for
multiple decub ulcers. Also treated with course of Flagyl for
diarrhea. C.diff A/B negative, likely [**2-18**] to tube feeds. NGT
d/ed and patient eating soft foods with improved MS. Nutrition
continued to recommend TFs however patient and husband refusing
tube feeds. Patient experience several episodes of HA, but
refusing CT head wanting only symptomatic treatment. Other
issues on the floor included vaginal bleeding. GYN consulted for
MRI showing endometrial thickening/?lesion. Biopsy was
performed, results still pending.
.
On [**2173-1-30**] patient found unresponsive to voice/painful stimuli,
code blue called. VS HR 110, BP 120/60, RR 10. O2 sat 100% RA.
Patient given 0.4mg of narcan without repsonse. Glucose checked
and was noted to be 76, given amp of D50 also w/out response.
DDx at the time included CVA, infetion/meningitis,
toxic/metabolic insult, and seizure. Neuro consulted. CT head
performed which showed evolution of prior infarction in the
right occipital lobe and questionable blurring of the [**Doctor Last Name 352**]-white
matter differentiation in the posterior right sylvian fissure,
which may represent an area of new acute infarction. Patient
treated with Ativan 2mg and loaded with Dilantin 20mg/kg. MRI
also c/w stoke in evolution, no new CVA. CXR showing RML and RLL
opacities which could be c/w PNA given hx of bacteremia. Patient
also started to spike temps again and therefore treated with IV
Vanco, zosyn continued. Blood cx drawn from all lines, PICC
d/ced, new central line placed.
.
Patient's mental status improved back to baseline and then
called back out to floor. EEG performed on [**2173-2-1**]. Patient made
DNR/DNI given ongoing medical problems. family meeting on [**2-4**]
decided that the patient would become CMO and would go to
hospice. Patient was refusing further testing and treatement and
wanted to be made comfortable. Patient understood this decision
and so did her family. At this stage, one blood culture also
came back positive for yeast and the patient did not want
further treatement. Currently, patient is very comfortable and
resting without patient. All interventions were discontinued
including hemodyalysis and all central lines. Her HD catheter
remains since it was felt that it would be uncomfortable to
remove it. Over the next several days while awaiting hospice
placement, patient remained comfortable with stable vital signs,
responsive but generally drowsy.
.
In terms of her individual medical problems:
.
Sepsis. Currently afebrile however patient WBC count was
elevated during her last MICU stay. Multipe possible sources of
infection including line infection, reaccumulation in spine,
endocarditis, worsening decubitus ulcers. Patient s/p R
subclavian central line prior to transfer from MICU. R heal
ulcer now with frank pus ->XR not showing osteomyelitis. CXR
also showing new RML/RLL infiltrates. d/ced PICC, R subclavian
central line placed. Now all lines d/ced except for her
tunnelled HD lines. Her blood cx from [**2-2**] is growing [**Female First Name (un) **]
albicans. Patient was treated with a >25 day course of
vancomycin which was later d/ce once she was afebrile, WBC
within normal limits. She then became unresponse and went back
to the MICU where Vancomycing was added back. She received this
for a few more days until she was made CMO and all antibiotics
were d/ced. She was also on Zosyn for some time for her
decubitus ulcers.
.
Altered MS. [**Name13 (STitle) **] currently back to baseline, remains drowsy
but arousable. CT/MRI showing evolution of old CVA, no new
lesions. ?sepsis vs. hypoglycemia. EEG performed [**2173-2-1**] which
did not show any seizure activity.
.
Vaginal bleeding. s/p endometrial biopsy. Hct trending
downwards. Transfuse with HD for Hct >30 given hx of CAD.
Endometrial bx negative for malignancy, but +polyps.
.
ESRD on HD. Continue HD per renal recs. Permanent tunnelled line
placed [**1-28**]. She continued routine hemodyalsis until the
decision was made to discontinue dyalysis on [**2173-2-4**]..
.
A.fib with RVR. Remains borderline tachycardic in 90s. She was
intially treated with Amiodarone and diltiazem. This was later
discontinued.
.
DM2: Hypoglycemic over last few days, likely [**2-18**] to d/ce tube
feeds with suboptimal po intake. Was at one point requiring high
dose glargine and sliding scale insulin. Currently off all
insulin products.
.
Cardiovascular Disease. History of CAD, unclear if patient was
had PCI. No active issues. Continue ASA given risk of MI.
.
FEN: NGT d/ced [**1-27**], taking POs since but Nutrition recommending
supplementation, re-placement of tube. Patient refusing further
tube feeds. Continue PO intake as tolerated.
.
Communication: patient, husband [**Name (NI) 449**] [**Name (NI) **] ([**Telephone/Fax (1) 102916**])
Medications on Admission:
1. Rescula 1 drop each eye [**Hospital1 **]
2. Cosopt 1 drop each eye [**Hospital1 **]
3. Atenolol 25mg po qd
4. Cozaar 100mg po qd
5. Nifedipine 90mg po qd
6. Catapres
7. Renagel 800mg po with meals tid
8. Reglan 10mg po with meals tid
9. Lipitor 4mg po qd?
10. Nephrocaps
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Morphine 10 mg/5 mL Solution Sig: [**1-18**] PO Q4-6H (every 4 to 6
hours) as needed.
Disp:*qs qs* Refills:*0*
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*30 Tablet(s)* Refills:*2*
4. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
5. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
7. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO Q8H (every
8 hours).
8. Diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: [**1-18**] PO Q6H
(every 6 hours) as needed.
9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed.
10. Dibucaine 1 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed.
11. Acetaminophen 160 mg/5 mL Solution Sig: [**1-18**] PO Q4H (every 4
hours).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] - [**Location (un) 3320**]
Discharge Diagnosis:
1. End stage renal disease on hemodyalysis
2. Atrial fibrillation with rapid ventricular rate
3. Epidural Abscess/Psoas abscess s/p resection and drainage
4. Diabetes Mellitus
5. Poor Nutrition
6. Vaginal bleeding s/p endometrial biopsy with endometrial
thickening on MRI, polyp found on biopsy
7. Occipital CVA
8. MRSA bacteremia
9. Chronic Diarrhea
10. Anemia
11. Sepsis/Fungemia
Discharge Condition:
Comfort Measures/DNR/DNI
Discharge Instructions:
Please take all medications as directed
Patient is comfort measures only, please provide symptom relief
with morphine liquid prn, ativan for anxiety, benadryl for
itching, tylenol #3 for pain.
Patient is also on liquid preparation of Phenytoin for seizure
prophylaxis
Followup Instructions:
none
Completed by:[**2173-2-9**]
|
[
"428.0",
"682.7",
"276.0",
"567.38",
"995.92",
"112.5",
"567.31",
"722.73",
"324.1",
"707.05",
"682.2",
"434.11",
"486",
"V49.75",
"357.2",
"344.60",
"038.11",
"627.1",
"585.6",
"V09.0",
"720.9",
"421.0",
"427.31",
"250.60",
"403.91",
"730.08",
"293.0",
"787.91",
"707.14"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"88.72",
"81.62",
"39.95",
"86.04",
"86.22",
"84.52",
"03.4",
"68.16",
"83.95",
"03.09",
"99.04",
"80.51",
"81.06",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15320, 15442
|
7003, 13941
|
275, 604
|
15868, 15895
|
3558, 3558
|
16213, 16248
|
2991, 3009
|
14265, 15297
|
15463, 15847
|
13967, 14242
|
15919, 16190
|
3024, 3539
|
226, 237
|
3574, 6980
|
632, 2469
|
2491, 2881
|
2897, 2975
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,109
| 197,934
|
18405
|
Discharge summary
|
report
|
Admission Date: [**2103-10-16**] Discharge Date: [**2103-10-18**]
Date of Birth: [**2040-8-1**] Sex: F
Service: ACOVE MEDICINE
HISTORY OF THE PRESENT ILLNESS: The patient is a 63-year-old
woman with a history of Crohn's disease, hypertension,
coronary artery disease, recent right MCA embolic stroke and
a recently diagnosed poorly differentiated adenocarcinoma of
her pancreas now status post recent ERCP and biliary stenting
for cholangitis who presents from rehabilitation with waxing
and [**Doctor Last Name 688**] mental status and increased somnolence over the
past 24 to 48 hours. Per medical records, the patient was
complaining of increased pain at rehabilitation. She was
noted to have a leukocytosis despite treatment with Unasyn
and the development of hyperkalemia requiring Kayexalate.
The patient had reportedly poor p.o. intake since discharge
from [**Hospital6 256**] and was not
participating in rehabilitation. In addition, the patient
was recently diagnosed with Clostridium difficile and was
started on Flagyl one day prior to admission. In addition,
she was also recently started on MS Contin 15 mg t.i.d.
PAST MEDICAL HISTORY:
1. Crohn's disease.
2. Hypertension.
3. CAD.
4. Recent right middle cerebral artery stroke.
5. Metastatic adenocarcinoma of the pancreas.
6. GERD.
7. Chronic back pain.
8. Status post TAH.
9. Status post left and right knee replacement.
ALLERGIES: Codeine.
ADMISSION MEDICATIONS:
1. Phenergan p.r.n.
2. Norvasc 10 q.d.
3. Lopressor 75 b.i.d.
4. Aspirin 325 q.d.
5. Subcutaneous heparin.
6. Haldol p.r.n.
7. Protonix 40 q.d.
8. Colace 100 b.i.d.
9. Tylenol p.r.n.
10. Senna one tablet b.i.d.
11. Regular insulin sliding scale.
12. Vioxx.
13. Oxycodone 0.5 to 1 q. six hours.
14. Potassium chloride.
15. Flagyl, day number two.
16. Unasyn, day number five.
SOCIAL HISTORY: The patient has a 90 pack year smoking
history. She has a history of prior alcohol abuse.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
96.3, pulse 98, blood pressure 160/90, respiratory rate 19,
saturating 100% on 4 liters nasal cannula. General: She was
a somnolent, flaccid, minimally responsive woman who does
withdrawal to sternal rub. Head and neck: Notable for
pupils that were 2-3 mm and reactive. The sclerae were
anicteric with dry oral mucosa. Cardiac: She had a regular
rate and rhythm. Normal S1 and S2. Lungs: Apneic periods,
respiratory rate 10. She had no wheezes or crackles
anteriorly. Abdomen: Soft, moderately distended with
hypoactive bowel sounds. Extremities: No edema, warm and
dry. Neurologic: Notable for flaccid extremities. Her toes
were upgoing bilaterally. Rectal: Guaiac positive brown
stool.
LABORATORY/RADIOLOGIC DATA: White count 45.7, with 42%
polys, 28% bands, 9% lymphocytes, 10% eosinophils, 4%
atypicals with a hematocrit of 27.7, platelets 553,000. Her
PT was 13.4, INR 1.2, PTT 35.2. Her Chem-7 was notable for a
sodium of 142, potassium 6.3, chloride 107, bicarbonate 17,
BUN 37, creatinine 1.7, glucose 146, ALT 24, AST 44, alkaline
phosphatase 720, T. Bilirubin 0.9, amylase 7, lipase 8,
albumin 2.5, ammonia 35. Her serum tox was negative. Her
urinalysis was notable for greater than 50 red cells, 21-50
white cells, moderate bacteria, [**2-28**] epis.
Chest film showed low lung volumes. No pneumonia or CHF.
Right upper quadrant ultrasound showed multiple hepatic
masses with a common bile duct stent, question of pneumobilia
and cholelithiasis. She had no cholecystitis, ascites, and
normal flow.
Her head CT was negative.
Her abdominal CT was notable for multiple liver lesions,
pneumobilia, focal linear area of low-density throughout the
midspleen, but no colonic wall thickening, abscess, or free
pelvic fluid.
HOSPITAL COURSE: 1. ALTERED MENTAL STATUS: The patient was
seen in the ED by the Toxicology Service. She was given
Narcan in the Emergency Department with an improvement in her
responsiveness. She was admitted to the ICU for closer
monitoring of her respiratory status. While there, she was
given Narcan p.r.n. but was soon stable enough for floor
transfer and on the second day of admission was transferred
out to the floor.
Overnight, she developed acute respiratory distress with 02
saturations in the 70s and she became hypotensive and
nonresponsive. She developed abdominal breathing and the
patient who had already been made DNR/DNI was not able to be
improved with conservative measures. Her family was called
who agreed to make her CMO. At 11:15 a.m., the patient died.
This will also serve as her death notice.
2. With respect to her other medical problems including her
leukocytosis, likely secondary to Clostridium difficile, and
acute renal failure, these became secondary issues once she
developed severe respiratory distress.
DISCHARGE STATUS: Deceased.
CONDITION ON DISCHARGE: Deceased.
The patient's family agreed to do a postmortem examination to
further investigate her cause of death and underlying disease
process.
DISCHARGE DIAGNOSIS:
1. Pancreatic adenocarcinoma.
2. Clostridium difficile infection.
3. Narcotic reuse.
4. Likely pulmonary embolus.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 7693**]
MEDQUIST36
D: [**2103-11-1**] 04:37
T: [**2103-11-2**] 08:35
JOB#: [**Job Number 50676**]
|
[
"724.5",
"008.45",
"584.9",
"197.7",
"599.0",
"157.8",
"276.7",
"415.19",
"292.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1976, 2015
|
5090, 5475
|
3834, 3846
|
1465, 1850
|
2030, 3816
|
3862, 4899
|
1172, 1442
|
1867, 1959
|
4924, 5069
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,945
| 149,663
|
26249
|
Discharge summary
|
report
|
Admission Date: [**2190-1-8**] Discharge Date: [**2190-1-15**]
Date of Birth: [**2136-1-21**] Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Slurred speech, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 53 year old right handed Italian American man
with past medical history of left parietal stroke 1 year ago
with
slurred speech, right sided incoordination (followed at [**Hospital1 2025**]),
obesity, atrial fibrillation on coumadin, diabetes,
hypertension,
hypercholesterolemia, CAD status post angioplasty, who presented
to ED today for evaluation of several day history of slurred
speech and 1 day of vertigo, nausea, vomiting.
Patient is unable to give a history so history taken from his
girlfriend. She states that she has noticed intermittent
slurring
of his speech for past 3 days. Yesterday, he seemed off balance
and unsteady when walking. Then this morning, he had a right
sided headache radiating from his right posterolateral neck up
to
over the vertex. Then around 10am, he started to have
nausea and vomiting of non-bloody, non-bilious material. He
became diaphoretic. He felt dizzy, like sensation room was
spinning and felt unsteady when walking. EMS was called and he
was transported to ED. Finger stick en route 175.
Patient able to tell me that he has had double vision and
problems with his hearing for months. No dysphagia. He feels
like
he is off balance and that he has to hold onto things to walk.
His right side is clumsier than usual. He states this is exactly
how he felt during his stroke, with exception of the nausea and
vomiting.
No recent illnesses, fevers, chills, chest pain, shortness of
breath, palpitations, cough, sputum, abdominal pain, increased
urinary frequency, dysuria. No new visual changes (states
diplopia has been going on for months), comprehension
difficulty,
focal numbness, weakness, paresthesias. No bowel or bladder
incontinence.
Past Medical History:
1. Stroke 1 year ago with slurred speech, right sided
incoordination
2. Atrial fibrillation, on coumadin
3. Obesity
4. Diabetes mellitus
5. Asthma
6. Obstructive sleep apnea
7. Hypertension
8. Hyperlipidemia
9. CAD status post angioplasty
10. History of melanoma resection over abdomen, remotely
11. COPD
Social History:
Divorced. 3 kids. Lives with girlfriend of 14 years.
Smoker, quite several years ago. No tobacco, alcohol, drug use
currently. Moved here from [**Country 2559**] 30 years ago.
Family History:
Girlfriend not aware if any history of neurologic
disease.
Physical Exam:
PHYSICAL EXAM:
Tc: 96.6
BP: 164/83
HR: 68, irregular
RR: 16
O2Sat.: 100%/2 liters
Gen: WD/WN obese male, diffusely diaphoretic, uncomfortable, in
moderate distress. Stops at several points during exam to vomit.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: Irregularly irregular. S1/S2. No M/R/G.
Abd: Soft, obese, NT, ND, +NABS. No rebound or guarding. No
HSM.
Extrem: Warm and well-perfused. No C/C/E.
.
Neuro:
Mental status: Awake and alert, but extremely inattentive.
Defers
to girlfriend to answer questions. Cannot relate coherent
history. Unable to recite [**Doctor Last Name 1841**] forwards and backwards. Did not
register despite multiple attempts. Speech fluent with fair
comprehension and repetition. Impaired naming for low frequency
naming. Moderate dysarthria. No apraxia, no neglect.
.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Unable to cooperate with formal resistance testing.
Blinks to threat bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus but complains of diplopia in all fields of gaze. Gets
frustrated and looks to girlfriend when I ask him to explain
further.
V, VII: Right nasolabial lobe flattening. Facial sensation
intact
and symmetric.
VIII: Hearing grossly intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Shoulder shrug strong bilaterally.
XII: Tongue midline without fasciculations. No tongue weakness.
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-30**] throughout. No pronator drift.
.
Sensation: Intact to light touch. Inattentive during rest of
sensory exam.
.
Reflexes: Trace but symmetric. Left toe is downgoing. Right toe
is upgoing.
.
Coordination: Right finger-nose-finger with mild dysmetria.
Dysrhythmia on rapid alternating movements, fine finger
movements. Normal on finger-nose-finger, rapid alternating
movements on left.
.
Gait: Did not assess. Out of concern for possible posterior
circulation problem, kept patient in bed with [**Name (NI) **] <30 degrees.
Pertinent Results:
[**2190-1-8**] 01:17PM PT-15.9* PTT-22.4 INR(PT)-1.7
[**2190-1-8**] 01:17PM PLT COUNT-350
[**2190-1-8**] 01:17PM NEUTS-65.7 LYMPHS-24.0 MONOS-6.9 EOS-2.4
BASOS-1.0
[**2190-1-8**] 01:17PM WBC-17.1* RBC-5.67 HGB-16.0 HCT-45.2 MCV-80*
MCH-28.3 MCHC-35.5* RDW-14.5
[**2190-1-8**] 01:17PM CALCIUM-10.1 PHOSPHATE-4.9* MAGNESIUM-1.8
[**2190-1-8**] 01:17PM CK-MB-13* MB INDX-4.8 cTropnT-0.03*
[**2190-1-8**] 01:17PM LIPASE-54
[**2190-1-8**] 01:17PM ALT(SGPT)-77* AST(SGOT)-39 LD(LDH)-261*
CK(CPK)-269* AMYLASE-187* TOT BILI-0.5
[**2190-1-8**] 10:00PM CK-MB-31* MB INDX-6.7* cTropnT-0.03*
.
CT head [**1-8**]:
FINDINGS: There is no evidence for intracranial hemorrhage.
There is no mass effect or shift of the normally midline
structures. The ventricles, sulci, and cisterns demonstrate no
effacement. The patient is status post left parietal lobe
infarct with hypodense sequelae at this site. There is no
hydrocephalus. The paranasal sinuses are clear. The [**Doctor Last Name 352**]-white
matter junction is indistinct.
IMPRESSION: No evidence for intracranial hemorrhage.
.
CT head [**1-9**]:
No intracranial hemorrhage is identified. Within the right
cerebellar hemisphere, there is a large area of low attenuation,
which was not seen previously, with associated slight mass
effect. The remainder of the [**Doctor Last Name 352**]-white matter differentiation
is preserved. There is an area of decreased attenuation within
the left parietal lobe, which is increased, and corresponds to
chronic changes from prior infarct. The ventricles are
symmetric, and there is no shift of normally midline structures.
Soft tissue and osseous structures are within normal limits.
IMPRESSION: There is a new area of low attenuation within the
right cerebellar hemisphere, which is concerning for a acute
right cerebellar infarct. No intracranial hemorrhage is
identified.
.
CTA head: prelim.
1. No evidence of vertebral artery or carotid dissection.
2. Area of decreased attentuation within the right cerebellar
hemisphere is again seen, likely representing subacute infarct.
Recons pending.
.
RUQ US:
1. Diffuse increased echogenicity of the liver parenchyma,
consistent with fatty infiltration. Other forms of liver
disease, including more severe forms such as hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. No radiographic evidence for acute cholecystitis or
cholelithiasis. No gallbladder wall edema, pericholecystic
fluid, or intrahepatic biliary dilatation.
.
CT head [**1-12**]:
No acute intracranial hemorrhage is seen. The previously
identified areas of low attenuation in the left parietal lobe,
as well as the right cerebellar hemisphere are unchanged.
There is no hydrocephalus or shift of normal midline structures.
Overall, the exam is not significantly changed from [**2190-1-9**].
.
Right LENIs [**1-13**]:
No evidence of DVT.
.
ECG:
Atrial fibrillation
Diffuse nonspecific ST-T wave abnormalities
Brief Hospital Course:
The patient is 53 year old man with a past medical history of
stroke one year ago (slurred speech and right sided
incoordination), obesity, type II DM, COPD, atrial fibrillation,
and a history of melanoma who presented to the ED [**1-8**] with a
three day history of slurred speech, imbalance, and vertigo.
During the initial exam, the patient was diffusely diaphoretic
and he had to stop during the exam to vomit several times. He
was also inattentive and confused, with his speech mildly
dysarthric, and complaints of diplopia in all directions of
gaze, mild right nasolabial flattening, and clumsiness on right
FNF, FFM,
RAMS. An initial CT head was negative for bleed and showed an
old left parietal infarct. A repeat CT on [**1-9**] showed a new R
cerebellar hypodensity that explains all his symtpoms. A CTA did
not show evidence for dissection.
Initially the patient was admitted to medicine for suspicion of
MI. He was transferred to the ICU for close monitoring after the
cerebellar ischemic stroke was noted. He was then transferred to
the floor [**1-11**].
.
Neuro:
After transfer to the floor, the patient continued to be
somnolent (combination of OSA and pain medications), but always
arousable. He had residual R-sided dysmetria (arms and legs) and
dysarthria His pain medications were kept to a minimum. The
neurological exam was significant for R-sided ataxia, rebound of
the R-arm and dysarthria. Lipid panel: chol 212 TG288 HDL50 4.2
LDL104. HbA1C 7.6.
The patient was started on ASA 325mg and lipitor 80mg. The
importance of life style modifications were discussed (weight
loss, healthy diet, exercise).
.
CV:
Initially the patient's blood pressure was allowed to
autoregulate.
Lopressor was started to rate control Afib. A dose of 25mg [**Hospital1 **]
appeared sufficient, whereas higher doses would drop the SBP to
90. Lisinopril was added to the regimen. Digoxin (0.125mg daily
at home) and verapamil (180mg daily at home) were held.
Coumadin was restarted [**1-11**] (5mg). INR [**1-11**] 1.3. On [**1-12**], 5mg
coumadin was given with an INR [**1-13**] of 1.1. [**1-13**] and [**1-14**] the
patient received 7.5mg, with an INR of 1.2 on [**1-15**] The patient
should continue to take Coumadin to titrate a goal INR of
2.0-3.0. As long as the INR is not therapeutic he will need to
receive lovenox (80mg sc BID).
.
Pain/psych:
Initially, oxycodone SR 20mg TID was prescribed, but this needed
to be held for sedation. Percocet was given PRN for
breakthrough. Please note that the patient easily becomes
somnolent on these medications.
In addition, clonazepam 1mg TID, topamax 50mg [**Hospital1 **], ativan 0.5mg
qHS and venlafaxine were continued.
.
CRI:
Creatinine was stable at 1.1-1.5. Creatinine at d/c was 1.1.
.
DM:
The patient was put on an ISS. Metformin 1000mg [**Hospital1 **] was resumed
once he was able to eat a regular diet.
.
COPD:
Stable; albuterol PRN as needed.
At night, BiPAP was indicated ([**4-3**]) given OSA in combination
with COPD. The patient was non-compliant. Please avoid
supplementary oxygen as this may add to CO2 retention and
lethargy.
.
Right Leg Pain:
The day of discharge the patient complained of right leg pain;
no swelling or tenderness to touch was present. Given that the
patient had been sedentary, right LENIs was obtained: there was
no evidence of DVT.
.
Prophylaxis:
-GI: ranitidine
-PE: VD boots, sc lovenox
.
Diet: Regular, cardiac-diabetic; the patient was non-compliant.
.
The patient was discharged to rehab.
Medications on Admission:
1. Effexor
2. Lasix
3. Verapamil
4. Ativan
5. Cialis
6. Metformin
7. Nasacort
8. Percocet
9. Zantac
10. Digoxin
11. Potassium chloride
12. Coumadin
13. Magnesium oxide
14. Topamax (for mood)
15. Singulair
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO HS (at bedtime).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
4. Topiramate 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
13. Insulin Regular Human 100 unit/mL Solution Sig: Two (2)
units Injection ASDIR (AS DIRECTED): per sliding scale.
14. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO ONCE (once)
for 1 doses: Please dose based INR.
Disp:*90 Tablet(s)* Refills:*0*
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] - TCU
Discharge Diagnosis:
1. cerebellar ischemid stroke, right
2. diabetes
3. hypertension
4. opioid dependence
5. chronic pain
Discharge Condition:
good
Discharge Instructions:
Please take your medications as instructed. Do not over-use
narcotics as these will depress your breathing.
.
Please have your INR checked and have the coumadin dosed
accordingly to a goal of [**1-29**]. Continue the lovenox until INR is
therapeutic.
.
Please follow up as indicated below.
Followup Instructions:
Please follow up at the [**Hospital 878**] Clinic:
- Dr. [**Last Name (STitle) **]. [**3-9**], 5:30 PM. [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**]
Building [**Location (un) 858**]
Please call [**Telephone/Fax (1) 2574**] to register before your appointment.
.
Please follow-up with your PCP.
Completed by:[**2190-1-15**]
|
[
"276.51",
"585.9",
"434.91",
"V12.59",
"784.5",
"584.9",
"276.2",
"278.00",
"276.8",
"493.20",
"414.01",
"427.31",
"272.4",
"V45.82",
"327.23",
"V10.82",
"401.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12962, 13011
|
7866, 11353
|
328, 335
|
13157, 13164
|
4912, 7843
|
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2602, 2663
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11608, 12939
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256, 290
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363, 2064
|
3600, 4893
|
3210, 3584
|
2086, 2392
|
2408, 2586
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,700
| 115,490
|
27267
|
Discharge summary
|
report
|
Admission Date: [**2154-4-18**] Discharge Date: [**2154-5-1**]
Date of Birth: [**2089-12-28**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Pancreatic Mass
Major Surgical or Invasive Procedure:
s/p Roux-en-Y hepaticojejunostomy, gastrojejunostomy, repair of
duodenal perforation
J-tube
History of Present Illness:
The patient is a 64 year old female who presents with 2-3 weeks
of jaundice and pruritis. She also reports a 17 lb weight loss
in the past month. She had previously been seen in at [**Hospital1 9191**] where she had a ERCP with stent placement and biopsy. A
EUS/FNA was positive for malignant cells. She presents to [**Hospital1 18**]
for a staging laparotomy.
Past Medical History:
Jaundice
Pruritis
Chronic Back Pain
Diverticulitis
Social History:
She is retired worker from a Chocolate Factory
Tobacco 1-2 packs for 30 years
Family History:
Brother and sister with pancreatic cancer
Father with prostate cancer
Niece with liver cancer
Niece with breast cancer
Physical Exam:
VS: HR 64, BP 112/65
HEAD: anterior cervical LAD - one 1cm x 1.5cm LN, soft,
nonmobile
Cardiac: RRR, S1, S2, no murmur
Pulm: RUL field - rhonchi
Abd: no scars, soft, nontender, ND, no HSM
Lymph: no axillary, supraclavicular LAD
Pertinent Results:
SPECIMEN SUBMITTED: GALLBLADDER.
Procedure date Tissue received Report Date Diagnosed
by
[**2154-4-18**] [**2154-4-18**] [**2154-4-22**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/kg
DIAGNOSIS:
Gallbladder:
1. Acute and chronic cholecystitis.
2. Cystic ductal lymph node, with hyperplasia.
3. No calculi in this specimen.
CHEST (PORTABLE AP) [**2154-4-22**] 6:28 PM
CHEST (PORTABLE AP)
Reason: Eval. for CHF
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with pancreatic ca with resp distress
REASON FOR THIS EXAMINATION:
Eval. for CHF
INDICATION: 64-year-old female with pancreatic carcinoma,
respiratory distress.
COMPARISON: [**2154-4-21**].
UPRIGHT CHEST: The tip of a right internal jugular venous
catheter terminates in the distal SVC. There is prior abdominal
surgery with a drain identified projecting over the right upper
quadrant. The tip of a nasogastric tube terminates in the distal
esophagus. The heart size is top normal, and the mediastinal and
hilar contours are stable. There is continued opacification of
the left lower lobe with air bronchograms and layering small
pleural effusion. Mild linear atelectasis is seen at the right
base. The pulmonary vasculature is within normal limits. No
pneumothorax is identified.
IMPRESSION: Nasogastric tube malpositioned in the distal
esophagus. Left lower lobe consolidation, representing a
combination of atelectasis and/or effusion. Pneumonia could be
considered in the right clinical circumstance. No pneumothorax.
CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST
Reason: eval for PE
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with dyspnea and tachycardia and resp distress
REASON FOR THIS EXAMINATION:
eval for PE
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Dyspnea, tachycardia, respiratory distress.
COMPARISONS: None.
TECHNIQUE: CT angiogram of the chest was performed. Axial MDCT
images were obtained through the lungs before and after
administration of nonionic Optiray contrast.
CT CHEST WITH AND WITHOUT IV CONTRAST: There is no evidence of
pulmonary embolism. There are moderate sized bilateral pleural
effusions, right greater than left with associated collapse of
the lower lobes bilaterally. There are scattered ground-glass
opacities within the lungs, predominantly in a perihilar
distribution. The main pulmonary is enlarged measuring 3.2 cm.
There are non-pathologically enlarged mediastinal nodes with no
pathologic lymphadenopathy. Within the anterior mediastinum,
inferior to the thymic bed, there is a 2.1 x 0.9 cm soft tissue
attenuation mass. This mass is immediately posterior to the
internal mammary vessels on the left side of the anterior
mediastinum and is well circumscribed.
Limited views of the upper abdomen are unremarkable.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Bilateral pleural effusions with reactive atelectasis.
3. Scattered ground-glass opacities in a perihilar distribution.
These finding are nonspecific, but likely represents pulmonary
edema.
4. 2 cm soft tissue mass in the left anterior mediastinum
posterior to the internal mammary vessels, of undetermined cause
or significance. Correlate clinically to determine nee4ed for
further evaluation which include short term follow up CT or MR
scan versus PET CTscan
Cardiology Report ECHO Study Date of [**2154-4-24**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function.
Height: (in) 61
Weight (lb): 110
BSA (m2): 1.47 m2
BP (mm Hg): 109/56
HR (bpm): 77
Status: Inpatient
Date/Time: [**2154-4-24**] at 13:01
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W018-0:53
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 251**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 3.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: 0.33 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 30% (nl >=55%)
Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.2 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 0.90
Mitral Valve - E Wave Deceleration Time: 175 msec
TR Gradient (+ RA = PASP): <= 25 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 0.7 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Moderate-severe
regional left ventricular systolic dysfunction. No resting LVOT
gradient. No
LV mass/thrombus. False LV tendon (normal variant).
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior -
hypo; mid anteroseptal - hypo; mid inferolateral - hypo; mid
anterolateral -
hypo; anterior apex - akinetic; septal apex- akinetic; lateral
apex -
akinetic; apex - akinetic;
RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV
systolic
function.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
AS.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral
annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is moderate to severe regional
left ventricular
systolic dysfunction. No masses or thrombi are seen in the left
ventricle.
Resting regional wall motion abnormalities include hypokinesis
of the mid
antero-septum, anterior and lateral walls with akinesis of the
distal LV and
apex. Right ventricular chamber size is normal. Right
ventricular systolic
function is borderline normal. The aortic valve leaflets (3)
appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
There is no aortic valve stenosis. The mitral valve leaflets are
mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation
is seen. The tricuspid valve leaflets are mildly thickened. The
estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic
pericardial effusion.
IMPRESSION: Moderate to severe regional LV systolic dysfunction
c/w CAD.
[**2154-4-27**] 11:18AM
CHEMISTRY
Amylase, Ascites 6 IU/L
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**2154-4-18**] under Dr.[**Name (NI) 9886**]
care. After the surgery she was NPO/NGT/IVF.
#Pain
She had an epidural for pain control and was followed by the
pain service. Pain was well controlled with the epidural. She
was transitioned to PO pain meds once taking a diet.
#Respiratory
The patient was transferred to the SICU from the floor for O2
saturation in the 70s and HR >120. ABG was PO2 38, PCO2 49, pH
7.41. She required pulmonary toilet, including nebs and chest
PT. A chest X-ray showed LLL consolidation, atelectasis and
effusion. she was started on Levofloxacin for pneumonia. She had
scattered wheezes and was coughing up clear sputum. She required
a face mask and careful monitoring of her respiratory status.
She was transferred back to the floor POD 2. She was again
transferred to the ICU for respiratory distress with O2 sats in
the 70's. She was transferred back to the floor on POD 7 with
much improved respiratory status.
#Hypotension
She was hypotensive immediately post-op BP 80's and was on a Neo
drip and IVF, which improved.
#Incision
The incision was clean, dry, and intact. She had a JP drain
serosanguinous fluid. A JP amylase on POD 7 was 6 and her drain
was D/C'd. The incision was opened slightly on the right lower
side and packed with a wet to dry dressing. There was a
moderated amount of drainage. She is to continue with dressing
changes TID. Her staples were D/C'd POD 13.
#Abdomen
The NGT remained in place to low wall suction. The NGT was
clamped on POD 5 as tube feedings were introduced. Her tube
feedings were held for a short time due to continued respiratory
distress. She was started back on tube feeds on POD 6 and
advanced to goal. Her diet was advanced slowly as she had return
of bowel function and tube feeds were eventually D/C'd.
#Cardiology
POD 5 she awoke with chest pain and O2 sats in the 80's.
Cardiology was consulted. A chest CT showed no evidence of
pulmonary embolism. An ECHO was done that showed moderate to
severe regional LV systolic dysfunction c/w CAD. A EKG showed
changes, troponin was 0.05 x 2. It is likely she had a cardiac
event on POD 5. She is presently chest pain free and
hemodynamically stable. She was treated with Lopressor, ASA and
Lasix per the cardiac recommendations.
Medications on Admission:
Glyburide 2.5 mg [**Hospital1 **]
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain for 4 weeks.
Disp:*35 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for GERD.
7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic Head Mass
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to pass gas or stool
* Redness/swelling/drainage/odor from wounds
* Other symptoms concerning to you
Please take all your medications as ordered
Pack the incision on the lower right side with a 2x2 damp gauze
and cover with a dry gauze 3x/day until the wound closes.
You may shower and wash incision. Pat incision dry after a
shower.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in 2 weeks. Call ([**Telephone/Fax (1) 27734**] to schedule an appointment.
Completed by:[**2154-5-2**]
|
[
"518.0",
"575.12",
"576.2",
"410.11",
"569.83",
"486",
"250.00",
"157.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.71",
"51.37",
"96.6",
"51.22",
"54.21",
"44.39",
"46.39"
] |
icd9pcs
|
[
[
[]
]
] |
11918, 11924
|
8494, 10805
|
286, 380
|
11989, 11996
|
1340, 1785
|
12441, 12602
|
955, 1076
|
10889, 11895
|
3015, 3081
|
11945, 11968
|
10831, 10866
|
12020, 12418
|
4849, 8471
|
1091, 1321
|
231, 248
|
3110, 4823
|
408, 770
|
792, 844
|
860, 939
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,156
| 163,180
|
2464
|
Discharge summary
|
report
|
Admission Date: [**2165-9-30**] Discharge Date: [**2165-10-24**]
Date of Birth: [**2102-8-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Left foot pain
Major Surgical or Invasive Procedure:
[**2165-10-1**]: Left Leg Fasciotomy
[**2165-10-1**] Trachesostomy
[**2165-10-2**]: Right Leg Fasciotomy
[**2165-10-14**] Tracheostomy decannulation
[**2165-10-14**] PICC placement
[**2165-10-17**]: Fasciotomy closure R leg, fasciotomy closure and skin
graft to left leg
[**2165-10-22**]: Bone marrow biopsy
History of Present Illness:
63 y/o M with PMHx of MM s/p autologous stem cell transplant in
05 presented to [**Hospital3 **] hospital with 5 days of worsening L
foot pain and elevated CKs. Pt transferred to [**Hospital1 18**] and was
noted to have rising CKs & abn LFTs, MRI showed non-specific
left lower extremity edema and u/s was negative for DVT. Pt
reported some tongue swelling and developped some mental status
changes on the evening of [**2165-9-30**] thought due to Ativan. Mental
status was improved in am but neuro, vascular, ID and renal were
consulted. During the day of [**10-1**], CKs were up the [**Numeric Identifier 6085**] range
and pt developped worsening pain with elevated compartment
pressure. Pt was taken to the OR urgently for emergency
fasciotomy due to compartment syndrome. Pt was found to have
[**Numeric Identifier **] pus in the compartments and deep cultures were sent. Pt
was extubated in the OR and suddenly became unresponsive. Pt was
found to be pulseless and had CPR for less than 5 minutes. A
profound drop in O2 sats were noted. Pt was given epinephrine
1mg and pacer pads placed. First rhythm was noted as sinus tach
at 100. LMA was placed and pt was being bagged with minimal
improvement in oxygen sats. There were multiple attempts to
establish an airway. Anesthesia was unable to place ETT tube,
after multiple attempts. Pt ultimately had an emergency trach
placed at bedside. Left femoral CVL was placed peri code and
arterial line was placed prior to transfer to ICU. On arrival to
ICU, pt was being ventilated via trach, not responding to
commands or withdrawing to pain. Sats initially in the 80s but
came up to 90s with increased PEEP. Deep suction produced some
bloody secretions. He was eventually weaned off peep and is
trach collar doing well. He has been having episodes of
unresponsiveness per icu staff and was seen by neuro yesterday
without clear explanation. mri, ct, lp were all negative to
date. ID's following him closely with recommendation in chart.
His belly has been somewhat distended but improved after ngt
placement. he's followed by surgical consult for this who saw
him this am and felt his belly's somewhat improved.
Past Medical History:
1) Multiple Myeloma, dx'ed by BM bx/UPEP in 09/[**2160**]. Briefly,
was treated with radiation for large plasmacytoma in L hip,
treated with 5 cycles of Velcade which showed persistant dz on
repeat BMBx and was started on DVD chemotherapy. Underwent
autologous stem cell transplant in [**2162**]. Afterwards, had very
low amount of plasma cells in the marrow, approximately 3-5% and
we have considered him to be in CR or very near CR. He has also
been treated with the dendritic
cell vaccine after his transplant.
2) Hypertension - Controlled without medicine, BP 130/80mmhg
today. was on HCTZ, off now.
3) Hypercholesterolemia - controlled on diet/exercise.
4) DVT in [**1-/2162**], treated with 6 months of Lovenox. Now off all
treatment. No hx of PE.
Social History:
Quit smoking 40 yrs ago. Denies drug use. EtOH history somewhat
questionable as pt reports different things at different times.
States he drinks 2-4 bottles wine weekly which he splits with
his husband and a couple martinis. Retired from teaching in
[**Location (un) 86**] public schools in [**2-5**]. Volunteers as a greeter at [**Hospital 3278**]
Medical Ctr. Lives in the [**Location (un) 4398**] with his husband, [**Name (NI) **]
[**Name (NI) 12616**] who is also HCP. [**Name (NI) **] a weekend home in [**Location 3615**], MA.
.
[**Name (NI) 12617**] Father with hypothyroidism.
Family History:
[**Name (NI) 12617**] Father with hypothyroidism.
Physical Exam:
VS: 96.3 118/76 70 98/RA
Gen: NAD
HEENT: no thyroid enlargement, no thyroid nodules or tenderness
Chest: CTABL
Heart: RRR, no M/R/G, nl S1 S2
Abd: soft, NT ND no HSM BS +
Extr: LLE warm to touch, no TTP, no significant erythema
Neuro: knee reflex normal, ankle reflex depressed on R side. did
not test on L side d/t foot pain
.
Pertinent Results:
[**2165-9-30**] 05:22AM PT-11.3 PTT-23.4 INR(PT)-0.9
[**2165-9-30**] 05:22AM PLT COUNT-112*
[**2165-9-30**] 05:22AM NEUTS-71.5* LYMPHS-21.8 MONOS-3.8 EOS-2.2
BASOS-0.6
[**2165-9-30**] 05:22AM WBC-3.5* RBC-3.82* HGB-12.5* HCT-34.7* MCV-91
MCH-32.6* MCHC-35.9* RDW-16.4*
[**2165-9-30**] 05:22AM TSH-54*
[**2165-9-30**] 05:22AM ALBUMIN-4.9* CALCIUM-8.6 PHOSPHATE-3.7
MAGNESIUM-1.9
[**2165-9-30**] 05:22AM CK-MB-65* MB INDX-1.2
[**2165-9-30**] 05:22AM cTropnT-0.02*
[**2165-9-30**] 05:22AM LIPASE-38
[**2165-9-30**] 05:22AM ALT(SGPT)-93* AST(SGOT)-215* CK(CPK)-5538*
ALK PHOS-53 TOT BILI-1.3
[**2165-9-30**] 05:22AM estGFR-Using this
[**2165-9-30**] 05:22AM GLUCOSE-131* UREA N-10 CREAT-1.4* SODIUM-125*
POTASSIUM-4.7 CHLORIDE-87* TOTAL CO2-28 ANION GAP-15
[**2165-9-30**] 11:14AM PEP-NO SPECIFI
[**2165-9-30**] 11:14AM OSMOLAL-258*
[**2165-9-30**] 11:14AM TOT PROT-6.3* CALCIUM-7.9* PHOSPHATE-2.9
MAGNESIUM-1.7 URIC ACID-4.6
[**2165-9-30**] 11:14AM ALT(SGPT)-91* AST(SGOT)-212* LD(LDH)-493* ALK
PHOS-50 TOT BILI-0.9
[**2165-9-30**] 11:14AM GLUCOSE-125* UREA N-9 CREAT-1.2 SODIUM-126*
POTASSIUM-3.6 CHLORIDE-89* TOTAL CO2-26 ANION GAP-15
[**2165-9-30**] 11:56AM URINE HOURS-RANDOM UREA N-283 CREAT-64
SODIUM-48 POTASSIUM-31 CHLORIDE-55 TOT PROT-15 PROT/CREA-0.2
[**2165-9-30**] 01:01PM FREE T4-<0.10*
[**2165-9-30**] 01:01PM CK-MB-70* MB INDX-0.9 cTropnT-0.01
[**2165-9-30**] 01:01PM CK(CPK)-8138*
[**2165-9-30**] 08:00PM CALCIUM-8.0* PHOSPHATE-2.6* MAGNESIUM-1.7
[**2165-9-30**] 08:00PM CK(CPK)-[**Numeric Identifier 12618**]*
[**2165-9-30**] 08:00PM GLUCOSE-103 UREA N-10 CREAT-1.3* SODIUM-131*
POTASSIUM-3.3 CHLORIDE-93* TOTAL CO2-27 ANION GAP-14
[**2165-10-22**] 12:00AM BLOOD WBC-1.7* RBC-3.29*# Hgb-10.4*# Hct-30.7*
MCV-93 MCH-31.6 MCHC-33.8 RDW-17.3* Plt Ct-101*
[**2165-10-24**] 01:00AM BLOOD WBC-2.8* RBC-2.44* Hgb-7.9* Hct-22.5*
MCV-92 MCH-32.3* MCHC-35.1* RDW-17.2* Plt Ct-139*
[**2165-10-24**] 01:00AM BLOOD Glucose-102 UreaN-14 Creat-1.1 Na-137
K-3.7 Cl-102 HCO3-26 AnGap-13
[**2165-10-3**] 01:53PM BLOOD CK(CPK)-[**Numeric Identifier 12619**]*
[**2165-10-9**] 05:00AM BLOOD ALT-100* AST-60* LD(LDH)-413*
CK(CPK)-1206* AlkPhos-84 TotBili-0.7
[**2165-10-24**] 01:00AM BLOOD ALT-23 AST-10 LD(LDH)-212 CK(CPK)-212*
AlkPhos-110 TotBili-0.5
[**2165-9-30**] 05:22AM BLOOD TSH-54*
[**2165-10-6**] 02:46AM BLOOD TSH-22*
[**2165-10-21**] 12:18AM BLOOD TSH-12*
[**2165-10-21**] 12:18AM BLOOD T4-6.5 T3-72* calcTBG-1.01 TUptake-0.99
T4Index-6.4
[**2165-10-11**] 12:59AM BLOOD PTH-163*
[**2165-10-6**] 02:46AM BLOOD T4-2.8* T3-34* calcTBG-1.14 TUptake-0.88
T4Index-2.5* Free T4-0.45*
[**2165-10-1**] 09:06AM BLOOD Cortsol-18.4
[**2165-10-21**] 12:17PM BLOOD PEP-NO SPECIFI IgG-1074 IgA-104 IgM-38*
IFE-TRACE BENC
FREE KAPPA, SERUM 23.3 H 3.3-19.4 MG/L
FREE LAMBDA, SERUM 410.0 H 5.7-26.3 MG/L
FREE KAPPA/LAMBDA RATIO 0.06 L 0.26-1.65
Muscle biopsy: Acute segmental myocytic necrosis, likely
ischemic. See note.
Fasciotomy Wound culture
GRAM STAIN (Final [**2165-10-1**]): NO POLYMORPHONUCLEAR LEUKOCYTES
SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2165-10-3**]):
NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID
FAST SMEAR (Final [**2165-10-2**]): NO ACID FAST BACILLI SEEN ON DIRECT
SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE
(Preliminary): NO FUNGUS ISOLATED.
- CMV negative
- stool viral cx ?????? neg , urine viral culture pending, throat
viral culture pending, west [**Doctor First Name **] serology pending, stool
enterovirus pending, ebv viral load, ebv
-hep A +, Hep B core Ab +, Hep B surf Ab +, Hep B viral load not
detected
- lyme Ab negative
SELECTED IMAGING
[**2165-10-8**] CT ABd/Pelvis
IMPRESSION:
1. No evidence of colonic perforation. Questionable thickening
of the distal
sigmoid and rectum which is difficult to evaluate due to
underdistention.
2. Large bilateral pleural effusions with adjacent atelectasis.
3. Plasmacytoma in the right iliac bone extending into the
sacrum as well as
multiple lytic lesions in the pelvis and lumbar spine consistent
with
patient's known multiple myeloma.
Head MRI/MRA: IMPRESSION: Unremarkable head MRI and MRA.
[**2165-10-1**] MR [**Name13 (STitle) **] IMPRESSION: Moderate, nonspecific dorsal
subcutaneous edema. No focal fluid
collection, fracture, nor marrow signal abnormalities.
[**2165-9-30**] US LLE: No DVT
Brief Hospital Course:
Assessment & Plan: 63 y/o M with PMHX of MM s/p autologous stem
cell transplant in [**2162**] presented with foot pain and elevated
CKs taken to the OR emergently for fasciotomy due to compartment
syndrome, now s/p cardiac arrest and emergency tracheostomy and
then subsequent fasciotomy on the other side.
.
# Elevated CK/Rhabdomyolysis/s/p emergent fasciotomy: Most
likely etiology was compartment syndrome which was most likely
secondary to hypothyroidism +/- statin use. CKs peaked at [**Numeric Identifier 389**]
and trended down to 200s at time of discharge. He was initially
treated with aggressive IV fluids. He was taken emergently to
the OR [**2165-10-1**] for elevated compartment pressures and had a L
fasciotomy followed by R sided fasciotomy on [**2165-10-2**]. Per OR
report, [**Date Range **] pus was found after opening compartments, however,
all cultures sent intra-op and all other cultures have been
negative. Patient initially was treated with Cefepime, clinda,
vanco to cover skin flora and clostridium. Infectious disease
was following. In the setting of negative cultures, antibiotics
were peeled off, and now patient completely off of antibiotics.
He was followed by Vascular Surgery and had closure of his
wounds with a skin graft to the left leg on [**2165-10-17**]. At time of
discharge, he was walking with assist and was receiving physical
therapy. Statin was held and was not continued due to concern
for exacerbating rhabdomyolysis.
# Hypoxemic Respiratory failure: The patient had hypoxemia with
respiratory distress after extubation from surgery. He was
initially intubated likely secondary to laryngeal edema
associated with hypothyroidism. Once stable in the [**Hospital Unit Name 153**], the
patient was extubated and tracheostomy performed. Echo showed no
evidency of right heart strain to suggest PE as etiology of
respiratory failure. He had standing suctioning, albuterol and
atrovent nebs and was weaned off ventilator. CT chest showed
bilateral pleural effusions w/associated atelectasis. He
tolerated trach downsizing on [**2165-10-11**] and had decannulation of
trach on [**2165-10-14**]. He had suture removal on [**2165-10-24**].
#) Abdominal distension: Patient was felt to have a distended,
tympanic abdomen on exam in the [**Hospital Unit Name 153**]. Abdominal x-ray
demonstrated 8.6 cm dilated loops. CT abd/pelvis unchanged from
previous and did not show any ileus, perforation or new acute
process. C. difficile was negative x 3. Abdominal distension
resolved by time of discharge.
#) Mental status changes: Patient had several nights of
sundowning in the ICU which were treated with reorientation and
haldol prn. On one occasion patient had an unresponsive period
in the early morning where he was not responsive to voice or
tactile stimulation. Patient does not recall this episode. CT,
MRI, and LP were negative. No sedating medications were given at
the time, finger stick was negative and EKG was unchanged.
Neurology was consulted, but it was unclear what the etiology of
these mental status changes were. Most likely etiology may have
been bacteremia given that blood cultures from this date grew
coag negative staph bacteria sensitive to vanco. He did not have
mental stsatus changes after transfer to the floor and remained
oriented x 3.
# Multiple Myeloma: Patient has been on Revlimid which may have
been contributing to hypothyroidism on admission. Anemia &
thrombocytopenia on admission likely due to marrow suppression
from treatment. Revlimid was held on admission secondary to
concern for contribution to presentation. Bone marrow biopsy
performed on [**2165-10-22**] for concern for worsening disease with
slightly elevated creatinine and decreased WBC. Results still
pending at time of discharge.
#Coag negative Staph Aureus bacteremia: Pt had Coagulase neg
staph aureus + blood cx x 2 on [**10-7**] and [**10-8**]. Repeat blood
cultures were negative and he was treated with Vancomycin IV.
His PICC was D/C'd and replaced [**2165-10-14**]. he was treated with 5
days of Vanco after PICC was pulled per ID recommendations.
Surveillance cultures were no growth at time of discharge.
# Anemia: Hct was 25.8 on admission stabilized after surgery.
HCT remained low around 25-29 during admission and he was
transfused as necessary to keep HCT greater than 25. Prior to
discharge, he was transufsed 1 unit PRBC on [**2165-10-24**].
# Hypothyroidism: Endocrine was consulted early in his admission
and followed throughout hospital course, He was initially
treated with Levothyroxine 200mg IV daily. Once he was
tolerating a diet, Levothyroxine was changed to 150 PO. Repeat
TFTs on Monday [**10-14**] showed decreased TSH of 27 (from 54) and
increased free T4 and T3 compared to prior. Levothyroxine was
increased to 175mcg PO daily. Follow up was arranged with Dr.
[**Last Name (STitle) 12620**] and Dr. [**Last Name (STitle) **] from Endocrinology.
# Hypertension: BP was well controlled in house with BPs
110s-120s/70s off of BP medications. These medications were
intitially held and were not continued at time of discharge.
Restarting them can be considered as an outpatient.
# Code: FULL
Medications on Admission:
Viagra 100mg tab prn
os-cal 500 + D1 tab PO daily
Zometa 4mg/5ml IV q 3 months
Revlimid 10mg cap 1 cap PO daily x 21 days
ASA 325 PO daily
MVI
HCTZ 25 PO daily
Lisinopril 10mg PO daily
Timolol eye drops
Simvastatin 10mg PO daily
Oxycodone 5mg tab. 1-2 tabs PO q4 hours prn pain
B Complex cap
Discharge Medications:
1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily): To both eyes.
2. Viagra 100 mg Tablet Sig: One (1) Tablet PO prn.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
4. B Complex Capsule Sig: One (1) Capsule PO once a day.
5. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
8. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnosis
1. Hypothyroidism
2. Rhabdomyolysis
3. Multiple Myeloma s/p auto SCT [**9-3**]
Secondary Diagnosis
1. Multiple Myeloma
2. HTN
3. Hypercholesterolemia
4. Glaucoma- diagnosed 5 yrs ago, stable on timolol
Discharge Condition:
Hemodynamically stable, afebrile, pain well controlled
Discharge Instructions:
You were admitted to the hospital with right foot pain and
elevated pressures in the muscle compartments in your legs with
blood work indicating muscle damage. You were taken to the
operating room for a procedure called a fasciotomy which
decreases the pressure in the legs. After this procedure, there
was difficulty in keeping your airway open so you had a
tracheostomy tube placed in your neck to keep your airway open.
Other blood work showed that you had low thyroid hormone levels
which may have contributed to your symptoms. The
Endocrinologists saw you and we started you on replacement
thyroid hormone and followed the thyroid hormone levels which
improved thoughout your hospital stay.
Vascular surgery followed you and you had a skin graft placed to
the left leg and closure of the right leg.
During your admission, we did studies that showed some bacteria
in your blood which we treated with an antibiotic called
Vancomycin through [**10-19**]. Repeat studies showed that this
infection had resolved.
On [**2165-10-22**] you had a bone marrow biopsy to evaluate the status
of your multiple myeloma since your white blood cell and red
blood cell counts were lower and your renal function was mildly
impaired. The results of this biopsy were still pending at the
time of discharge.
We made the following changes to your medications
1. We stopped your Lininopril, HCTZ, Simvastatin, and Revlimid.
You did not receive Zometa in house. We stopped your calcium
carbonate since it can interact with Levothyroxine and increased
your Vitamin D dose since you were found to have low levels.
Please call your primary oncologist or the hematology/oncology
or BMT fellow on call if you develop fever >100.4, chills,
nausea, vomiting, worsening leg pain, redness or pain around the
wounds.in your legs.
Followup Instructions:
You have the following appointments.
Endocrinology: (For your hypothyroidism) [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**],
M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2165-11-27**] 1:00
Vascular surgery: Dr. [**Last Name (STitle) 1391**] on [**11-6**] at 10:30am. Office
located at [**Hospital1 18**] [**Last Name (NamePattern1) **] Suite 5C. The phone number is
[**Telephone/Fax (1) 1393**] if you have any questions.
Interventional Pulmonary (for the trachesotomy site): Dr. [**Last Name (STitle) **]
[**Doctor Last Name 12554**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2165-10-31**] 12:00
You also have an appointment for a follow up bronchoscopy on
Tuesday [**12-10**] at 9am. They will discuss the details of
this appointment with you at your first appointemnt
Hematology/Oncology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2165-10-30**] 11:30
You also have a previously scheduled appointment with your
opthalmologist [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2165-11-1**] 10:45
VISUAL FIELD SCREENING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2165-11-1**]
10:00
|
[
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"401.9",
"276.1",
"244.9",
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"365.9",
"560.9",
"272.0",
"728.88",
"729.4",
"041.19",
"584.9",
"V42.82",
"729.72",
"203.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.69",
"41.31",
"31.1",
"97.37",
"33.22",
"38.93",
"96.71",
"97.23",
"83.65",
"83.14"
] |
icd9pcs
|
[
[
[]
]
] |
15205, 15277
|
9111, 14283
|
339, 649
|
15544, 15601
|
4656, 7860
|
17456, 18791
|
4239, 4291
|
14625, 15182
|
15298, 15523
|
14309, 14602
|
15625, 17433
|
4306, 4637
|
8024, 9088
|
285, 301
|
677, 2840
|
7896, 7991
|
2862, 3618
|
3634, 4223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,302
| 149,148
|
41229
|
Discharge summary
|
report
|
Admission Date: [**2153-3-11**] Discharge Date: [**2153-3-18**]
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 24344**] is a 86 yo RHW with h/o HTN, HL who presents with
difficulty speaking this morning. The patient lives in
apartment
attached to son/daughter-in-law's home, and daughter-in-law
checks on her frequently. She checked on patient last night at
10:30pm, and patient was at her baseline. She had been feeling
tired with GI upset yesterday, but was walking, speaking and
interacting normally. This AM, she checked on the patient at
8am.
The patient was still in bed but was awake. She seemed "distant"
and was answering questions in one or two words only. One hour
later, at 9am, the patient had gotten up herself to her rocking
chair. She was only responding "yup" to questions, and she would
not say her daughter-in-law's name. She seemed not to be
processing the question asked of her. She had also been
incontinent of urine, which is not typical for her. EMS was
called. The patient did say some short phrases later in the
morning, and said her son's name, but continues to have paucity
of speech. Speech was never slurred or garbled.
Patient was brought to [**Hospital3 **], where head CT showed
L frontal ICH. BP ranged 130-140s. Exam showed no weakness.
There
is no mention of facial droop in the notes, though family member
states they thought R face was slightly drooped transiently at
OSH.
On arrival to [**Hospital1 18**], GCS 13. BP 130-140s without treatment.
At her baseline, patient takes care of own ADLs including
dressing, cooking some meals, eating. She walks with a walker.
She stopped driving a few years ago. She is continent. She has
had gradually memory decline over past several months, and has
some days better than others. She typically knows where she is
and names of family/friends. For example, this Monday she could
not remember who was at Sunday night dinner. She last fell 6
months ago, with no injuries.
Patient and family deny recent headaches, visual changes,
dysphagia, bowel/bladder changes, gait changes, fevers/chills,
N/V, chest pain, abdominal pain, falls or trauma.
Past Medical History:
- HTN
- HL
- neuropathy of unclear etiology (no diabetes)
- stress incontinence, has pesary in place
Social History:
lives in in-law apt, adjacent to son/daughter in law. Has 5
children, widowed. Never used tobacco or EtOH.
Family History:
No history of early strokes (<55y/o)
Physical Exam:
NEURO: On admit.
Mental status: eyes closed but opens to voice or gentle
stimulation, somnolent and has to be redirected to exam. Resists
eye opening. AOx0, unable to say name. When asked how many
children she has, states 26. Repeats "I don't know" often. Not
able to name any objects. Able to repeat simple phrase, but not
able to repeat >4 words or complex words. Follows midline but
not
appendicular commands. No evidence of neglect.
CN: PERRL 3 to 2 mm. EOMI. Unable to assess visual fields due to
poor cooperation with eye opening. Face symmetric with no droop
no NLF flattening. Tongue protrudes in midline.
MOTOR: moving all extremities spontaneously with no asymmetries.
All extremities at least antigravity. Increased tone in
bilateral
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 28147**]. No adventitious movements.
[**Last Name (un) **]: withdraws briskly and localizes to pain in all extremities
DTR: 2+ and symmetric at bilateral biceps, triceps, brachiorad,
patellar, 0 achilles. Toes upgoing bilaterally.
Pertinent Results:
CT head:
IMPRESSION: Unchanged size of a large left frontal
intraparenchymal hematoma. There is minimally increased
rightward shift of neighboring midline structures. Moderate
effacement of the left lateral ventricle is stable.
ECHO: IMPRESSION: Mild mitral regurgitation with normal valve
morphology. Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No
structural cardiac source of embolism identified.
Brief Hospital Course:
Patient [**Name (NI) 24344**] was admitted after being found to have a large
frontal hemorrhage (Left side). It was felt to be secondary to
amyloid angiopathy given the location. She was admitted as a
DNR/DNI to the ICU for closer monitoring and being placed on
mannitol. Her stay was prolonged in the ICU after receiving
lorazepam for agitation resulting in significant lethargy. Her
examination improved over her short ICU stay from a globally
aphasic patient to one that was able to answer questions
appropriately using 3 word sentences. The patient could not
tolerate the placement of an NG tube and she was placed on PPN.
Her medical condition continued to deteriorate over the
following days, including hypotension and atrial fibrillation
with rapid ventricular rates that was poorly tolerated. Her
family, acting on her wishes, requested that she was not
intubated. She was made CMO and passed shortly afterward.
Medications on Admission:
ASA 325
Lipitor 40 mg
HCTZ 12.5 mg
atenolol 50 mg
Ativan 0.25 mg prn anxiety (took last Monday)
colace
Discharge Medications:
Not applicable.
Discharge Disposition:
Expired
Discharge Diagnosis:
Not applicable.
Discharge Condition:
Not applicable.
Discharge Instructions:
Not applicable.
Followup Instructions:
Not applicable.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"431",
"V49.86",
"721.0",
"625.6",
"401.9",
"V49.87",
"486",
"788.30",
"277.39",
"348.5",
"355.8",
"272.0",
"V58.66",
"437.9",
"784.3",
"434.91",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
5265, 5274
|
4150, 5071
|
224, 230
|
5333, 5350
|
3668, 3668
|
5414, 5524
|
2559, 2597
|
5225, 5242
|
5295, 5312
|
5097, 5202
|
5374, 5391
|
2612, 2630
|
180, 186
|
258, 2293
|
3677, 4127
|
2645, 3649
|
2315, 2418
|
2434, 2543
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,877
| 137,644
|
45301
|
Discharge summary
|
report
|
Admission Date: [**2190-11-17**] Discharge Date: [**2190-11-30**]
Date of Birth: [**2112-9-12**] Sex: M
Service: SURGERY
Allergies:
Doxycycline
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Gastric Adenocarcinoma
Major Surgical or Invasive Procedure:
Total gastrectomy
History of Present Illness:
mr. [**Known lastname 26802**] is a 78-year-old man with history of hypertension,
AS s/p AVR, atrial fibrillation/ flutter, CHF, s/p CVA, and
gastric cancer which was found on upper endoscopy.It has been
staged as having a resectable lesion which is T2 lesion.
No obvious nodes wereseen on endoscopic ultrasound, and
metastatic survey was
negative for distal disease. A lesion was seen in his skull
which seemed to be a meningioma, as this has been followed
for awhile and has not changed and was PET negative. He
presents now for resection.
Past Medical History:
Anemia, iron def, resolved
Hypertension
Afib/ flutter
Aortic stenosis, s/p porcine valve replacement @ [**Hospital1 2025**] in [**1-10**],
LVEF 50-55%
CHF, LVEF 50-55%
s/p CVA (post-op complication from AVR) in [**1-10**] with residual
speech difficulty and L facial droop
GERD
CKD (baseline cre 1.5-1.7)
Chronic back pain
DJD
Colon polyps
Gastric cancer
BPH s/p TURP x 2
.
ALL: Doxycycline (per OMR, patient does not recall)
Social History:
Previous work as insurance salesman
1 daughter, lives in [**Name (NI) 7349**]
[**Name (NI) **]: 100 pack-yr smoking history (3ppd x 35yrs), quit 15yrs ago
No EtOH or illicits.
Lives with wife in [**Name (NI) 3597**].
Independent ADLs
Family History:
3 siblings passed away from pancreatic cancer
2 siblings passed away from lung cancer
Physical Exam:
Post-op Check:
Vitals: T-98.2, HR-80, BP-100/52, RR-16, O2 sat-97 on 3L NC
Gen:NAD, A/Ox3
Pulm:CTAB
CV:RRR
ABD:Incision TTP, decreased bowel sounds, dressing with minimal
serosanguinous drainage.
Pertinent Results:
[**2190-11-29**] 07:15AM BLOOD WBC-9.4 RBC-3.41* Hgb-9.6* Hct-30.4*
MCV-89 MCH-28.2 MCHC-31.7 RDW-19.7* Plt Ct-893*
[**2190-11-17**] 09:18PM BLOOD WBC-10.5# RBC-4.13* Hgb-11.8* Hct-36.6*
MCV-89 MCH-28.7 MCHC-32.4 RDW-22.4* Plt Ct-304
[**2190-11-29**] 07:15AM BLOOD PT-14.4* PTT-27.9 INR(PT)-1.3*
[**2190-11-20**] 02:02AM BLOOD PT-11.9 PTT-30.7 INR(PT)-1.0
[**2190-11-18**] 10:14AM BLOOD PT-14.7* PTT-31.7 INR(PT)-1.3*
[**2190-11-29**] 07:15AM BLOOD Glucose-98 UreaN-37* Creat-1.4* Na-138
K-5.0 Cl-101 HCO3-30 AnGap-12
[**2190-11-17**] 09:18PM BLOOD Glucose-136* UreaN-26* Creat-1.5* Na-144
K-4.4 Cl-111* HCO3-23 AnGap-14
[**2190-11-20**] 02:02AM BLOOD ALT-45* AST-25 LD(LDH)-173 AlkPhos-48
Amylase-21 TotBili-0.6
[**2190-11-29**] 07:15AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.6
[**2190-11-17**] 09:18PM BLOOD Calcium-9.3 Phos-4.4 Mg-1.9
.
Pathology Examination [**2112-9-12**]
DIAGNOSIS:
I. Portal lymph node (A):
1. Lipogranulomas and hyperplasia.
2. No tumor.
II. Perigastric nodes (B):
1. Hyperplasia.
2. No tumor.
III. First proximal margin (C):
Fragment of esophagus with squamous epithelium: No tumor.
IV. Anastomotic ring, most proximal margin (D):
Fragment of esophagus with squamous epithelium: No tumor.
V. Esophagogastrectomy (E-Y):
1. Adenocarcinoma of the gastric cardia, see synoptic report.
2. Gastric fundic mucosa, within normal limits.
3. Esophageal mucosa with squamous epithelium at the proximal
margin, and duodenal tissue at the distal margins
Stomach: Resection Synopsis
MACROSCOPIC
Specimen Type: Total gastrectomy.
Tumor Site: Cardia.
Tumor configuration: Exophytic (polypoid).
Tumor Size
Greatest dimension: 4.5 cm. Additional dimensions: 3.1 cm
x 1.3 cm.
MICROSCOPIC
Histologic Type: Adenocarcinoma, hyperplastic glandular type.
Histologic Grade: G2: Moderately differentiated.
Primary Tumor: pT1b: Tumor invades submucosa.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 18.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed.
Margins
Proximal margin: Uninvolved by invasive carcinoma.
Distal margin: Uninvolved by invasive carcinoma.
Omental (radial) margins
Lesser omental margin: Uninvolved by invasive
carcinoma.
Greater omental margin: Uninvolved by invasive
carcinoma.
Distance from closest margin: 45 mm.
Specified margin: Proximal margin, including separate
specimens.
Lymphatic (Small Vessel) Invasion: Present in submucosa.
Venous (Large vessel) invasion: Absent.
Comments: The tumor invades under the adjacent squamous
epithelium.
Clinical: Gastric adenocarcinoma.
.
Cardiology Report ECG Study Date of [**2190-11-18**] 2:14:44 AM
Atrial flutter with moderate ventricular response. Compared to
the prior
tracing of [**2190-11-12**] the ventricular response has slowed.
Otherwise, no
diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
86 0 82 344/389 0 3 16
.
RADIOLOGY Final Report
ESOPHAGUS [**2190-11-22**] 2:19 PM
[**Hospital 93**] MEDICAL CONDITION:
78 year old man s/p total gastrectomy with concern regarding the
esophago-jejunal anastomosis
IMPRESSION:
1. No evidence for leak or obstruction at anastomotic site.
2. Mild amount of free esophageal reflux.\
.
ECHOCARDIOGRAM [**2190-11-23**]
Conclusions:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated.
Right ventricular systolic function is borderline normal. A
bioprosthetic aortic valve prosthesis is present. The prosthetic
aortic valve leaflets are thickened. The transaortic gradient is
normal for this prosthesis. A paravalvular aortic valve leak is
probably present. Mild to moderate ([**1-5**]+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**1-5**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate to severe [3+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. Mild pulmonic regurgitation is
seen. The end-diastolic pulmonic regurgitation velocity is
increased suggesting pulmonary artery diastolic hypertension.
There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 96777**] operative course was uncomplicated. He was routinely
observed in the PACU. He was admitted to SICU from PACU for pain
issues, hypotension, & fluid requirement postoperatively.
.
Pain:He had an epidural place intra-op. He became hypotensive in
PACU. On [**11-18**]: He was switched to Epidural Demerol 1mg/mg @
12cc/h with some relief. His pain continued be unmanaged. On
[**11-19**]: His BP became more stable with IV resuscitation, he was
switched back to the APS 10 solution. On [**11-20**]: He continued
with the APS 10 solution at 4-8cc/h. He began to hallucinate.
The APS team was aware, and Geriatric Team was consulted. He is
currently well managed with oxycodone elixir and PO Tylenol. He
is currently rating his pain [**2193-3-7**].
.
[**Female First Name (un) **]: He was evaluated per team on [**2190-11-22**]. Per [**Female First Name (un) 1634**] exam, he
was difficult to arouse, but able to answer some questions. He
denied pain anywhere. Tylenol was orderd around the clock
because he was not able to verbalize pain due to delirium.
Oxycodone use was minimized due to opiate sensitivity, and
Haldol order was minimized. A [**1-4**] sitter vs pharmacologic
measures was recommended as well. These recommendations were
initiated, and his mental status cleared significantly.
.
NUT: He was evaluated per Nutrition in the ICU, and followed
once transferred to surgical unit. He was started on Tube feeds
via the JTUBE in the ICU. The rate was advanced slowly as his
bowel function and cognitive function cleared. He was advanced
to his goal rate. He is currently being fed with 3/4 str impact
with fiber at 120cc/h x 12 hours. In addition, he is tolerating
small frequent meals, regular food with Ensure supplements. His
blood sugars were checked QAC&HS. He was treated with Regular
insulin per sliding scale. His bloods sugars were stable during
the past 3-4 days on CC6. He should continue to have his blood
sugars checked at least daily, and treated as needed.
.
CARDIO:His HR persisted in 90-100's AFIB in ICU. He was managed
with IV Lopressor. Cardiology was consulted because he was in
aflutter with HR in 150s on [**2194-11-25**]. He was started on a
diltiazem drip in ICU with better controlled heart rate.He was
Told weaned off diltiazem drip, and started on diltiazem PO and
beta-blocker. He underwent an ECHO (refer to results section).
He did have a few bursts of Aflutter over this past weekend
([**Date range (1) 29692**]). He was re-evaluated per Cardiology, and
Electrophysiology were considering cardioversion vs. ablation.
He has remained stable, and cardioversion/ablation was not
indicated at this time. He continues to be stable on the current
medication regimen. He will follow-up with his Cardiologist and
the EP lab for management in the future.
.
INR/COUMADIN: His goal INR is [**2-6**]. He should continue with 5mg
of Coumadin daily, and have his doses adjusted according to
daily INR values.
.
ELIM: His foley was removed post-op. He has been urinating
adequate amounts of urine. He has had multiple loose stools
related to tube feeds.
.
ABD: His abdominal binder is intact. He has a Midline abdominal,
and multiple ex/lap incisions OTA with steris. The sites are
clean and healing. His old JP site continues to drain scant
amounts of serous fluid, DSD applied. The LLQ JTUBE site is
intact and tube is patent.He has active bowel sounds. He denies
abdominal tenderness with no visible distention.
.
EXTREM: He has 2+ lower extremity edema. He will continue with
oral Lasix. His pulses are strong and palpable bilaterally with
normal sensation & circulation. He ambulates with an assist, but
is steady on his feet. He was evaluated per physical therapy,
and will required conditioning due to extended surgical
recuperation.
Medications on Admission:
coumadin 5', atenolol 50', FeSo4 325", lasix 20', omeprazole 20'
Discharge Medications:
1. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: GOAL
INR: [**2-6**]. Titrate accordingly.
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
9. Oxycodone 5 mg/5 mL Solution Sig: 0.5 PO Q6H (every 6 hours)
as needed for breakthrough pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab center
Discharge Diagnosis:
Primary:
exophytic T2No fundic gastric adenocarcinoma
hiatal hernia
Post-op hypovolemia managed with IV fluid resuscitation
Post-op arrhythmia managed with IV Diltiazem drip in ICU
Post-op pain managed per consultation with Acute Pain Service
Post-op delirium managed per consultation with Geriatric Service
.
Secondary:
porcine AVR, HTN, BPH, anemia, GERD
Discharge Condition:
Stable
Tolerating small amounts of regular food, and tube feeds.
Adequate pain control with medication administered orally and
via JTUBE.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-Please wear abdominal binder with ambulation and activity.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
1. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2981**] Call to
schedule appointment in [**2-6**] weeks.
2. Please follow-up with your primary care provider, [**Last Name (NamePattern4) **].[**First Name (STitle) **] A.
[**Doctor Last Name **],[**Telephone/Fax (1) 1144**] for future management of your Coumadin
dosing.
3. Please follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (Cardiology) ([**Telephone/Fax (1) 16930**] as needed.
Completed by:[**2190-11-30**]
|
[
"401.9",
"553.3",
"E937.9",
"397.0",
"338.18",
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"428.33",
"151.0",
"276.52",
"428.0",
"427.32",
"292.81",
"458.29",
"E849.7",
"244.9",
"530.81",
"V42.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"53.7",
"43.99",
"46.39",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10954, 11009
|
6301, 10096
|
296, 316
|
11411, 11551
|
1922, 4939
|
13041, 13639
|
1604, 1691
|
10212, 10931
|
4976, 6278
|
11030, 11390
|
10122, 10189
|
11575, 12620
|
12635, 13018
|
1706, 1903
|
234, 258
|
344, 887
|
909, 1336
|
1352, 1588
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,600
| 136,560
|
35208
|
Discharge summary
|
report
|
Admission Date: [**2184-9-24**] Discharge Date: [**2184-10-20**]
Date of Birth: [**2124-4-24**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ampicillin / Folic Acid
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
60M s/p wittnessed seizure while at homeless shelter and then
fell to ground
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
The Pt is a 60y/o M with a PMH of CHF, seizures transferred to
[**Hospital1 18**] for evaluation of left frontal IPH and right [**Doctor First Name 15799**] EDH.
The patient was found to have a witnessed seizure in bed at
homeless shelter. He was taken to [**Hospital1 8**] where a CT showed
bleed and he was sent to [**Hospital1 18**] for neurosurgical evaluation. In
ED initial vitals, T 102.8, BP 124/84, HR 16, O2 sat 97% 2L NC.
The patient was intubated for airway protection. CT scan was
repeated showing an intraparenchymal bleed L>R and epidural
bleed of R occipital region. He was loaded with dilantin and
neurosurgery consultation was obtained, recommending medical
management. He was given levaquin and flagyl for suspected
retrocardiac opacity.
Past Medical History:
Diastolic CHF
Chronic Pleural Effusions s/p VATS and decortication [**10-29**]
COPD
EtOH abuse with history of withdrawal seizures
Pulmonary HTN
Chronic Atrial Fibrillation
Adenocarcinoma of the Esophagus s/p chemotherapy and radiation
Depression
OSA
GERD
Social History:
Per OSH DC summary - Pt is homeless and lives in a shelter in
[**Hospital1 8**]. Drinks 1pt vodka daily
Family History:
Unable to obtain
Physical Exam:
Vitals: Tm:98 Tc:95.6 BP: 148/100 P: 97 R: 18 O2: 98% on RA
General: Unkempt, alert/oriented to time, place, and person,
Lying on bed, uncooperative
HEENT: Sclera anicteric, pupils slightly sluggish but reactive,
MMM, oropharynx with some erythema, poor dentition, pink
complexion
Neck: supple, JVP not elevated, patient refusing to wear
C-collar so not in place, 3cm round soft tissue mass on right
side of neck, not TTP, soft.
Lungs: Decreased BS at bases, no wheezes appreciated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, no appreciable organomegaly, no
rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2184-10-20**]
Na 129 Cl 93 BUN 8 Glc 94
K 4.5 HC03 24 Cr 0.6
Phenytoin: 8.7; most recent albumin 3.4; corrected phenytoin is
11.1
WBC 4.5 Plts 579
Hct 28.1
[**2184-9-24**] CT Head with reconstruction
IMPRESSION:
1. The appearances of the right posterior fossa extra-axial most
likely an
epidural hematoma and bilateral frontal and left temporal
subarachnoid blood as well as intraparenchymal blood in the left
frontal lobe has not changed. Chronic infarcts are again
visualized.
2. Normal CT angiography of the head for stenosis or occlusion.
3. The transverse sinuses are not well visualized. This could be
related to the acquisition obtained during the arterial phase.
However, given the
presence of epidural hematoma and fracture in the right
occipital bone
evaluation of right transverse sinus may be required but could
not be
evaluated on the current study. If clinically indicated a CT
venography of
the head can be obtained.
[**2184-9-24**] CT C spine
1. Multilevel degenerative changes of the spine as described
above with no
acute spinal fracture.
2. Centrilobular emphysema.
3. Right occipital fracture, refer to CT head report from same
date
4. Right sided subcutaneous cystic lesion, perhaps a sebaceous
cyst.
CXR [**2184-9-24**]
IMPRESSION:
1. Endotracheal tube tip in satisfactory position.
2. Feeding tube side port appears to be in the distal esophagus
and should be advanced. The distal tip of the feeding tube is
not visualized.
3. Dense retrocardiac consolidation could represent atelectasis
or perhaps
aspiration. Probable right pleural effusion. Dedicated PA and
lateral views of the chest are recommended when the patient is
in stable condition.
Repeat CT head [**9-25**] IMPRESSION:
1. Small amount of new hemorrage layering along the tentorium.
2. New sinus disease since recent comparison with air-fluid
level suggesting acute sinusitis.
3. Right occipital fracture with no interval growth of a
presumed venous
epidural hematoma.
4. Small amount of hemorrhage layering within the occipital
horns of the
lateral ventricles without appreciable change to the ventricular
appearence.
ATTENDING NOTE: Small amount of new posterior falx/tentorium SDH
described
above could just be due to redistribution and is likely not a
new finding.
[**10-18**] EGD:
Findings: Esophagus:
Contents: Two coins were found in the lower third of the
esophagus, one nickel and one [**Female First Name (un) **]. There was associated food
mixed in as well. The foreign body was successfully removed
using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] net
Excavated Lesions A large nearly circumferential ulcer was
found in the lower third of the esophagus at the site of coin
impaction.
Stomach:
Mucosa: Diffuse erythema and petechiae of the mucosa were noted
in the whole stomach.
Duodenum: Normal duodenum.
Impression: Two coins in the lower third of the esophagus
(foreign body removal)
Ulcer in the lower third of the esophagus
Erythema and petechiae in the whole stomach c/w gastritis
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
A/P: Pt is a 60yo M with PMH of EtOH abuse admitted with fever,
multifocal intraparenchymal hemorrhagic contusions, course
complicated by aspiration pneumonia and SIADH
# Traumatic Head Injury with Intraparenchymal bleed and subdural
bleed - pt found s/p seizure per report, had mechanism
significant enough for occipital frx. Evaluated by Neurosurgery
with no indication for surgical intervention. Tox screen
negative. No evidence of lelevated ICP. Repeat CT Head showed
likely stable blood, redistribution, but no new acute bleed.
Dilantin was started in house; he had apparently been on
Depakote before, and Keppra was considered, however, cost makes
dilantin more appropriate. Currently on stable dose 250mg [**Hospital1 **]
with levels, corrected for albumin, in the therapeutic range
(target [**10-11**], recent corrected levels on this dose have been
[**12-5**]).
Will followup with neurosurgery/Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**10-28**] at which
time he will also have repeat CT of head (noncontrast) for
resolution.
# SIADH: likely [**1-24**] ICH, also consider drug effect from SSRI,
which was stopped. Stable on regimen of NaCl tabs (3gm tid with
meals) and lasix 20mg daily, which has kept serum sodium between
126 and 130 for over a week. Should have sodium checked at least
twice a week; we expect this to resolve as ICH resorbs and brain
parenchyma heals.
# Cervical spine injury: Pt w/ negative c-spine CT. MRI obtained
to eval for ligamentous injury but not useful due to motion
artifact.
# Aspiration pneumonia- Retrocardiac opacity on initial CXR was
thought most likely aspiration pneumonia, which was treated with
a full course of antibiotics. He continues to have silent
aspiration secondary to dysphagia; speech and swallow therapist
recommended thickened liquids and soft foods, 1:1 assistance
with meals, and aspiration precautions (sitting fully upright to
eat, chewing carefully, small bites alternating with sips).
However, patient has been intermittently noncompliant, drinking
tap water in his room despite our recommendations not to.
# Chronic Pleural Effusions s/p VATS and decortication - unclear
if CXR change from baseline.
# COPD - Reported history of chronic pleural effusions, s/p VATS
and decortication, as well, which may explain poor/rhonchorous
breath sounds on exam. Continued on spiriva and albuterol.
# Alcohol withdrawal seizures - Unclear seizure history - pt on
depakote as outpatient. Possible seizure focus related to bleed,
although report from OSH indicated pt had seizure event prior to
fall with head trauma. EtOH level negative on presentation,
# Atrial Fibrillation - holding ASA as above, will restart per
Neurosurgery recs on/after [**10-21**].
# GERD, esophageal ulcer - increased ppi to [**Hospital1 **], which should be
continued until pt sees GI in follow-up in [**Month (only) **] to evaluate
for resolution with repeat EGD.
Medications on Admission:
Advair 50/500
Albuterol MDI
ASA 325mg
Depakote 500mg [**Hospital1 **]
Lasix 40mg
Toprol XL 25mg daily
Paxil 40mg daily
Prilosec 20mg daily
Simvastatin 40mg daily
Spiriva 18mg daily
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*1 inhaler* Refills:*2*
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 capsule* Refills:*2*
6. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Phenytoin 125 mg/5 mL Suspension Sig: Ten (10) cc PO Q12H
(every 12 hours): = 250mg [**Hospital1 **].
Disp:*600 cc* Refills:*11*
8. Sodium Chloride 1 gram Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*300 Tablet(s)* Refills:*2*
9. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
10. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1. hyponatremia
2. Intracranial hemorrhage
3. occipital fracture
4. Seizure
5. chronic obstructive pulmonary disease
6. diastolic congestive heart failure
7. pulmonary hypertension
8. chronic pleural effusion
9. adenocarcinoma of esophagus s/p chemo and radiation therapy
10. Aspiration
11. foreign body ingestion with associated esophageal ulceration
(foreign bodies removed)
Secondary:
1. depression
2. obstructive sleep apnea
3. gastroeshopageal reflux disease
Discharge Condition:
alert and oriented. ambulating at baseline.
Discharge Instructions:
You were admitted with witnessed seizure and fall. You were
brought to [**Hospital1 18**] from [**Hospital 8**] hospital. you were intubated for
your airway protection in Emergency Department and monitored in
Medicine intensive care unit for few days before you came to
regular floor for further care.
.
The CT from [**Hospital1 8**] and [**Hospital1 18**] showed that you have some
bleeding in your brain as well as non-displaced fracture in the
base of your skull. Neurosurgeon (Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) evaluated you
and thought that you do not need operation. Neurology team
examined you and recommended the medication (Dilantin) for
seizure prevention and we titrated the dose and measure your
blood level of medication which was improving. The repeated CT
of your head showed no additional acute bleed.
.
You had difficulty swallowing with food going into your airway
caused coughs and sputum production. You were treated with
antibiotic for possible aspiration pneumonia. Series of chest
x-ray showed chronic fluid in your lung which has worsened with
aspiration. Speech and swallow team examined you and you had
swallowing test done which showed that you are aspirating some
of your food. Be sure to sit up straight while eating, and
soft/ground consistency foods will be easier to eat than solids.
.
You experienced low blood pressure and change in mental status
in setting of dehydration and low sodium (from [**Date range (1) 80335**],
sodium has been stable between 126 and 130). The nephrologists
examined you and recommend additional salt in your diet to help
with low sodium. Do not drink more than 1 liter of water or
other fluids in a day. Your mental status improved as the sodium
level improved.
.
It is important that you take all the medications as prescribed
to prevent further seizure and fall. Also, you will need to
follow up with your primary care nurse practitioners and
neurosurgeon for the blood in your brain and the broken skull
bone. You can resume taking aspirin 81mg starting on [**2184-10-23**] per
neurosurgeon.
.
Finally, while in the hospital, you swallowed 2 coins, which had
to be removed endoscopically. An ulcer was seen in the distal
esophagus, so you will need to take lansoprazole twice a day for
4 weeks and then have a repeat endoscopy with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4539**] to
make sure this is resolving.
.
If you have shortness of breath, fever, chills, nausea,
vomiting, difficulty breathing, severe headache, vision changes
or chest pain, please contact your primary care physician or
come to emergency room.
.
[**Location (un) 80336**] contacts: case manager: Mr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 80337**],
[**Telephone/Fax (1) 80338**] [**Hospital 23536**] clinic: [**Telephone/Fax (1) 80338**]/Fax [**Telephone/Fax (1) 80339**]; NP:
[**Doctor First Name **] (pager-[**Telephone/Fax (1) 42414**])
Followup Instructions:
You will get non-contrast Head CT at 8:30am on [**2184-10-28**] prior to
seeing Dr. [**First Name (STitle) **]. on [**2184-10-28**]. [**Hospital1 18**] [**Hospital Ward Name **] in clinical
center [**Location (un) 470**], CT scan. The number for radiology is
[**Telephone/Fax (1) 327**].
.
You will need see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Neurosurgery department on
[**2184-10-28**] at 9:00 am.([**Doctor First Name 80340**]. [**Hospital Unit Name **] [**Location (un) 470**] # 3B.
Gastroenterology (GI/stomach doctor) followup for ulcers in your
esophagus: [**Hospital Ward Name 516**], [**Location (un) 453**] [**Hospital Unit Name 1825**]:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8718**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2184-11-9**]
1:30
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11,331
| 131,594
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29484
|
Discharge summary
|
report
|
Admission Date: [**2110-12-15**] Discharge Date: [**2110-12-21**]
Date of Birth: [**2085-1-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
N/V, abdominal pain
Major Surgical or Invasive Procedure:
Pt is 25 yo f with h/o cocaine use who presented to OSH on [**12-10**]
with abdominal pain and N/V. Pt also had episode of non-bloody
diarrhea 2-3 weeks ago without fever, which resolved
spontaneously. On [**12-10**], a RUQ u/s was performed and
demonstrated gallbladder sludge and pericholecystic fluid. Her
labs were wnl with the exception of elevated WBC count of 16.4
(unclear if electrolytes were checked at that time, as they are
not included in chart). She was prescribed Reglan and Percocet,
and was discharged home. Over the next 4 days, pt reports
worsening abdominal pain and N/V, as well as F/C, episode of
bloody diarrhea, "yellow skin", blurry vision, decreased PO
intake, "difficulty urinating", HA, cough productive of green
sputum, lightheadedness, mild SOB, mild confusion, and several
episodes of hematemesis. Pt denies CP. Denies urinary/bowel
incontinence. She has been living with her friend for the past
4 days, who she says has had similar episodes of N/V. On [**12-14**],
pt presented again to the OSH becuase of her worsening symptoms.
She was found to have hct 19.4, plt 18, Cr 6.1, and LDH 2065.
A CT abd was performed, which was consistent with pancreatitis.
She was given Morphine 2mg IV, Reglan 10mg IV, Solumedrol 125mg
IV, and was then transferred to [**Hospital1 18**] for further management.
.
In the [**Hospital1 18**] [**Name (NI) **], pt had repeat labs, which showed hct 19, Plt
12, and Cr 5.7. A peripheral smear reportedly showed
schistocytes. She received Dilaudid 0.5mg IV x2. Transfusion
medicine, heme/onc, and nephrology were consulted.
Pt currently c/o blurry vision, sharp epigastric pain worsened
by movement, and mild SOB. Denies CP. Pt denies hx of
bleeding/clotting disorders. No recent NSAID use.
Past Medical History:
Bulimia (x 2 years)
s/p C-section in [**2109**]
Social History:
Lives at home with sister, however has been staying with friend
for the past 4 days. Has 1 year old son. Smokes [**1-20**] ppd since
age 13. Drinks 2 beers/day. + cocaine use (last snorted 2 weeks
ago). Denies IVDU.
Family History:
Mother died last year of "unknown cause." Grandmother with
diabetes. No family hx of bleeding/clotting disorders. Has
healthy 24 yo sister.
Physical Exam:
Vitals: T 98 BP 107/59 HR 78 RR 19 O2 97% RA
Gen: jaundiced young female, NAD, pleasant.
HEENT: PERRL. Sclera midly icteric.
Neck: Supple. No LAD. No thyromegaly
Cardio: RRR, nl S1S2, 2/6 SEM @ LLSB
Resp: CTAB. No wheezes/rales/rhonchi.
Abd: soft, non-distended, +BS, + RUQ/epigastric/LUQ tenderness
to palpatation. Diffuse voluntary guarding, but no rebound. No
hepatosplenomegaly appreciated.
Ext: 1+ BL LE edema.
Neuro: A&Ox2 (says she's in "[**Hospital **] Hospital", but knows date
and name). CN 2-12 tested and intact. 4+/5 strength in UE and
LE. 2+ DTR's throughout. Normal FTN. Sensation grossly intact.
Skin: jaundiced. tattoo on L shoulder.
Pertinent Results:
[**2110-12-14**] 11:30PM WBC-13.5* RBC-2.24* HGB-7.1* HCT-19.0* MCV-85
MCH-31.9 MCHC-37.5* RDW-18.7*
[**2110-12-14**] 11:30PM NEUTS-85.8* BANDS-0 LYMPHS-10.7* MONOS-1.6*
EOS-1.8 BASOS-0.2
[**2110-12-14**] 11:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL SCHISTOCY-2+ BITE-OCCASIONAL
[**2110-12-14**] 11:30PM PLT COUNT-12*
[**2110-12-14**] 11:30PM TSH-4.7*
[**2110-12-14**] 11:30PM HAPTOGLOB-<20*
[**2110-12-14**] 11:30PM TOT PROT-5.5* ALBUMIN-3.4 GLOBULIN-2.1
CALCIUM-8.6 PHOSPHATE-2.3* MAGNESIUM-2.6
[**2110-12-14**] 11:30PM LIPASE-123*
[**2110-12-14**] 11:30PM ALT(SGPT)-14 AST(SGOT)-47* LD(LDH)-2156* ALK
PHOS-61 AMYLASE-89 TOT BILI-1.9*
[**2110-12-14**] 11:30PM GLUCOSE-122* UREA N-112* CREAT-5.7*
SODIUM-132* POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-29 ANION GAP-14
[**2110-12-15**] 12:10AM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2110-12-15**] 12:10AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2110-12-15**] 12:10AM URINE UCG-NEGATIVE
[**2110-12-15**] 01:55AM URINE HOURS-RANDOM UREA N-722 CREAT-113
SODIUM-16 TOT PROT-31 PROT/CREA-0.3*
.
HISTORY: Central line placement.
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Tip of a dual channel right internal jugular line projects over
the mid SVC. No pneumothorax. There is leftward displacement of
the mid cervical trachea and fullness in the soft tissues of the
right lower neck. If this isn't a mass, this is due to a
hematoma. There is no pneumothorax or pleural effusion. The
heart is normal size and the lungs are clear.
.
IMAGING:
[**12-10**] RUQ U/S (at OSH): There appears to be sludge within the
gallbladder and also there may be some pericholecystic fluid.
Finally, there was a positive [**Doctor Last Name 515**] sign.
.
[**12-14**] Abd CT (at OSH): Pancreatic enlargement and stranding c/w
pancreatitis. Thickening of the transverse mesocolon.
.
EKG: NSR @ 90, nl axis, nl intervals, TWI in V1-V3 (no prior for
comparison)
.
Renal US [**2110-12-16**]:
1. Unremarkable renal ultrasound with no cause of acute renal
failure identified.
2. Trace free fluid anterior to the uterine fundus, if there is
concern for pelvic pathology, a dedicated pelvic ultrasound may
be ordered for further assessment
.
[**12-17**] panorex: small lucency at apex of tooth #2 c/w abscess.
.
[**2110-12-20**] MRCP: done not yet read.
.
blood cx [**12-14**], [**12-16**] pending
urine cx [**12-15**] <10,000 organisms
admission LFT's: AST 47 ALT 14 AP 61 Amylase 89 lipase 123
LD 2156, hapto <20, t.bili 1.9
Fe 62, TIBC 259 Ferritin 758
C3 127, C4 16
TSH 4.7
HIV, ANCA, dsDNA, [**Doctor First Name **] neg
Adamtst13 pending
Coombs Neg
Urine tox: + cocaine, neg asa, acetominophen, benzos,
barbiturates, tricyclics
.
platelets [**2110-12-21**]: 328
hct [**2110-12-21**]: 23.2
Brief Hospital Course:
Assessment:
Patient was admitted to the ICU for plasma pheresis in setting
of likely cocaine induced [**Doctor First Name **] vs. TTP/HUS. Her platelets rose
with plasma exchange and renal failure improved. She was also
transfused 3 units total of blood with improvement in
hematocrit. She was also with pancreatitis for which she was
given narcotic medication and bowel rest. She was transferred
to the general medical floor where her anemia gradually started
to improve and her platelet count rose. Her pancreatitis
improved and she was able to tolerate PO with out pain
medication. She was evaluated by psychiatry given her history of
bipolar, which is felt more likely to be substance induced
depression vs. major depression vs. dysthymia as well as her
substance abuse. She was set up to start a partial dual
diagnosis treatment program in [**Location (un) 5503**] on discharge.
.
1) [**Doctor First Name **]: Thought to be TTP/HUS vs. cocaine induced [**Doctor First Name **]. Pt with
recent diarrheal illness and OCP use, but no h/o quinine use,
malignancy, chemo, pregnancy, autoimmune d/o, or HIV infection
that would predispose her to TTP/HUS. There have been case
reports of cocaine causing ARF/thrombocytopenia/anemia which can
mimic TTP/HUS, so this remains on the ddx. Transfusion medicine
consulted and arranged for plasma pheresis x3 sessions which
were well tolarated and resulted in improvement in platelets and
hct. Her autoimmune work-up including C3, C4, dsDNA, [**Doctor First Name **], ANCA,
lupus anti-coagulant, DAT was negative. HIV was negative. She
was cautioned against using cocaine in the future as this may
have triggered either [**Doctor First Name **] or TTP/HUS. She was discharged on
folate supplementation which she should take through the next
month for hematopoesis. She was also recommended to follow-up
with a primary care doctor within 1 month to be sure her counts
continue to recover, and was provided with a listing of MD's in
[**Location (un) 5503**].
.
2 Pancreatitis: Her nausea/vomitting/abdominal pain was though
likely [**2-20**] TTP/HUS, however she also had elebated lipase and
imaging at OSH c/x pancreatitis. She was treated with bowel rest
and dilaudid iv, then pca, then oral. She was able to tolerate
PO by discharge and had an MRCP done prior to discharge (not yet
read). Etiology of pancreatitis unclear, weak literature to
support either TTP/HUS or cocaine as etiology. Initial labs with
mildly elevated AST (47) with flat ALT could represent etoh
(though she denied it and tox negative) so this may have been
contributing. No elevated alk phos and t.bili mildly elevated on
admission (1.9) but this is during hemolysis and it subsequently
fell. US at OSH showed gallbladder sludge and + [**Doctor Last Name **] sign,
here she had diffuse upper/epigastric abdominal pain but no
clear cholecystitis. It was recommended that she follow-up with
GI upon discharge for further eval. of pancreatitis and possibly
surgery to eval. for cholecystitis.
.
3) Hematemesis: Noted initially, most likely [**2-20**] [**Doctor First Name **]-[**Doctor Last Name **]
tear in thrombocytopenic pt with h/o bulimia. She had no further
hematemesis through her hospitalization and should f/u with GI
as an outpatient regarding this symptom if it
.
4) ARF: This improved rapidly with hydration/pheresis, unclear
etiology, could be related to [**Doctor First Name **], autoimmune w/u negative,
renal followed in house but no indication for dialysis, renal us
negative.
.
5) Right tooth abscess: She had a root canal that was never
completed 6 months PTA with tooth pain and some swelling of her
right cheeck, panorex c/w small abscess at right apex, seen by
dental, started amoxacillin 500mg po bid, then advanced to QID
when her renal function improved. Her symptoms and facial
swelling improved dramatically with antibiotic. She was
discharged with a 2 week supply of this medication to bridge her
until she can see a dentist, which she was recommended to do
within 1 week of discharge.
.
6) subjective fevers: likely in setting of TTP/HUS, resolved by
the time she was transferred to the general medicine floor,
blood and urine cultures neg, CXR neg for PNA.
.
7) h/o bipolar: no current treatment, does not seem active
currently, seen by psychiatry, thought to have substance-induced
mood d/o vs. depressive d/o vs. dysthymia; they coordinated her
to start a partial dual diagnosis treatment program in [**Location (un) 29158**] on discharge.
.
8) Substance abuse: given + cocaine, could have had recent EtOH
not reported, covered with CIWA through 5 days of admission, no
evidence of withdrawl so CIWA d/c'd, referal as above.
.
9) h/o bulemia: no dysphagia here though with c/o dysphagia (?
[**2-20**] not chewing food appropriately given tooth pain) and h/o
bulemia could have stricture, should f/u with GI as outpatient.
.
10) Abnormal EKG: pt with TWI's V1-V3 on admission EKG, repeat
TW upright, likely demand related with anemia, CE's negative.
Medications on Admission:
OCP's
Reglan prn
Percocet prn
Tylenol PM prn
Paxil (stopped several weeks ago)
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 weeks.
Disp:*56 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Microangiopathic hemolytic anemia, either TTP-HUS or
cocaine-induced, pancreatitis.
.
Substance abuse, bulemia, substance induces mood disorder vs.
depressive disorder
Discharge Condition:
Stable.
Discharge Instructions:
You will need to establish a new primary care doctor once you
are discharged, until then, please visit your current PCP,
[**First Name8 (NamePattern2) 6480**] [**Last Name (NamePattern1) 6402**], MD, to monitor your blood counts over the next
3-4 weeks to be sure they continue to recover. Attached is a
list of primary care doctors in your [**Name5 (PTitle) **]. That doctor should
refer you to a Gastroenterologist for follow-up of your
pancreatitis and also possibly a surgeon for follow-up of your
gallbladder. Additionally you should see a dentist within a week
of discharge to address your dental abscess. Until you see a
dentist you should continue taking amoxacilin 500mg by mouth
four times daily (every 6 hours).
given your history of bulemia it would be wise also to meet with
a dietician regarding your diet.
Followup Instructions:
Please follow-up with your primary care physician, [**First Name8 (NamePattern2) 6480**]
[**Last Name (NamePattern1) 6402**], MD, within 2 weeks to monitor your blood count and
refer you to Gastroenterology.
Please follow-up with a dentist within 1 week for dental
abscess.
Please follow-up with outpatient psychiatric services, including
the SSTAR Ambulatory services program in [**Location (un) 8973**] ([**Telephone/Fax (1) 70767**].
You have been set up with the SSTAR program - you can start at
7:15am on Tuesday, [**2110-12-23**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
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11781, 11951
|
11217, 11297
|
12006, 12828
|
2573, 3227
|
276, 297
|
2117, 2166
|
2182, 2400
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,841
| 196,761
|
41292
|
Discharge summary
|
report
|
Admission Date: [**2108-2-16**] Discharge Date: [**2108-3-9**]
Date of Birth: [**2057-7-28**] Sex: F
Service: SURGERY
Allergies:
eye drops
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
Incisional Hernia Repair
History of Present Illness:
50 yoF with history of Prader Willi syndrome, who underwent
open cholecystectomy at [**Hospital1 **] [**Location (un) 620**] on [**2108-1-24**]. It was noted
that she had bilious drainage from her [**Doctor Last Name **] drain and work up
of
this discovered a small biliary leak from the Right hepatic
duct.
This was easily controlled with endoscopic stent placement. She
was discharged back to her facility on [**2108-2-2**].
She now returns with reported fever as high as 101.8, abdominal
pain increased from prior exams and tachycardia to the 140's.
Here she is [**Age over 90 **].8, HR in 110-120's. It is difficult to
communiucate with her due to her baseline mental status, but she
groans to pain when palpating her abdomen, which is distended.
Her [**Doctor Last Name **] drain is empty, and per report, it has not drained
anything in 7 days.
Past Medical History:
PMH: Prader-Willi syndrome, mood instability,
anxiety, osteoporosis
PSH: open cholecystectomy [**2108-1-24**]
Social History:
- lives in a group home, cared for by her caregiver
- ambulates independently
- signs her own consent form.
- denies ever smoking or alcohol
Family History:
Both father and mother died of unknown cancer.
Physical Exam:
On admission:
VS: T: 99.8 HR: 120 ST BP: 110/p RR: 20 - 30 98% RA
Patient awake, somnolent, responds to questions minimally.
Tachycardic, No MRG appreciated
CTA at apices, rales at bases b/l
distended, soft, tender diffusely, no masses, JP in place, no
evidence of infection. wound healing nicely.
no CCE
Pertinent Results:
[**2108-2-16**] 03:05PM BLOOD WBC-37.9*# RBC-3.71*# Hgb-11.5*#
Hct-34.4* MCV-93 MCH-30.9 MCHC-33.4 RDW-14.3 Plt Ct-947*#
[**2108-2-16**] 03:05PM BLOOD Glucose-127* UreaN-14 Creat-0.5 Na-141
K-3.9 Cl-102 HCO3-26 AnGap-17
[**2108-2-16**] CT abd/pel: 1. Pan-colitis concerning for C. difficile.
2. Para-umbilical hernia which results in a degree of small
bowel obstruction, partial very early high grade. 3. JP drain in
the gallbladder fossa, along with surgicell, without focal
drainable fluid collection or abscess.
[**2108-2-17**] Stool: FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA
[**2108-2-26**] CT abd/pel: 1. Interval improvement overall of the
pancolitis with complete resolution of wall thickening in the
transverse colon compared to [**2108-2-16**]. 2. Interval removal
of right-sided liver drain. Persistent small liver collection in
the gallbladder fossa. 3. Unchanged positioning of left-sided
biliary stent. 4. Partial small-bowel obstruction at the level
of the inferior ventral hernia. Overall, there is less
distention compared to the [**2108-2-16**], examination.
URINE CULTURE (Final [**2108-3-6**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**2108-3-5**] blood cx drawn off PICC: [**Female First Name (un) **] ALBICANS.
[**2108-3-6**] PICC tip cx: no significant growth.
[**2108-3-6**] 12:23 am URINE Source: CVS.
**FINAL REPORT [**2108-3-8**]**
URINE CULTURE (Final [**2108-3-8**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**3-7**] ERCP: No evidence of biliary leak. A single partially
obstructing stone in the distal bile duct.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2108-2-16**] for evaluation and treatment. In the emergency room the
patient was found to be hypotensive, but she responded
appropriately to 4L of fluid. A CT scan was performed that
showed pan colitis. C-diff was positive and patient was sent to
the ICU for management of her C-diff colitis. Vancomycin and
flagyl were started. On HD2, the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 5283**] [**Doctor Last Name **] drain was
removed. She was given IVF, and albumin to help resolve her
tachycardia. As patient's fluid status and pain improved, her
tachycardia began to resolve. The patient was ultimately
transferred to the floor on HD7. At that time her pain had
improved, and she was hemodynamically stable.
Neuro: The patient received tylenol and IV dilaudid breakthrough
with good effect and adequate pain control. When tolerating
oral intake, the patient was transitioned to oral pain
medications.
CV: The patient was initially hypotensive upon admission but
this improved with adequate fluid resuscitation. Her tachycardia
improved during her hospital course with the help of IVF and
albumin. The patient did trigger for a HR in the 160s on the
floor on [**2-23**], but this improved once she was re-started on her
home beta blocker.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially made NPO/IVF and she had an
NGT in place. A picc line was placed on HD 3 and TPN was
started. A KUB on [**2-21**] showed improving distension. The
patient's pain continued to improve and on [**2-22**], the NGT was
removed. Her diet was advanced when appropriate, which was well
tolerated. When the patient was tolerating regular food, TPN was
discontinued. Patient was given ensure to supplement her
nutrition. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary. Foley was
removed on [**2108-2-22**] and patient voided without problems. On
[**2108-2-26**], patient was complaining of worsening pain. A CT scan
was performed that showed interval improvement in colitis, but
also a partial SBO through a ventral hernia. Patient was taken
back to the OR on [**2108-2-29**] for incisional hernia repair. She
tolerated the procedure well. Post-operatively she was initally
NPO, and then advanced to clears to regular on [**3-2**], which she
tolerated well. TPN was restarted until patient was tolerated
regular diet. On [**3-7**] patient underwent ERCP: biliary stent was
removed, a small partially obstructing stone was removed from
the CBD, and no leak was seen. The following day, labs were
negative for pancreatitis and patient was advanced to a regular
diet, which she tolerated.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Her WBC trended down
during her hospital stay, and she remained afebrile. The
vacomycin and Flagyl were continued throughout her hospital
stay. Patient triggered for fever to 101.3 with agitation on
[**3-4**]. She was pan-cultured: urine culture X2 demonstrated
vancomycin-resistant enterococcus, for which she was started on
linezolid. Blood culture drawn off the PICC demonstrated [**Female First Name (un) **]
albicans, for which she was started on fluconazole. Other blood
cultures were negative. PICC was removed and tip was cultured on
[**3-6**]; tip culture was negative. Linezolid and vancomycin were
discontinued at discharge. She will continue Flagyl and
fluconazole for 10 days.
Endocrine: The patient's blood sugar was monitored throughout
her stay; insulin dosing was adjusted accordingly. Insulin was
discontinued after TPN was stopped as blood sugars were not
elevated.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; she was encouraged to
get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
SQ heparin 5000 TID, bupropion HCl 100 TID, propranolol 20TID,
oxycodone 5 Q4 PRN, famotidine 20 [**Hospital1 **], multivitamin, aspirin 81
QD, docusate sodium 100 [**Hospital1 **], acetaminophen 325 PRN, clonidine
0.1 QHS, divalproex 250 TID, fexofenadine 60 QD
Discharge Medications:
1. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
2. propranolol 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for Pain.
4. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO three times a day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
8. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day) as needed for c. diff.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 10 days.
11. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
C-diff colitis
incisional hernia s/p repair
Discharge Condition:
Mental Status: Clear and coherent, developmentally delayed.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
General 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 [**4-17**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Antibiotics: Your metronidazole and fluconazole for 10 days
following discharge.
Followup Instructions:
Please call Dr.[**Name (NI) 11471**] office to schedule a follow up
appointment in [**12-11**] weeks. ([**Telephone/Fax (1) 6347**]
|
[
"785.0",
"998.2",
"599.0",
"995.91",
"038.9",
"300.00",
"552.21",
"E870.0",
"E879.8",
"008.45",
"996.62",
"759.81",
"733.00",
"556.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.91",
"38.93",
"96.07",
"53.51",
"54.74"
] |
icd9pcs
|
[
[
[]
]
] |
10185, 10263
|
4272, 8840
|
290, 317
|
10351, 10351
|
1907, 4249
|
12183, 12318
|
1511, 1560
|
9154, 10162
|
10284, 10330
|
8866, 9131
|
10559, 11539
|
1575, 1575
|
11571, 12160
|
229, 252
|
345, 1201
|
1589, 1888
|
10366, 10535
|
1223, 1336
|
1352, 1495
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,622
| 164,770
|
72+55182
|
Discharge summary
|
report+addendum
|
Admission Date: [**2164-6-15**] Discharge Date: [**2164-7-13**]
Date of Birth: [**2115-11-19**] Sex: M
Service: NEUROLOGY
Allergies:
Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /
Tranxene Sd
Attending:[**First Name3 (LF) 848**]
Chief Complaint:
Emesis, lethargy, and decreased PO intake
Major Surgical or Invasive Procedure:
Central Venous Line placement
Small bowel exploratory laparotomy
Small-bowel resection with primary anastomosis
History of Present Illness:
A 48-year-old patient who presents episodically for evaluation
of emesis. Pt has a complicated PMH, including [**Location (un) 849**] Gastaut
Syndrome, mental retardation, and seizure disorder He was
recently admitted to [**Hospital1 18**] from [**2164-5-4**] to [**2164-5-18**] and
then subsequently to [**Hospital **] Rehabilitation status post ex
lap,open chole, J-tube placement and venting decompressed
colotomy for abdominal pain. Pt was brought back to [**Hospital1 18**] by
his caregivers because of emesis, lethargy, and decreased PO
intake. It was unclear if the emesis was bilious or bloody.
Denies any change of bowel movements. No fevers recorded at
living center. No other focal complaints. The patient has been
unable to provide any history. Per caregivers, the patient does
not report pain, although at baseline it is unclear if he
experiences pain.
Past Medical History:
[**Location (un) 849**] Gastaut Syndrome, [**Location (un) 850**] Dr. [**Last Name (STitle) 851**]
Seizure disorder
Mental retardation
Osteoporosis
Peripheral neuropathy secondary to dilantin
h/o hyponatremia secondary to trileptal
GERD
Behavioral d/o
s/p recent ex lap, open cholecystectomy, J-tube placement, and
transverse colon needle decompression
Social History:
Lives in group home. Non-verbal at baseline. Does not smoke or
drink EtOH.
Patient lives in a group home. # [**Telephone/Fax (1) 852**]. Has a legal
guardian, Rev [**First Name8 (NamePattern2) **] [**Name (NI) 853**], c # [**Telephone/Fax (1) 854**], w # [**Telephone/Fax (1) 855**].
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 120/60, temperature 97.7, heart
rate 98.
GENERAL: Gentleman appears chronically ill, in a wheelchair,
nontoxic.
HEENT: Oropharynx notable for somewhat dry membranes. He is
anicteric.
LUNG: Complicated by poor effort, but no crackles are
appreciated.
CARDIAC: Notable for mild tachycardia.
ABDOMEN: Soft. J-tube site appears somewhat erythematous.
There is no discharge. There are bowel sounds. No palpable
organomegaly.
Neuro Exam very limited since pt is non-verbal at baseline and
unable to cooperate with exam:
MSE: Awake and alert; non-verbal
CN: Pupils round and reactive equally (5-->3mm), EOMI intact (pt
tracks in all directions), face symmetric and responds to
sounds.
Motor: Decreased tone and bulk in all extremities. Voluntarily
moves all limbs against gravity but strength unable to determine
further.
[**Last Name (un) **]: unable to test
Reflexes: Unable to elicit in patellar and achilles but 2+ in
biceps and tricep. Both toes upward going bilaterally.
Pertinent Results:
ADMISSION LABS:
[**2164-6-14**] 05:45PM BLOOD WBC-15.7* RBC-3.93*# Hgb-10.4* Hct-33.5*
MCV-85# MCH-26.4*# MCHC-31.0 RDW-15.1 Plt Ct-591*
[**2164-6-14**] 05:45PM BLOOD Plt Ct-591*
[**2164-6-14**] 05:45PM BLOOD Glucose-118* UreaN-15 Creat-0.7 Na-135
K-5.0 Cl-94* HCO3-33* AnGap-13
[**2164-6-14**] 05:45PM BLOOD ALT-17 AST-43* CK(CPK)-54 AlkPhos-132*
TotBili-0.2
[**2164-6-14**] 06:40PM BLOOD cTropnT-<0.01
[**2164-6-14**] 05:45PM BLOOD Lipase-45
[**2164-6-14**] 05:45PM BLOOD HoldBLu-HOLD
[**2164-6-16**] 07:45AM BLOOD Phenyto-6.0*
DISCHARGE LABS:
[**2164-7-13**] 06:55AM BLOOD WBC-8.6 RBC-3.38* Hgb-9.4* Hct-29.0*
MCV-86 MCH-27.8 MCHC-32.4 RDW-18.4* Plt Ct-974*
[**2164-7-10**] 06:45AM BLOOD Neuts-91* Bands-0 Lymphs-2* Monos-5 Eos-0
Baso-1 Atyps-1* Metas-0 Myelos-0
[**2164-7-13**] 06:55AM BLOOD Glucose-99 UreaN-11 Creat-0.5 Na-130*
K-4.9 Cl-97 HCO3-25 AnGap-13
[**2164-7-11**] 06:15AM BLOOD ALT-104* AST-203* LD(LDH)-274* AlkPhos-89
TotBili-0.2
[**2164-7-13**] 06:55AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.3
[**2164-7-13**] 06:55AM BLOOD Phenyto-2.1*
[**2164-7-10**] 05:41PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->=1.035
[**2164-7-10**] 05:41PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2164-6-29**] 11:02AM URINE RBC-0-2 WBC-[**2-15**] Bacteri-RARE Yeast-NONE
Epi-0-2
MICROBIOLOGY:
Stool Cx ([**6-16**]): C. diff positive
Stool Cx ([**7-3**], [**7-4**], [**7-5**], [**7-11**]): Negative for C. diff
PEG Swab ([**6-23**]):
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Sputum Cx ([**6-26**]):
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Induced Sputum ([**6-29**]):
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
PEG Swab ([**7-10**]):
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
IMAGING:
CT Abdomen/Pelvis ([**6-15**]):
IMPRESSION:
1. Large amount of fecal packing within the colon throughout the
colon. Mild to moderate dilitation of several loops of jejunum
with concern for partial obstruction. Complete obstruction is
not present as some contrast travels into the proximal colon.
2. Large fluid distention of the stomach with reflux of fluid
into the distal esophagus. Placement of NG tube is recommended
for decompression. A proximal obstruction cannot be excluded as
contrast was administered through the jejunostomy tube.
Abdominal XRay ([**6-22**]):
IMPRESSION:
Nonspecific bowel gas pattern. There are dilated loops of small
bowel within the abdomen as well as air and stool seen
throughout the colon.
CXR ([**6-23**]): FINDINGS: Comparison is made to the previous study
from [**2164-6-22**].
There is an endotracheal tube whose tip is 4.7 cm above the
carina
appropriately sited. The left-sided IJ central venous catheter
has the distal tip in the proximal SVC and is also unchanged.
Since the previous study, there has been development of diffuse
airspace opacities, mostly at the lung bases, which can be
compatible with the suggested history of aspiration. No
pneumothoraces are seen.
CT Abdomen/Pelvis ([**6-25**]): CONCLUSION:
1. Significant small bowel dilatation. The configuration raises
the
possibility of a closed loop obstruction. with narrowing of a
single segment, concerning for obstruction. Interval development
of ascites may also support small bowel obstruction.
2. Bilateral airspace consolidation.
3. Interval development of ascites.
Abdominal Pathology ([**6-27**]): Ileum, segmental resection:
1. Ischemic enteritis with stricture.
2. Proximal dilation and focal hemorrhage.
3. The margins are free of disease.
CT Abdomen/Pelvis ([**7-10**]): IMPRESSION:
1. Marked interval improvement in the small-bowel obstruction
noted on [**2164-6-25**] with passage of contrast predominantly up
to the splenic flexure of colon.
2. Apparant 2.1 X 4.4 cm loculated fluid collection as described
above could represent a fluid filled pelvic ileal loop. Short
term follow-up pelvic CT with oral contrast to evaluate for
change or filling is suggested to aid differentiaion.
3. Improved bibasilar atelectasis and patchy ground glass and
tree-and-[**Male First Name (un) 239**]
opacities suggesting resolving infectious process. New small
bilateral pleural effusions are noted.
CT Pelvis ([**7-11**]):
IMPRESSION: The previously described possible fluid collection
on today's
study appears to be a loculated pocket of ascites or intrapelvic
abscess
measuring 2.7 x 4.8 x 2.2 cm (AP, transverse, craniocaudal). No
other short term interval changes.
Brief Hospital Course:
1. SBO:
Pt was initially found to not have an obstruction or
intra-abdominal free air. Pt was made NPO with an NGT and IVF.
The patient pulled out his NGT and was subsequently placed on UE
restraints. The NGT was not replaced as the patient subsequently
had copious large bowel movements initially. At the time, Pt's
lab values during the initial period, including CBC and
electrolytes were all normal throughout the hosptial course.
However, over the next few days, he continued to have trouble
with SBO, and a significant high-grade bowel obstruction distal
from the J-tube site was found on Abd CT on [**6-25**]. We tried to
care for this with 2 days of
conservative therapy, including venting of the J tube and NG
decompression. There was clearly no progression of his
distention, and he was not making bowel movements, and since he
is noncommunicative, the decision was made to not delay any
further and operate on him.
On [**6-27**], he went to the OR for:
1. Small bowel exploratory laparotomy.
2. Small-bowel resection with primary anastomosis.
Post-operatively, an NGT was placed, and he was put on bowel
rest. By [**7-2**], he was passing stools, and his NGT output was
decreased until it came out and it was not replaced. Tubefeeds
through J tube were restarted on [**7-3**] and his goal was met on
[**7-5**]. He did fail a swallow study on [**7-4**], and he has remained
NPO. He did have some anemia to 20.8 on [**7-3**], and was given
2URBCs which he responded well to.
The patient seemed to be more somnolent and less responsive on
[**7-10**], and he had a repeat CT abdomen/pelvis which showed
interval improvement in his SBO, but also a 2.1 X 4.4 cm
loculated fluid collection as described above could represent a
fluid filled pelvic ileal loop. A subsequent Pelvic CT with PO
contrast showed a loculated pocket of ascites or intrapelvic
abscess measuring 2.7 x 4.8 x 2.2 cm. The surgeons (including
Dr. [**Last Name (STitle) **] reviewed the films and determined that this was
unlikely to be an abscess, and there was no need to take him for
CT guided drainage or back to the OR.
2. C. Difficle Colitis:
On HD 2 the patient was found to have stool positive for C.Diff.
He was started on flagyl PO 500 TID for a course fo 2 weeks then
switched to PO vancomycin 250mg every 6 hrs on [**6-17**] for total 14
day treatment. Pt completed his course of PO vanco on [**7-1**], and
was not having diarrhea at that time. Repeat C. diff stool
cultures on [**8-17**], [**7-5**], and [**7-11**] were negative.
3. Seizures:
The patient was found to be tachycardic and hypertensive on HD
2. In context of his PMH, it was believed that he likely had a
seizure. It was noted that he was having between 1 and 3
seizures daily at his current home prior to admission. Dilantin
levels were checked daily and often found to be subtherapeutic.
400 mg boluses of dilantin were given accordingly and the
neurology service at [**Hospital1 18**] was consulted for appropriate
management of his seizures. The patient was transferred to the
Neurology service on HD4.
While on neuro service, he had no increase in his usual seizure
frequency.
Post-operatively, Mr. [**Known lastname **] was maintained on IV Dilantin and
Lorazepam, and his dilantin levels were followed. By [**7-5**], he
was restarted on Dilantin, Lorazepam, Felbatol, and Trileptal
through J tube per Neurology.
His Keppra was discontinued during this hospitalization. His
Phenytoin was changed to 100 mg three times a day. His Trileptal
was kept at 300-600-300, and his Felbatol was kept at 1400 mg
[**Hospital1 **]. He was started on Ativan 1 mg PO q8 hr. IN ONE WEEK THIS
SHOULD BE TAPERED TO 1 MG PO Q12 HR, and will be further
titrated during his follow up appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 856**].
4. Upper GI Bleed: On [**6-22**], pt had black vomitus which was
guaiac positive hence NGT was placed and pt had copious black
fluid output which was once again guaiac positive. Pt did not
have any IV access and peripheral access could not be obtained
hence L IJ central line was placed per medical procedure team.
Pt had stat CBC, type and screen and IV PPI [**Hospital1 **] was started and
GI was consulted who recommended CT scan to rule out
obstruction. Surgery was contact[**Name (NI) **] given that pt was initially
admitted per surgery and recently had ex-lap, cholecystectomy
and open j tube placement per Dr. [**Last Name (STitle) **]. Pt became
hemodynamically unstable with decreasing BP and tachycardia plus
decreased urine output, pt was transferred to MICU for intensive
care.
5. Aspiration Pneumonia: While in the MICU, he developed
respiratory failure, which was likely aspiration given
significant amounts of gastric contents from OG tube after
intubation. CXR [**6-25**] showed increased prominence of the airspace
consolidations at both bases, consistent with pneumonia. He was
treated with Vancomycin/Cefepime. Repeat CXR on [**7-10**] showed
marked improvement compared to 10 days prior with small residual
right lower lobe consolidation
6. Hyponatremia: Sodium nadired at 128, but was 130 at the time
of discharge. He has a history of hyponatremia secondary to
Trileptal use. Nutrition changed his tube feeds to Probalance to
decrease the amount of free water he was taking in.
7. Thrombocytosis: His platelets peaked at 1255, and were 974 at
the time of discharge. This was thought to be a reactive
thrombocytosis secondary to an underlying process, and not a
primary bone marrow disorder.
Medications on Admission:
Heparin 5000 UNIT SC TID
MetRONIDAZOLE (FLagyl) 500 mg PO TID [**6-17**] @ 0740
Bisacodyl 10 mg PR HS
LeVETiracetam 1000 mg PO QAM
LeVETiracetam 1500 mg PO QPM
Pantoprazole 40 mg PO Q24H
Docusate Sodium 100 mg PO BID:PRN
Senna 1 TAB PO BID:PRN
Phenytoin (Suspension) 150 mg PO QAM
Phenytoin 200 mg PO QHS
Phenytoin 400 mg PO ONCE Duration: 1 Doses
bolus for corrected Dilantin = 7.57 [**6-18**] @ 0823
Felbatol *NF* 1400mg Oral [**Hospital1 **] seizures
Oxcarbazepine 300 mg PO BID
Oxcarbazepine 600 mg PO QMID-DAY seizures
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U
Injection TID (3 times a day).
2. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
at bedtime.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twenty-four(24)
hours.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO three times a day: Please give as CHEWABLE
formulation ONLY, must be crushed and give through J-tube .
7. Felbamate 400 mg Tablet Sig: 3.5 Tablets PO BID (2 times a
day).
8. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO Q AM ():
Please give through J-tube .
9. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO Q MID-DAY
(): Please give through J-tube .
10. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO Q HS ():
Please give through J-tube .
11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
13. Metoprolol Tartrate 50 mg Tablet Sig: 1.25 Tablets PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
PRIMARY:
C. difficile colitis
SBO from adhesions
Ischemic bowel
GI bleed
Hyponatremia likely secondary to Trileptal
Reactive Thrombocytosis
SECONDARY:
[**Location (un) 849**]-Gastaut syndrome
Mental retardation
s/p recent J-tube placement
Discharge Condition:
Stable, nonverbal, moving all extremities against gravity,
tracks eyes past midline, no obvious abdominal pain
Discharge Instructions:
You presented to the hospital with C. difficile colitis, and
this treated with antibiotics. You then had hematemesis and your
blood pressure became low, consistent with an upper GI bleed. GI
and surgery were consulted, and you were taken to the OR. You
had an exploratory laparotomy, and were found to have an SBO
secondary to adhesions and ischemic bowels s/p resection and
primary anastamosis. You were in the ICU under the care of the
surgeons during this part of your hospitalization. You were then
transferred back to the floor, and were under the care of the
neurologists. Your sodium remained low (130 at the time of
discharge) during this hospitalization which is likely secondary
to Trileptal use. Because of this, nutrition changed your tube
feeds to Probalance to decrease the amount of free water you
were receiving (and increase your kilocalories). Your platelet
count was elevated to the 1000s, which is likely a reactive
thrombocytosis. Speech and Swallow evaluated you, and
recommended you remain NPO with supplemental nutrition.
Your Flagyl course was completed while you were in the hospital,
so you no longer need to take this medication. You were started
on Metoprolol 62.5 mg PO three times a day, because your heart
rate was fast during the hospitalization. Your Keppra was
discontinued. Your Phenytoin was changed to 100 mg three times a
day. You were started on Ativan 1 mg PO q8 hr. IN ONE WEEK THIS
SHOULD BE TAPERED TO 1 MG PO Q12 HR. Any further titration will
be determined when he follows up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 856**] in
Neurology.
If you develop increased frequency of seizures, decreased
responsiveness, abdominal pain, increased frequency of diarrhea,
fevers/chills, or any other symptoms that concern you, call your
PCP, [**Name10 (NameIs) 850**], or return to the ED.
Followup Instructions:
You have a follow up appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 856**] in
Neurology ([**Telephone/Fax (1) 857**]) on [**2164-8-1**] at 9:00 am in the [**Hospital Ward Name 23**]
Building, [**Location (un) 858**].
You have a follow up appointment with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Month (only) **]
([**Telephone/Fax (1) 250**]) on [**2164-9-5**] at 9:10 in the [**Hospital Ward Name 23**] Center, [**Location (un) 859**].
You have a follow up appointment with Dr. [**Last Name (STitle) **] in
Neurology ([**Telephone/Fax (1) 857**]) on [**2164-9-25**] at 10:00 am in the [**Hospital Ward Name 860**]
Building, [**Location (un) 861**].
Name: [**Known lastname 62**],[**Known firstname 63**] Unit No: [**Numeric Identifier 64**]
Admission Date: [**2164-6-15**] Discharge Date: [**2164-7-13**]
Date of Birth: [**2115-11-19**] Sex: M
Service: NEUROLOGY
Allergies:
Phenobarbital / Depakote / Zarontin / Gabapentin / Zonegran /
Tranxene Sd
Attending:[**First Name3 (LF) 65**]
Addendum:
Please note: The patient was discharge on Famotidine 20 mg q12
hr instead of Protonix.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 66**] MD [**MD Number(2) 67**]
Completed by:[**2164-7-13**]
|
[
"560.81",
"285.9",
"356.9",
"518.81",
"319",
"507.0",
"578.9",
"733.00",
"530.81",
"V44.2",
"557.0",
"345.10",
"276.52",
"008.45",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"99.04",
"96.71",
"45.62",
"46.32",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
19876, 20110
|
8892, 14424
|
377, 491
|
16629, 16742
|
3173, 3173
|
18643, 19853
|
2087, 2104
|
14998, 16243
|
16366, 16608
|
14450, 14975
|
16766, 18620
|
3720, 8869
|
2119, 2119
|
2141, 3154
|
296, 339
|
519, 1391
|
3189, 3704
|
1413, 1767
|
1783, 2071
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,530
| 167,530
|
40954
|
Discharge summary
|
report
|
Admission Date: [**2157-8-22**] Discharge Date: [**2157-8-25**]
Date of Birth: [**2094-4-24**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
cardiac catheterization with no intervention
History of Present Illness:
Mr. [**Known lastname 28272**] is a 63 year-old man with PAF, PVD, HLD, HTN and OSA
with complaint of several months of exertional chest pain and
dyspnea. Patient describes that chest pain and dyspnea occur
only the setting of exertion, typically climbing the three
flights of stairs to his apartment. He describes the chest pain
as substernal burning that occurs suddenly and lasts 2-3 minutes
promptly relieved with rest. He recalls taking nitroglycerin on
a single occasion, but he believes that his pain was already
improved prior to taking nitroglycerin. He denies diaphoresis,
pre-syncope and nausea during these episodes. He also denies
symptoms at rest. He underwent a nuclear stress test on
[**2157-5-27**] that revealed inferior and apical wall defects with
preserved EF.
.
Mr. [**Known lastname 28272**] was previously observed to have renal failure with a
serum Cr of 2.5 thus his cardiac catheterization was deferred
pending improved renal function. Mr. [**Known lastname 89380**] renal function
improved after the discontinuation of sotalol, lisinopril and
HCTZ with a recent Cr of 1.3 on [**2157-7-8**].
.
He now presents to [**Hospital1 18**] for aspirin desensitization prior to
left heart catheterization tomorrow.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia and Hypertension
2. CARDIAC HISTORY: PAF, Sinus Bradycardia, PVD, HLD, HTN and
OSA
3. OTHER PAST MEDICAL HISTORY: Renal Failure, Cataract Surgery
OU
Social History:
- Tobacco history: Former Smoker
- ETOH: No
- Illicit drugs: No
Family History:
- Brother CAD/CABG at age 57, No sudden cardiac death; otherwise
non-contributory.
- Mother: deceased 50's lung CA
- Father: estranged
Physical Exam:
Admission Exam
GENERAL: NAD. Oriented x3. Restricted affect.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Clear oropharynx.
NECK: Supple with unable to determine, but likely normal.
CARDIAC: Bradycardic with regular rhythm, normal S1, S2. [**3-13**]
systolic murmur radiating to carotids, no change with valsalva.
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, obese with midline hernia. Bowel sounds present.
No HSM. Mild tenderness laterally along right abdominal wall.
Abd aorta not enlarged by palpation. No abdominial bruits.
EXTREMITIES: Mildly enlarged and subjectively doughy hands. No
clubbing or cyanosis or edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. No
evidence of urticaria, although face appears somewhat enlarged
with slight acne.
PULSES:
Right: Carotid 2+ , DP 1+, PT 1+
Left: Carotid 2+ , DP 1+, PT 1+
Discharge Exam
VS: T 97.7-98.7 BP 124-156/34-66 HR 50-87 RR 18 O2 sat 95% RA
GENERAL: NAD
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2. 2/6 systolic murmur radiating to carotids, no change
with valsalva.
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding, neg HSM.
EXT: wwp, no edema. DPs, PTs 1+. right groin with no hematoma,
bruit or erythema.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities.
SKIN: no rash
PSYCH: somewhat flat affect, short answers to questions,
oriented and alert.
Pertinent Results:
[**2157-8-22**] 12:46PM BLOOD WBC-9.0 RBC-4.14* Hgb-13.1* Hct-35.9*
MCV-87 MCH-31.6 MCHC-36.4* RDW-13.5 Plt Ct-234
[**2157-8-25**] 06:35AM BLOOD WBC-10.1 RBC-3.97* Hgb-12.2* Hct-33.8*
MCV-85 MCH-30.6 MCHC-35.9* RDW-13.7 Plt Ct-197
[**2157-8-22**] 12:46PM BLOOD Glucose-101* UreaN-24* Creat-1.1 Na-139
K-5.1 Cl-104 HCO3-24 AnGap-16
[**2157-8-25**] 06:35AM BLOOD Glucose-110* UreaN-27* Creat-1.1 Na-137
K-4.2 Cl-103 HCO3-27 AnGap-11
[**2157-8-22**] 12:46PM BLOOD CK-MB-2 cTropnT-<0.01
EKG [**2157-8-24**]:
Sinus rhythm. Left ventricular hypertrophy. Left anterior
fascicular block. Compared to the previous tracing of [**2157-8-23**]
the rate has increased.
Ventricular ectopy is absent. The ST-T wave changes and the Q-T
interval
prolongation have improved. Otherwise, no diagnostic interim
change.
CARDIAC CATH [**2157-8-23**]:
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrates no hemodynamically significant disease in any of
the
epicardial coronary arteries. The left anterior descending has a
30%
lesion in the mid-vessel. The circumflex artery contains a 30%
lesion in
the mid vessel at the second OM bifurcation. The right coronary
artery
has 20-30% lesions, ostially as well as at the rPDA bifurcation.
2. Limited resting hemodynamics demonstrate systemic
hypertension.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Normal systemic blood pressure.
Brief Hospital Course:
63 year-old man with paroxysmal atrial fibrillation and
hypertension admitted for evaluation of exertional chest pain
and aspirin desensitization for diagnosit cardiac
catheterization.
# ASPIRIN DESENSITIZATION: Per [**Hospital1 18**] protocol, he was given 10
doses of escalating aspirin (0.1 mg to 325 mg) at 15 minute
interval. He premedicated with monteleukast 10 mg po x 1. He
tolerated the desensitization without any complications. He was
continued on aspirin daily following desensitization.
# EXERTIONAL DYSPNEA/CHEST PAIN: Likely due to LVH from
hypertension. He underwent diagnostic cardiac catheterization
to evaluate for coronary artery disease which showed
nonobstructive coronaries.
# HYPERTENSION: His antihypertensive regimen was modified with
labetolol 300 mg po BID, lasix 20 mg po qdaily and amlodipine 10
mg po qdaily. He will follow up with his PCP/cardiology for
follow up electrolytes and creatinine check along with further
modification of his antihypertensives.
# DYSLIPIDEMIA: Continued on pravastatin.
# OSA: Continued on home CPAP
# Paroxysmal atrial fibrillation: CHADS2 score of 1. He will be
anticoagulation with aspirin 325 mg po qdaily. Plavix was
discontinued as he is now able to tolerate aspirin 325 mg po
qdaily post desensitization. He will be rate controlled with
labetalol 300 mg po BID.
# Follow up for PCP:
1. Refractory hypertension: Medication change as per above.
Consider workup for renal artery stenosis.
Medications on Admission:
HOME MEDICATIONS:
Plavix 75mg Qday
Toprol XL 50mg Qday
Pravastatin 40mg Qday
Norvasc 10mg Qday
Imdur 60mg Qday
Celexa 40mg Qday
NTG 0.4 mg Q5min PRN
MVI
Discharge Medications:
1. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. labetalol 300 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertension
Hyperlipidemia
Coronary Artery Disease
Aspirin Desensitization
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had chest pain and trouble breathing with activity and was
admitted for a cardiac catheterization that showed a small
degree of blockage in your arteries but was not thought to be
causing your chest pain or trouble breathing. Your blood
pressure has been very high and may be contributing to your
symptoms. We have chaged your medicines to better control your
blood pressure and today you do not have any symptoms with
walking or exertion. It is very important to take your
medications as prescribed to keep your blood pressure under
control and check your blood pressure at different times of the
day to assess whether the medication is working. Please keep a
log of all your home blood pressures to share with Dr. [**Last Name (STitle) 24913**]
and Dr. [**Last Name (STitle) 77919**]. You also need to lose weight and increase
your activity. Start with walking a short distance and
increasing the distance daily with a goal of walking [**3-10**] miles
per day. You will need to avoid salt in your diet. A booklet
with specific dietary instructions was given to you at
discharge.
.
We made the following changes to your medicines:
1. STart taking Labetalol twice daily to lower your blood
pressure
2. Start taking furosemide daily to lower your blood pressure
3. Start taking aspirin daily, do not stop taking this medicine
from now on.
4. Stop taking Plavix, Metoprolol and Imdur
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] P.
Location: [**Hospital 46644**] MEDICAL ASSOCIATES
Address: [**Location (un) 32946**], [**Location (un) **],[**Numeric Identifier 32948**]
Phone: [**Telephone/Fax (1) 32949**]
Appt: [**8-29**] at 10;30am
Name: [**Month (only) 77919**], [**Last Name (un) 83355**] S. MD
Location: CLIPPER CARDIOVASCULAR ASSOCIATES
Address: 112A [**Location (un) **] ST, [**Location (un) **],[**Numeric Identifier 12023**]
Phone: [**Telephone/Fax (1) 65733**]
Appt: [**9-8**] at 10:45am
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
[
"327.23",
"427.31",
"443.9",
"272.4",
"401.9",
"786.59",
"786.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7905, 7911
|
5764, 7234
|
322, 369
|
8031, 8031
|
4334, 5654
|
9592, 10213
|
2470, 2608
|
7438, 7882
|
7932, 8010
|
7260, 7260
|
5671, 5741
|
8182, 9569
|
2623, 4315
|
2259, 2305
|
7278, 7415
|
272, 284
|
397, 2161
|
8046, 8158
|
2336, 2372
|
2183, 2238
|
2388, 2454
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,037
| 198,589
|
6805
|
Discharge summary
|
report
|
Admission Date: [**2165-9-25**] Discharge Date: [**2165-9-26**]
Date of Birth: [**2120-2-3**] Sex: M
Service: TRA
ADMISSION DIAGNOSES: Generalized fatigue.
Rosacea.
Allergic rhinitis.
Hyperlipidemia.
Obesity.
C5-6 traumatic disc herniation.
Status post C5-C6 diskectomy with fusion.
Blunt trauma.
HISTORY OF PRESENT ILLNESS: The patient is a 45 year old
male with a history of a cervical spine injury causing a
herniated C5-C6 disc which was subsequently excised with a C5-
C6 fusion who on the evening of admission had his motor
vehicle that he was operating struck from behind in a motor
vehicle collision. He reports having a mom[**Name (NI) 12823**] loss of
consciousness. He denied any noticeable injury except for
mild left upper extremity and right lower extremity weakness.
This weakness had been steadily improving throughout the
course of the day but the patient presented to a hospital and
was given a dose of steroids and transferred to the [**Hospital1 1444**] for further evaluation.
PAST MEDICAL HISTORY: His past medical history is
significant for generalized fatigue, rosacea, allergic
rhinitis, hyperlipidemia and obesity.
PAST SURGICAL HISTORY: Is significant for the C5-C6
diskectomy with fusion.
MEDICATIONS: At home include Nasacort.
ALLERGIES: Are to penicillin.
SOCIAL HISTORY: Is that he is a widower and a father of
three.
FAMILY HISTORY: Is noncontributory.
REVIEW OF SYSTEMS: Was noncontributory.
PHYSICAL EXAMINATION: The temperature was 97, heart rate 74,
blood pressure 133/36, respirations 16, 94 percent saturation
on room air. He was awake and alert with no apparent
distress. His pupils were equal, round and reactive to light
with 3 mm reactive pupils bilaterally. His [**Location (un) 2611**] Coma
Scale was 15. His neck was supple with a mild midline C-6
tenderness. His trachea was midline. His neck was otherwise
without evidence of abrasion, contusion or tenderness. There
was no jugular venous distension. His lungs were clear to
auscultation bilaterally. His heart was regular rate and
rhythm. His abdomen was soft, nontender, nondistended with
no contusions noted. He was moving all extremities with no
evidence of trauma.
ASSESSMENT AND PLAN: Is that this is a 45 year old male who
suffered a rear end collision who had a previously traumatic
C5-C6 disc herniation, status post diskectomy and fusion who
presents with diminished left upper extremity strength and
right lower extremity strength. At the time of his
evaluation this deficit in strength had essentially resolved.
HOSPITAL COURSE: He was admitted to the Trauma Surgical
Intensive Care Unit for observation and neurosurgical
consultation. This consultation was performed and his
imaging studies revealed that there was no acute injury and
the patient's symptoms had completely resolved. Having been
cleared by the surgical spine team the patient had his
cervical collar removed, remained stable and was cleared for
discharge on that day in stable condition. He was given
instructions to follow up with his primary care physician.
[**Name10 (NameIs) **] was discharged in stable condition.
DISCHARGE DIAGNOSES: Generalized fatigue.
Rosacea.
Allergic rhinitis.
Hyperlipidemia.
Obesity.
C-6 traumatic disc herniation.
Status post C5-C6 diskectomy with fusion.
Blunt trauma.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**]
Dictated By:[**Last Name (NamePattern1) 25777**]
MEDQUIST36
D: [**2165-9-26**] 15:07:36
T: [**2165-9-26**] 16:19:08
Job#: [**Job Number 25778**]
|
[
"E812.0",
"782.0",
"723.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1403, 1424
|
3179, 3610
|
2596, 3157
|
1194, 1321
|
157, 320
|
1489, 2578
|
1444, 1466
|
349, 1025
|
1048, 1170
|
1338, 1386
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,638
| 116,151
|
32538+57809
|
Discharge summary
|
report+addendum
|
Admission Date: [**2194-1-23**] Discharge Date: [**2194-2-5**]
Date of Birth: [**2138-6-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back pain, leg weakness
Major Surgical or Invasive Procedure:
Thoracic instrumented fusion T1-12
History of Present Illness:
HPI: Pt is a 55 yo male w/ PMHx sig for metastatic renal cancer
to the thoracic spine, rheumatoid arthritis who presents as a
transfer from an OSH for leg weakness. The patient was found to
have a renal tumor in [**2190**] s/p resection. In [**6-21**] the patient
was found to have an extradural mass at T5 that was felt to be
metastases. The patient is also known to have a kyphotic
collapse at T10. The patient was seen in Dr.[**Name (NI) 2845**] office
several days ago where it was felt that the patient would need
surgical instrumentation of the thoracic spine for
stabilization.
This was scheduled for the future. In the last couple of days,
the patient has had increased difficulty walking and numbness in
his legs. He was seen at an OSH and then transferred to [**Hospital1 18**]
for further evaluation.
Pt denies headache, vertigo, tinnitus, hearing loss, dysarthria,
dysphagia, visual changes, shortness of breath, chest pain,
abdominal pain, joint pain, bleeding, nausea, vomiting, fevers,
chills, night sweats, bowel/bladder incontinence, rash
: deferred
Past Medical History:
Past Medical History: rheumatoid arthritis x 20 years, renal ca
s/p nephrectomy, metastatic spine disease
Social History:
Social History: Lives with a friend and his wife. 2 ppd x
30-40
years. Recovering alcoholic. Past history of drug abuse, clean
for last two years.
Family History:
Family History: father deceased at 63 yo of heart disease.
Physical Exam:
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: radial deviation of MCP joints of both hands.
Neurological Exam:
Mental status: A & O x3, relays coherent history. Fluent speech
with no paraphasic or phonemic errors. Adequate comprehension.
Follows simple and multi-step commands. Repetition intact (no
ifs, ands or buts). Able to name low and high frequency
objects.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light. VFF.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**5-19**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift.
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB
C5 C7 C6 C8 L2 L3 L4-S1 L4 L5 L5
RT: 5 5 5 5 5 5 5 3 5 3- 4 5 4 4
LEFT: 5 5 5 5 5 5 5 4+ 5 4+ 5 5 4+ 5
Sensation: Decreased pinprick from ~ T10 to R thigh but intact
to
pinprick on left. Impaired proprioception large movements at
the
ankle, decreased vibration in toes.
Reflexes: Bic T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes upgoing bilaterally.
Coordination: FNF intact.
Gait: deferred
Pertinent Results:
[**2194-1-24**] 07:00AM BLOOD WBC-8.0 RBC-4.64 Hgb-11.2* Hct-34.0*
MCV-73* MCH-24.2* MCHC-33.1 RDW-13.8 Plt Ct-296
[**2194-2-3**] 05:35AM BLOOD Hct-26.1*
[**2194-2-1**] 08:49AM BLOOD PT-13.5* PTT-45.8* INR(PT)-1.2*
[**2194-2-1**] 02:04AM BLOOD Glucose-146* UreaN-27* Creat-0.7 Na-131*
K-4.5 Cl-101 HCO3-26 AnGap-9
[**2194-2-1**] 02:04AM BLOOD Calcium-7.7* Phos-2.1* Mg-1.9
CT [**2194-1-22**]: IMPRESSION: Enhancing lytic mass involving the left
posterior elements of T5 with left lateral epidural extension
and near complete extension into the left T4/5 foramen.
Severe destructive changes of the T9 vertebral body and the T10
vertebral body with focal kyphosis measuring approximately 50
degrees. Approximately 2-cm anterior spondylolisthesis of T8 on
T10. This is causing severe canal stenosis and likely
compression of the cord.
High-density material seen within and around the destroyed T9
vertebral body and right posterior elements with some
well-circumscribed bony defects of the T9 body on the left.
These findings likely represent prior corpectomy with graft
material or polymethylmethacrylate placement. The lytic lesions
causing the bony destructive changes at these levels likely
represent metastases given the prior right nephrectomy.
Differential diagnostic possibility would also include myeloma.
Mild anterior wedge deformity of the T11 vertebral body.
Brief Hospital Course:
Pt was admitted to the hospital for increasing leg weakness and
pain. He had pain management and was readied for the OR. On
[**2194-1-28**] he went to Or where under general anesthesia he
underwent thoracic instrumented fusion T1-12. H etolerated this
procedure well, was kept intubated and transferred to ICU post
op for close monitoring. He was extubated on POD#1. He required
PCA pain management. He had 2 JP drains placed intraop and
output was followed closely along with hematocrit. The first
drain was removed [**2194-1-31**] and second [**2194-2-1**] without any
difficulties. He was then transferred to the floor. Diet and
activity were advanced. he pain was well controlled. His leg
strength improved. He was evaluated by PT. On discharge he was
noted to have some serosangous drainage from his wound no
redness, fluid collection or edema. His staples should stay in
an additional 7 days.
Medications on Admission:
Medications: Celexa 20 mg PO DAILY, Methadone 50 mg/50 mg/20 mg,
Cyclobenzaprine, Dilaudid 4 mg PO DAILY.
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Methadone 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
7. Methadone 10 mg Tablet Sig: Five (5) Tablet PO Q 6 AM AND Q 6
PM ().
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
14. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) for 2 days.
15. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours) for 2 days.
16. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily)
for 2 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Renal cell carcinoma metastatic to thoracic spine
Discharge Condition:
Neurologically improved
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ change dressing daily / take daily showers
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed
at your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
Have your staples removed at rehab on [**2194-2-12**].
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT
Completed by:[**2194-2-5**] Name: [**Known lastname 1799**],[**Known firstname 63**] Unit No: [**Numeric Identifier 12405**]
Admission Date: [**2194-1-23**] Discharge Date: [**2194-2-5**]
Date of Birth: [**2138-6-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2427**]
Addendum:
Mr. [**Known lastname **] had radiologic evidence of pneumonia on studies
done just prior to admission. Treatment was begun during his
hospital stay here.
Major Surgical or Invasive Procedure:
Thoracic instrumented fusion T1-12
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **]
Discharge Diagnosis:
Renal cell carcinoma metastatic to thoracic spine
community acquired pneumonia
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2428**] MD [**MD Number(2) 2429**]
Completed by:[**2194-2-14**]
|
[
"486",
"070.54",
"737.10",
"336.3",
"733.13",
"304.01",
"198.5",
"V10.52",
"714.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.05",
"81.64",
"99.04",
"84.51",
"03.09",
"03.53",
"77.89"
] |
icd9pcs
|
[
[
[]
]
] |
9669, 9764
|
4794, 5701
|
9609, 9646
|
7352, 7378
|
3397, 4771
|
8773, 9571
|
1810, 1855
|
5857, 7138
|
9785, 10023
|
5727, 5834
|
7402, 8750
|
1870, 2164
|
2183, 2183
|
278, 303
|
406, 1481
|
2458, 3378
|
2198, 2442
|
1525, 1610
|
1643, 1778
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,409
| 173,666
|
32694
|
Discharge summary
|
report
|
Admission Date: [**2130-10-13**] Discharge Date: [**2130-11-30**]
Date of Birth: [**2049-4-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
CHF exacerbation transfer from OSH
Major Surgical or Invasive Procedure:
Thoracentesis
Colonoscopy x 2
EGD x 2
Cardiac Catheterization
Central Line Placement
Intubation/Extubation
PICC placement
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
.
81 y.o. M with CAD, s/p atrial closure surgery, h/o BPH s/p TURP
who presented to [**Hospital1 **] last week with an acute on chronic
systolic CHF exacerbation and weight gain requiring
thoracentesis of 2L of fluid. Patient has been having
progressively worsening heart failure symptoms over last 9
months. He has recently moved here from [**Country 4194**] 5 months ago.
Patient was subsequently transferred to [**Hospital1 18**] for possible
MVR/TVR and/or CABG depending on cath results. Patient also
unable to lay flat for cardiac catherization
Patient's course was complicated by hematuria requiring urology
evaluation and subsequently patient is being transfered to
cardiology service for further workup. He has been gently
diuresed with IV lasix during his CSRU stay. Patien also had L
femoral triple lumen catheter inserted. He is transfered to
medicine service for continued CHF management.
As far as the hematuria, course at OSH was complicated by
traumatic foley insertion. A foley was placed with a urologist
assistance after he performed a cystoscopy to place a Couniltip
catheter over a wire as there were multiple false passages and
urethral trauma causing hematuria. Patient continued to have
gross hematuria with clots especially since heparin gtt was
instituted for management of Afib.
Past Medical History:
PAST MEDICAL HISTORY:
HTN
DM2
AF
CHF EF 30-35% - ischemic; MT/TR
BPH s/p TURP
CRI
CAD, NO CABG
Atrial Septal repair surgery
.
Social History:
No etoh, used to smoke, moved from [**Country 4194**] 6 mo/ago and lives
with son, through whom the history was obtained
Family History:
Brother with extensive cardiac history including bypass surgery;
parents were well without heart disease, no HTN
Physical Exam:
PHYSICAL EXAMINATION:
VS: T 97.2, BP 102/57 SBP (95-120), P 99 (85-100), SaO2 94% 4L
-RR 16
GENERAL: No apparent distress, laying comfortably, use of
accessory neck muscles
HEENT: EOMI, pink conjunctiva. Oral mucosa moist and clear.
NECK: supple with ~ JVP of 10 cm. No carotid bruits auscultated.
No thyromegaly.
CHEST: no deformities, scoliosis or kyphosis. labored
respirations with mild use of accessory muscles. decreased BS,
with no clear crackles appreciated
CVS: RRR, nl S1/S2. ? S4, 3/6 SEM at apex
ABD: +BS. soft, NT/ND. mild guarding The abdominal aorta was not
palpated. No hepatosplenomegaly.
EXT: Warm, without edema. several echymosis with scabs and
surrounding erythema - due to recent trauma
.
Pertinent Results:
Diagnostic Imaging:
[**2130-10-16**].Echo.
The left atrium is markedly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild to moderate regional left ventricular systolic
dysfunction with inferior akinesis and focal distal septal
hypokinesis. [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is mildly dilated.
There is mild global right ventricular free wall hypokinesis.
The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
[**2130-11-1**]. Cardiac cath.
COMMENTS:
1. Right heart catheterization revealed elevated right sided
filling
pressures, with RVEDP of 17 mm Hg and mean RA pressure of 16 mm
Hg.
There was moderate to severe pulmonary arterial hypertension
with PA
pressure 64/27 mm Hg. The cardiac index was preserved at 3
l/min/m2.
2. Resting hemodynamics revealed normal systemic arterial
pressure of
115/46 mm Hg.
FINAL DIAGNOSIS:
1. Elevated cardiac filling pressures.
2. Moderate to severe pulmonary arterial hypertension.
.
Renal Ultrasound. [**2130-10-23**].
IMPRESSION: Large simple cysts on the left and on the right a
septated cyst as well as multiple cysts TSTC by US; likely
simple cysts.
.
[**2130-10-21**] Tib/Fib XRAY
IMPRESSION: Normal radiographic appearance with no evidence for
osteomyelitis.
.
[**2130-10-23**] Urine Cytology
ATYPICAL. Rare atypical urothelial cells present singly.
.
[**2130-10-23**] CT HEAD:
FINDINGS: There is no evidence of hemorrhage, edema, masses,
mass effect, or
major vascular territorial infarction. A small chronic left
occipital pole
infarct is seen, as well as probable chronic infarcts in the
region of the
posterior limb of the right internal capsule and subinsular
white matter. The ventricles and sulci are unremarkable. Age-
related changes are noted. No fractures are identified.
Scattered ethmoid sinus mucosal thickening is
noted, likely a chronic inflammatory process. The sinuses are
otherwise
unremarkable. The visualized orbits are normal.
.
IMPRESSION: No acute intracranial pathology. Probable multiple
chronic
infarcts, as noted above.
.
[**2130-10-28**] CT HEAD:
FINDINGS: Nsignificant interval change from [**2130-10-23**]
without evidence for intra- or extra-axial hemorrhage or mass
effect. There is mild brain atrophy and a small lacunar infarct
in the right thalamus/posterior limb of the internal capsule as
well as further periventricular white matter hypodensities that
are sequelae of chronic small vessel infarction. There is no
evidence for fracture.
.
IMPRESSION: No intracranial hemorrhage or fracture.
.
[**2130-11-1**] Right Heart Catheterization
COMMENTS:
1. Right heart catheterization revealed elevated right sided
filling
pressures, with RVEDP of 17 mm Hg and mean RA pressure of 16 mm
Hg.
There was moderate to severe pulmonary arterial hypertension
with PA
pressure 64/27 mm Hg. The cardiac index was preserved at 3
l/min/m2.
2. Resting hemodynamics revealed normal systemic arterial
pressure of
115/46 mm Hg.
.
FINAL DIAGNOSIS:
1. Elevated cardiac filling pressures.
2. Moderate to severe pulmonary arterial hypertension.
.
[**2130-11-3**] Pleural Fluid Cytology:
Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
Virtually acellular specimen with abundant proteinaceous
debris, red blood cell fragments and extremely rare benign-
appearing cells, likely histiocytes, mesothelial cells and
lymphocytes.
.
.
[**2130-11-6**] CXR portable:
Moderate bilateral pleural effusions greater on the right side
are unchanged from [**11-5**], increased from [**11-3**]. Left
lower lobe atelectasis is persistent. Moderate cardiomegaly is
unchanged. The right IJ tip is in the cavoatrial junction,
unchanged. NG tube tip is out of view below the diaphragm. ET
tube tip is 4 cm above the carina. Mild pulmonary edema is
stable.
.
[**2130-11-3**] Left Ankle Xray
FINDINGS: In comparison with the study of [**2130-10-21**], there is no
interval
change. Specifically, no evidence of bone erosion.
.
[**2130-11-11**] CXR portable
FINDINGS: A single portable image of the chest was obtained and
compared to the prior examination dated [**2130-11-9**] demonstrating
no significant interval change. Moderate-sized bilateral
pleural effusions persist. There is persistent perihilar
fullness associated with indistinct bronchopulmonary vasculature
with an appearance most consistent with underlying edema. The
right internal jugular central venous line and right PICC line
are grossly unchanged and in satisfactory position. The bony
thorax is grossly intact.
.
LABORATORY RESULTS:
.
[**2130-11-14**] 06:43AM BLOOD WBC-5.7 RBC-3.15* Hgb-9.2* Hct-29.0*
MCV-92 MCH-29.2 MCHC-31.7 RDW-16.3* Plt Ct-421
[**2130-11-14**] 06:43AM BLOOD PT-15.7* PTT-47.4* INR(PT)-1.4*
[**2130-10-21**] 06:44AM BLOOD ESR-22*
[**2130-11-14**] 06:43AM BLOOD Glucose-94 UreaN-57* Creat-3.1* Na-146*
K-3.9 Cl-101 HCO3-39* AnGap-10
[**2130-11-10**] 04:51AM BLOOD ALT-9 AST-16 TotBili-0.4
[**2130-11-3**] 05:17AM BLOOD LD(LDH)-270*
[**2130-11-1**] 10:55AM BLOOD ALT-10 AST-16 LD(LDH)-242 AlkPhos-43
Amylase-46 TotBili-0.2
[**2130-11-1**] 10:55AM BLOOD Lipase-39
[**2130-11-1**] 10:55AM BLOOD CK-MB-5 cTropnT-0.16*
[**2130-11-14**] 06:43AM BLOOD Calcium-8.3* Phos-5.4* Mg-2.6
[**2130-11-7**] 04:50AM BLOOD Albumin-2.3* Calcium-7.9* Phos-3.4 Mg-2.1
[**2130-10-18**] 03:44PM BLOOD %HbA1c-5.9
[**2130-11-1**] 10:55AM BLOOD TSH-8.0*
[**2130-11-2**] 05:17AM BLOOD T4-3.4* T3-38*
[**2130-11-1**] 03:49PM BLOOD Cortsol-52.1*
[**2130-11-1**] 03:09PM BLOOD Cortsol-44.3*
[**2130-11-1**] 10:55AM BLOOD Cortsol-26.9*
[**2130-10-21**] 06:44AM BLOOD CRP-6.1*
[**2130-11-1**] 02:12AM BLOOD Digoxin-1.6
[**2130-11-10**] 01:47PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.006
[**2130-11-10**] 01:47PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2130-11-2**] 10:24AM URINE RBC-[**2-27**]* WBC-[**2-27**] Bacteri-OCC Yeast-MOD
Epi-0-2
[**2130-11-2**] 10:24AM URINE Mucous-FEW
[**2130-10-30**] 09:55AM URINE Eos-NEGATIVE
[**2130-10-31**] 12:27PM URINE Hours-RANDOM UreaN-456 Creat-139 Na-13
TotProt-81 Prot/Cr-0.6*
[**2130-11-3**] 11:16AM PLEURAL WBC-17* RBC-[**Numeric Identifier 3871**]* Polys-4* Lymphs-58*
Monos-0 Atyps-5* Meso-1* Macro-30* Other-2*
[**2130-11-3**] 11:16AM PLEURAL TotProt-2.0 Glucose-95 LD(LDH)-80
Albumin-1.2
.
CULTURE DATA:
URINE CULTURE (Final [**2130-10-17**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SECOND MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S <=2 S
NITROFURANTOIN-------- <=16 S <=16 S
TETRACYCLINE---------- =>16 R =>16 R
VANCOMYCIN------------ 2 S 2 S
.
WOUND CULTURE (Final [**2130-10-17**]):
STAPH AUREUS COAG +. HEAVY GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**6-/2429**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R <=0.12 S
OXACILLIN------------- =>4 R =>4 R
PENICILLIN------------ =>0.5 R =>0.5 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- <=1 S 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S 2 S
.
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2130-11-3**]):
REPORTED BY PHONE TO [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], R.N. ON [**2130-11-3**] AT 0640.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
[**2130-11-3**] 11:16 am PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2130-11-3**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2130-11-6**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2130-11-9**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2130-11-4**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
.
.
[**2130-11-4**] 12:03 am SPUTUM Site: EXPECTORATED
Source: Expectorated.
**FINAL REPORT [**2130-11-8**]**
GRAM STAIN (Final [**2130-11-4**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S)
(PROBABLE
CELLULAR DEBRIS).
SMEAR REVIEWED [**2130-11-6**].
RESPIRATORY CULTURE (Final [**2130-11-8**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. RARE GROWTH.
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
.
Blood Cultures: All negative
.
Brief Hospital Course:
In summary, Mr. [**Known lastname **] is an 81 year old male with A. Fib,
dilated cardiomyopathy, systolic CHF, [**Hospital 76187**] transferred to [**Hospital1 18**]
for possible mitral and tricuspid valve replacement. Course has
been complicated by GI bleed due to healing gastric ulcer,
hematuria due to traumatic foley placement, delerium likely due
to hypoxia and hypercarbia, and acute on chronic renal failure.
He was then transferred to the CCU for treatment of sepsis and
hypercarbia/hypoxia, c.diff colitis, and volume overload. He had
a prolonged hospital course and eventually developed hypercarbic
respiratory failure requiring BiPAP and eventually intubation.
He then became hypotensive not responsive to fluid boluses and
anuric. His code status was changed to DNR as he was not a
candidate for hemodialysis nor was he a surgical candidate for
his severe mitral regurgitation. He ultimately died due to
multisystem failure.
.
CAD. Cardiac cath for pre-operative evaluation on [**10-18**] showed
total occlusion of RCA with good collateralization. He has
ischemic cardiomyopathy (echo shows multiple focal wall
abnormalities and EF of 40-45%). The patient then developed
sepsis with hypotension requiring transfer to the CCU. As his
sepsis was treated, the patient's BP improved, and he was able
to be started on metoprolol for rate control as well as his CAD.
He was able to return to the medical floor from the CCU. He did
not have any further ischemic issues during his admission.
.
Pump. Patient has ischemic cardiomyopathy with EF of 40-45% by
ECHO. His volume status was aggressively managed while he was
admitted, both on the medical floor and in the unit.
.
Rhythm. Patient was in Atrial Fibrilation during the admission.
He was rate controlled with beta blockade, first with
Carvedilol, then with Metoprolol as the former caused a more
significant decrease in his blood pressures. He was also
anticoagulated on a heparin drip which was intermittantly held
in the setting of GI bleeding. A GI consult was called, and the
patient had an EGD/Colonoscopy which did not show any source of
bleeding- likely caused by a small bowel AVMs. His hematocrit
remained stable for the duration of his admission.
.
Pulmonary: The patient had a thoracentesis performed at the OSH
prior to transfer to [**Hospital1 18**]. During this hospitalization,
repeated chest x-rays showed reaccumulation of the bilateral
pleural effusions, right greater than left. On [**11-3**], the
patient underwent another thoracentesis. The fluid analysis was
consistent with a transudative effusion, likely due to his
worsening heart failure and valvular disease. As above, his
volume status was aggressively managed. He had 2L drained by
thoracentesis, however, rapidly reaccumulated his effusions. He
was intubated initially for hypercarbic respiratory failure and
was extubated prior to transfer to the medical floor. He then
required re-intubation after a repeat episode of hypercarbic
respiratory failure not improved with BiPAP. He was intubated
at the time of his death.
.
Delerium. Patient has had intermittent delerium since
approximately [**10-26**]. No clear etiology was determined. Head CT
was normal twice. Delerium was thought to be due to hypoxia and
hypercarbia when nasal canula has fallen off at night. In
addition, patient has a history of working night shifts his
entire life and has an altered sleep wake cycle. He was treated
with zyprexa 2.5 prn for agitation. The patient's mental status
never returned to baseline during this hospitalization, but
according to his family, he communicated fairly well with them
in Portuguese.
.
Guaiac positive stool. Patient had Colonoscopy [**10-25**] that
showed non-bleeding angioectasia, internal hemorrhoids, and
diverticulosis. EGD on [**10-23**] showed healing gastric ulcer.
Gastric biopsy did not show H. pylori. Heparin drip for A. fib
was intermittently held due to guiaic positive stools. He was
started on a PPI [**Hospital1 **] for gastric ulcer. He had another
colonoscopy and EGD after he was intubated which did not show
any active bleeding source. His bleeding was likely due to an
AVM in the small bowel. Hematocrit remained relatively stable
for the duration of his admission.
.
Hematuria. Patient had hematuria due to traumatic foley
insertion and was followed by urology. Hematuria resolved
during hospital stay. Patient was treated intermittently with
CBI. His hemautria was evaluated with renal ultrasounds
significant only simple cysts and a single septated cyst. Urine
cytology showed rare atypical urothelial cells. He continued to
have occasional hematuria during his hospitalization, but
heparin was continued for his atrial fibrillation.
.
Acute on Chronic renal failure. Patient has a baseline
creatinine of 2.0 which was stable until approximately [**10-27**] when it began to rise. Cr rose to 3.9 with little urine
output. Renal was consulted and patient was thought to be
pre-renal. Urine eosinophils were negative making AIN unlikely.
Unresponsive to fluid boluses. With aggressive diuresis, and
improvement in his cardiac function and forward flow, the
patient's creatinine improved to 2.9. However, patient became
septic, likely from C. Diff colitis, and became hypotensive and
anuric. Renal consult service continued to follow the patient
and did not feel he would be able to tolerate hemodialysis. He
received multiple fluid boluses with minimal improvement in his
blood pressure or urine output. His creatinine continued to
rise and his urine output did not improve. Given his poor
functional status secondary to his cardiac and renal disease,
his code status was changed to DNR/intubated and he passed away
in the CCU.
.
Infectious Disease: The patient had enterococcus in his urine
prior to transfer to CCU. He also had a leg ulcer which was
positive for MRSA and was treated with vancomycin and wound care
consults were called. He was transferred to the CCU for
hypothermia, hypotension, and bradycardia in the setting of
likely sepsis. He was found to have MRSA in his sputum, and was
positive for c.diff colitis. Initially, he was treated with
vancomycin and zosyn, for a 7 day course. He was also treated
with a 12 day course of metronidazole for his c.diff. He was
initially stable and then became hypotensive, hypothermic and
unresponsive. Most likely etiology was his C. Diff. He was
treated aggressively with IV Vanc, PO Vanc and Flagyl with no
improvement.
Medications on Admission:
Home Meds:
glyburide 2.5 daily
prozac 20 mg daily
coreg 25 mg [**Hospital1 **]
lasix 80 mg Daily
coumadin 3mg po daily
spriva 1 puff [**Hospital1 **]
Discharge Medications:
Not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis: Severe Mitral Regurgitation
Acute on Chronic Systolic Heart Failure
Atrial Fibrillation
Pseudomembranous Colitis
Pneumonia
End stage renal disease
Secondary Diagnosis: Hypertension
Pleural Effusions
Gastrointestinal Bleeding
Anemia
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
|
[
"038.9",
"008.45",
"486",
"707.09",
"531.40",
"428.0",
"569.0",
"428.23",
"427.1",
"518.81",
"569.85",
"562.10",
"585.9",
"995.92",
"424.0",
"584.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"45.23",
"34.91",
"96.6",
"38.93",
"88.56",
"45.16",
"37.23",
"96.72",
"45.13",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
21128, 21137
|
14377, 20888
|
352, 476
|
21432, 21450
|
3020, 4512
|
21514, 21533
|
2156, 2272
|
21089, 21105
|
21158, 21158
|
20914, 21066
|
6625, 13092
|
21474, 21491
|
2287, 2287
|
13125, 13243
|
2309, 3001
|
13272, 14354
|
278, 314
|
504, 1852
|
5732, 6608
|
21345, 21411
|
21177, 21324
|
1896, 2002
|
2018, 2140
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,735
| 166,348
|
28473
|
Discharge summary
|
report
|
Admission Date: [**2169-12-23**] Discharge Date: [**2170-1-4**]
Date of Birth: [**2100-11-26**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Syncopal episode with a fall
Major Surgical or Invasive Procedure:
[**12-24**] Exploratory laparotomy, duodenotomy, oversewn duodenal
ulcer, pyloroplasty, placement of gastrostomy, and jejunostomy
tubes
History of Present Illness:
Ms. [**Known lastname **] is a 69 year old Vietnamese speaking female who presented
to [**Hospital1 18**]-ED via ambulance on [**12-23**] after sustaining a syncopal
episode with loss of consciousness and a fall with a head
trauma. She has a history of a known duodenal ulcer with a UGIB
[**9-8**] and CAD s/p NSTEMI; she was found to have melena by rectal
exam and NG lavage revealed coffee ground contents; she was
hypotensive with improvement after fluid resuscitation,
hematocrit was 28.4 which was down from her baseline of 35. A
central venous line was placed, CT scan of the head demonstrated
small subdural hematoma with subacrachnoid hemorrhage; CT
C-spine showed C5-C6 inferanterior avulsion fracture with disc
retropulsion. She was transferred to the surgical intensive care
unit for further treatment.
Past Medical History:
Past Medical History:
GI bleed with duodenal ulcer, s/p electrocauterization [**9-8**]
CAD s/p NSTEMI in setting of UGIB [**9-8**]
Prior strokes seen on CT without deficits
Social History:
Social History
From [**Country 3992**]. In US for last 3 years. Never smoked or any EtOH.
Lives with husband. [**Name (NI) **] a daughter who is married.
Family History:
Family History
Unknown
Physical Exam:
Upon admission:
96.4 80 83/38 14 99% room air
Gen: No active distress
Head/Eyes: Pupils equal and reactive to light, 6cm right
occipital scalp laceration
ENT/Neck: Oropharynx clear,
Chest: Clear to auscultation bilaterally
CV: Regular rate and rhythm
Abd: Soft, nontender, nondistended
Rectal: Guaiac positive
MSK: Full range of motion, 5/5 strength upper and lower
extremities; deep tendon reflexes 2+ bilaterally, sensation
intact
Neuro: Glascow comma scale=15, Cranial nerves III-XII intact
Pertinent Results:
Operative Note:
Exploratory laparotomy, duodenotomy
with oversewing of bleeding duodenal ulcer, Finney closure of
duodenotomy, gastrostomy, tube placement and jejunostomy tube
placement.
CT L-spine [**12-23**]:
IMPRESSION: No evidence of fracture or dislocation
CT T-spine [**12-23**]:
IMPRESSION:
1. No evidence of thoracic spine fracture.
2. Slight stranding in the right upper abdominal quadrant,
probably an artifactual appearance due to motion. However,
correlation with abdominal examination is recommended, in the
setting of recent trauma.
CT C-spine
IMPRESSION:
1. Possible minimally displaced anteroinferior fracture at C5,
with probable associated soft tissue swelling, v. unfused
osteophyte.
2. Probable C5/6 disc protrusion- if there are myelopathic
symptoms, a follow-up MR study is advised.
3. 4mm lytic lesion in the dens, of unclear significance.
Particularly if there is a history of prior malignancy,
radionuclide bone scan could be helpful in further evaluation of
this finding.
CT head [**12-23**]:
IMPRESSION:
1. Small subdural hematoma along the falx cerebri with adjacent
foci of subarachnoid hemorrhage.
2. Soft tissue swelling and subgaleal hematoma overlying the
left parietal region.
3. Tiny hypodense foci near the [**Doctor Last Name 352**]-white matter junction in
the right frontal lobe- see above report. MRI could be helpful,
when clinically feasible to evaluate further.
CT head [**12-23**]:
IMPRESSION: No significant interval change in the appearance of
the brain since [**2169-12-23**] at 9:47 a.m. Stable parafalcine subdural
hematoma, and small right frontal subarachnoid hemorrhage. No
mass effect or shift of normally midline structures.
MR Cervical spine:
IMPRESSION:
1. Minimal central disc protrusion at C5-6 level, without
significant neural foraminal or central canal stenosis at this
or other levels and without signal abnormality in the underlying
spinal cord.
2. No prevertebral soft tissue hematoma or evidence of
ligamentous injury.
3. Findings consistent with a hemangioma within the dens,
corresponding to lytic lesion seen on the CT of [**2169-12-23**].
Cardiology Report ECG Study Date of [**2169-12-23**] 8:30:24 AM
Sinus rhythm. Slight non-specific ST segment elevation in leads
V1-V4 with
biphasic and inverted T waves. Cannot exclude ischemia. Compared
to the
previous tracing of [**2169-9-20**] the ST-T wave changes are new.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
79 136 74 420/454.42 70 52 81
CT head [**12-25**]:
IMPRESSION: Unchanged subarachnoid and subdural blood.
No new intracranial hemorrhage.
Soft tissue edema within the scalp is new from the prior
examination and likely is secondary to the patient's volume
status after the recent surgery.
Echo [**12-25**]:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is moderate regional left
ventricular systolic
dysfunction with severe hypokinesis of the distal half of the
septum and
anterior walls. The apex is mildly dyskinetic. A left
ventricular
mass/thrombus cannot be excluded - vs. artifact vs.
trabeculation. The
remaining left ventricular segments contract normally. 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. The mitral valve leaflets are mildly thickened.
Mild (1+)
mitral regurgitation is seen. There is borderline pulmonary
artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2169-9-19**],
an apical
thrombus vs. trabeculation is now suggested. Left ventricular
systolic
dysfunction is more pronounced (anterior wall and apex).
If clinically indicated, a follow-up study with echo contrast
may be able to
better define the possible apical left ventricular thrombus.
Conclusions:
There is mild to moderate regional left ventricular systolic
dysfunction with
focal hypokinesis of the distal septum and anterior wall, and
apex. No masses
or thrombi are seen in the left ventricle.
Echo [**1-1**]:
Compared with the prior study (images reviewed) of [**2169-12-25**], left
ventricular
dysfunction is improved and the apical abnormality is now better
defined as a
trabeculation.
Brief Hospital Course:
Neuro: neurologically intact, cervical collar was placed and
will need to be worn for a total of 6 weeks, will need to
follow-up with Dr. [**Last Name (STitle) 548**] from neurosurgery in 6 weeks for a
C-spine CT scan.
Experienced hyponatremia secondary to cerebral salt wasting on
POD 7, sodium 120, treated with hypertonic solution with
correction in 24 hours to a serum sodium of 134.
CV: Cardiac enzymes positive for ischemia, cardiology consult
placed, echo done [**12-25**] with findings compared with the prior
study (images reviewed) of [**2169-9-19**], an apical thrombus vs.
trabeculation is now suggested. Left ventricular systolic
dysfunction is more pronounced (anterior wall and apex);
beta-blockade was continued, diuresis with Lasix administered
secondary to fluid overload initially post-operatively, started
on an Ace inhibitor, Aspirin, and Lipitor on POD 4.
Repeat echo demonstrated improved and the apical abnormality is
now better defined as a trabeculation, no evidence of thrombus.
Pulm: Extubated post-operatively without difficulty, oxygenating
well on nasal cannula, at time of discharge was ambulating with
minimal assistance and oxygenating well on room air.
GI: EGD done [**12-24**] demonstrated pulsatile arterial bleeding in
second portion of duodenum, gastric ulcer along less curvature;
she was taken to the operating room and underwent an exploratory
laparotomy, duodenotomy, oversewn duodenal ulcer, pyloroplasty,
placement of gastric and jejunostomy tubes.
Proton pump inhibitors drip started upon admission, changed to
twice a day dosing post-operatively, gastrostomy tube was to
straight drainage immediate post-operatively, tube feeds were
started via jejunostomy tube.
Experienced one additional episode bright red blood per rectum
on POD 7, hemodynamically stable with no further episodes. Diet
advanced on POD 7, tube feeds stopped, no residuals from G tube.
Had +flatus, +bowel movements, and was tolerating a regular,
diabetic consistency diet.
H. pylori screen negative, discharged home with H. pylori
treatment for a total of two weeks. Discharged home with both
gastrostomy and jejunostomy tubes clamped, to follow-up with Dr.
[**Last Name (STitle) **] in [**12-5**] weeks.
Heme: Transfused: 11 units packed red blood cells, 3 units of
single donor platelets, and 4 units fresh frozen plasma
pre-operatively, post-operatively hemodynamically stable.
ID: Afebrile without leukocytosis
Endo: Regular Insulin sliding scale with stable blood sugars
during initial post-operative period. Blood glucose levels
ranged from 150 to 200 while tolerating regular diet, [**Last Name (un) **]
consult placed with recommendations of starting Glipizide.
Discharged home with glucometer and instructions to monitor
glucose twice a day, to follow-up with her PCP [**Last Name (NamePattern4) **] 1 week.
GU: Foley to straight drainage, removed and was voiding without
difficulty at time of discharge.
DVT prophylaxis: Subcutaneous Heparin, venodyne boots
Ms. [**Known lastname **] had been evaluated by physical therapy during course of
her hospitalization who recommended continued home physical
therapy. At the time of discharge she was ambulating well with a
walker. She was discharged home in good condition on [**1-4**] with
visiting nurse services. All of her discharge instructions were
communicated to her and husband with the assistance of a
Vietnamese interpreter. She was provided prescriptions for:
Protonix, Lipitor, Metoprolol, Clarithromycin, Amoxicillin,
Aspirin, Tylenol, Glipizide, and Lisinopril.
Medications on Admission:
None
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO DAILY (Daily).
Disp:*30 Tab,Sust Rel Osmotic Push 24HR(s)* Refills:*0*
7. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 12 days: Last dose 2/12.
Disp:*48 Tablet(s)* Refills:*0*
8. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 12 days: Last dose pm [**1-15**].
Disp:*48 Capsule(s)* Refills:*0*
9. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for fever or pain.
Disp:*90 Tablet(s)* Refills:*2*
10. One Touch UltraSoft Lancets Misc Sig: Lancets
Miscellaneous twice a day.
Disp:*60 1 box* Refills:*2*
11. One Touch II Test Strip Holder Misc Sig: One (1)
Miscellaneous twice a day.
Disp:*60 1 box* Refills:*2*
12. One Touch II Test Strip Sig: One (1) Miscellaneous
twice a day.
Disp:*60 1 box* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Duodenal ulcer
Cornary artery disease with Myocardial infarction
Subdural hematoma and subarachnoid hemorrhage
Cervical spine fracture
Diabetes Mellitus
Cerebral salt wasting
Discharge Condition:
Good
Discharge Instructions:
Notify MD or return to the emergency department if you
experience:
*Increased or persistent pain
*Fever > 101.5
*Nausea, vomiting, diarrhea, or abdominal distention
*Inability to pass gas, stool, or urine
*If incision or drain sites appear red or if there is drainage
*If drains are pulled out
*Shortness of breath, chest pain, or dizziness
*Bleeding from any part of the body
*Neck pain, numbness, or tingling at any part of the body
*Extreme thirst, constant urination, or extreme fatigue
*Any other symptoms concerning to you
Please take all medications as directed, do not skip any doses
You may take Tylenol every 4 to 6 hours as needed for pain
Be sure to eat small frequent meals throughout the day along
with a bedtime snack
Be sure to drink fluids throughout the day, minimum of 10
glasses
Please check your blood glucose twice a day and write down each
number on a piece of paper
If your glucose is less than 60, take some juice and repeat
level in 30 minutes, if still less than 60, call Dr.[**Month (only) 28614**]
office
Please wear the cervical collar at all times until your
follow-up appointment with Dr. [**Last Name (STitle) 548**]
You may wash incision with soap and water, pat dry.
Allow white paper strips to peel away on their own
Both tubes must be flushed once a day with 30mL sterile water or
normal saline. The exit sites should be covered at all times
with a dry gauze dressing.
No swimming or tub baths for 4 weeks
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **], part of the group that works with Dr.
[**First Name (STitle) 216**], your PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 766**] [**1-8**] at 2pm, call
[**Telephone/Fax (1) 250**] for questions or concerns. Bring your log of your
blood glucose levels and glucometer with you to the appointment.
Follow-up with Dr. [**Last Name (STitle) **] on [**1-19**] at 11:15am, call
[**Telephone/Fax (1) 1864**] for questions or concerns
Follow-up with Dr. [**Last Name (STitle) 548**] from neurosurgery regarding the
cervical collar on [**1-30**] at 9:30am. [**Hospital Unit Name 69021**]. Call [**Telephone/Fax (1) 1669**] for questions or concerns
Completed by:[**2170-1-4**]
|
[
"428.0",
"276.1",
"250.00",
"518.81",
"785.59",
"852.02",
"287.5",
"414.01",
"532.00",
"780.2",
"285.1",
"410.71",
"412",
"805.05",
"E888.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.07",
"99.05",
"44.29",
"96.6",
"46.39",
"96.04",
"44.42",
"96.34",
"99.06",
"43.19",
"38.93",
"00.17",
"44.43",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11748, 11805
|
6598, 10156
|
343, 480
|
12024, 12031
|
2269, 6575
|
13531, 14247
|
1709, 1734
|
10211, 11725
|
11826, 12003
|
10182, 10188
|
12055, 13508
|
1749, 1751
|
275, 305
|
508, 1323
|
1766, 2250
|
1368, 1520
|
1536, 1693
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,541
| 146,546
|
31691
|
Discharge summary
|
report
|
Admission Date: [**2111-10-18**] Discharge Date: [**2111-11-11**]
Date of Birth: [**2064-11-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Transfer from OSH for treatment of MSSA Sepsis and Endocarditis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 year old male with history of DM2, HTN, hypercholesterolemia,
presented to OSH on [**2111-10-6**] complaining of fatigue, weakness,
generalized malaise x several weeks. Noted decreased energy with
increasing fatigue. Denies f/c. +intermittent nausea, with
episode of vomiting 2 days PTA. Pt had been on insulin in past,
self-discontinued over 6 years ago and has not seen a physician
in that time. Over the past several weeks (since [**Month (only) 216**]) he has
noted the development of skin infections in his left forearm,
right thigh, with pain and swelling. Denies recent weight loss,
rigors, abdominal pain, diarrhea, BRBPR, etc.
At OSH: Very briefly, 46-M c very complex medical issues
including infected native valve endocarditis with likely
embolization to lung; multifactorial heart failure (sepsis,
hypoalbuminemia, cardiomyopathy - likely ischemic); anasarca
with difficulty to diurese due to hypotension, who may likely
need valvular surgical intervention if further hemodynamic
compromise occurs. Additionally, further complicated by likely
underlying hepatoma for which patient will require liver [**Last Name (LF) **], [**First Name3 (LF) **]
possibly have metastatic dz. These issues have been discussed
with the patient and his wife who understand that his prognosis
is guarded.
During his stay, he was found to have a eustachian valve
vegetation on TEE, without evidence of vegetations on tricuspid
valve.
Past Medical History:
- Diabetes Mellitus, Type II - formerly treated with insulin,
not on any meds in 6+ years
- Hypertension
- Hypercholesterolemia
Social History:
Pt lives with wife and 5 children. 25-pack-year h/o smoking,
also h/o cocaine use, denies IVDU. h/o alcohol abuse, sober x20+
years.
Family History:
+DM2, CAD, HTN, no Ca
Father - MI in [**2064**]
Mother - s/p CABG age 54
Brother - MI d. age 57
Brother - s/p CABG age 46
Physical Exam:
VS - Temp 98.6, BP 98/70, HR 99, RR 18, O2 99%RA
General - ill-appearing man, NAD
HEENT - NC/AT, PERRL, EOMI, sclera aniceric, MMM, OP clear, poor
dentition
Neck - supple, no thyromegaly
Lungs - decreased BS at bases bilat, slight end-expiratory
wheeze bilat.
Heart - RRR, nl S1-S2, +diastolic murmur @ LUSB
Abdomen - NABS, soft/NT, slightly distended abdomen,
+hepatomegaly (liver edge palpated ~5cm below costal margin)
Extremities - +left forearm large area of erythema, swelling,
warmth, and fluctuance, also similar on right thigh; 1+
bilateral pitting edema to waist
Neuro - non-focal
Pertinent Results:
[**2111-10-18**] 10:00PM BLOOD WBC-12.0* RBC-3.25* Hgb-10.5* Hct-31.2*
MCV-96 MCH-32.3* MCHC-33.7 RDW-14.8 Plt Ct-266
[**2111-10-18**] 10:00PM BLOOD Neuts-82.2* Lymphs-14.3* Monos-2.7
Eos-0.6 Baso-0.2
[**2111-10-18**] 10:00PM BLOOD PT-12.8 PTT-25.5 INR(PT)-1.1
[**2111-10-18**] 10:00PM BLOOD Glucose-160* UreaN-30* Creat-1.5* Na-132*
K-4.9 Cl-100 HCO3-25 AnGap-12
[**2111-10-18**] 10:00PM BLOOD ALT-1 AST-27 LD(LDH)-168 AlkPhos-228*
Amylase-41 TotBili-1.0
[**2111-10-18**] 10:00PM BLOOD Lipase-30
[**2111-10-18**] 10:00PM BLOOD Albumin-1.9* Calcium-8.2* Phos-4.0 Mg-2.2
[**2111-10-28**] 08:55AM BLOOD WBC-10.4 RBC-3.00* Hgb-9.7* Hct-29.0*
MCV-97 MCH-32.4* MCHC-33.5 RDW-14.7 Plt Ct-322
[**2111-10-29**] 05:16AM BLOOD WBC-7.8 RBC-2.52* Hgb-8.0* Hct-23.7*
MCV-94 MCH-31.9 MCHC-33.9 RDW-14.9 Plt Ct-243
[**2111-10-30**] 05:24AM BLOOD WBC-7.7 RBC-2.63* Hgb-8.6* Hct-25.0*
MCV-95 MCH-32.8* MCHC-34.5 RDW-14.7 Plt Ct-266
[**2111-11-1**] 05:30PM BLOOD Hct-19.9*
[**2111-11-3**] 06:30AM BLOOD WBC-6.4 RBC-2.90* Hgb-9.2* Hct-26.5*
MCV-91 MCH-31.6 MCHC-34.7 RDW-16.3* Plt Ct-237
[**2111-11-4**] 06:16AM BLOOD WBC-6.3 RBC-2.79* Hgb-9.0* Hct-26.1*
MCV-94 MCH-32.3* MCHC-34.5 RDW-16.5* Plt Ct-256
[**2111-11-11**] 05:02AM BLOOD WBC-6.0 RBC-2.59* Hgb-8.2* Hct-24.8*
MCV-96 MCH-31.7 MCHC-33.2 RDW-17.1* Plt Ct-192
[**2111-11-7**] 06:08AM BLOOD Neuts-80.3* Bands-0 Lymphs-15.2*
Monos-0.9* Eos-3.1 Baso-0.4
[**2111-11-8**] 06:06AM BLOOD PT-14.2* PTT-31.0 INR(PT)-1.3*
[**2111-11-11**] 05:02AM BLOOD Glucose-137* UreaN-63* Creat-3.8* Na-139
K-3.5 Cl-98 HCO3-30 AnGap-15
[**2111-10-21**] 05:30AM BLOOD Glucose-236* UreaN-33* Creat-2.0* Na-133
K-3.7 Cl-98 HCO3-24 AnGap-15
[**2111-10-21**] 05:30AM BLOOD Glucose-236* UreaN-33* Creat-2.0* Na-133
K-3.7 Cl-98 HCO3-24 AnGap-15
[**2111-10-26**] 06:27AM BLOOD Glucose-157* UreaN-42* Creat-2.9* Na-133
K-3.1* Cl-100 HCO3-23 AnGap-13
[**2111-11-4**] 06:16AM BLOOD Glucose-72 UreaN-58* Creat-4.0* Na-130*
K-3.0* Cl-95* HCO3-24 AnGap-14
[**2111-11-6**] 04:31AM BLOOD ALT-6 AST-24 LD(LDH)-208 AlkPhos-113
TotBili-1.3
[**2111-11-11**] 05:02AM BLOOD Calcium-7.7* Phos-4.5 Mg-1.9
[**2111-10-31**] 03:11PM BLOOD CK-MB-3 cTropnT-0.32*
[**2111-10-31**] 08:15PM BLOOD CK-MB-NotDone cTropnT-0.36*
[**2111-11-1**] 01:44AM BLOOD CK-MB-NotDone cTropnT-0.41*
[**2111-11-1**] 10:22AM BLOOD CK-MB-NotDone cTropnT-0.42*
[**2111-11-1**] 05:30PM BLOOD CK-MB-5 cTropnT-0.33*
[**2111-10-23**] 05:00AM BLOOD calTIBC-125* Ferritn-899* TRF-96*
[**2111-10-29**] 11:38AM BLOOD Hapto-86
[**2111-10-18**] 10:00PM BLOOD %HbA1c-7.9*
[**2111-10-29**] 11:38AM BLOOD TSH-6.7*
[**2111-10-30**] 05:24AM BLOOD Free T4-0.53*
[**2111-10-30**] 04:51PM BLOOD Cortsol-25.8*
[**2111-10-30**] 05:33PM BLOOD Cortsol-40.5*
[**2111-10-30**] 06:09PM BLOOD Cortsol-46.4*
[**2111-10-21**] 05:30AM BLOOD CRP-62.5*
[**2111-10-22**] 05:35AM BLOOD AFP-632.7*
[**2111-10-23**] 05:00AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2111-10-26**] 06:27AM BLOOD C3-110 C4-23
[**2111-11-3**] 06:30AM BLOOD IgG-1615* IgA-573* IgM-43
[**2111-10-19**] 01:00PM BLOOD HIV Ab-NEGATIVE
[**2111-10-21**] 05:30AM BLOOD HCV Ab-NEGATIVE
[**2111-11-1**] 01:38AM BLOOD Lactate-1.9
MICROBIOLOGY:
- Serial Blood cultures all negative
- H. Pylori Antibody negative
- HCV viral load negative
- CMV viral load negative
[**10-18**] CXR:
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Lateral aspect of the left lower chest is excluded from the
examination. However, pleural surfaces show small-to-moderate
right pleural effusion and no pneumothorax. 4 cm wide discrete
opacity projecting over the left mid lung could be a mass or
focal infection, including septic infarction. Bibasilar
atelectasis present. Heart size is normal. Mediastinal veins are
not dilated despite pulmonary vascular plethora. No pulmonary
edema.
[**10-19**] MR [**First Name (Titles) **] [**Last Name (Titles) 1093**]:
FINDINGS: There is an irregular multicystic area identified to
the left of midline extending from L2-3 disc to L5 vertebral
level within the erector spinae muscle. The margins of the
cystic area demonstrate enhancement on post-gadolinium images.
Findings are suggestive of a soft tissue intramuscular abscess.
There is subtle increased signal identified within the soft
tissues adjacent to the left L3-4 facet joint. There is subtle
increased marrow signal identified at the articular margins of
left L3-4 facet joint, with small amount of fluid in the joint.
It is unclear whether this is secondary to degenerative change
or due to early involvement of the joint by the adjacent
inflammatory process.
IMPRESSION: Multiloculated abscess within the soft tissues on
the left to the midline from L2-3 to L5 level with questionable
involvement of the adjacent left L3-4 facet joint. For better
assessment of the facet joints, followup examination is
recommended. Mild degenerative changes are seen in the lumbar
region. No evidence of epidural abscess. Bilateral pleural
effusions are seen in the visualized thorax.
[**10-20**] TEE:
Conclusions:
No spontaneous echo contrast is seen in the body of the left
atrium. Mild
spontaneous echo contrast is seen in the body of the right
atrium. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is dilated. LV systolic function appears
severely depressed, particularly in the mid-ventricular and
apical segments. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 45 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. Trace aortic egurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**2-3**]+) mitral
regurgitation is seen. There is a distinct 0.9 x 1.0 cm
spherical mass consistent with vegetation which appears ttached
to the Eustachian valve (clips 37, 46, 53, 61). The tricuspid
valve shows no evidence of mass or vegetation. There is a
small circumferential pericardial effusion.
IMPRESSION: 0.9 x 1.0 cm mass suggestive of vegetation which
appears attached to the Eustachian valve. No evidence of mass
or vegetation affecting the tricuspid, pulmonic, mitral, or
aortic valves. Severe global left ventricular dysfunction.
Small circumferential pericardial effusion.
[**10-21**] CT L-Spine:
FINDINGS: The paravertebral soft tissue abscesses which were
apparent on the [**Month/Year (2) 4338**] are difficult to discern on CT. There may be
some hypodensity within the muscles posterior to the L3
vertebral body on the left (3:54), and extending downward to the
L4 level (up to 3:68). There are small erosive changes of the
left L3/4 facet joint concerning for septic joint.
There are minimal evidence of degenerative change at several
lumbar facet joints with subchondral sclerosis and mild
spurring. At the L1-L2 level on the left, there may be mild
calcification at the ligamentum flavum.
The alignment of the vertebral bodies is normal. The vertebral
body heights are preserved. Minimal posterior spurring is seen
at T12-L1. The visualized retroperitoneum demonstrates minimal
perinephric stranding bilaterally without evidence of
hydronephrosis. There is calcification of the non-aneurysmally
dilated abdominal aorta.
There is subcutaneous edema in the posterior soft tissues.
Bilateral pleural effusions are noted. There is residual barium
in the visualized colon.
IMPRESSION: The known paraspinal abscesses are very subtle on
non-contrast CT, as detailed above. There are erosive bony
changes of the adjacent left L3/4 facet joint concerning for
septic joint.
[**10-21**] U/S Guided Parcentesis:
ULTRASOUND-GUIDED DIAGNOSTIC AND THERAPEUTIC PARACENTESIS
IMPRESSION: Technically successful ultrasound-guided diagnostic
and therapeutic paracentesis (700 cc).
[**10-20**] U/S Guided Liver Biopsy:
IMPRESSION: Technically successful ultrasound-guided targeted
core biopsy of segment VI hepatic lesion.
[**10-21**] Pathology Liver Biopsy:
DIAGNOSIS: Hepatic biopsy:
Carcinoma with hepatocellular and cholangiolar differentiation;
adjacent hepatic parenchyma with intracytoplasm hyaline and
lobular neutrophils (recommend evaluation for toxic-metabolic
injury)--see note.
Note: The tumor is positive for AE1/AE3, keratin cocktail
(AE1/AE3; CAM 5.2), CK7, CK20. Heppar 1 staining is seen
focally. A canalicular pattern is not seen within tumor (CD10,
CEA unabsorbed). This immunoperoxidase profile indicates both
hepatic and cholangiolar differentiation.
[**10-22**] Renal U/S:
IMPRESSION:
1. Normal renal ultrasound. No evidence of hydronephrosis.
2. Probable mild diffuse thickening of the bladder wall, a
finding of uncertain significance.
3. Ascites.
[**10-22**] Paravertebral Abscess Pathology:
DIAGNOSIS:
Perivertebral abscess:
Blood with few neutrophils.
[**10-22**] TTE:
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity is dilated. The basal
segments are mildly hypokinetic, the mid and distal segments
are severely hypokinetic/akinetic (LVEF = 20=25 %). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. Mild (1+) mitral regurgitation is seen. The
presence of a mass or vegetation on the tricuspid valve cannot
be excluded.
Compared with the prior study (images reviewed) of [**2111-10-20**],
the
vegetation/mass seen in the area of the Eustachian valve is not
seen on the current study. However, the ability of
trans-thoracic echo to see this area is very limited. The other
findings - severely depressed ejection fraction, relative
preservation of the basal segments and mild mitral/tricuspid
regurgitation are similar.
[**10-22**] Paravertebral Cytology:
Neutrophils only
[**10-23**] U/S LUE:
IMPRESSION: No evidence of DVT
[**10-24**] CT Chest w/o contrast:
IMPRESSION:
1. Limited study due to lack of intravenous contrast [**Doctor Last Name 360**],
especially for the evaluation of vasculature and embolism.
Peripheral consolidation in the superior segment of left lower
lobe abutting pleura with air bronchogram, and cavitary 8-mm
nodule. The location and appearance of the findings are
suggestive of thromboembolic disease especially septic emboli,
or infarction due to pulmonary embolism, given the setting of
endocarditis. The other possibility includes pneumonia. Please
correlate clinically.
2. Moderate amount of pleural effusion with atelectasis.
3. 3-mm nodule in the right lower lobe, for which followup is
recommended with HCC.
4. Coronary artery calcification.
5. Cirrhotic liver with large amount of ascites and right lobe
lesion likely corresponding to HCC, only partially visualized.
[**10-26**] [**Month/Year (2) 4338**] of the Head:
IMPRESSION:
1. No evidence of septic emboli, infarction, or enhancing mass
lesion within the brain.
2. Left maxillary sinusitis.
[**10-28**] CXR:
AP SUPINE PORTABLE CHEST X-RAY: The appearance of the chest is
not significantly changed. Moderately large bilateral pleural
effusions and bibasilar atelectasis persist. An ill-defined
rounded opacity in the left mid lung zone corresponds with a
rounded consolidation on recent CT. The lungs are otherwise
clear. A right PIC catheter reaches the mediastinum, with the
tip in the mid SVC.
IMPRESSION: No significant interval change.
EGD [**2111-10-29**]:
Impression:
- Ulcer in the gastroesophageal junction
- Erythema in the stomach body and fundus compatible with
gastritis
- Ulcer in the antrum
- Ulcers in the first part of the duodenum and distal bulb
- Ulcer in the duodenal bulb
- Erythema in the duodenal bulb and distal bulb compatible with
duodenitis
[**2111-11-10**] ECHO:
EF 40%. The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is top normal/borderline dilated. There is mild to
moderate regional left ventricular systolic dysfunction with mid
to apical anteroseptal akinesis, anterior hypokinesis and mild
inferior hypokinesis. Right ventricular chamber size and free
wall motion are normal. The aortic arch is mildly dilated. 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. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2111-11-1**],
left ventricular systolic function appears improved. Regional
wall motion abnormalities were present previously and are also
noted in the present study.
Brief Hospital Course:
This is a 46 year old male with very complex medical problems
transferring from an outside hospital whose medical problems
include Eustachian valve endocarditis with possible embolization
to the lung; heart failure that appears to be multifactorial
(sepsis, dilated cardiomyopathy - ischemia vs EtOH), newly
diagnosed Hepatocholangiolar carcinoma, L3-L4 paraverterbral
abscess, and cellulitis of left arm and right thigh, hospital
course complicated by an UGIB secondary to duodenal and gastric
ulcers.
# Hepatocholangiolar Carcinoma: A hepatic mass was first
reported on outside hospital imaging reports. U/S guided biopsy
was done here at [**Hospital1 18**]. Pathology showed carcinoma with
hepatocellular and cholangiolar differentiation. AFP 623.
Given multiple comorbidities, Mr. [**Known lastname **] is not a surgical
candidate. Only possible treatments include Chemoembolization
vs Chemotherapy with Sorafenib. Treatment regimen will be
decided as an outpatient. Mr. [**Known lastname **] is to follow up with
his new Onocologist, Dr. [**Last Name (STitle) **] in 3 weeks.
#Cardiovascular
*Endocarditis: TEE here at [**Hospital1 18**] diagnosed a Eustachian valve
vegetation. He has been placed on Nafcillin IV for treatment of
his MSSA sepsis/endocarditis. All blood cultures are negative
here. ID will follow as an outpatient, he is to complete his
Nafcillin course on [**2111-11-30**].
.
**Ischemia: Troponin bump at OSH, thought to be demand ischemia
in the setting of sepsis and CHF. Mr. [**Known lastname **] has been chest
pain free throughout his hospital stay. He is to continue on
atorvastatin and carvedilol.
**Congestive Heart Failure: CHF initially was of unknown
etiology. EF of 20% on echo from OSH. TTE at [**Hospital1 18**] on [**2111-10-22**]
with comparable results to outside TTE (EF 20-25% The left
ventricular cavity is dilated. The basal segments are mildly
hypokinetic, the mid and distal segments are severely
hypokinetic/akinetic). These findings were consistent with a
nonischemic cardiomyopathy. However, last ECHO performed on
day prior to discharge was more consistent with an ischemic
cardiomyopathy. Given troponin bump at the OSH, ischemic
cardiomyopathy seems more likely. EF on final ECHO improved to
40%. Plan is to continue with Lasix, spironolactone and
carvedilol for treatment of his CHF.
# UGIB - Patient had a HCT drop on [**11-1**]. He was transfused with
1uPRBC. HCT continued to fall so Mr. [**Known lastname **] was taken for
endoscopy which showed gastric and hepatic ulcers. H.Pylori
antibody is negative. Etiology of ulcers is unknown. He has
been placed on Pantoprazole 40mg daily for prophylaxis.
.
# Spinal Abscess: Patient complained of lower back pain on the
day after admission. Spinal [**Known lastname 4338**] revealing for paravertebral
abscess in L3-4 distribution with possible involvement of
facet's joint. Interventional neuroradiology biopsy on [**2111-10-22**]
submitted samples for histopath and cultures, which were
negative for malignancy. IR consulted for possible drainage of
abscess, however abscess was deemed not large enough for drain
placement. Plan is to have [**Date Range 4338**] followup in 3 weeks. Mr.
[**Known lastname **] will then be seen by his new ID specialist Dr. [**First Name (STitle) 1075**]
on [**2111-11-27**].
# Renal Failure: Creatinine has risen over past two weeks from
1.7 to 4.1. Renal U/S from [**2111-10-22**] was not indicative of
obstruction or hydronephrosis. FeNa = 0.6%, which is suggestive
of pre-renal azotemia. Mr. [**Known lastname **] is likely intravascularly
depleted from CHF and liver disease but total body volume
overloaded. Other contributor of renal failure is gentamicin
induded ATN. Urine sediment showed granular casts which is
consistent with ATN. Patient also showing signs of K+ wasting,
which is also seen in ATN secondary to gentamicin toxicity.
Ultimate cause of his renal failure is likely multifactorial
from CHF, liver failure and gentamicin toxicity. Plan is to
continue with lasix, spironolactone and Potassium
supplementation. He will follow up in renal clinic.
Surveillance labs will also be done weekly to monitor his serum
Potassium and BUN/Cr levels.
# Cellulitis: Patient presented with cellulitis on the left
forearm and right thigh. Unknown etiology in the setting of
poorly controlled DM2. No abscess seen on ultrasound.
Cellulitis was resolved on discharge.
# Diabetes Mellitus Type 2: Patient with long-standing poorly
controlled DMT2 on insulin (lantus). Glucose on transfer was
408. A1c at OSH was 12.7. A1c here was 7.9.
Mr. [**Name14 (STitle) **] has been placed on Lantus and on an Insulin
Sliding Scale. He has been told to monitor his blood glucose
levels at home. He is to follow up with me in clinic. I will
adjust his insulin regimen as needed.
# Pulmonary Nodules: Mr. [**Known lastname **] was found to have a
cavitation of the left mid lung, which was consistent with a
septic emboli. However, in the setting of his newly diagnosed
Hepatocholangiolar carcinoma, this pulmonary nodule is also
concerning for metastasis. However, given cavitary nature of
the nodule it is more likely septic emboli. Pulmonology states
nodule cannot be biopsied via CT or bronchoscopy given location.
Patient is to follow up with Heme/Onc in 3 weeks as an
outpatient and will be reevaluated at that time. Patient to
continue on Nafcillin IV for MSSA sepsis and endocarditis.
Medications on Admission:
Home Medications: none
Transfer Medications:
Ancef 2g IV q8hrs
Gentamicin 80mg IV q8hrs
Rifampin 300mg PO q12hrs
Coreg 3.125mg PO bid
Captopril 6.25mg PO tid
Reglan 10mg IV q8h PRN
Lasix 20mg IV bid
Colace 100mg PO bid
Senna 1 tablet PO qhs
Mylanta 30cc PO q6h PRN
Lantus 16units SC qhs
Lispro Sliding Scale Level IV tid with meals
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
3. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
Disp:*1 1* Refills:*1*
5. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
Disp:*150 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO BID (2 times a day).
Disp:*240 Capsule, Sustained Release(s)* Refills:*2*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
11. Nafcillin 2 gram Piggyback Sig: One (1) Intravenous every
four (4) hours for 20 days.
Disp:*120 qs* Refills:*0*
12. PICC
PICC line care per CCS protocol
13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)) as needed for
nausea.
Disp:*60 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
Lab draw [**2111-11-16**]
Please obtain, CBC, Chem 7 panel, Ca, Mg, Phos, AST, ALT, Alk
Phos, [**Name (NI) 3539**], PT, PTT, INR.
Fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] in [**Hospital **] clinic at [**Telephone/Fax (1) 1419**]
Fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Hospital 3390**] clinic at
[**Telephone/Fax (1) 4004**].
15. Outpatient Lab Work
Lab draw [**2111-11-23**] Please obtain, CBC, Chem 7 panel, Ca, Mg,
Phos, AST, ALT, Alk Phos, [**Name (NI) 3539**], PT, PTT, INR. Fax results to
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] in [**Hospital **] clinic at [**Telephone/Fax (1) 1419**] Fax results to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Hospital 3390**] clinic at [**Telephone/Fax (1) 4004**].
16. Outpatient Lab Work
Lab draw [**2111-11-30**] Please obtain, CBC, Chem 7 panel, Calcium,
Magnesium, Phosphate, AST, ALT, Alk Phos, [**Name (NI) 3539**], PT, PTT, INR.
Fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] in [**Hospital **] clinic at [**Telephone/Fax (1) 1419**] Fax
results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Hospital 3390**] clinic at [**Telephone/Fax (1) 4004**].
17. Outpatient Lab Work
CBC, Chem 7, Calcium, Magnesium, Phosphate, AST, ALT, Alk phos,
[**Name (NI) 3539**], PT, PTT, INR.
Please obtain labwork on [**2111-12-7**] at your Primary Care
Physician's office located at:
[**Hospital Ward Name 23**] Clinical Center
[**Location (un) **], Atrium
[**Location (un) **]
[**Location (un) 86**], [**Numeric Identifier 718**]
18. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous at bedtime.
Disp:*qs qs* Refills:*2*
19. Lancets,Thin Misc Sig: One (1) Miscellaneous at
bedtime.
Disp:*40 qs* Refills:*2*
20. Glucometer Elite Classic Kit Sig: One (1) Miscellaneous
at bedtime.
Disp:*qs qs* Refills:*2*
21. Glucometer Dex Test Sensors Strip Sig: One (1) In [**Last Name (un) 5153**]
twice a day.
Disp:*60 * Refills:*2*
22. Insulin Lispro 100 unit/mL Solution Sig: [**2-11**] unit
Subcutaneous once a day as needed for hyperglycemia: Please
dispense 10 vials.
Disp:*10 qs* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Methicillin Sensitive Staphylococcus Aureus sepsis
Endocarditis
Hepatocholangiolar Carcinoma
Congestive Heart Failure
Acute Renal Failure
Upper GI Bleed
Gastric and Duodenal Ulcers
Paraspinal Abscess
Cellulitis
Discharge Condition:
Stable, afebrile and feeling well.
Discharge Instructions:
You were admitted into the [**Hospital1 69**]
for treatment of your blood infection. You have been treated
with an antibiotic, Nafcillin 2gm IV every 4hours for treatment
of your infection. This antibiotic will also treat your heart
valve infection, skin infection, and paraspinal abscess.
While in the hosptial you have also been treated for congestive
heart failure. Please weigh yourself daily. If you gain more
than 3lbs in one day, you should notify your doctor immediately.
You have been treated for your acute renal failure. This is
thought to be due to gentamicin toxicity. You are to follow up
with the kidney specialists.
A liver mass was found on CT scan. A biopsy was performed and
was positive for liver cancer. You have been diagnosed with
Hepatocholangiolar Carcinoma. You are to follow up with your
Hematologist, Dr. [**Last Name (STitle) **].
You have been started on Atorvastatin 40mg once daily for
prevention of heart disease.
You have been started on Calcium Carbonate 500mg twice daily for
treatment of low calcium.
You have been started on Potassium Chloride 40mEq twice daily
for treatment of low potassium.
You have been started on Metoclopromide 10mg four times daily.
You have been started on Pantoprazole 40mg every twelve hours
for treatment of your stomach/intestinal ulcers.
You have been started on Furosemide 100mg twice daily for
treatment of your congestive heart failure.
You have been started on Spironolactone 50mg daily for treatment
of your congestive heart failure.
You have been started on Carvedilol 3.125mg twice daily for
treatment of your congestive heart failure.
You have been started on Senna one tablet twice daily as needed
for constipation.
You have been started on Docusate 100mg twice daily as needed
for constipation.
You have been started on Lantus Insulin 25units injection at
bedtime. Please check your blood sugars twice daily, before
breakfast and before nightime insulin dose.
Please remain on a low sugar, low cholesterol and low sodium
diet.
If you experience fevers, chills, chest pain, shortness of
breath, abdominal pain, nausea, vomiting, lightheadedness,
fainting, falls, diarrhea, worsening rash, worsening skin
infections, increased swelling of your legs or any other
concerning symptoms then please call your doctor or report to
the nearest emergency room.
Please attend all follow up as listed below.
Followup Instructions:
You will be contact[**Name (NI) **] for a follow up appointment next week in
the Primary Care Clinic of [**Hospital1 69**].
Hematology/Oncololgy:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2111-11-13**]
3:00
Nephrology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2111-11-17**] 8:00
[**Month/Day/Year 4338**]:
Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2111-11-24**] 10:30
Infectious Disease:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] MD Phone:([**Telephone/Fax (1) 74462**] Date/Time [**2111-11-27**]
10:00
Primary Care:
Provider: [**Name10 (NameIs) 7405**],[**Name11 (NameIs) 31804**] MD Phone:([**Telephone/Fax (1) 1921**] Date/Time
[**2111-12-9**] 1:30
|
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"272.0",
"532.40",
"263.9",
"038.11",
"425.4",
"584.9",
"682.6"
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icd9cm
|
[
[
[]
]
] |
[
"50.11",
"38.93",
"88.72",
"45.13",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
25632, 25638
|
15840, 21301
|
381, 388
|
25902, 25939
|
2918, 15817
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28378, 29242
|
2168, 2291
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21684, 25609
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25659, 25881
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21327, 21327
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25963, 28355
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2306, 2899
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21345, 21351
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278, 343
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21373, 21661
|
416, 1849
|
1871, 2001
|
2017, 2152
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,643
| 189,791
|
24686
|
Discharge summary
|
report
|
Admission Date: [**2150-10-27**] Discharge Date: [**2150-11-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Source: Interviewed daughter through [**Name2 (NI) **] translater:
[**Age over 90 **] YO woman with pmhx only significant for lower extremity
arthritis p/w with SOB. Pt was in usual state of poor health,
typically cared for dressed/fed/bathed by daughter, when being
assisted to bathroom developed acute SOB. Tried using
isosorbide and korvalol and valokardin (2 [**Age over 90 **] meds) to
alleviate SOB without effect. Typically has 3-4 episodes of
similar SOB but resolves with medication. She otherwise denied
recent fever/chills, has had chronic cough w/o sputum
production. Does affirm 2 pillow orthopnea, denies PND, Denied
CP/N/V. On ROS: does have chronic swelling of lower extremity.
Pt last visited Dr. [**Last Name (STitle) 18685**] 1 wk ago was told she had mild
anemia, and should add iron, o/w no issues. D/W Dr. [**Last Name (STitle) 18685**] who
will fax latest blood work, otherwise does not acknowledge any
other pmhx.
<br>
In [**Name (NI) **], pt received lasix, nebulizers, aspirin, nitroglycerin,
steroids, levaquin.
Past Medical History:
4 yrs ago Pneumonia
4 yrs ago CAD with MI ? intervention
LE arthritis
Denies kidney problems, DM, HTN,
Social History:
Social: Lives with daughter, no smoking/etoh
baseline ADLS are poor, is typically orientated to place, uses
cane for some ambulation
Family History:
FH: NC
Physical Exam:
VS: 79 151/76 16 100% 5L
GEN: NAD, comfortable, lying at 80% in bed
HEENT: PERRL, JVP noted to mandible, no distention, dry mm,
CV: S1S2 soft SEM I/VI >LLSB, no displaced PMI
Chest: Good airmovement, no w/r/r
Abd: Normoactive BS, large umbilical hernia, tender to palpation
Ext: No c/c, L foot pitting edema noted
Pertinent Results:
EKG: NSR, left axis deviation, AVL t wave inversion, J pt
elevation V2/V3
[**2150-10-28**] 12:00AM PT-14.8* PTT-55.6* INR(PT)-1.5
[**2150-10-27**] 10:03PM URINE HOURS-RANDOM UREA N-179 CREAT-11
SODIUM-126 POTASSIUM-20 CHLORIDE-136 TOT PROT-63 CALCIUM-4.9
PHOSPHATE-13.1 TOTAL CO2-LESS THAN PROT/CREA-5.7*
[**2150-10-27**] 10:03PM URINE OSMOLAL-340
[**2150-10-27**] 10:03PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2150-10-27**] 10:03PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2150-10-27**] 10:03PM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2150-10-27**] 09:05PM CK(CPK)-99
[**2150-10-27**] 09:05PM CK-MB-NotDone cTropnT-0.63*
[**2150-10-27**] 04:57PM GLUCOSE-532* UREA N-55* CREAT-1.8* SODIUM-134
POTASSIUM-5.3* CHLORIDE-96 TOTAL CO2-19* ANION GAP-24
[**2150-10-27**] 04:57PM CK(CPK)-96
[**2150-10-27**] 04:57PM CK-MB-NotDone cTropnT-0.57*
[**2150-10-27**] 04:57PM PT-21.0* PTT-150* INR(PT)-3.1
[**2150-10-27**] 09:15AM PT-13.8* PTT-23.2 INR(PT)-1.3
[**2150-10-27**] 09:15AM D-DIMER-2523*
[**2150-10-27**] 07:35AM GLUCOSE-272* UREA N-58* CREAT-1.6* SODIUM-142
POTASSIUM-5.3* CHLORIDE-108 TOTAL CO2-20* ANION GAP-19
[**2150-10-27**] 07:35AM CK-MB-NotDone cTropnT-<0.01 proBNP-1819*
[**2150-10-27**] 07:35AM CK-MB-NotDone cTropnT-<0.01 proBNP-1819*
[**2150-10-27**] 07:35AM CALCIUM-9.4 PHOSPHATE-5.4* MAGNESIUM-2.2
[**2150-10-27**] 07:35AM WBC-12.2* RBC-3.82* HGB-12.3 HCT-37.3 MCV-98
MCH-32.1* MCHC-32.9 RDW-13.9
[**2150-10-27**] 07:35AM NEUTS-42.5* LYMPHS-50.5* MONOS-2.6 EOS-3.6
BASOS-0.8
[**2150-10-27**] 07:35AM HYPOCHROM-1+ MACROCYT-1+
[**2150-10-27**] 07:35AM PLT COUNT-332
[**2150-10-27**] 04:57PM BLOOD CK-MB-NotDone cTropnT-0.57*
[**2150-10-27**] 09:05PM BLOOD CK-MB-NotDone cTropnT-0.63*
[**2150-10-28**] 05:15AM BLOOD CK-MB-NotDone cTropnT-0.46*
[**2150-10-28**] 03:15PM BLOOD CK-MB-8 cTropnT-0.34*
[**2150-10-28**] 09:15PM BLOOD CK-MB-10 MB Indx-4.3 cTropnT-0.59*
[**2150-10-29**] 05:00AM BLOOD CK-MB-10 MB Indx-4.8 cTropnT-0.56*
[**2150-10-30**] 07:45PM BLOOD cTropnT-0.66*
[**2150-10-31**] 06:22AM BLOOD CK-MB-NotDone cTropnT-0.66*
.
ECG [**2150-10-27**] 7:36 am: Sinus tachycardia at rate 114
Ventricular premature complex
Left ventricular hypertrophy with ST-T abnormalities
Poor R wave progression with late precordial QRS transition - is
nonspecific Clinical correlation is suggested No previous
tracing available for comparison
.
ECG [**2150-10-27**] 6:20 pm: Sinus rhythm
Left ventricular hypertrophy with ST-T abnormalities
Anterior myocardial infarction - possible acute/recent/in
evolution
Diffuse ST-T wave abnormalities with prolonged Q-Tc interval -
cannot exclude in part metabolic/drug effect in addition to
ischemia
Clinical correlation is suggested Since previous tracing of the
same date, further ST-T wave changes and Q-Tc interval
prolongation present
.
TTE [**2150-10-28**]:
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Shortness of breath.
Height: (in) 58
Weight (lb): 130
BSA (m2): 1.52 m2
BP (mm Hg): 116/60
HR (bpm): 60
Status: Inpatient
Date/Time: [**2150-10-28**] at 17:03
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2005W467-0:11
Test Location: West [**Hospital Ward Name 121**] [**2-12**]
Technical Quality: Adequate
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 3.9 cm (nl <= 5.0 cm)
Left Ventricle - Ejection Fraction: 30% to 35% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
TR Gradient (+ RA = PASP): 25 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Moderate regional LV systolic dysfunction.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior - hypo; mid anteroseptal - hypo; anterior apex -
akinetic; septal apex- akinetic; inferior apex - hypo; lateral
apex - akinetic; apex - akinetic;
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Cannot
assess regional RV systolic function.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+)
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular
calcification. Mild to moderate ([**1-11**]+) MR.
TRICUSPID VALVE: Mild [1+] TR. Normal PA systolic pressure.
PERICARDIUM: No pericardial effusion.
Conclusions:
1. The left atrium is mildly dilated. The left atrium is
elongated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is moderate
regional left ventricular systolic dysfunction. Resting regional
wall motion abnormalities include apical, apical, mid anterior
and mid anteroseptal hypokinesis with apical inferolateral
akinesis.
3.Right ventricular chamber size is normal.
4.The aortic valve leaflets are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Mild to
moderate ([**1-11**]+)
mitral regurgitation is seen.
6.The estimated pulmonary artery systolic pressure is normal.
7.There is no pericardial effusion.
.
ECG [**2150-10-29**]: Sinus rhythm
Atrial premature complex
Left ventricular hypertrophy
Abnormal R wave progression - is nondiagnostic but consider
anterior myocardial infarct, age indeterminate
Diffuse ST-T wave abnormalities with prolonged Q-Tc interval -
cannot exclude in part ischemia, metabolic/drug effect or
possible central nervous system event. Since previous tracing of
[**2150-10-28**], no significant change
.
ECG [**2150-10-30**]: Sinus rhythm. The QTc interval is prolonged. Left
ventricular hypertrophy. Diffuse ST-T wave changes most likely
due to left ventricular hypertrophy. There is a late transition
which is also most likely due to left ventricular hypertrophy.
Compared to the previous tracing there is no significant change.
.
CXR [**2150-10-30**]: PORTABLE AP CHEST: Comparison is made to
[**2150-10-29**]. Examination is limited by the superimposition of the
patient's chin over the upper lung fields. Interstitial and
alveolar edema is unchanged and predominates within the upper
lung fields. Confluent areas of opacity in the right lung base
may represent developing pneumonia or asymmetric edema. There is
improving aeration of the left lower lobe. No pleural effusions.
IMPRESSION: Improving aeration of the left lower lobe.
Otherwise, no change.
.
Renal U/S [**2150-11-2**]: FINDINGS: The right kidney measures 7.5 cm
in length, and the left kidney measures 7.4 cm in length. No
stone, mass, or hydronephrosis is apparent. The bladder is
decompressed and is not visible.
IMPRESSION: Small kidneys bilaterally without hydronephrosis.
.
CHEST (PORTABLE AP) [**2150-11-6**] 9:56 AM
CHEST (PORTABLE AP)
Reason: eval interval pulmonary edema and r/o infiltrates
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old woman with [**Last Name (LF) **], [**First Name3 (LF) **] be in flash pulmonary edema
and leukocytosis.
REASON FOR THIS EXAMINATION:
eval interval pulmonary edema and r/o infiltrates
HISTORY: F/U CHF/pneumonia.
AP bedside chest. Assessment limited by oblique positioning.
Since exam one week ago ([**2150-10-30**]) the focal edema and/or
consolidations seen in the right lung and to a less extent in
the perihilar portions of the left lung have fall markedly
diminished or resolved. No focal consolidations or vascular
congestion.
IMPRESSION: Marked improvement in previously pneumonia and/or
unusual CHF.
.
Labs at Discharge:
WBC 15.7 Hct 31.3 Plt 340
Glucose 114 UreaN 42 Creat 143 Na 143 K 3.7 Cl 208 HCO3 23
Calcium 8.9 Phos 3.3 Mg 2.1
.
[**2150-11-8**] 9:48 pm STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2150-11-9**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2150-11-9**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2150-11-7**] 10:14 am URINE
**FINAL REPORT [**2150-11-8**]**
URINE CULTURE (Final [**2150-11-8**]):
PROBABLE GARDNERELLA VAGINALIS. 10,000-100,000
ORGANISMS/ML..
Brief Hospital Course:
[**Age over 90 **]yo F presented with shortness of breath, found to have a non
ST elevation myocardial infarction, CHF with EF of 30%, and
acute on chronic renal failure.
# CAD/CHF - Initially the patient was admitted for shortness of
breath, ultimately secondary to a non ST elevation myocardial
infarction. She was initially given steroids, nebulizers,
Lasix, and Levaquin the ED. Her cardiac enzymes were initially
negative, with a unimpressive ekg, but she subsequently
developed elevated troponins correlated with new anterolateral T
wave inversions on ekg. She had already been started on heparin
and maintained on telemetry while she was being ruled out.
Cardiology was consulted and Integrilin and Plavix were
initially added, after determination that she would require a
catherization, Integrilin and Plavix were discontinued. The
following day after admission, the patient developed acute
shortness of breath hours prior to transfer to the CCU. She
became tachypneic, utilizing accessory muscles, and was noted to
have an O2 sat of 85 on 2L, she was started on a non-rebreather
face mask, give 80mg Lasix then 40mg Lasix, started on
nitroglycerin titrated to pressures, which initially were SBP
170, with an associated tachycardia at 110. She was also given
morphine. A ekg did not show acute changes at that time, an abg
did reveal an acidosis of 7.14 with elevated carbon dioxide, but
good oxygenation. An cxr revealed pulmonary congestion. She was
then started on a bipap, which improved her oxygen saturation,
and a repeat evaluation indicated improved pH, with normalized
carbon dioxide levels. She was transferred to the CCU for
further management. After a one day stay in the CCU where she
was diuresed and weaned of bipap to a 70% facemask, she was
transferred back to the floor on [**10-30**].
On the floor, She was continued on medical management for CAD
with ASA, Plavix, low dose metoprolol, hydralazine, Isordil, and
Lipitor. Given hypernatremia from aggressive diuresis and
dehydration, the patient was started on gentle 1/2 NS IVF and no
further Lasix was given. The hypernatremia improved with gentle
hydration without worsening of CHF. Her CHF was stable and
pulmonary status gradually improved. The patient was weaned to
2L of O2 via nasal cannula and was satting 93-97%. For better
renal perfusion and given her blood pressures were running in
the 100s to 110s, hydralazine and Isordil were discontinued on
[**11-2**] and [**11-3**], respectively. The patient's blood pressure
remained well controlled (100s-120/50-60s with pulse 60s)with
only low dose metoprolol (12.5mg [**Hospital1 **]). At the time of
discharge, the patient is satting at 94-99% on room air.
.
# Acute on chronic renal failure- The causes were felt to be
most likely multifactorial- CHF, pre-renal from aggressive
diuresis, and chronic renal insufficiency (creat 1.6 at
admission) from untreated hypertension (U/S of kidney showed
small kidneys and no hydronephrosis). Her creatine continued to
increase and a FeNa was calculated which suggested an ATN
scenario. The patient was thought to be intravascularly
dehydrated as she had an episode of hypernatremia, she was
gently hydrated with 1/2 NS and her hypernatremia resolved.
Renal was consulted for further recommendations on managing her
creatinine in the setting of her low ejection fraction and
pulmonary congestion. Renal recommended decreasing or
discontinuing unnecessary antihypertensives for better renal
perfusion. Hydralazine and Isordil were discontinued, and along
with gentle hydration, her renal function improved from 4.7 to
1.3. Once her gentle IVF was discontinued, her hypernatremia
returned as the patient does not spontaneously eat or drink
fluid. The patient was given gentle IV fluid as needed for
dehydration. The team spoke to the daughter regarding [**Name2 (NI) **] fluid
hydration, and the daughter understood and will make sure that
her mother stays hydrated. On the day of discharge, her serum
sodium was 143. dehydration.
.
# Hx of anemia- The patient had a history of iron deficiency
anemia, but was admitted with a normal hematocrit likely because
of dehydration, after IV hydration, her hematocrit decreased.
She received 1 unit of PRBC in the unit on [**10-29**] and her hct
increased appropriately. Her iron studies were suggestive of
anemia of chronic disease (likely from her chronic renal
failure) +/- iron deficiency. Her hct was stable at 31.3 at the
time or discharge.
.
# Hyperglycemia- The patient was without a history of diabetes,
but was admitted with elevated glucose secondary to steroids
given in the ED. Given her fingersticks on the floor were in
the 100s and hgb A1c 6.1, FS checks and insulin sliding scale
were discontinued on [**11-3**].
.
# HTN - She was admitted with hypertensive urgency but
responded well to nitroglycerin, and was maintained on iv
Lopressor with good control of pressures until her flash
pulmonary edema. She was placed temporarily placed on
hydralazine, Isordil but for better renal perfusion and low BPs
in 100-110s, they were discontinued. Currently, the patient's
blood pressure runs 120-130s on metoprolol 12.5mg [**Hospital1 **].
.
# Leukocytosis- Bacterial vaginosis [**11-7**] Ucx grew PROBABLE
GARDNERELLA VAGINALIS. Started Flagyl 500mg [**Hospital1 **] on [**11-9**]. The
patient is to finish 7day course of Flagyl for treatment.
Otherwise, unclear source of leukocytosis. CXR remained
negative for pneumonia. C.diff was negative. The patient never
had any fevers during hospitalization.
.
# Arthritis- History of arthritis, controlled with tylenol
.
# FEN- The patient affirmed taking crushed pills at home, a
speech and swallow evaluation showed that nectar think liquids
would be tolerated. Of note, the patient doesn't spontaneously
eat or drink.
.
# PPX: Heparin, PPI, Social work, PT
.
# Code Status- Full d/w daughter.
Medications on Admission:
Isosorbide 30mg TID
korvalol
valokardin
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): for constipation.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): for constipation.
6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for fever or pain.
7. Toprol XL 25 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*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 6 days. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] of [**Location (un) 583**]
Discharge Diagnosis:
Principal:
1. [**Location (un) 7792**].
2. Systolic Heart Failure.
3. Acute Renal Failure.
4. Dehydration/Hypernatremia.
5. Bacterial vaginosis
Secondary:
1. End-stage Renal Failure.
2. Ischemic Cardiomyopathy EF ~ 30%, 2+ MR.
Discharge Condition:
Stable, 94-99% on room air
Discharge Instructions:
Return to the emergency room or call your primary care physician
if you develop fever, chills, cough, chest pain, severe
shortness of breath, nausea, vomiting, abdominal pain, or any
other worrisome symptoms.
Please keep your follow-up appointment.
.
Take medications as instructed.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2150-11-16**] 1:30
|
[
"585.6",
"276.51",
"041.89",
"280.9",
"414.8",
"616.10",
"584.9",
"414.01",
"428.21",
"410.71",
"276.0",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
17149, 17226
|
10397, 16308
|
282, 289
|
17497, 17526
|
2018, 4980
|
17858, 18007
|
1661, 1669
|
16398, 17126
|
9126, 9258
|
17247, 17476
|
16334, 16375
|
17550, 17835
|
5006, 9089
|
1684, 1999
|
223, 244
|
9287, 9764
|
9783, 10374
|
317, 1369
|
1391, 1495
|
1511, 1645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,679
| 107,883
|
6803
|
Discharge summary
|
report
|
Admission Date: [**2117-5-25**] Discharge Date: [**2117-6-4**]
Date of Birth: [**2045-3-27**] Sex: M
Service:
CHIEF COMPLAINT: Syncope.
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
male with a past medical history significant for
hypertension, hypercholesterolemia, coronary artery disease,
status post myocardial infarction, status post coronary
artery bypass graft in [**2101**], status post percutaneous
transluminal coronary angioplasty of the right coronary
artery in [**2113**]. Admitted to [**Hospital **] Hospital with syncope.
While in the hospital the patient's syncope occurred again in
the Intensive Care Unit with a polymorphic Ventricle run. At
that time the patient was unresponsive and was defibrillated
times two. At that time the patient was loaded with
intravenous Amiodarone and stabilized. At that time the
cardiac enzymes were negative for an myocardial infarction.
An echo at the outside hospital showed an ejection fraction
of 45 to 50% and inferior wall akinesia. The patient was
then transferred to the [**Hospital1 69**]
for cardiac catheterization to rule out ischemia.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, coronary
artery disease, status post coronary artery bypass graft in
[**2100**], status post tonsillectomy, status post vasectomy.
MEDICATIONS:
1. Prilosec 10 mg q day.
2. Lisinopril 20 mg q day.
3. Isosorbide 60 mg p.o. q day.
4. Lopressor 50 mg twice a day.
5. Aspirin.
6. Lipitor 10 mg p.o. q day.
7. Benadryl p.r.n.
SOCIAL HISTORY: The patient lives with his wife, has five
children and is a retired school teacher.
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: The patient was admitted to this service
with an initial diagnosis of possible acute coronary
syndrome. The patient had a cardiac catheterization which
showed severe three vessel coronary artery disease and a
nearly normal left ventricular systolic function.
Cardiothoracic surgery was consulted at that time and it was
decided the patient would benefit from a coronary artery
bypass graft.
On the [**9-26**] the patient was brought to the operating
room with initial diagnosis of recurrent coronary artery
disease, status post coronary artery bypass graft in [**2100**].
The patient had a re-do coronary artery bypass graft times
three with a RIMA to the left anterior descending, saphenous
vein graft to the PD and a left radial to the OM. The
procedure was performed by Dr. [**Last Name (STitle) 1537**] and Scarzgard. The
patient tolerated the procedure well and was transported to
the Coronary Intensive Care Unit in stable condition.
On postop day one, the patient had a rash in the distribution
of the iodine scrub after several doses of Benadryl the rash
dissipated. Also during postop day one the patient was
extubated, weaned from the Neo but continued on atrial pacing
to help with cardiac output. Prior to extubation the patient
had a bronchoscopy performed by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. The
procedure was performed due to increased respiratory
secretions and a temperature in the 101.5 range. The
bronchoscopy was normal with no signs of pus or higher than
normal secretions. Later in the day the patient was
extubated without difficulty.
Postop day two the patient continued to do well with no major
events. Postop day three the dressings, wires and chest
tubes were discontinued. The patient was transferred to the
floor in stable condition. Postop day six, the patient
continued to do well, had an EP consult to evaluate the V-fib
arrest. EP noted that an ICD was not indicated secondary to
a negative EP study. It was decided that the patient would
follow-up with Dr. [**Last Name (STitle) 25775**] at the [**Hospital **] Hospital, would
have an ETP with Q-wave alteration study and a Holter Monitor
in roughly one month.
On postop day seven, a small amount of drainage was noted
from the patient's inferior chest wall and a click was noted
on exam. Due to the concerns of wound dehiscence the patient
was continued in the hospital until the [**10-4**]. On
the 24th and 25th there was no drainage from the wound and
there is no signs of cellulitis. On the 25th it was decided
that the patient could be discharged home in stable
condition.
DISCHARGE PHYSICAL EXAMINATION: Temperature 98.5, 74 and
sinus, 128/68, 20, 94% on room air. The patient's discharge
weight was roughly 3 kg below preoperative levels. Crit was
28.3. BUN 19, creatinine 1.1.
The patient was regular rate and rhythm. Abdomen soft,
nontender, nondistended. Incision was clean, dry and intact
with no signs of drainage. No click was heard on exam with
gentle pressure and patient coughing.
DISCHARGE DIAGNOSIS:
1. Status post re-do coronary artery bypass graft times
three with RIMA to the left anterior descending, SVG
to the PD and left radial artery to the OM.
SECONDARY DIAGNOSIS:
1. Hypertension.
2. Coronary artery disease.
3. Status post coronary artery bypass graft in [**2100**].
4. Status post tonsillectomy.
5. Status post vasectomy.
COMPLICATIONS: Wound drainage requiring several days of
hospitalization.
DISCHARGE MEDICATIONS:
1. Lopressor 37.5 mg p.o. twice a day.
2. Lisinopril 20 mg p.o. q day.
3. Torvostatin 10 mg p.o. q day.
4. Imdur 60 mg p.o. q day times three months.
5. Aspirin 325 mg p.o. q day.
6. Protonix 40 mg p.o. q day.
7. Colace 100 mg p.o. twice a day.
8. Lasix 20 mg p.o. twice a day.
DISCHARGE CONDITION: Good stable to home with VNA.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 25775**] in
two to four weeks. At that time the patient will have an ETT
with T-wave alteration studies. The patient will also have a
Holter monitor at that time. The patient will follow-up with
Dr. [**Last Name (STitle) 1537**] in four weeks, the patient is to call Dr.[**Name (NI) 18056**]
office with any concerns.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2117-6-7**] 21:27
T: [**2117-6-7**] 22:52
JOB#: [**Job Number 25776**]
|
[
"E849.7",
"413.9",
"401.9",
"998.32",
"E878.2",
"414.01",
"414.04",
"427.1",
"414.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"37.22",
"39.61",
"33.24",
"36.15",
"88.56",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5501, 6205
|
5192, 5479
|
4744, 4907
|
1679, 4305
|
4328, 4723
|
148, 158
|
187, 1139
|
4928, 5169
|
1162, 1521
|
1538, 1661
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,724
| 173,160
|
20831
|
Discharge summary
|
report
|
Admission Date: [**2143-8-1**] Discharge Date: [**2143-8-13**]
Date of Birth: [**2064-6-2**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11217**]
Chief Complaint:
Left hip fracture
Major Surgical or Invasive Procedure:
Open reduction, internal fixation of Left hip
EGD X 2 with banding X 2
History of Present Illness:
79 yo female, h/o PBC, portal HTN, chronic blood loss anemia,
presenting now s/p fall. Fall seemed to be mechanical; no
LOC/CP/dizziness/SOB. Pt was reaching for walker and fell;
found to have left intertrochanteric fracture on x-ray, she did
not hit her head. Pt has been living at [**Hospital3 **], just
finished abx for pnuemonia, has had decreased PO's, and has
stage IV decub ulcer. PBC is stable (HCT 25-28), no major
problems with fluid balance. Pt complaining of pain at this time
and is admitted for ORIF of left hip.
Past Medical History:
PMH:
Primary biliary cirrhosis ([**Doctor First Name **] positive, EGD with grade II
varices, portal gastropathy)
Chronic blood loss anemia
thrombocytopenia
Stage IV decubitus ulcer on buttocks
COPD
TTE [**3-7**] showing EF=65%
angiolipoma of right kidney
GERD
Choledocholithiasis
h/o falls
Social History:
Living at [**Hospital3 **] for 1 month, widowed, denies
tobacco/alcohol/drugs. Has been reported to live in disheveled
and unkempt conditions. History of
prior tobacco use less than 30 pack years.
Family History:
non-contributory
Physical Exam:
Vitals: 96.8 90/50 58 18 99%4L 1200/1250
Gen: pale, jaundiced, A&Ox3, in no distress
HEENT: no JVD, no LAD, neck supple, PERRL, EOMI, conjunctiva
pale, poor dentition
CV: RRR, nl S1/S2, no m/r/g
Chest: CTA bilaterally, no w/r/r, large sacral decube tracking
up back with small oozing unchanged from admission
Abd: soft, mild sub-q edema, NT,
Extr: ecchymoses around left hip, 1+ edema around ankles, some
erythematous areas around ankles, DP 1+ bilaterally, staples
c/d/i
Neuro:moves all 4 extremities, sensation intact to LT in LE
bilaterally, exam limited by pain
Pertinent Results:
[**2143-8-13**] 07:00AM BLOOD WBC-5.4 RBC-3.10* Hgb-10.1* Hct-31.3*
MCV-101* MCH-32.8* MCHC-32.4 RDW-19.9* Plt Ct-147*
[**2143-8-2**] 03:30PM BLOOD WBC-6.7 RBC-2.12*# Hgb-7.2*# Hct-20.1*#
MCV-95 MCH-33.8* MCHC-35.6* RDW-19.5* Plt Ct-61*
[**2143-8-1**] 05:00PM BLOOD WBC-5.4# RBC-2.58* Hgb-9.3* Hct-26.7*
MCV-104* MCH-36.0* MCHC-34.7# RDW-16.9* Plt Ct-104*#
[**2143-8-13**] 07:00AM BLOOD Plt Ct-147*
[**2143-8-3**] 03:04AM BLOOD Plt Ct-49*
[**2143-8-1**] 05:00PM BLOOD Plt Ct-104*#
[**2143-8-13**] 07:00AM BLOOD Glucose-118* UreaN-35* Creat-1.1 Na-144
K-4.6 Cl-111* HCO3-26 AnGap-12
[**2143-8-9**] 05:03AM BLOOD ALT-8 AST-40 AlkPhos-354* TotBili-4.0*
[**2143-8-8**] 08:04PM BLOOD CK(CPK)-43
[**2143-8-8**] 08:09AM BLOOD CK(CPK)-51
[**2143-8-6**] 12:55PM BLOOD ALT-11 AST-55* AlkPhos-388* Amylase-67
TotBili-4.1*
[**2143-8-1**] 05:00PM BLOOD ALT-40 AST-77* AlkPhos-449* Amylase-128*
TotBili-1.6*
[**2143-8-12**] 06:15AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.8
Brief Hospital Course:
79 yo woman with hip fracture s/p mechanical fall. No EKG
changes or chest pain/LOC.
S/P ORIF: B-blocked pre and perioperatively. Procedure was
successfully completed, complicated by oligouria after the
procedure. Pt was intravascularly dry, though total volume
overloaded. Initially her urine output responded slightly to 4
units of blood and multiple NS boluses. Her regular aldactone
and Lasix were held secondary to concern re ATN.
Anticoagulation: pt was anticoagulated with Coumadin after
surgery.
The patient experienced melena and a decreased hematocrit to
24.6 at which time she received 1U PRBC and 2u FFP followed by
EGD which showed non-bleeding grade III varices and during
withdrawel, fresh blood from likely variceal hemorrhage. The
patient was intubated for repeat EGD and sent to the MICU.
During her repeat EGD, banding times two was succesfully
performed and hematocrit remained stable with no further
episodes of melena or hematocrit drop.
Her ARF resolved with fluid. AFter discharge from the unit,
the patient did well, with decreased hip pain and no further
bleeding. Once she was stable, her code status was adressed
with her. In response to an open ended questions, she lucidly
described her disease and poor prognosis and reiterated her
desire to be full code.
On admission, she was known to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] stage IV decub ulcer
which is without change. The patient remains uninterested in
treatment more agressive than duoderm dressing changes.
Medications on Admission:
Oxycodone PRN
Lactulose 30 once per day
celex 20 once per day
oscal 500 two tabs
advair discus
aldactone 25 mg once per day
lasix 20mg once per day
Vitamin D
Roxicet
Duralgesic 75ug q3days
Nadolol 20mg once per day
Protoxon 40mg once per day
Discharge Medications:
1. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours) as needed for pain.
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed for pain.
5. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours) for 5 weeks.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Hold for loose stooling.
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
11. Nadolol 20 mg Tablet Sig: 1.5 Tablets PO QD (once a day).
12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
13. Morphine Sulfate 8 mg/mL Syringe Sig: One (1) Injection Q2H
(every 2 hours) as needed for breakthrough pain.
14. Ondansetron HCl 2 mg/mL Solution Sig: One (1) Intravenous
Q6H (every 6 hours) as needed.
15. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
16. Os-Cal 500 mg Tablet Sig: One (1) Tablet PO once a day.
17. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Left Hip fracture, s/p ORIF hip
Discharge Condition:
Stable
Discharge Instructions:
Please let the doctors at rehab know if you are experiencing
chest pain, shortness of breath, fever, chills, extreme hip
pain, or with any other concerns
Followup Instructions:
1. Follow up with your PCP and doctors at Rehab facility
2. F/U with Dr. [**First Name (STitle) **] (liver) as below
3. F/u with Orthopedics / Dr. [**Last Name (STitle) 9694**] approximately [**8-23**]. His
number is ([**Telephone/Fax (1) 52625**]
Appointments:
Provider: [**Name10 (NameIs) 12161**] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 7129**] CENTER
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2143-8-16**] 9:30
|
[
"571.6",
"707.0",
"820.21",
"997.5",
"518.5",
"427.31",
"997.1",
"584.9",
"456.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"96.71",
"99.04",
"79.35",
"45.13",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6460, 6530
|
3107, 4648
|
327, 400
|
6606, 6614
|
2130, 3084
|
6816, 7258
|
1506, 1524
|
4941, 6437
|
6551, 6585
|
4674, 4918
|
6638, 6793
|
1539, 2111
|
270, 289
|
428, 961
|
983, 1276
|
1292, 1490
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,677
| 165,437
|
39784
|
Discharge summary
|
report
|
Admission Date: [**2160-6-18**] Discharge Date: [**2160-6-20**]
Date of Birth: [**2134-8-13**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Morphine / Hydrocodone / Iodine
Attending:[**First Name3 (LF) 87599**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 25 year old woman with a history of asthma and
Ehrlers-Danlos syndrome and currently undergoing IVF treatment
who presents as a transfer from [**Hospital6 33**] with acute
onset shortness of breath. She had 2 embryos implanted on Monday
in her first cycle of IVF. She had ongoing abdominal pain since
the Friday before and had been seen at [**Hospital6 33**]
although it is not clear what happened there. On the morning of
admission she started feeling short of breath, cough, and
pleuritic chest pain that radiated to her back. She took two
puffs of her ProAir which did not significantly help. Her
shortness of breath got worse and so she called EMS.
When EMS arrived they administered an epi pen, nebulizers and
magnesium given concern for an allergic reaction or asthma. At
the outside hospital they started her on steroids. They also did
a CT chest w/contrast to rule out a dissecting aortic aneurysm
given her description of the pain. The timing of the contrast
however was unable to evaluate for a PE. An ABG at OSH showed a
respiratory alkalosis. She was transferred to [**Hospital1 18**] for further
workup.
On arrival at [**Hospital1 18**] she was breathing in the 60s and noted to be
very anxious. She had an expiratory wheeze that was felt to be
forced due to her tachypnia. A creatinine was uptrending 0.6 ->
0.9 and a lactate was 8.1. She noted that she had made minimal
urine for the 24 hours prior to coming to ED. A chest x-ray
showed pulmonary edema and bilateral pulmonary effusions. She
received a total of 2mg of ativan for anxiety. Briefly on bipap,
20-25 min, then switched to high flow O2. No actual desats.
A FAST exam (modified because sitting up) but has some fluid in
bilateral lower abdominal quadrants which was felt to be more
than just physiologic. Her VS at the prior to transfer were hr
138 rr 26 sat 97/30% BP 129/70.
On arrival to the MICU she was in visible respiratory distress
breathing about 40 times per minute on a high flow face mask and
complaining of ongoing chest and abdominal pain.
Past Medical History:
Asthma
Right shoulder pain
Multiple joint surgeries
Ehlers Danlos
Past Surgical History:
Multiple orthopedic surgeries for joint problems
Social History:
Works as a nanny. Lives with her husband. [**Name (NI) **] tobacco, alcohol or
drugs.
Family History:
No FH of blood clots. Mother and multiple other family members
with breast cancer. Multiple family members with strokes. Uncle
with brain aneurysm.
Physical Exam:
Admission Physical Exam:
Vitals: afebrile hr 112 bp 145/77 rr 44 100%/high flow face mask
General: Alert, oriented, moderately acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: decreased breath sounds at bases, expiratory wheezes in
upper lung fields
Abdomen: soft, mildly distended, bowel sounds present, no
organomegaly, mild tenderness to palpation, no rebound or
guarding
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
ADMISSION LABS:
[**2160-6-18**] 06:30PM BLOOD WBC-19.3* RBC-4.45 Hgb-12.2 Hct-38.5
MCV-87 MCH-27.4 MCHC-31.7 RDW-12.9 Plt Ct-272
[**2160-6-18**] 06:30PM BLOOD Neuts-97.1* Lymphs-2.5* Monos-0.2*
Eos-0.1 Baso-0
[**2160-6-18**] 06:30PM BLOOD PT-11.1 PTT-114.7* INR(PT)-1.0
[**2160-6-19**] 12:13AM BLOOD Fibrino-450*
[**2160-6-18**] 06:30PM BLOOD Glucose-305* UreaN-7 Creat-0.9 Na-136
K-3.1* Cl-103 HCO3-12* AnGap-24*
[**2160-6-19**] 12:13AM BLOOD ALT-13 AST-39 LD(LDH)-381* CK(CPK)-60
AlkPhos-75 TotBili-0.3
[**2160-6-18**] 06:30PM BLOOD Calcium-9.0 Phos-0.2* Mg-2.4
[**2160-6-19**] 12:13AM BLOOD Hapto-126
[**2160-6-19**] 12:13AM BLOOD D-Dimer-1403*
[**2160-6-19**] 12:37AM BLOOD Type-ART Rates-/18 FiO2-21 pO2-72*
pCO2-32* pH-7.40 calTCO2-21 Base XS--3 Intubat-NOT INTUBA
[**2160-6-18**] 06:35PM BLOOD Lactate-8.1*
[**2160-6-19**] 12:37AM BLOOD Lactate-2.8*
[**2160-6-19**] 08:44AM BLOOD Lactate-1.6
Brief Hospital Course:
25 year old woman with a history of asthma recently on IVF who
is presenting with acute onset dyspnea felt to be consistent
with ovarian hyperstimulation syndrome.
# Ovarian Hyperstimulation Syndrome: Her acute dyspnea and
pleural effusions are consistent with this diagnosis. Given her
Ehlers-Danlos syndrome, chest pain and the acute onset of these
symptoms, she had a CTA which was negative for aortic
dissection. This study did not adequately assess for PE. Given
her symptoms and the evidence of a S1Q3T3 pattern on her
admission EKG, a second CTA chest was obtained to look for PE
which showed no evidence of PE. Her ovarian hypersensitivity
syndrome was managed conservatively with cabergoline and gentle
IVF.
# Dyspnea: Patient was tachypneic to 60s on presentation,
resolved with reassurance and pain control. Likely large
component of anxiety on top of pleural effusions and pulmonary
edema. She has an unclear possible history of thrombus. LENIs
were negative for DVT and as above, CTA chest negative for PE.
She was briefly on a heparin gtt until the chest CT results came
back. Echo showed very small pericardial effusion with no
evidence of tamponade physiology. She received ATC duonebs for
mild wheezing.
# Concern for Abdominal Compartment Syndrome: Per discussion
with OBGYN there is concern for abdominal compartment syndrome.
When she presented, her abdomen is slightly distended but soft
with mild diffuse tenderness. A bedside ultrasound does not show
any significant drainable pockets of fluid. Bladder pressure
was 14-16 which was reassuring. Her abdominal pain improved
throughout her admission although she remained somewhat
distended with known ascites given OHSS.
# Chest Pain: Pleuritic in nature, likely secondary to increased
work of breathing. No evidence of PNA on chest x-ray. As above,
no PE or aortic pathology on CTA chest. Initial set of cardiac
enzymes negative.
# Hyperglycemia: FS 305, given steroids at OSH, no history of
diabetes. Checked FS QID and were other wise normal.
# Asthma: Reportedly well controlled at home. She was placed on
standing albuterol and ipratropium nebs q6h given her
respiratory symptoms at admission.
# Leukocytosis: Received steroids at OSH. UA potentially
consistent with UTI however asymptomatic so will await urine
cultures and not treat empirically.
On [**2160-6-19**] she was transferred to the floor from the ICU. She
did well and was discharged to home on [**2160-6-20**] with follow-up at
[**Location (un) 86**] IVF, possibly for transvaginal paracentesis.
Medications on Admission:
Dilaudid PO 4-6mg prn
Trazadone 100mg QHS
Oxycodone 10mg as needed (takes about 1/week)
Prenatal Vitamins
Cyclobenzaprine
Progesterone Cream
Discharge Medications:
1. cabergoline 0.5 mg Tablet Sig: One (1) Tablet PO daily () for
7 days: continue until [**6-26**], as per outpatient prescription.
2. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*30 doses* Refills:*2*
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
Disp:*30 doses* Refills:*2*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
6. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*3 Tablet(s)* Refills:*0*
7. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
Disp:*8 Tablet, Rapid Dissolve(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
ovarian hyperstimulation syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms [**Last Name (Titles) 87600**],
You were admitted following an embryo transfer with OHSS-
Ovarian Hyperstimulation Syndrome. This manifested by pleural
effusions causing shortness of breath and ascites causing
abdominal distention. Initally there was concern over a
pulmonary embolism and you were on a heparin drip, but repeat
studies were negative and this was discontinued. You were
treated with medications for asthma symptoms, which should be
continued until you are re-evaluated by Dr. [**Last Name (STitle) **]. Please call
his office if you experience any of the symptoms listed below.
Followup Instructions:
You will need to follow-up at [**Location (un) 86**] IVF with Dr. [**Last Name (STitle) **]. Please
call his office [**Telephone/Fax (1) 36218**] on Monday [**2160-6-23**] to schedule this
appointment.
|
[
"256.1",
"756.83",
"288.60",
"276.3",
"300.00",
"E932.4",
"493.90",
"789.59",
"511.9",
"628.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8212, 8218
|
4498, 7054
|
314, 321
|
8296, 8296
|
3575, 3575
|
9072, 9277
|
2678, 2828
|
7246, 8189
|
8239, 8275
|
7080, 7223
|
8447, 9049
|
2507, 2558
|
2868, 3556
|
267, 276
|
349, 2395
|
3591, 4475
|
8311, 8423
|
2417, 2484
|
2574, 2662
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,860
| 191,509
|
53056+53057
|
Discharge summary
|
report+report
|
Admission Date: [**2159-2-19**] Discharge Date: [**2159-2-24**]
Date of Birth: [**2118-9-29**] Sex: F
Service: Neurosurgery
INDICATIONS: This is a 40 year old female well known to our
service who is status post a subarachnoid hemorrhage two
years ago. She has known left fetal posterior cervical
cerebral artery origin aneurysm, [**2158-5-25**]. She is status
post a diagnostic angiogram which found her to have a slight
increase in growth and she is scheduled to be coiled this AM,
[**2159-2-19**].
Past medical history is the subarachnoid hemorrhage status
post coiling, hypertension and history of drug abuse.
Past surgical history is hysterectomy.
Admission medications are Hydrochlorothiazide and Oxycodone.
Allergies are to Codeine-itching.
On [**2159-2-20**] she underwent a cerebral angiogram for
coiling of the left fetal PCA origin residual aneurysm. A coil
was placed in the aneurysm then after placement of a second coil,
the latter was noted to migrate into the left fetal
PCA and occlude flow in that branch. An effort at
retrieving the coil was unsuccessful because of the
tortuosity of the fetal PCA proximal segment. The
coil was left in place and the patient awaken from
anesthesia. She was not noted to have any changes in her
vision. No double vision or loss of vision was reported prior to
the procedure. At the completion of the procedure her vision was
intact, visual fields were grossly intact, she was moving all
extremities well. She was alert and oriented without any
neurological deficits. She was transferred to the Post
Anesthesia Care Unit where she remained for the next two days.
During her stay in the Post Anesthesia Care Unit, neurologically
she remained unchanged. She denied any changes in her visual
fields. Her only complaint was for a headache. She reports
that it was the same intensity as preoperatively. She denied
any nausea or vomiting with these headaches. There was no
change in her mentation. She was transferred to the floor
and she has remained neurologically unchanged. Vital signs
have been stable. She has been afebrile. She was placed on
a heparin drip for 24 hours with a goal PTT of 50 to 60. She
was started on Plavix as well as to continue with her Aspirin
q. day.
On [**2159-2-22**] she was transferred to the floor. She
has remained neurologically stable. Her heparin was
discontinued. She has continued on her Aspirin and Plavix.
She has been out of bed, ambulating in the halls without
difficulties. Her neurological examination has remained
unchanged. She is scheduled for discharge on [**2159-2-24**].
ASSESSMENT: A 40 year old female status post cerebral
angiogram for coiling of recurrently regrowing
previously clipped left PCA origin aneurysm, complicated by a
coil migration into and occlusion of the left PCA. She tolerated
the procedure despite the occlusion of the vessel without
neurological deficit. She is slated for close follow-up in 1
month to rule out residual regrowth of a small pocket of contrast
filling at the origin of the left PCA.
PLAN:
1. Discharge on [**2159-2-24**].
2. She is to follow up with Dr. [**Last Name (STitle) 1132**] in one month.
3. Monitor the groin site for any signs of drainage, redness
or fever, and for any neurological symptoms including headache,
weakness, numbess, she is to call Dr.[**Name (NI) 9224**] office or return
to the Emergency Department.
DISCHARGE MEDICATIONS:
1. Hydrochlorothiazide 25 mg p.o. q. day
2. Percocet 5/325 one to two tablets p.o. q. 4-6 hours prn
as needed.
3. Acetaminophen 325 1 to 2 tablets p.o. q. 4-6 hours prn as
needed.
4. Docusate sodium 100 mg one p.o. b.i.d.
5. Aspirin 325 mg p.o. q. day.
6. Nicotine patch 21 mg/24 hour one p.o. q. day.
7. Famotidine 20 mg tablets, one p.o. b.i.d.
8. Plavix 75 mg one p.o. q. day.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Name8 (MD) 109328**]
MEDQUIST36
D: [**2159-2-23**] 15:12
T: [**2159-2-24**] 09:15
JOB#: [**Job Number 109329**]
Admission Date: [**2159-2-19**] Discharge Date: [**2159-2-24**]
Date of Birth: [**2118-9-29**] Sex: F
Service: Neurosurgery
INDICATIONS: This is a 40 year old female well known to our
service who is status post a subarachnoid hemorrhage two
years ago. She has known left fetal posterior cervical
cerebral artery origin aneurysm, [**2158-5-25**]. She is status
post a diagnostic angiogram which found her to have a slight
increase in growth and she is scheduled to be coiled this AM,
[**2159-2-19**].
Past medical history is the subarachnoid hemorrhage status
post coiling, hypertension and history of drug abuse.
Past surgical history is hysterectomy.
Admission medications are Hydrochlorothiazide and Oxycodone.
Allergies are to Codeine-itching.
On [**2159-2-20**] she underwent a cerebral angiogram for
coiling of the left PCA. A complication of the procedure was
that a coil inadvertently went into the left PCA. She has
not noted any changes in her vision. No double vision or
loss of vision was reported prior on [**Known firstname **]. At the
completion of the procedure her vision was intact, visual
fields were grossly intact, she was moving all extremities
well. She was alert and oriented without any neurological
deficits. She was transferred to the Post Anesthesia Care
Unit where she remained for the next two days. During her
stay in the Post Anesthesia Care Unit, neurologically she
remained unchanged. She denied any changes in her visual
fields. Her only complaint was for a headache. She reports
that it was the same intensity as preoperatively. She denied
any nausea or vomiting with these headaches. There was no
change in her mentation. She was transferred to the floor
and she has remained neurologically unchanged. Vital signs
have been stable. She has been afebrile. She was placed on
a heparin drip for 24 hours with a goal PTT of 50 to 60. She
was started on Plavix as well as to continue with her Aspirin
q. day.
On [**2159-2-22**] she was transferred to the floor. She
has remained neurologically stable. Her heparin was
discontinued. She has continued on her Aspirin and Plavix.
She has been out of bed, ambulating in the halls without
difficulties. Her neurological examination has remained
unchanged. She is scheduled for discharge on [**2159-2-24**].
ASSESSMENT: A 40 year old female status post cerebral
angiogram for clueing of aneurysm, complicated by a quill
entering the left PCA and concern for occlusion. She is
neurologically intact and stable.
PLAN:
1. Discharge on [**2159-2-24**].
2. She is to follow up with Dr. [**Last Name (STitle) 23813**] in one month.
3. Monitor the groin site for any signs of drainage, redness
or fever. If any of those symptoms
|
[
"401.9",
"996.2",
"E878.8",
"437.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"38.91",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
3442, 6828
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,659
| 176,048
|
8342
|
Discharge summary
|
report
|
Admission Date: [**2138-7-1**] Discharge Date: [**2138-7-2**]
Date of Birth: [**2062-4-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
OSH transfer for shock
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
Mr. [**Known lastname 174**] is a 76 year old man with CAD s/p CABG, severe sCHF EF
12%, s/p prolonged repeated hospitalizations recently admitted
to [**Hospital1 2025**] until [**6-15**] for pacer lead change c/b sepsis sent in from
home to OSH ED for increased lower extremity edema and wound
drainage, SOB, weakness and melena x 2-3 days. Family also noted
decreased UOP, 5cc last 24 hours and elevated blood sugars 200s.
At OSH ED, initial BP 77/46 and sats 99%3L. After receiving 2L
NS for BP 60s-80s, he desatted to 80s so was placed on a NRB. He
appeared to be sleepy and in worse respiratory distress so was
intubated for distress and airway protection with etomidate/succ
7.5 ETT for hemodynamic instability and respiratory distress. Bp
did not improve with IVF so he was started on dopamine and
propofol drips. CXR significant for L pleural effusion and could
not r/o infiltrate so he was given Zosyn 3.375g and transferred
to [**Hospital1 18**] ED. He was also given calcium gluconate, insulin and
D50 for hyperkalemia K 6.8.
.
In our ED, he was weaned off of propofol and dopamine but then
started on low dose 0.1 mcg levophed for borderline hypotension.
Labs significant for renal failure with Cr 3.0, hyperkalemia K
6.3, WBC 18K, ALT 190, AST 315, trop 0.04, CK 282, lactate 1.7.
ABG 7.4/35/167. CXR revealed L lung whiteout and R mainstem
intubation so ETT pulled back. RIJ was placed. He was given
additional calcium gluconate, insulin, D50 and kayexalate for
hyperK. Given ascites on exam of unclear etiology, he had CT
torso which revealed ascites, diverticulosis, left pleural
effusion, no apparent etiology of sepsis. He was given vanco for
additional coverage as well as versed and fentanyl. GI was also
called given melena on exam and he was given pantoprazole for
melena despite normal HCT.
.
VS prior to trasnfer 105/55 60 100% on AC FiO270% Vt500 PEEP 5
RR 14.
.
On the floor, he is intubated and sedated.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
DM2
s/p BKA Left leg
L CEA [**2130**]
CAD s/p 4V CABG [**2120**] LIMA-LAD, SVG-OM1, SVG-OM2, SVG-RCA
CHF EF 12% [**3-/2138**]
HTN
Defibrillator placed [**2135**]
s/p pacer placement [**1-/2138**]
Guaiac positive stool
PAD
Dyslipidemia
s/p RLE bypass grafting
CRI
s/p total colectomy for colon CA
Syncope due to VT with rib fx [**2-/2138**]
RLE ulcer
Infected ICD s/p explant-[**2138-6-13**] BiV new ICD placement
MSSA bacteremia [**3-/2138**] s/p cpmpletion 6 weeks antibiotics
Social History:
Lives alone with 24 hour care form 5 children. Formerly emplyed
in coal transport, as handyman, and at general Foods as forklift
operator. Quit tobacco 40 years prior. Smoked approx. 10 years
in the navy.
.
Family History:
nc
Physical Exam:
on admission
General: Intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear. Dried blood in
OG tube.
Neck: Supple, JVP 10cm, no LAD. Scar L neck from CEA
Lungs: Decreased BS L base. Bibasilar rales. No wheezes
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
LLSB radiating to axilla with laterally displaced PMI.
Abdomen: soft, distended with fluid wave, hypoactive bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley draining scant clear-yellow urine with dried blood at
urethral meatus
Ext: Cool, doplerable pulses RLE. s/p L BKA. No clubbing,
cyanosis. Diffuse 1 + edema.
Skin: RLE with ulcer dorsum of foot with clean edges, slight
erythema, intact pink granulation tissue. No purulent exudate.
Multiple ecchymoses
Pertinent Results:
==============
Radiology
==============
CXR [**7-1**]
IMPRESSION: 4.2 x 1.1 x 3.2 cm fluid collection over the area of
clinical
concern in the left chest wall. This is amenable to US-guided
aspiration
.
CT Head [**7-1**]
IMPRESSION:
1. No intracranial hemorrhage.
2. Old right ACA infarct.
3. Small vessel ischemic disease, chronic.
.
CT Chest [**7-1**]
1. Large left pleural effusion with near complete collapse of
the left lower
lobe.
2. Large volume abdominal ascites and nodular-appearing omentum
- in the
absence of liver disease, these findings are concerning for
underlying
malignancy (peritoneal carcinomatosis versus omental caking).
3. Densely calcified atherosclerotic disease of the aorta,
coronary arteries,
celiac, SMA, and renal arteries.
4. Status post CABG, cholecystectomy, and right partial
colectomy.
5. Diverticulosis without evidence of diverticulitis or
perforation.
6. Status post left femoral neck fracture fixation.
7. Old right posterolateral rib fractures, fourth through
seventh.
.
============
Labs
============
[**2138-7-1**] 09:00AM BLOOD WBC-18.6* RBC-4.03* Hgb-11.0* Hct-34.6*
MCV-86 MCH-27.2 MCHC-31.8 RDW-18.4* Plt Ct-360
[**2138-7-1**] 07:02PM BLOOD Glucose-208* UreaN-81* Creat-3.0* Na-125*
K-5.5* Cl-92* HCO3-22 AnGap-17
[**2138-7-1**] 07:02PM BLOOD CK-MB-4 cTropnT-0.04*
[**2138-7-1**] 12:54PM BLOOD CK-MB-5 cTropnT-0.04*
[**2138-7-1**] 09:00AM BLOOD cTropnT-0.04*
[**2138-7-1**] 09:00AM BLOOD Albumin-2.9* Calcium-8.1* Phos-6.5*
Mg-2.6 Iron-27*
[**2138-7-1**] 08:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2138-7-1**] 09:10AM BLOOD Type-ART Temp-36.3 FiO2-100 pO2-167*
pCO2-35 pH-7.40 calTCO2-22 Base XS--1 AADO2-530 REQ O2-86
Intubat-INTUBATED
Brief Hospital Course:
76yo M with CAD s/p CABG, severe sCHF EF 12%, recent prolonged
hospital course c/b pacer lead infection and explant transferred
from OSH ED with hypotension and likely cardiogenic shock.
Hypotension was felt to be due to cardiogenic shock as well as
hypovolemia from GI bleed. Cardiogenic shock was supported
cold/wet appearance on exam, pleural effusions, and increased
ascites in the setting of increased LE edema and know low EF.
Patient was initially treated with dobutamine for improved
cardiac output and lasix drip. Initially covered with broad
spectrum antibiotics with vanco, cefepime, and cipro for initial
concern for sepsis.
Respiratory failure was felt to be secondary to cardiogenic
shock and possible contribution of pneumonia. Acute on chronic
renal failure was thought to be due to cardiogenic shock as
well. In regards to his gastrointestinal bleed, NG lavage was
positive but stool was nonmelanotic yet guaiac positive.
On the night of admission, family gathtered at the bedside and
patient's son and HCP [**Name (NI) **] [**Name (NI) 174**] [**Name (NI) 1105**] decided to pursue comfort
measures only care. Patient was extubated at 1 am on hospital
day #2 and was pronounced dead at 1 pm the following day with
family at the bedside.
Medications on Admission:
Home Meds: ASA 81 daily
Plavix 75mg Po daily
Omega 3 fatty acid 1000mg
Miralax 17 g daily
Senna 2 tabs PO daily
Keflex 500mg PO daily
lasix 80mg PO daily
Amio 200mg Po daily
Coreg 6.25mg PO BID
Salien nasal spray
Simvastatin 80mg PO daily
ergocalciferol [**Numeric Identifier 1871**] units once weekly
Potassium 20 meq PO daily
Albuterol prn
Nitro SL
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiogenic shock
Gastrointestinal bleed
Acute on chronic renal failure
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2138-7-2**]
|
[
"585.9",
"578.9",
"789.59",
"511.9",
"276.52",
"518.81",
"V66.7",
"785.51",
"403.90",
"V45.81",
"584.9",
"272.4",
"440.20",
"428.21",
"250.00",
"428.0",
"440.4",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7722, 7731
|
6032, 7291
|
334, 359
|
7846, 7855
|
4283, 6009
|
7908, 7942
|
3461, 3465
|
7693, 7699
|
7752, 7825
|
7317, 7670
|
7879, 7885
|
3480, 4264
|
272, 296
|
2338, 2718
|
387, 2320
|
2740, 3220
|
3236, 3445
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,704
| 109,026
|
49369
|
Discharge summary
|
report
|
Admission Date: [**2180-10-27**] Discharge Date: [**2180-11-2**]
Date of Birth: [**2122-7-24**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
nausea/vomiting, thrombocytopenia
Major Surgical or Invasive Procedure:
L burr holes for evacuation of L SDH
History of Present Illness:
58 y/o female with metastatic breast cancer was seen by heme/onc
for thrombocytopenia, plt count 8000. Patient presented with n/v
and a head CT was done which showed L chronic SDH. Neurosurgery
was then conulted for further neurosurgical workup.
Past Medical History:
# CHF: seen every 6 months by Dr.[**First Name (STitle) 2031**] at [**Hospital **].
# Breast Ca: on [**9-14**] started faslodex (Estrogen Receptor
Antagonist) monthly
# Osteoporosis
# ? GERD/Esophageal Spasms
# Scoliosis
Social History:
The patient lives at home with her husband who work from home.
Family History:
Non-contributory
Physical Exam:
BP:134 /79 HR:105 R18 O2Sats: 95% 2L
Gen: WD/WN, comfortable, NAD, lethargic, has difficulty keeping
eyes open
HEENT: Pupils: [**4-13**] bilarerally EOMs: intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, opens eyes to physical stimuli and
needs prodding
Orientation: Oriented to person, place, and date
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. islated muscle group exam limited secondary to
patient's
mental status, but subjectively 4 to 4+ strength on the right,
right pronator drift
Sensation: Intact to light touch,
Toes downgoing bilaterally
Discharge Exam: Patient has expired
Pertinent Results:
CT HEAD W/O CONTRAST [**2180-10-27**]
1. Small acute bifrontal subfalcine subdural hematoma. Large
subacute left
frontoparietal subdural collection, but new since [**2180-10-4**].
2. Mass effect including 11 mm rightward shift of normally
midline structures. No evidence of significant transtentorial
herniation.
CHEST (PA & LAT) [**2180-10-27**]
No acute cardiopulmonary findings
CT HEAD W/O CONTRAST [**2180-10-29**]
1. Post-surgical changes, with pneumocephalus overlying the left
cerebral
convexity.
2. Residual left subdural hematoma, smaller in size from prior
study.
3. Persistent, but slightly improved, rightward shift of
normally midline
structures.
4. Stable acute subdural hemorrhage layering along the falx.
CT HEAD W/O CONTRAST [**2180-10-30**]
1. Interval slight increase in size of the left subacute
subdural hematoma.
2. No interval change in size or appearance of the subdural
hemorrhage along the falx.
3. Stable shift of normally midline structures since prior
examination.
4. No evidence of a new hemorrhage or mass effect.
CHEST (PORTABLE AP) [**2180-10-31**]
As compared to the previous radiograph, there is no relevant
change. Severe dextroscoliosis, substantial cardiomegaly without
evidence of overhydration. No safe evidence of larger pleural
effusions. No focal
parenchymal opacities suggesting pneumonia.
Brief Hospital Course:
Patient was admitted for a chronic L SDH with 8mm midline shift
to the SICU for Q1H neuro checks. She presented to the
hematology clinic for transfusion of platelets clinic for a very
low count of 8000 and was then transferred to [**Hospital1 18**] after an
episode of n/v. Her exam was difficult to obtain due to her
lethargy and a head CT was ordered for AMS and lethargy. Upon
examiniation, she was oriented x 3 and spontaneous with all
extremities, but her RUE was significantly weaker, [**3-16**]. On
[**10-28**], she was taken to the OR in the morning for L burr holes
to evacuated the SDH. Post operatively the patient was much more
alert and oriented, moving all extremities spontaneously and [**4-16**]
in the RUE. Head CT showed some pneumocephalus, but was overall
stable. She was observed in the ICU for tachycardia in the 100s.
She became more lethargic over the next day and repeat head CT
was stable in midline shift. Patient then had a very low
platelet count to [**Numeric Identifier 6085**] and was transfused to a goal of [**Numeric Identifier **].
Neuro and heme/onc consults were obtained. Dilantin level in the
AM was 22 where all antiepliptics were held that day. She will
recieve an EEG in the afternoon to rule out subclinical seizures
as a cause of her increase lethargy. Patient was seen by
heme/onc in the afternoon and discussed poor prognosis with
husband. Dr. [**First Name (STitle) **], the patient's primary oncologist, also spoke
to the patient and husband regarding poor prognosis and code
status. Patient was made DNR/DNI, considering hospice care and
pallative care will see patient to discuss these needs further.
On [**11-2**], husband has decided to make patient [**Name (NI) 3225**]. At 11:15 am,
patient passed away in the SICU with husband at bedside.
Medications on Admission:
CAPECITABINE [XELODA] - 500 mg Tablet - Two Tablet(s) by mouth
Twice daily x fourteen days then off seven days, then repeat.
EFFEXOR XR - 75MG Capsule
FULVESTRANT [FASLODEX] - (Prescribed by Other Provider) -
Dosage
uncertain
LETROZOLE [FEMARA] - 2.5 mg Tablet - 1 Tablet(s) by mouth once a
day
LORAZEPAM - 0.5 mg Tablet - [**1-14**] Tablet(s) by mouth Before bed as
needed for insomnia
ONDANSETRON HCL - 8 mg Tablet - One Tablet(s) by mouth every
eight hours as needed for nausea
OXYCODONE - 10 mg Tablet Sustained Release 12 hr - One Tablet(s)
by mouth every 12 hours as needed for pain
PROCHLORPERAZINE MALEATE - 10 mg Tablet - one Tablet(s) by mouth
every 4-6 hours as needed for nausea
TRIMETHOPRIM-SULFAMETHOXAZOLE - (Prescribed by Other Provider)
-
800 mg-160 mg Tablet - 1 Tablet(s) by mouth
Monday-Wednesday-Friday
Discharge Disposition:
Expired
Discharge Diagnosis:
L SDH
Metastatic breast CA
Thrombocytopenia
DIC
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2180-11-15**]
|
[
"197.7",
"432.1",
"198.5",
"428.0",
"286.6",
"V10.3",
"737.43",
"733.00",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
6318, 6327
|
3645, 5441
|
354, 393
|
6419, 6429
|
2282, 3622
|
6482, 6518
|
1010, 1028
|
6348, 6398
|
5467, 6295
|
6453, 6459
|
1045, 1286
|
2241, 2263
|
281, 316
|
421, 668
|
1492, 2225
|
1301, 1476
|
690, 913
|
929, 994
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,897
| 149,669
|
9441
|
Discharge summary
|
report
|
Admission Date: [**2122-2-2**] Discharge Date: [**2122-2-19**]
Date of Birth: [**2088-11-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 33 year old white male is
status post aortic valve replacement with a homograft in
[**2117**]. Over the summer he had increased chest tightness and
shortness of breath after running a mile. He saw his primary
care physician in the fall of [**2120**]. He has had palpitations.
In [**2121-11-13**] he had a stress echocardiogram which
revealed an ejection fraction of 60%, mild left ventricular
hypertrophy, ascending aorta of 3.9 cm, 3.7 cm of the arch,
aortic stenosis with a peak gradient of 80 mm of mercury and
a mean gradient of 50 mm of mercury, with an aortic valve
area of 0.8 cm squared. He has 1 to 2+ aortic insufficiency
and 1+ mitral regurgitation. He is now admitted for elective
redo aortic valve replacement.
PAST MEDICAL HISTORY: Significant for a history of aortic
stenosis, a history of hypercholesterolemia, a history of
status post pericardial effusion with pericarditis repleted
with steroids, history of a right flank lipoma and status
post homograft aortic valve replacement in [**2117**].
MEDICATIONS ON ADMISSION: Minoxidil 1 drop topically b.i.d.,
Amoxicillin at dental examinations.
ALLERGIES: No known drug allergies. His last dental
examination was two to three months ago and was unremarkable.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: He lives with his wife, quit smoking, drinks
alcohol occasionally.
PHYSICAL EXAMINATION: On physical examination he is a well
developed, young man in no apparent distress. Vital signs
were stable and afebrile. Head, eyes, ears, nose and throat
examination, normocephalic, atraumatic, extraocular movements
intact. Oropharynx benign. Neck was supple. Full range of
motion, no lymphadenopathy or thyromegaly. Carotids 2+ and
equal bilaterally with radiating murmurs bilaterally. Lungs
were clear to auscultation and percussion. Cardiovascular
examination, regular rate and rhythm with a IV/VI
holosystolic murmur. Abdomen was soft, nontender with
positive bowel sounds. No masses or hepatosplenomegaly.
Extremities were without cyanosis, clubbing or edema.
Neurological examination was nonfocal. Pulses were 2+ and
equal bilaterally throughout.
HOSPITAL COURSE: On [**2122-2-2**], he underwent a redo
aortic valve replacement with a #19 St. [**Male First Name (un) 923**] Regent Valve.
Crossclamp time was 117 min. Total bypass time was 166
minutes. Circum rest time 8 minutes. He was transferred to
the Cardiac Surgery Recovery Unit on Neo-Synephrine and
Propofol in stable condition. His postoperative night he
went into atrial fibrillation, he also had spontaneous eye
movement but was not following commands and was not moving
his extremities. He was seen by Neurology the following
morning and also he began to have seizures. He was loaded
with Dilantin and he had a head computerized tomography scan
which revealed a right frontal hypodensity and left
cerebellar hypodensity and a left occipital hypodensity. He
remained intubated as he was not following commands. He had
his chest tube discontinued on postoperative day #2. He
continued to be followed by Neurology. He had an magnetic
resonance imaging scan on postoperative day #2 which
confirmed these multiple infarcts. He slowly became more
arousable. Also, on postoperative day #3, he desaturated and
had a lot of secretions removed but recovered well from that.
He also was started on anticoagulation. He was bronchoscoped
a few more times on subsequent days and tolerated this well.
He remained intubated and slowly regained more neurologic and
became more awake and was following commands somewhat. He
eventually had regained his extremity movement. He was
extubated on postoperative day #6. He was able to swallow
well and eat. He was followed by aggressive occupational
therapy and physical therapy. On [**2-6**] and [**2-7**] he
grew out coagulase negative Staphylococcus in his blood.
This was treated with Vancomycin, and he was followed closely
by Infectious Disease. On postoperative day #8 he was
transferred to the floor instrument table condition. He
continued to improve neurologically. He did have some
confusion at night. He had a PICC line placed, and he did
eventually have a transesophageal echocardiogram which
revealed on the posterior of his prosthetic aortic valve a
small mobile mass which was felt to be suture, not
endocarditis, but he will need to be followed closely for
this. Infectious Disease recommended six weeks of total
intravenous Vancomycin and on postoperative day #17, he was
discharged to rehabilitation in stable condition. He had
some elevated liver function tests on Dilantin and was
switched to Keppra and his liver function tests returned to
very close to normal.
MEDICATIONS ON DISCHARGE: His medications on discharge are
Colace 100 mg p.o. b.i.d., Ecotrin 81 mg p.o. q. day,
Lopressor 50 mg p.o. b.i.d., Amiodarone 200 mg p.o. q. day
for one week, Vancomycin 1500 mg intravenously q. 12 hours
times and Keppra 1000 mg p.o. b.i.d., Coumadin 2.5 mg p.o. q.
day for an INR goal of 2 to 2.5.
His laboratory data on discharge revealed hematocrit of 25.7,
white count 7,300, platelets 513,000, sodium 141, potassium
4.0, chloride 104, carbon dioxide 30, BUN 13, creatinine 1.1,
blood sugar 86, PT 18.2, INR 2.2. His ALT was 155, AST 73,
alkaline phosphatase 149, total bilirubin 0.4.
DISCHARGE DIAGNOSIS:
1. Aortic stenosis, status post aortic valve replacement.
2. Multiple small cerebrovascular accidents.
3. Staphylococcus coagulase negative bacteremia.
4. Atrial fibrillation.
FOLLOW UP: He will follow up with Dr. [**First Name (STitle) 216**] in one week
following discharge from rehabilitation, Dr. [**Last Name (STitle) **] in
four weeks, Dr. ............ from Infectious Disease on [**2122-3-24**] at 11:30 AM and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from Neurology if
needed. The patient will also every week while on Vancomycin
have a trough Vancomycin level, creatinine, complete blood
count, ESR and CRP which will be called to the Infectious
Disease Clinic at [**Telephone/Fax (1) 1419**].
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2122-2-19**] 11:43
T: [**2122-2-19**] 12:21
JOB#: [**Job Number 32203**]
|
[
"427.31",
"780.39",
"507.0",
"790.7",
"998.59",
"997.02",
"424.1",
"997.1",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"39.61",
"88.72",
"96.72",
"33.23",
"38.91",
"35.22",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1419, 1434
|
5501, 5682
|
4887, 5480
|
1213, 1402
|
2326, 4860
|
5693, 6504
|
1542, 2308
|
160, 895
|
918, 1186
|
1451, 1519
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,779
| 137,903
|
34208
|
Discharge summary
|
report
|
Admission Date: [**2103-8-20**] Discharge Date: [**2103-8-27**]
Date of Birth: [**2042-8-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Trachael-Esophageal fistula
Major Surgical or Invasive Procedure:
[**2103-8-20**] Rigid bronchoscopy, Flexible bronchoscopy, Y-silicone
stent removal.
[**2103-8-20**] Bronchoscopy, Esophagogastrouduodenoscopy, right
thoracotomy,
repair trachaelesophageal fistula with intercostal flap
[**2103-8-22**] Flexible bronchoscopy with therapeutic aspiration
of secretions.
[**2103-8-23**] Transthoracic ultrasound.
History of Present Illness:
Dr. [**Known lastname 31624**] is a 61-year-old gentleman who is status post
esophagectomy for gastric cancer who was found to have a
tracheoesophageal fistula, who underwent Y-stent placement in
[**2103-6-17**] and biliary diversion with insertion of gastrostomy
and feeding jejunostomy. He is being admitted for
tracheoesophogeal fisula repair.
Past Medical History:
Esophageal Cancer s/p Esophagectomy at [**Hospital1 112**] [**2091**] c/b stricture
requiring 2 dilatation procedures, left vocal cord paralysis,
Depression s/p ECT (following [**2091**] surgery), Anxiety disorder,
Social History:
General Surgeon, lives w/ wife and 2 small children ages 5 and
7.
non-smoker
Family History:
non-contributory
Physical Exam:
VS: T: 98.0 HR: 76 SR BP: 106/64 Sats: 96% RA
General: ambulating in halls
Neck: supple
Card: RRR normal S1,S2
Resp: decreased breath with faint crackles RLL otherwise clear
GI: G-tube to gravity, J-tube to feeds
Extr: warm no edema
Incision: Right thoracotomy site clean/dry/intact no erythema
Neuro: non-focal
Pertinent Results:
[**2103-8-22**] WBC-7.7 RBC-3.00* Hgb-8.7* Hct-26.1* Plt Ct-328
[**2103-8-20**] WBC-9.9 RBC-3.64* Hgb-10.4* Hct-30.7* Plt Ct-368
[**2103-8-24**] Glucose-100 UreaN-16 Creat-0.9 Na-135 K-4.1 Cl-102
HCO3-25
[**2103-8-20**] Glucose-149* UreaN-24* Creat-0.8 Na-137 K-4.1 Cl-102
HCO3-29
[**2103-8-23**]: IMPRESSION:
1. Interval removal of two right-sided chest tubes, no
development of
pneumothorax.
2. Persistent moderate right pleural effusion with associated
lower and
middle lobe atelectasis.
3. Persistent left lower lobe opacity, most pronounced in the
retrocardiac
region, a developing pneumonia cannot be excluded.
Brief Hospital Course:
Dr. [**Known lastname 31624**] was admitted on [**2103-8-20**] went to the operating room
and had the Y stent removed without difficulty then proceeded to
undergo Bronchoscopy, Esophagogastroduodenoscopy, right
thoracotomy, repair tracheoesophageal fistula with intercostal
flap. He was extubated in the operating room, monitored in the
PACU prior to transfer to the floor. The 2 chest-tube were to
suction, J and G tube were to gravity, he had an bupivacaine
epidural for pain managed by the acute pain team and a foley in
place.
On POD #1 the chest tubes remained to suction. His tube feeds
were restarted and IV fluids weaned to off. His epidural was
increased for better pain control. He underwent flexible
bronchoscopy for aspiration of mild to moderate secretions.
On POD #2 the anterior chest tube was removed. His tube feeds
were increased to goal of 90cc/hr. The epidural was removed and
he was converted to Roxicet via J-tube for pain management.
On POD #3 the posterior chest tube was removed. A follow-up
chest x-ray showed a moderate right pleural effusion.
Interventional radiology performed a thoracic ultrasound but
felt there was no fluid to drain. His foley was removed and he
voided without difficulty. His G-tube remained to gravity
On POD #[**4-21**] he continued to make steady progress.
On POD #6 he had a barium swallow which revealed no leak. He
was discharged to home and will follow-up with Dr. [**Last Name (STitle) **] as an
outpatient.
Medications on Admission:
Ativan 1 mg daily, Oxycodone-Acetaminophen 5/325 mg/5ml [**5-26**]
q4h, ipratropium bromide nebs, xopenex nebs, acetylcysteine 20%
nebs.
Discharge Medications:
1. Ativan 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for sleep.
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*500 ML(s)* Refills:*0*
3. Ipratropium Bromide 0.02 % Solution Sig: 0.2 ML Inhalation
Q6H (every 6 hours).
4. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO every twelve (12)
hours: crush give via J-tube.
Disp:*30 Tablet(s)* Refills:*2*
5. Xopenex 0.63 mg/3 mL Solution for Nebulization Sig: Three (3)
ML Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
6. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous every four (4) hours as needed for shortness of
breath or wheezing: mix with xopenex.
Discharge Disposition:
Home
Discharge Diagnosis:
Tracheoesophageal fistula
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased shortness of breath or cough
Incision develops drainage: steri-strips remove if start to come
off.
You may shower. No swimming or tub bathing for 6 weeks.
Continue stool softners with narcotics.
G-tube remains to gravity
J-tube for tube feeds: Tubefeeding: Replete w/fiber Full
strength;
Goal rate: 120 ml/hr x 18 hours
Flush w/ 50 ml water q6h
Sips of liquid
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**9-13**] at 4:00pm on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**].
Report to the [**Location (un) **] Radiology Department for a Chest X-Ray
45 minutes before your appointment
Completed by:[**2103-8-27**]
|
[
"V44.4",
"511.9",
"E878.8",
"V44.1",
"530.84",
"V10.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"98.15",
"83.82",
"45.13",
"33.22",
"34.91",
"96.6",
"31.73"
] |
icd9pcs
|
[
[
[]
]
] |
4865, 4871
|
2441, 3923
|
348, 692
|
4941, 4950
|
1796, 2418
|
5479, 5790
|
1421, 1439
|
4110, 4842
|
4892, 4920
|
3949, 4087
|
4974, 5456
|
1454, 1777
|
281, 310
|
720, 1071
|
1093, 1310
|
1326, 1405
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,734
| 102,872
|
44587
|
Discharge summary
|
report
|
y
Name: [**Known lastname 95474**], [**Known firstname **] Unit No: [**Numeric Identifier 95475**]
Admission Date: [**2189-3-6**] Discharge Date: [**2189-3-9**]
Date of Birth: Sex: F
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old
woman who presented to the Emergency Department complaining
of bright red blood per rectum three days after polypectomy.
While at work on the day of admission the patient noted loose
bowel movements, which were brown and without obvious blood.
At 8:00 p.m. on [**3-5**] she had a large bloody bowel movement
times two, felt dizzy, weak and nauseated. She had two more
blood bowel movements and presented to the Emergency
Department feeling lightheaded, dizzy and "presyncopal."
The patient describes vague abdominal cramping. No vomiting,
shortness of breath, chest pain, orthopnea, or paroxysmal
nocturnal dyspnea. She denies hematemesis or melena. She
denies history of ulcers, NSAID use, tobacco or alcohol use.
In the Emergency Department her blood pressure was noted to
be in the 70s. She was given intravenous fluids. She also
had a 10 point hematocrit drop since three days prior to
admission.
PAST MEDICAL HISTORY: [**Doctor Last Name 933**], status post ablation in [**2179**],
colonic polyps per colonoscope on [**2189-3-2**].
MEDICATIONS: Levoxyl 125 micrograms q.d., T3 5 micrograms
q.d.
ALLERGIES: Sulfa, which causes a rash and Ampicillin, which
causes a rash.
SOCIAL HISTORY: The patient is a psychiatrist. She denies
alcohol or tobacco use.
PHYSICAL EXAMINATION: Heart rate 80 lying, 116 sitting up.
Blood pressure initially 70/30 increased to 136/92 after
intravenous fluids and sating 98% on room air. The patient
is an obese woman lying on the stretcher in no acute
distress. HEENT normal. Chest is clear to auscultation
bilaterally. Heart regular rate and rhythm. No murmurs.
Abdomen soft, mild epigastric and left upper quadrant
tenderness. Extremities no edema.
LABORATORIES ON ADMISSION: White blood cell count 13.3,
hematocrit 31.4 (on [**2189-1-21**] her hematocrit was 41), platelets
391. Sodium 141, K 4.1, chloride 105, bicarb 26, BUN 16,
creatinine 0.7, glucose 159, INR 1.1. Electrocardiogram
normal sinus rhythm at 90, normal axis, normal intervals. No
ST or T wave changes. Colonoscopy showed two polyps 8 mm in
diameter 2 mm distal to the transverse colon and rectum.
HOSPITAL COURSE: The patient was admitted to the SICU and
transfused two units of blood and intravenous fluids. She
was also given Golytely and Fleets. She had a few episodes
of maroon stools. She denied abdominal pain. The patient
remained hemodynamically stable and post transfusion
hematocrits were stable around 33. The patient was
transferred from the Intensive Care Unit to the floor on [**3-7**].
Her hematocrit was followed and it remained stable in the low
30s. On [**3-6**] the patient received a Fleets prep with a plan
of doing colonoscopy. However, during the prep her blood
cleared and it felt that she was not longer bleeding. The GI
team wished to pursue a colonoscopy to double check that
there was no active bleeding. The patient refused this and
was felt to be stable and safe for discharge.
Of note, the patient had some right upper quadrant pain on
[**3-6**]. Liver function tests were [**Doctor First Name **], but due to risk
factors a right upper quadrant ultrasound was done to rule
out cholelithiasis. The results of ultrasound are pending at
the time of discharge.
The patient was continued on her thyroid medication without
incident throughout her hospitalization.
DISCHARGE DIAGNOSES:
Lower gastrointestinal bleed, colonic polyps status post
excision, hypothyroidism.
MEDICATIONS ON DISCHARGE: Levoxyl 125 micrograms q.d., T3 5
micrograms q.d.
DISCHARGE STATUS: The patient will be discharged home to
follow up with her primary care physician as needed.
DR.[**First Name (STitle) **],[**First Name3 (LF) 275**] 11-498
Dictated By:[**Last Name (NamePattern1) 6765**]
MEDQUIST36
D: [**2189-3-9**] 14:15
T: [**2189-3-10**] 11:46
JOB#: [**Job Number 95476**]
|
[
"998.11",
"E878.8",
"244.0",
"578.9",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3671, 3755
|
3782, 4183
|
2460, 3650
|
1607, 2032
|
280, 1219
|
2047, 2442
|
1242, 1499
|
1516, 1584
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,865
| 168,563
|
13820
|
Discharge summary
|
report
|
Admission Date: [**2194-4-28**] Discharge Date: [**2194-5-2**]
Date of Birth: [**2133-12-15**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This 60 year old white female
has had evaluations for complaints of atypical chest
discomfort. She had a negative stress echocardiogram but at
this time she is found to have a dilated thoracic aorta. A
computerized tomography scan in [**2194-2-24**], revealed dilated
ascending aorta up to 5 cm in diameter, no evidence of aortic
dissection, dilated proximal takeoff of the arch vessels as
well as congenital bovine arch configuration. An
echocardiogram on [**2194-3-26**], revealed an ejection
fraction of greater than 55%, trivial mitral regurgitation
and no aortic insufficiency. The ascending aorta was noted
at 5 cm and the aortic arch at 3.4 cm. The patient complains
of frequent chest pain and occasional palpitations and walks
2 to 4 miles per day in geriatrics. She has noted increased
fatigue and weakness since [**Month (only) 956**] and is now admitted for
elective ascending aortic aneurysm resection.
PAST MEDICAL HISTORY: Significant for history of a dilated
aorta, history of anxiety, history of colonic adenoma,
history of osteopenia and history of hypertension, status
post fatty tumor removal from right arm, status post cesarean
section, status post tonsillectomy and history of
hypertension.
MEDICATIONS ON ADMISSION: Atenolol 25 mg p.o. q. day,
Hydrochlorothiazide 25 mg p.o. q. day, Clonazepam 0.5 mg p.o.
b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She lives with her husband. She does not
smoke cigarettes, does not drink alcohol.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: On physical examination she is a well
developed, well nourished white female in no apparent
distress. Vital signs, stable and afebrile. Head, eyes,
ears, nose and throat examination, normocephalic, atraumatic,
extraocular movements intact. Oropharynx benign. Neck is
supple. Full range of motion, no lymphadenopathy or
thyromegaly. Carotids are 2+ and equal bilaterally without
bruits. Lungs were clear to auscultation and percussion.
Cardiovascular examination was regular rate and rhythm,
normal S1 and S2, no rubs, murmurs or gallops. Abdomen was
soft, nontender, with positive bowel sounds, no masses or
hepatosplenomegaly. Extremities: Without clubbing, cyanosis
or edema. Neurological examination was nonfocal.
HOSPITAL COURSE: He was admitted and on [**2194-4-28**], she
underwent an ascending aortic aneurysm resection with a 28 mm
Gelweave graft. Her crossclamp time was 69 minutes,
circumflex arrest was 9 minutes, total bypass time 101
minutes. She was transferred to the Cardiac Surgery Recovery
Unit on Propofol in stable condition. She was extubated on
her postoperative night and was on Nipride and insulin and
had a stable night. On postoperative day #1, the Nipride was
being weaned. She was started on Captopril and Lopressor.
On postoperative day #2, her Nipride was weaned. On
postoperative day #3, her chest tubes and wires were
discontinued and she was transferred to the floor in stable
condition. She continued with a stable course and on
postoperative day #4, she was discharged to home in stable
condition.
Her laboratory data on discharge revealed white count 8,100,
hematocrit 35.8, platelets 143,000. Sodium 138, potassium
4.3, chloride 109, carbon dioxide 28, BUN 11, creatinine 0.7,
blood sugar 83.
MEDICATIONS ON DISCHARGE:
1. Lopressor 50 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. for seven days.
3. Potassium 20 mEq p.o. b.i.d. for seven days.
4. Colace 100 mg p.o. b.i.d.
5. Aspirin 325 mg p.o. q. day.
6. Percocet 1 to 2 p.o. q. 4-6 hours prn pain.
7. Clonazepam 0.5 mg p.o. b.i.d.
FO[**Last Name (STitle) 996**]P: She will be followed by Dr. [**Last Name (STitle) **] in one to two
weeks and Dr. [**Last Name (Prefixes) **] in four weeks.
DISCHARGE DIAGNOSIS:
1. Hypertension.
2. Aortic dilatation.
3. Anxiety.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2194-5-2**] 16:58
T: [**2194-5-2**] 19:14
JOB#: [**Job Number 41512**]
|
[
"747.21",
"401.9",
"V15.82",
"441.2",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"89.60",
"35.39",
"38.45"
] |
icd9pcs
|
[
[
[]
]
] |
3935, 4252
|
3484, 3914
|
1409, 1545
|
2452, 3458
|
1705, 2434
|
1667, 1682
|
160, 1082
|
1105, 1382
|
1562, 1647
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,195
| 187,436
|
7886
|
Discharge summary
|
report
|
Admission Date: [**2175-4-19**] Discharge Date: [**2175-5-3**]
Date of Birth: [**2140-11-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Erythromycin / Compazine / Aspirin / Ssri
&Antipsych,Atyp,Dop&Serotonin Antag / Maois Non-Selective &
Irreversible / Codeine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Mitral Regurg/SOB
Major Surgical or Invasive Procedure:
[**4-19**] Minimal Invasive Mitral Valve Repair (30mm CE Band)
[**4-19**] Exploratory laparotomy and cauterization of liver
lacerations with temporary abdominal closure.
[**4-21**] Exploratory laparotomy with removal of intra-abdominal
packing and cauterization of liver lacerations. Closure of the
abdomen.
History of Present Illness:
Mr [**Known lastname 6884**] is a 34yo male with a history of rheumatic heart
disease, IV drug abuse, and recently enterococcal endocarditis
in [**May 2174**]. He now has severe mitral regurg associated with
increasing shortness of breath with minimal activity.Dr.[**Last Name (STitle) 914**]
was consulted for MVR.
Past Medical History:
1.Rheumatic Fever
2. s/p endocarditis [**2163**] (IVDU)
3. s/p pericarditis [**2161**]
4. s/p ear surgery
5. s/p foot debridements for MRSA infection
6. negative for HIV at [**Hospital3 **] [**5-13**]
7. Hepatitis C
8. Enterococcal Endocarditis diagnosed at [**Hospital1 3494**] in [**Month (only) **],
patient non compliant with antibiotics, admitted here late [**Month (only) **],
c/b valve destruction and renal septic emboli
9. fungemia with PICC line
10. tooth abcesses
11. CKD stage II
12. ADHD
13. bipolar disorder
14. CT scan in [**6-/2174**] showed emphysematous changes and a right
lower lobe nodule
15. h/o injection drug use
16. fibromyalgia
Social History:
Social history is significant for current tobacco use- 2cig/day.
He has been drinking 1 qrt vodka/day for the last 2 weeks
because he ran out of lyrica for pain, but says he normally
drinks moderately. He is presently living his male partner
independently. [**Name2 (NI) **] has smoked two to six cigarettes daily over
the past 20 years. He states he has not used any illicit drugs
since using amphetamines approximately 2 yrs ago.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Discharge Physical Exam:
VSS: T:98'2,BP:100/61, P:63,RR:18, O2SAT:94% R/A
General: A&O x3, NAD
HEENT: AT/NC, wnl
CVS:RRR
LUNGS: decreased at right base, ess. CTA, Right thoracotomy site
C/D/I
ABD: soft, NT, +BS, midline incision with steri strips/C/D/I.
EXT:warm, neg. C/C/E
Right groin: staples intact, incision C/D/I
Pertinent Results:
[**2175-4-30**] 06:30AM BLOOD WBC-11.0 RBC-3.26* Hgb-9.7* Hct-29.6*
MCV-91 MCH-29.7 MCHC-32.7 RDW-16.0* Plt Ct-658*
[**2175-4-19**] 02:37PM BLOOD WBC-12.4*# RBC-2.70*# Hgb-8.7*#
Hct-25.7*# MCV-95 MCH-32.2* MCHC-33.8 RDW-14.3 Plt Ct-104*
[**2175-4-25**] 03:41AM BLOOD PT-13.7* PTT-28.5 INR(PT)-1.2*
[**2175-5-1**] 09:13AM BLOOD Glucose-127* UreaN-9 Creat-1.0 Na-136
K-4.6 Cl-102 HCO3-24 AnGap-15
[**2175-4-19**] 07:16PM BLOOD Glucose-186* UreaN-12 Creat-0.8 Na-141
K-5.4* Cl-118* HCO3-17* AnGap-11
[**2175-4-26**] 02:54AM BLOOD ALT-51* AST-57* LD(LDH)-271* AlkPhos-89
Amylase-79 TotBili-0.4
[**2175-4-30**] 06:30AM BLOOD Vanco-18.5
[**2175-4-27**] 09:34AM BLOOD Vanco-12.5
[**2175-4-21**] 03:05AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
[**2175-4-28**] 5:10 pm SWAB Source: umbilicus.
GRAM STAIN (Final [**2175-4-28**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2175-4-30**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2175-4-25**] 12:36 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-Aline.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2175-4-25**] 10:37 am BLOOD CULTURE Source: Line-Aline.
**FINAL REPORT [**2175-5-1**]**
Blood Culture, Routine (Final [**2175-5-1**]): NO GROWTH.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2175-5-2**] 11:33 AM
[**Hospital 93**] MEDICAL CONDITION:
34 year old man s/p mvr
REASON FOR THIS EXAMINATION:
asssess for effusions/infiltrates
HISTORY: Post-cardiac surgery.
FINDINGS: In comparison with study of [**4-29**], the central catheter
has been removed. Streaks of atelectasis or fibrosis are again
seen in the right lung. However, no evidence of acute pneumonia.
No vascular congestion or pleural effusion.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2175-5-2**] 1:11 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 28383**] (Complete)
Done [**2175-4-19**] at 1:07:10 PM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2140-11-8**]
Age (years): 34 M Hgt (in): 75
BP (mm Hg): 120/70 Wgt (lb): 190
HR (bpm): 70 BSA (m2): 2.15 m2
Indication: Intraoperative TEE for MVR--minimally invasive
ICD-9 Codes: 424.90, 786.05, 440.0, 424.0
Test Information
Date/Time: [**2175-4-19**] at 13:07 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW5-: Machine: [**Pager number 28384**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Dilated LA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Mildly dilated
ascending aorta. Normal descending aorta diameter. Simple
atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
to severe (3+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Pulmonic valve not visualized. No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. The left atrium is dilated. No atrial septal defect is seen
by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The ascending aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
6. The mitral valve leaflets are mildly thickened. Moderate to
severe (3+) mitral regurgitation is seen. The is a leaflet
[**Pager number 11368**] at the posterior medial commissure with a
posteriorly directed jet of mitral regurgitaton. A centrally
directed jet is noted at the point of coaptation.
7. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and was
in normal sinus rhythm.
1. A well-seated mitral annuloplasty ring is seen with normal
leaflet motion and gradients (mean gradient = 6 mmHg). MVA is
2.6cm2 by PHT. There is no valvular systolic anterior motion
([**Male First Name (un) **]). No mitral regurgitation is seen.
2. Regional and global left ventricular systolic function are
normal.
3. Right ventricular systolic function is normal.
4. Aortic contours are intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
CT ABD W&W/O C; CT PELVIS W&W/O C
Reason: assess for bleeding, injury to liver
[**Hospital 93**] MEDICAL CONDITION:
34 year old man s/p MVR with traumatic injury to liver with
angiocath intraop, now with distended abdomen, dropping
hematocrit.
REASON FOR THIS EXAMINATION:
assess for bleeding, injury to liver
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL INDICATION: MVR with traumatic injury to liver.
TECHNIQUE: MDCT images are acquired from the lung bases to the
pubic symphysis with and without intravenous contrast.
FINDINGS: Comparison is made to a prior study dated [**2174-6-22**].
Bilateral consolidation seen at the lung bases. The right chest
tube is seen with minimal air within the right pleural space.
Previously noted right lower lobe nodule is not again seen on
image #11 of series 4, unchanged since the prior exam.
There is significant hemoperitoneum. Hyperattenuation is noted
immediately about the liver, though no clear liver injury is
identified. There does appear to be a splenic laceration, well
seen on image #26 of series 4.
The adrenal glands, pancreas, gallbladder appear grossly
unremarkable. The left kidney appears grossly normal. Small
hypoattenuating foci seen within the right kidney, which are too
small to characterize but likely represent simple cysts.
Scattered subcentimeter periportal and peripancreatic lymph
nodes are incidentally noted.
The visualized bowel appears grossly unremarkable. Pelvic
structures appear grossly normal. Foley catheter is seen within
the bladder.
No suspicious lytic or blastic bony lesions are seen.
IMPRESSION:
1. Moderate hemoperitoneum. There is no clear injury to the
liver. However, there does appear to be a splenic laceration.
These findings are discussed with [**First Name8 (NamePattern2) **] [**Doctor Last Name **] at the time of
dictation.
2. Bibasilar consolidation seen.
3. Stable right lower lobe pulmonary nodule.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 28385**],[**Known firstname **] [**2140-11-8**] 34 Male [**Numeric Identifier 28386**] [**Numeric Identifier **]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name **], [**Doctor Last Name 15785**],[**Doctor First Name **]/cofc
SPECIMEN SUBMITTED: liver biopsy.
Procedure date Tissue received Report Date Diagnosed
by
[**2175-4-19**] [**2175-4-20**] [**2175-4-24**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/mb????????????
Previous biopsies: [**Numeric Identifier 28387**] TEETH.
[**-6/2659**] TEETH (29,30)
[**-4/3031**] RIGHT UPPER BACK.
DIAGNOSIS:
Liver, needle biopsies:1. Moderate portal and mild
lobular/periportal mixed cell inflammation (grade 2).2.
Moderate steatosis, without balloon degeneration or
intracytoplasmic hyalin. 3. Trichrome stain: Increased portal
and focal periportal fibrosis (stage 2).4. Iron stain: No
stainable iron.
Note: The findings are most consistent with chronic hepatitis
C. The mixed inflammation is suggestive of an additional drug
effect. There are no features of ischemic disease or abscesses.
Clinical: Pre-operation diagnosis: Liver injury.
Post-operation diagnosis: Liver injury. HCV, polysubstance
IVDU.
Gross: The specimen is received in one formalin container,
labeled with the patient's name "[**Known lastname 6884**], [**Known firstname 1726**]" and the medical
record number. It consists of two tan-yellow tissue cores
ranging in sizes from 0.4 cm to 0.6 cm. Entirely submitted in
A.
Brief Hospital Course:
On [**2175-4-19**] Mr [**Known lastname 6884**] went to the OR and underwent minimally
invasive Mitral Valve repair with #30mm [**Doctor Last Name **] band. Please
refer to Dr[**Last Name (STitle) 5305**] operative note for further details. Cross
clamp time was 71", cardiopulmonary bypass time was 93". Mr.[**Known lastname 6884**]
was transferred to the CVICU intubated, requiring Propofol and
Neosynephrine drips to optimimize blood pressure and cardiac
output. Mr.[**Known lastname 28388**] immediate post operative course was
complicated by hemodynamic instability due to anemia with
hematocrit dropping from 35 to 16. The addition of Levophed was
required and serial monitoring of hematocrit,platlets, and
fibrinogen ensued, along with transfusion of multiple blood
products.CT csan of the abdomen revealed extensive
hemoperitoneum with no obvious source. He was taken back to the
OR where Dr.[**First Name (STitle) **] performed an exploratory laparotomy. Upon
exploration a liver evulsion and splenic laceration was
identified and cauterized.Please refer to Dr[**Location (un) **] operative
report for further details. The patient was transferred back to
the CVICU with his abdomen packed,left open due to high bladder
pressures and in anticipation of further resuscitation
requirements. [**4-21**] Mr.[**Known lastname 6884**] was taken back to the OR to have his
abdomen washed out and closed. ID was consulted due to
postoperative fevers and in light of his recent hixtory of
endocarditis.ABX regiment and serial pan cultures were
performed. ID continued to follow throughout his hospital
admission.The next few days the patient remained in the CVICU
sedated to protect him from DTs due to his current extensive
drug and alcohol abuse.[**4-25**] Mr.[**Known lastname 6884**] was extubated without
incident.He continued to remain febrile and on ABX regiment
until cultures revealed haemophilus in his sputum. His right
groin incision demonstrated purulent drainage that required a
wound vac for several days. On POD#8 he was stable, doing well
and was transferred to the floor. The remainder of his
postoperative course was essentially uneventful. POD#13 the
right groin was closed and staples put into place, to be removed
at follow up. Addiction services was consulted for
recommendations prior to discharge. ID signed off after
recommending the discontinuation of all ABX. Pt was doing well
and it was felt he was ready to be discharged to home on
[**2175-5-3**]. As discussed with Addiction services, a plan for pain
meds for discharge was discussed and and Mr.[**Known lastname 6884**] is required to
follow up with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in one week. He has also been
recommended to follow up withDr.[**Doctor Last Name 914**], Dr.[**First Name (STitle) **], and
Dr.[**Last Name (STitle) **] as documented in his discharge instructions.
Medications on Admission:
Methadone 20(2), Lyrica NF 100(2),Zolpidem 10qhslisinopril
10(1), Atenolol 25(1), Colace 200(2), Dilauded ?dose
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Methadone 10 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Mitral Regurgitation s/p Minimal Invasive Mitral Valve Repair
Liver Lacerations s/p Exploratory Laparotomy and Cauterization
of liver lacerations
PMH: Endocarditis, Rheumatic Heart Disease, Pericarditis [**2161**],
h/o MRSA s/p foot debridements, Hepatitis C, h/o IVDU, Chronic
Kidney Disease, ADHD, Bipolar disorder, Fibromyalgia, s/p Ear
surgery
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**First Name (STitle) **] in 2 weeks
Dr. [**Last Name (STitle) **] in [**1-8**] weeks
Dr. [**Last Name (STitle) **] in 1 week
Completed by:[**2175-5-3**]
|
[
"585.2",
"997.3",
"998.11",
"E878.8",
"998.2",
"998.59",
"287.5",
"682.2",
"285.1",
"070.54",
"868.03",
"424.0",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"50.29",
"54.12",
"39.61",
"50.11",
"35.12",
"54.62",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
16907, 16965
|
13182, 16081
|
422, 732
|
17357, 17364
|
2661, 3626
|
17591, 17796
|
2223, 2306
|
16243, 16884
|
9466, 9594
|
16986, 17336
|
16107, 16220
|
17388, 17568
|
2321, 2321
|
3801, 4139
|
365, 384
|
9623, 13159
|
760, 1077
|
3662, 3768
|
1099, 1755
|
1771, 2207
|
2346, 2642
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,788
| 150,449
|
37732
|
Discharge summary
|
report
|
Admission Date: [**2114-7-29**] Discharge Date: [**2114-7-31**]
Date of Birth: [**2049-4-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and sludge removal - [**2114-7-30**]
History of Present Illness:
65 year-old male with hypertension, hypercholesterolemia, and
former alcohol abuse transferred from OSH for pancreatitis. He
presented to [**Hospital 19135**] Hospital [**2114-7-29**] with abdominal pain x1 day.
Pain initially began as chest pain prior evening, described as
pressure at left chest, nonradiating, and not associated with
dyspnea. Pain began 3-4 hours after dinner. Pain progressed to
abdomen, periumbilical, with sensation of "someone punching my
stomach." Abdominal pain was also associated with "pulling" low
back pain, both improved with laying still. Also with nausea,
one episode of nonbloody, nonbilious vomiting this morning. Pain
worsened with drinking water, deep respiration. Had associated
chills, no fevers. No diarrhea, constipation, blood in stools.
.
Evaluation at OSH showed WBC 20.8 with 90% N, lipase 2790, alk
phos 198, AST 1090, ALT 480, Tbili 2.1, direct bilirubin 1.0,
troponin I <0.02. CTA chest/abdomen, CT abdomen/pelvis
noncontrast performed due to concern for aortic dissection
showed no aneurysm, dissection, PE; "mild edema in the
peripancreatic fat adjacent to the pancreatic head and body,
compatible with mild pancreatitis." Patient reportedly also had
normal RUQ ultrasound at OSH; records for this study are not
available to us. He received dilaudid for pain control.
.
In the ED, 99.5, 97, 120/98, 15, 98%RA. Patient remained
hemodynamically stable. He received Flagyl, Unasyn in ED. No
narcotics needed for pain control. He was seen by surgery, ERCP.
Consultants asked that patient be admitted to [**Hospital Unit Name 153**] with plan for
ERCP in the morning.
.
On the floor, patient reports feeling generally well. Abdominal
pain is [**6-15**] with associated mild low back pain, improved with
lying still. No chills. No chest pain, shortness of breath. No
nausea.
.
Review of sytems:
(+) Per HPI. Mild frontal headache. (-) Denies night sweats,
recent weight loss or gain. Denies cough, shortness of breath.
Denies chest pain, palpitations. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Hypertension, Hypercholesterolemia, Depression, Stuttering
Social History:
Former mechanic. Laid off after 43 years. Smoked 2PPD for 40
years, quit [**2098**]. Drank 1 quart per weekend, quit [**2098**]. Denies
current tobacco, alcohol, or illicit drug use.
Family History:
Maternal grandfather and mother with rectal cancer. Several
family members with DM, CAD. No known history of pancreatic or
gallbladder disease.
Physical Exam:
On admission:
100.5, 87, 127/76, 15, 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Few bibasilar crackles; decreased breath sounds upper
lung fields bilaterally; no wheezes, ronchi
CV: RRR; normal S1/S2; no murmurs, rubs, gallops
Abdomen: Hypoactive bowel sounds; mild guarding at epigastrum;
no rebound; no hepatomegaly; positive [**Doctor Last Name 515**] sign
Ext: Warm, well perfused; radial and DP pulses 2+; no edema
Pertinent Results:
On [**Hospital Unit Name 153**] admission [**2114-7-29**]:
WBC-18.7* RBC-4.83 Hgb-14.0 Hct-41.6 MCV-86 MCH-28.9 MCHC-33.6
RDW-12.8 Plt Ct-333
Neuts-95.1* Lymphs-2.7* Monos-2.1 Eos-0 Baso-0.2
PT-13.3 PTT-23.3 INR(PT)-1.1
Glucose-144* UreaN-12 Creat-0.7 Na-137 K-3.9 Cl-97 HCO3-26
AnGap-18
ALT-751* AST-1447* AlkPhos-234* Amylase-709* TotBili-2.6*
DirBili-1.6* IndBili-1.0 Lipase-1320*
Ethanol-NEG
.
[**2114-7-30**] ERCP:
Food mixed with liquid was found in the stomach. The liquid
content was completely suctioned. Edema of the duodenal wall
was noted.
Bile and sludge was seen coming out of the papilla. Cannulation
of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique. Contrast medium was
injected resulting in complete opacification. Small sludge like
filling defect was seen in the distal CBD. The CBD, left and
right hepatic and intrahepatic ducts were normal.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire. Bile and sludge was
seen coming out of the bile duct at the end of the
sphinterotomy. A balloon sweep was performed using a balloon
catheter. Small amount of sludge was removed from the bile duct.
.
[**2114-7-30**] AP CXR: Lungs fully expanded and clear. Heart size
normal. No pleural abnormality. Probable hiatus hernia
projecting to the right of the midline just above the diaphragm.
Brief Hospital Course:
65M with hypercholesterolemia, former alcohol abuse admitted
with pancreatitis versus cholangitis. He was amde NPO except
medications, started on IV fluids and Unasyn, given IV Dilaudid
PRN for pain, and a foley was placed. He underwent ERCP with
sphincterotomy and sludge removal; no stent was placed. After
ERCP, he was admitted to the [**Hospital Unit Name 153**].
#1. Pancreatitis: Concern for obstructive etiology given
elevated total and direct bilirubin, alkaline phosphatase. Ddx
also includes pancreatitis secondary to gallstone, alcohol
(although alcohol negative as pt has not drunk for many years),
hypertriglyceridemia. TG normal making hypertriglyceridemia less
likely cause. Patient's pain improved after ERCP sphincterotomy
with passage of sludge. He received IVFs, Unasyn, and dilaudid
as well as Zofran PRN with good effect.
#2. Leukocytosis: Likely secondary to pancreatitis. Also
concern for cholangitis. Positive [**Doctor Last Name 515**] sign on exam,
concerning for cholecystitis. Symptoms, pulmonary exam not
consistent with infectious etiology. No urinary symptoms. CXR as
above. Feels better after ERCP today.
#3. Transaminitis: Can have transaminitis in light of
significant obstructive pathology. No known risk factors for
infectious hepatitis. AST/ALT 2:1, increasing suspicion for
alcoholic hepatitis. NASH also possible, although transaminitis
higher than would be expected for this.
#4. Hypercholesterolemia: Statin continued.
#5. Depression: Continue Effexor at home dose of 50mg [**Hospital1 **].
Condition remained stable.
On [**2114-7-30**], the patient was transferred to the floor. The
patient's diet was progressively advanced to regular, IV fluids
discontinued, and the foley was discontinued. The patient was
able to void without problem. At the time of discharge on
[**2114-7-31**], the patient was doing well, afebrile with stable vital
signs. The patient was tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled. The
patient was discharged home without services, and will return on
Tuesday, [**2114-8-7**] for laparoscopic cholecytectomy. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
Effexor 50mg PO BID, ASA 81mg PO daily, Lipitor 20mg PO daily
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for Constipation.
Disp:*60 Capsule(s)* Refills:*0*
3. Venlafaxine 50 mg Tablet Sig: One (1) Tablet PO twice a day.
4. Aspirin prophylaxis:
Do NOT restart Aspirin 81mg daily until advised to do [**Name6 (MD) **] by MD
after planned surgery [**2114-8-7**].
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3-4 HOURS:
PRN as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain; Cholangitis versus pancreatitis
Discharge Condition:
Stable.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-15**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
You will be contact[**Name (NI) **] by Dr.[**Name (NI) 2829**] Office (Surgery)
regarding the time you should report to [**Hospital1 18**] for your surgery
on Tuesday, [**2114-8-7**]. You should take nothing by mouth starting at
midnight on [**2114-8-7**]. Please do NOT restart your preventative
daily Aspirin or take any NSAID (Aleve, Motrin, Ibuprofen,
Naprosyn) pain relievers prior to the surgery date. Please call
([**Telephone/Fax (1) 2828**] with any questions.
Please schedule a follow-up appointment with your Primary Care
Provider (PCP) in [**2-7**] weeks (2-3 weeks after your surgery next
week).
Completed by:[**2114-7-31**]
|
[
"303.93",
"401.9",
"288.60",
"790.4",
"576.1",
"577.0",
"272.1",
"272.0",
"576.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
7907, 7913
|
4960, 7238
|
328, 392
|
8005, 8015
|
3527, 4937
|
9517, 10158
|
2806, 2951
|
7351, 7884
|
7934, 7984
|
7264, 7328
|
8039, 9494
|
2966, 2966
|
274, 290
|
2259, 2507
|
420, 2241
|
2981, 3508
|
2529, 2590
|
2606, 2790
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,661
| 160,569
|
33098+57835
|
Discharge summary
|
report+addendum
|
Admission Date: [**2118-3-29**] Discharge Date: [**2118-4-11**]
Date of Birth: [**2045-4-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
exertional chest pain
Major Surgical or Invasive Procedure:
redo sternotomy MVR(#27 StJude tissue) [**3-29**]
History of Present Illness:
72 yo F s/p CABG in [**2112**] now with worseing fatigue, DOE and
occasional exertional angina. Workup showed severe MR and she is
referred for surgery.
Past Medical History:
PMH: CHF, MR, Ischemic CM, HTN, ^chol, Bigeminy, Diverticular
dz, Vit B deficiency,
PSH: CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-RCA)'[**12**], Rt hand/amp
w/skin graft
Social History:
lives with husband
retired factory worker
denies tobacco, etoh
Family History:
no premature CAD
Physical Exam:
HR 80 RR 14 BP 122/46
NAD
Well healed sternotomy and leg incisions
Lungs CTAB
Heart RRR, no murmur
Abdomen benign
Extrem warm, no edema
No varicosities
No carotid bruits
Pertinent Results:
[**2118-4-11**] 05:14AM BLOOD WBC-13.7*
[**2118-4-10**] 03:44AM BLOOD WBC-13.3* RBC-3.01* Hgb-9.0* Hct-27.0*
MCV-90 MCH-29.8 MCHC-33.3 RDW-15.2 Plt Ct-166
[**2118-4-9**] 05:31AM BLOOD WBC-14.2* RBC-3.24* Hgb-9.4* Hct-29.6*
MCV-91 MCH-29.1 MCHC-31.9 RDW-14.8 Plt Ct-149*
[**2118-4-5**] 02:04AM BLOOD WBC-24.9* RBC-2.86* Hgb-8.6* Hct-25.8*
MCV-90 MCH-30.2 MCHC-33.4 RDW-14.7 Plt Ct-59*
[**2118-4-10**] 03:44AM BLOOD PT-18.1* INR(PT)-1.7*
[**2118-4-4**] 03:21AM BLOOD PT-18.2* PTT-34.7 INR(PT)-1.7*
[**2118-4-3**] 03:39AM BLOOD PT-14.3* PTT-33.8 INR(PT)-1.2*
[**2118-4-2**] 12:11AM BLOOD PT-12.6 PTT-29.5 INR(PT)-1.1
[**2118-4-10**] 03:44AM BLOOD Glucose-88 UreaN-12 Creat-0.9 Na-136
K-4.5 Cl-104 HCO3-24 AnGap-13
UNILAT UP EXT VEINS US [**2118-4-8**] 10:02 AM
UNILAT UP EXT VEINS US
Reason: RIGHT IJ FOR CLOT
INDICATION: 72-year-old female with right arm swelling.
COMPARISON: No previous exams for comparison.
FINDINGS: Grayscale, color, and Doppler son[**Name (NI) 1417**] of the right
IJ, subclavian, axillary, brachial, basilic, and cephalic veins
were performed. There is nonocclusive thrombus seen within the
right IJ. Flow is documented around the clot at this site. The
right cephalic vein does not compress, and no flow is identified
in that vessel. Normal flow, compression, and augmentation are
seen within the remainder of the right arm veins.
IMPRESSION:
1. Nonocclusive thrombus in the right IJ.
2. Occlusive thrombus in the right cephalic vein.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 76932**]Portable TTE
(Complete) Done [**2118-4-7**] at 11:56:56 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2045-4-21**]
Age (years): 72 F Hgt (in): 67
BP (mm Hg): 160/70 Wgt (lb): 170
HR (bpm): 89 BSA (m2): 1.89 m2
Indication: Pericardial effusion.
ICD-9 Codes: 423.9, 424.0
Test Information
Date/Time: [**2118-4-7**] at 11:56 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6
Contrast: None Tech Quality: Adequate
Tape #: 2008W006-0:10 Machine: Vivid [**8-7**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.6 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.8 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: *0.23 >= 0.29
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: *3.5 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec
Mitral Valve - Peak Velocity: 2.2 m/sec
Mitral Valve - Mean Gradient: 13 mm Hg
Mitral Valve - Pressure Half Time: 119 ms
Mitral Valve - E Wave: 2.1 m/sec
Mitral Valve - A Wave: 2.3 m/sec
Mitral Valve - E/A ratio: 0.91
TR Gradient (+ RA = PASP): *39 to 45 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2118-4-1**].
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV cavity size. Moderately depressed
LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with prior cardiac surgery.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).
Increased MVR gradient. No MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Physiologic TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
Conclusions
The left ventricular cavity size is normal. Overall left
ventricular systolic function is moderately depressed with
global hypokinesis (LVEF= 35-40 %). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis appears well-seated with good leaflet motion. The
gradients are higher than expected for this type of prosthesis
(may be due to small sized valve). No mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is a
partially echodense effusion predominantly around the right
atrium (less echodense and less prominent than previously).
Compared with the prior study (images reviewed) of [**2118-4-1**],
left ventricular systolic function appears slightly more
impaired.
CHEST PORT. LINE PLACEMENT [**2118-4-7**] 4:15 PM
CHEST PORT. LINE PLACEMENT
Reason: please check picc tip position. #4f, 44cm picc for abx.
plea
[**Hospital 93**] MEDICAL CONDITION:
72 year old woman with
REASON FOR THIS EXAMINATION:
please check picc tip position. #4f, 44cm picc for abx. please
page beeper #[**Numeric Identifier 28765**] with wet read asap. thanks.
INDICATION: Please check PICC tip position.
COMPARISON: The chest AP portable upright from [**2118-4-5**].
CHEST AP PORTABLE UPRIGHT: The heart is still enlarged with
evidence of increased pulmonary venous pressure and bilateral
pleural effusions and atelectasis. The bilateral effusion on the
right appears more prominent. The tip of the PICC line is in the
wall of the proximal SVC. No pneumothorax detected.
IMPRESSION:
1. Tip of PICC line in wall of proximal SVC. No pneumothorax.
2. Bilateral atelectasis, more prominent on the right.
Otherwise, no other interval changes since the previous study.
Brief Hospital Course:
She was taken to the operating room on [**3-29**] where she underwent
a redo-sternotomy and MVR. She was transferred to the ICU in
critical but stable condition on epinephrine and neo.
Postoperative echo showed clot around the right atrium. She had
a large volume requirement and was transfused as well. Her epi
was weaned to off by POD #2. She was extubated on POD #2. She
was thrombocytopenic, HIT screen was negative. Her platelet
count continued to drop, she was given platelets and she was
seen by hematology who continued to follow. She had aflutter for
which she was put on amio, and she returned to NSR. Blood
cultures grew gram negative rods and she was seen by general
surgery. CT abdomen/pelvis was negative. She was seen by ID.
Line tip also grew gram negative rods and she was started on
cipro and flagyl. Coverage was broadened to include ceftazidime.
She improved and was transferred to the floor on POD #8.
Antibiotics were changed to cefepime plus empiric flagyl. PICC
line was placed. Multiple Cdiff's negative, and flagyl was dc'd.
She was ready for discharge to rehab on POD #13. She will
require 2 weeks of IV cefapime then 4 weeks of PO cipro.
Medications on Admission:
ASA 325', Amio 200', Coreg 3.25", Lisinopril 25", Vytorin
20/10', Protonix 40', Oscal, Iron 325'
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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ferrous Gluconate 300 mg (35 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day).
7. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Cefepime 2 gram Recon Soln Sig: Two (2) Grams Injection Q8H
(every 8 hours) for 2 weeks.
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 4 weeks: to start after 2 weeks of IV cefepime.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11792**] Nursing & Rehabilitation Center - [**Location (un) 13360**]
Discharge Diagnosis:
MR now s/p MVR
acute on chronic systolic heart failure
CHF, Ischemic CM, HTN, ^chol, Bigeminy, Diverticular dz, Vit B
deficiency, s/p CABGx4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-RCA)'[**12**], s/p
Rt hand/amp w/skin graft
Discharge Condition:
Stable.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) 4281**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2118-4-11**] Name: [**Known lastname 2856**],[**Known firstname **] [**Last Name (NamePattern1) **] Unit No: [**Numeric Identifier 12518**]
Admission Date: [**2118-3-29**] Discharge Date: [**2118-4-11**]
Date of Birth: [**2045-4-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4551**]
Addendum:
Called by ID just prior to pt discharge. They would prefer 3
weeks of IV cefepime and then 3 weeks of cipro secondary to the
thrombus in the right IJ. D/w RN and patient.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 12519**] Nursing & Rehabilitation Center - [**Location (un) 12520**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**] MD [**MD Number(1) 359**]
Completed by:[**2118-4-11**]
|
[
"414.00",
"E879.8",
"E849.7",
"570",
"038.9",
"999.31",
"266.2",
"428.23",
"428.0",
"562.10",
"272.0",
"424.0",
"995.91",
"414.8",
"287.4",
"427.32",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"39.63",
"38.93",
"88.72",
"99.05",
"99.04",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
11069, 11336
|
7284, 8451
|
343, 395
|
9996, 10006
|
1086, 6429
|
10305, 11046
|
862, 880
|
8598, 9603
|
6466, 6489
|
9759, 9975
|
8477, 8575
|
10030, 10282
|
895, 1067
|
282, 305
|
6518, 7261
|
423, 577
|
599, 766
|
782, 846
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,588
| 176,009
|
3150
|
Discharge summary
|
report
|
Admission Date: [**2165-8-17**] Discharge Date: [**2165-8-23**]
Date of Birth: [**2104-2-16**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Hortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stent to left circumflex
artery
History of Present Illness:
61 year old male with a history of hypercholesterolemia, CAD s/p
MI in [**4-2**] s/p stent x3 (2 LAD, 1 D2)with 2 separate caths, CHF
(EF 20-30%)[**7-2**], and non-sustained VT s/p ICD who presents with
shortness of breath. Patient reports that he has been feeling
more SOB for the past 2 weeks and this morning he was feeling
fine and decided to go golfing. Before starting he developed
acute SOB and some chest pressure. Denied N/V but had some
palpitations. His ICD did not fire. On route to the ED he
complained of some right arm pain which he reports is his
anginal equivalent. Denies orthopnea or PND and says that he has
been taking all of his medications but has not been following a
low salt diet recently.
Of note his SBP was 106 this am and he says it is normally
around 95. He reports no change in his weight and says that his
dry weight is around 150 lbs. He denies any chest pain on
exertion but says he is unable to walk more than 30 yards as he
develops LE pain. He had arterial dopplers of his LE rest and
exercise [**6-2**] which were normal. He also reports that he has
been having black stools for 2 weeks and occasional brigt red
blood and pain on defecation when having hard BM. His last
colonscopy was [**1-29**] which showed Grade 2 internal hemorrhoids
otherwise normal Colonoscopy to cecum. Denies dysuria, nocturia,
some increased urgency since being on lasix. Denies fevers,
chills,dizziness, cough, palps.
In the ED he recieved lasix 80mg Iv, morphine, nitro gtt,
heparin gtt with bolus. He was put on BIPAP and was attempted
to be weaned but sats dropped into 80's and was set to CCU for
management of CHF.
Past Medical History:
1)anterior STEMI [**5-2**]: 2 stents to the LAD, and had angioplasty
x 2 (2 separate caths) as the diagonal restenosed within days
after the first angioplasty.
2)Bronchitis
3)Hypercholesterolemia
4) CHF - EF 20-30%, 1+MR, 2+TR, apical akinesis, hypokinesis of
most of LV, mild symmetric left ventricular hypertrophy
5) S/P ICD and Pacer
Social History:
Married, lives with wife, works in maintenance for the court
system but has not yet returned to work.
Smoked 1.5 ppd for 40 years, quit on last admission in [**Month (only) 116**]
.
Family History:
Paternal GM with MI age 54
Paternal GF with MI age 58
Father with MI age 58
Uncle with MI age 46
Physical Exam:
BP 108/73 HR 75 R 20 O2 sats 100% on BIPAP, 1400 cc out after
lasix 80 mg IVx1
Gen: NAD, lying in bed breathing with BiPAP
HEENT: PERRL, JVP to angle of jaw
Neck: no carotid bruits
Lungs: bilateral crackles [**12-30**] way up lung fields
CV: RRR, nl s1/s2, no m/r/g
Abd: soft, nt/nd, normal BS
Extr: no c/c/e, DP 1+ bilat
Neuro: AAOx3
Guaiac: negative but difficult to get good specimen secondary to
pain on exam
Pertinent Results:
[**2165-8-17**] 10:00AM BLOOD WBC-5.0 RBC-3.59* Hgb-10.7* Hct-34.1*
MCV-95 MCH-29.9 MCHC-31.5 RDW-15.1 Plt Ct-328#
[**2165-8-18**] 02:02AM BLOOD WBC-6.3 RBC-3.02* Hgb-9.2* Hct-27.0*
MCV-89 MCH-30.6 MCHC-34.3 RDW-15.0 Plt Ct-269
[**2165-8-19**] 06:05AM BLOOD WBC-4.3 RBC-3.43* Hgb-10.4* Hct-30.2*
MCV-88 MCH-30.5 MCHC-34.6 RDW-15.8* Plt Ct-266
[**2165-8-22**] 06:45AM BLOOD WBC-7.0 RBC-3.56* Hgb-10.5* Hct-32.6*
MCV-92 MCH-29.5 MCHC-32.2 RDW-15.2 Plt Ct-252
[**2165-8-23**] 06:35AM BLOOD WBC-5.8 RBC-3.39* Hgb-10.0* Hct-31.0*
MCV-92 MCH-29.6 MCHC-32.3 RDW-15.0 Plt Ct-236
[**2165-8-17**] 10:00AM BLOOD Neuts-49.7* Lymphs-36.8 Monos-6.5
Eos-6.0* Baso-1.0
[**2165-8-17**] 10:00AM BLOOD PT-19.5* PTT-30.2 INR(PT)-2.5
[**2165-8-21**] 06:45AM BLOOD PT-15.8* PTT-48.9* INR(PT)-1.7
[**2165-8-21**] 05:25PM BLOOD Plt Ct-307
[**2165-8-17**] 10:00AM BLOOD Glucose-161* UreaN-17 Creat-1.0 Na-139
K-4.8 Cl-102 HCO3-22 AnGap-20
[**2165-8-23**] 06:35AM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-139
K-4.2 Cl-104 HCO3-26 AnGap-13
[**2165-8-17**] 10:00AM BLOOD CK(CPK)-185*
[**2165-8-17**] 04:08PM BLOOD CK(CPK)-151
[**2165-8-17**] 08:24PM BLOOD CK(CPK)-137
[**2165-8-18**] 02:02AM BLOOD CK(CPK)-108
[**2165-8-22**] 01:01AM BLOOD CK(CPK)-401*
[**2165-8-22**] 06:45AM BLOOD CK(CPK)-420*
[**2165-8-22**] 03:49PM BLOOD CK(CPK)-297*
[**2165-8-23**] 06:35AM BLOOD CK(CPK)-127
[**2165-8-17**] 10:00AM BLOOD CK-MB-5
[**2165-8-17**] 10:00AM BLOOD cTropnT-<0.01
[**2165-8-17**] 04:08PM BLOOD CK-MB-6 cTropnT-0.01
[**2165-8-17**] 08:24PM BLOOD CK-MB-5 cTropnT-0.02*
[**2165-8-18**] 02:02AM BLOOD CK-MB-4 cTropnT-0.02*
[**2165-8-21**] 03:00PM BLOOD CK-MB-2 cTropnT-<0.01
[**2165-8-22**] 01:01AM BLOOD CK-MB-68* MB Indx-17.0* cTropnT-1.30*
[**2165-8-22**] 06:45AM BLOOD CK-MB-70* MB Indx-16.7* cTropnT-2.38*
[**2165-8-22**] 03:49PM BLOOD CK-MB-38* MB Indx-12.8*
[**2165-8-23**] 06:35AM BLOOD CK-MB-11* MB Indx-8.7*
[**2165-8-17**] 10:00AM BLOOD Calcium-9.7 Phos-4.0 Mg-1.9
[**2165-8-17**] 04:08PM BLOOD calTIBC-384 Ferritn-139 TRF-295
[**2165-8-17**] 10:00AM BLOOD Digoxin-0.5*
.
[**2165-8-17**] CXR:FINDINGS: The heart is within normal limits in size.
The mediastinal contours appear unremarkable. There is a
left-sided pacemaker with single electrode in unchanged
position. In comparison with [**2165-5-16**], there is development
of diffuse bilateral interstitial opacities and probable slight
prominence of the upper zone pulmonary vasculature. In addition,
there is increase in hazy opacity within the right lower lung.
No pleural effusion and no pneumothorax. The osseous structures
appear unchanged.
IMPRESSION:
1. Interval development of pulmonary vascular congestion.
2. Focal opacity in the right lower lung, suggestive of
developing pneumonia. Repeat radiography after treatment is
recommended
.
[**2165-8-18**] CXR: Comparison with the prior chest x-ray shows
considerable improvement in the appearance of the failure over
the past 24 hours with some residual changes in the right lung.
There are no other significant alterations in the appearance of
the chest.
.
[**2165-8-21**] Cardiac catheterization: 1. Selective coronary
angiography revealed angiographic evidence of two vessel CAD.
The LMCA was normal. The LAD had good flow and all stents were
patent. The D1 and D2 were patent. The LCX was chronically
occluded. The RCA had moderate disease with a 40% proximal
lesion.
2. Hemodynamic evaluation revealed elevated filling pressures
with mean
PCWP of 21mm HG. There was borderline pulmonary hypertension
with mean
pressure of 27mmHG. The cardiac output and index were
preserved.
3. A saturation run revealed a step up from SVC of 59% to PA of
66%.
The patient is known to have an ASD. Formal shunt fraction
calculation
was not done as no arterial sat was drawn.
4. Successful PCI of the CTO LCX with three overlapping
Minivision
stents (2.5 x 23 mm, 2.5 x 28 mm, and 2.0 x 28 mm).
Brief Hospital Course:
61 yo male with h/o CAD s/p MI in [**4-2**] s/p stent x3 (2 LAD, 1
D2), CHF (EF 20-30%)[**7-2**], and non-sustained VT s/p ICD who
presents with acute shortness of breath and chest pressure
.
1. CHF: Patient has EF of 20-30% on Echo from [**7-2**] and had been
non-compliant with his diet. Chest x-ray revealed decompensated
heart failure. In the ED he required BiPap and was attempted to
be weaned but dropped his sats to the 80's. He was started on
heparin drip, nitro drip, morphine and given Lasix 80 mg IV. CXR
revealed decompensated heart failure. He was diuresed and his
oxygen requirement decreased significantly by the second
hospital day with improvement on chest x-ray. He was ruled out
for MI with enzymes and was continued on his [**Last Name (un) **] and BB and
given IV Lasix for diuresis. Hi Coumadin was held given that he
was planned to go to cath. He was transferred from the CCU to
the floor where he remained stable on room air. However given
his pain on admission and the degree of his CAD, he was taken to
cardiac catheterization. His Coumadin was held during this time
and was the restarted after catheterization his INR was 1.5 at
discharge and will be monitored closely as an outpatient with a
goal of [**1-31**].
2. CAD: Patient is s/p stents x3 in [**5-2**] now presenting with
shortness of breath and his anginal equivalent. Cath showed
chronic occlusion of the left circumflex-OM and 3 overlapping
minivision stents were placed. After the catheterization he had
only mild chest discomfort but his enzymes ruled him in for MI.
This was felt to be secondary to ischemia from instrumentation
of left circumflex. The patient soon was pain free, satting
well. His aspirin, Statin, Plavix, BB and [**Last Name (un) **] were all continued
and he was restarted on Coumadin as above for his apical
akinesis.
3. GI: Patient reports having melena x 2 weeks. His colonoscopy
showed internal hemorrhoids 2/[**2160**]. He was started on a PPI and
his stools were guaiac negative. He will follow up for an
outpatient colonoscopy and EGD.
4. Hypercholesterolemia: Continued on Statin.
.
5. Anemia: Patient's baseline HCT 30. Given his recent melena
his HCT was closely monitored and iron studies were checked. His
HCT remained stable and his iron studies were within normal
limits except for a low iron. He was started on ferrous sulfate
for iron deficiency anemia.
-
Medications on Admission:
Medications on admission:
Aspirin 325 mg qd
lipitor 80 mg po qd
Plavix 75 mg qd
digoxin 0.125 mg qd
Coreg 3.125 mg qd
Aldactone 12.5 mg qd
Cozaar 25 mg qd
Lasix 10 mg qd
Coumadin 5mg 6 days, 2.5 mg sunday
albuteral inh
ipratropium inh
.
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).
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO once a day.
5. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Losartan Potassium 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.
11. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
12. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
1. Decompensated CHF
2. Coronary artery disease s/p stent to LCX
Discharge Condition:
chest pain free, no shortness of breath, afebrile
Discharge Instructions:
If you have any chest pain, shortness of breath, palpitations,
abdominal pain or any other concerning symtoms you should call
your doctor or go to the mergency room.
You should weight yourself every day. If your weight increases
by more than 3 lbs you should call your doctor.
Your should restrict your fluid intake to 1.5 liters and
maintain a low sodium diet (2 grams).
Check your blood pressure every morning and if your systolic
blood pressure is <90, do not take the Coreg and call your
cardiologist.
Take coumadin 5 mg each night until you have your INR checked
next week (the INR on day of discharge was 1.6)
Followup Instructions:
Please make an appointment to follow up with Dr. [**Last Name (STitle) **] in [**12-30**]
weeks, ([**Telephone/Fax (1) 11176**].
You should make an appointment with your primary doctor in [**3-1**]
weeks. You should discuss having a colonoscopy as you were found
to have an iron deficiency anemia.
Continue you have you INR checked at [**Company **]. You
should have it checked sometime next week. Dr. [**Last Name (STitle) **] will follow
up the results.
|
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"414.8",
"414.01",
"496",
"401.9",
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"997.1",
"412",
"280.9",
"272.4",
"V45.01",
"428.0",
"V70.7",
"410.91",
"V53.32",
"518.82",
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icd9cm
|
[
[
[]
]
] |
[
"93.90",
"89.49",
"99.20",
"36.01",
"36.06",
"99.04",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10670, 10676
|
7067, 9455
|
287, 361
|
10785, 10837
|
3163, 7044
|
11506, 11967
|
2615, 2714
|
9743, 10647
|
10697, 10764
|
9507, 9720
|
10861, 11483
|
2729, 3144
|
229, 249
|
389, 2038
|
2060, 2399
|
2415, 2599
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,099
| 177,334
|
468
|
Discharge summary
|
report
|
Admission Date: [**2137-1-18**] Discharge Date: [**2137-2-4**]
Service: VSU
HISTORY OF PRESENT ILLNESS: Patient is an 83-year-old,
Russian only speaking female admitted due to likely
cellulitis of her right above the knee amputation stump. Her
history was limited by absence of a family member or
translator at the time of interview, and the remainder of her
history was obtained from her medical record.
Past medical history includes coronary artery disease, status
post percutaneous transluminal coronary angioplasty and stent
in [**2131**], coronary artery bypass graft in [**2132-7-29**],
cerebrovascular accident in [**2128**], right medullary
cardiovascular accident in [**2135-3-29**], seizure disorder,
diabetes, hypertension, hypercholesterolemia, carotid artery
stenosis, renal artery stenosis status post stent placement
in the left renal artery, recurrent urinary tract infection,
severe depression status post ECT therapy, left femoral neck
fracture, right groin hematoma, recurrent urinary tract
infections, peripheral vascular disease.
Past surgical history includes repair of a ruptured infected
right femoral pseudo aneurysm, coronary artery bypass graft,
right common femoral to anterior tibial artery bypass graft
with a PTFE and distal talar vein patch in [**2131**] by Dr.
[**Last Name (STitle) **], left closed reduction internal fixation of the left
hip fracture, and evacuation of right groin hematoma.
SOCIAL HISTORY: Patient does not drink alcohol. She does
not smoke cigarettes. She has a son and daughter-in-law and
daughter who are involved in her care.
PHYSICAL EXAMINATION: Temperature 98.8, heart rate 70, blood
pressure 118/74, sating 96 percent on room air. In general,
the patient was alert, in no acute distress. She has slight
scleral icterus and some sublingual icterus. Heart is
regular rate and rhythm. Lungs are clear to auscultation
bilaterally. Abdomen is soft, nontender, obese; positive
bowel sounds. She has a bluish tinge periumbilically.
Extremities, particularly the left lower extremity, show 2 to
3 plus pitting edema. Pulses right femoral is 2 plus, left
femoral 2 plus, popliteal 1 plus, DP triphasic, PT triphasic.
PERTINENT RESULTS AT THE TIME OF ADMISSION: White blood cell
count 9.3 with 73 percent neutrophils. Creatinine of 1.5.
CT of the legs showed skin thickening and subcutaneous
stranding in the medial thigh corresponding to physical exam
without underlying abscess, similar skin thickening and
pronounced subcutaneous stranding and extensive soft tissue
attenuation surrounding the prosthetic graft in the anterior
lateral thigh also suspicious for infection, mottled and
demineralized appearance of the femur likely related to
disease.
Medications on admission include nifedipine 30 mg p.o. once
daily, metoprolol 50 mg p.o. b.i.d., atorvastatin 20 mg p.o.
once daily, glyburide 5 mg p.o. b.i.d., aspirin 325 mg p.o.
once daily, valsartan 80 mg p.o. once daily, levofloxacin 250
mg p.o. once daily, buspirone 10 mg p.o. b.i.d., bupropion
150 mg p.o. b.i.d., multivitamin 1 cap p.o. once daily,
acetaminophen 325 to 650 mg p.o. q. [**4-3**] p.r.n., lorazepam at
1.5 mg p.o. at bedtime, vancomycin 1 gm IV q. 48h., Flagyl
500 mg p.o. t.i.d., heparin 5000 units subcutaneously b.i.d.
Patient was admitted on [**2137-1-18**] and was continued on IV
vancomycin and levofloxacin for presumed right above the knee
amputation stump infection. She was also evaluated for heart
failure causing the peripheral edema. During the patient's
stay she had considerable difficulty receiving blood pressure
control. This required multiple medication maneuvers.
She was taken on [**2137-1-21**] to the Operating Room for an I
and D of the infected leg and removal of her right thigh
graft, which she tolerated well. Renal function was a
concern, however, afterwards and her chronic renal
insufficiency with acute exacerbation required monitoring.
Postoperatively, she continued to receive her IV antibiotics
and did receive a PICC line for easier administration. Also
postoperatively, the patient was seen by Psychiatry both for
treatment of her severe depression as well as acute mental
status exacerbations and need for a one-to-one sitter.
After a couple days of dressing changes soaked in acetic
acid, the patient's leg wound had a VAC dressing placed,
which worked well for healing purposes.
On postoperative day 3 the patient did experience a fever and
received a fever workup. Her chest x-ray did not have any
CHF or pneumonia. She also had blood and urine cultures
performed. During her stay the patient did require blood
transfusion which did cause a degree of heart failure and the
need for Lasix. Cardiac service was made involved at that
time because during her blood transfusion her systolic blood
pressure decreased and the patient went into a junctional
escape rhythm requiring telemetry and close observation.
However, the patient did spontaneously convert back to sinus
rhythm. The cardiac service made recommendations to hold
beta blockers as well as began to make plans for possible
pacer placement.
On the morning of [**2137-1-30**] the patient was noted on
telemetry to acutely brady down to asystole. She was
emergently coded, requiring artificial respiration and chest
compressions. She was shocked a number of times as well as
received a number of cardiac inotropic medications. Patient
was successfully revived and was transferred to the Intensive
Care Unit for further care. She was, at that time, seen by
the Electrophysiology Department, who then placed a cardiac
pacemaker. While in the ICU the patient never truly woke up
from a neurological standpoint, although she would turn her
head to the left and withdraw her left leg to pain. She
never truly regained consciousness. She was started on tube
feeds. She did require IV blood pressure management and
drips for severe hypertension. She did remain vent dependent
after resuscitation in the ICU, and finally on [**2137-2-4**] the
patient was made comfort measures only by the family.
Patient's ventilatory support was removed and by the evening
of [**2137-2-4**] at 9:55 p.m. the patient expired with no blood
pressure and no respiratory effort. Patient's family has
been contact[**Name (NI) **] to alert them of the passing, and they do not
wish an autopsy to be performed. She will be discharged to
the funeral home.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3186**]
Dictated By:[**Last Name (NamePattern1) 3956**]
MEDQUIST36
D: [**2137-2-4**] 22:51:38
T: [**2137-2-5**] 10:33:29
Job#: [**Job Number 3957**]
|
[
"250.00",
"427.5",
"E878.5",
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"997.62",
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"996.62",
"682.6",
"E878.2",
"780.99",
"427.89",
"V09.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"99.60",
"38.91",
"37.83",
"37.78",
"84.3",
"96.04",
"96.71",
"99.04",
"39.49",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1627, 6675
|
117, 1444
|
1461, 1604
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,866
| 125,023
|
45622
|
Discharge summary
|
report
|
Admission Date: [**2178-3-4**] Discharge Date: [**2178-3-28**]
Date of Birth: [**2115-4-1**] Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Flagyl
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
fever, back pain
Major Surgical or Invasive Procedure:
Central line placement-no complications. Placement of left
antecubital PICC line
History of Present Illness:
Ms. [**Known firstname 1494**] [**Known lastname 41236**] is a 61-year old female with cervical and
lumbar laminectomy/fusion who presents with fever to 101.3
degrees and increased back pain.
In the ED, she was initially scheduled for an MRI. She got
multiple doses of ativan, morphine, and haldol for sedation
before the study but had a near respiratory arrest. She was
intubated for increasing sedation for the MRI and put on
propofol and given a dose of vecuronium for paralysis before
MRI. The MRI preliminarily showed no abscess but was an
extrememly limited study. Orthopedics decided there was no role
for surgery at this time, so she was transferred to the MICU for
monitoring of this intubated patient.
Past Medical History:
Cervical and lumbar spondylosis.
- Anterior cervical corpectomy and fusion at C3 to C7 in
[**2173-11-23**].
- C7 through T1 laminectomies and partial laminectomy of C6 and
T2 on [**2176-4-23**]
- L4-L4 laminectomy in [**2166**].
- L2-S1 spinal fusion in [**2169**].
- L1 stimulator ? in [**2170**].
Osteoarthritis, status post bilateral shoulder surgery.
Hypertension
Hypercholesterolemia
Hypothyroidism
Social History:
The patient has not smoked for the past 30
years. She has never had alcohol. Denies any history of
illicit drug use.
Family History:
She had a father with a transient ischemic
attack. Both parents have hypertension. There is no family
history of coronary artery disease or diabetes.
Physical Exam:
V: Tm 103.0, 115/49, p87, spo2 97%
vent: AC 550x14/5/.5
ABG: 7.38/39/106
Gen: intubated, sedated
HEENT: no meningismus, no objective photophobia (per ortho),
NC/AT
lungs: CTA b
CV: s1/s2, rrr
abd: soft, nabs, nttp
ext: no edema, warm and dry, dp 2+
neuro: intubated and sedated
Pertinent Results:
[**2178-3-4**] 01:05PM PT-11.3 PTT-21.1* INR(PT)-1.0
[**2178-3-4**] 11:35AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2178-3-4**] 11:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2178-3-4**] 11:12AM LACTATE-3.2*
[**2178-3-4**] 11:00AM GLUCOSE-106* UREA N-33* CREAT-1.1 SODIUM-138
POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-25 ANION GAP-19
[**2178-3-4**] 11:00AM CALCIUM-9.8 PHOSPHATE-4.1 MAGNESIUM-2.0
[**2178-3-4**] 11:00AM CRP-34.2*
[**2178-3-4**] 11:00AM WBC-17.4*# RBC-4.04* HGB-12.6 HCT-36.9 MCV-91
MCH-31.1 MCHC-34.1 RDW-14.0
[**2178-3-4**] 11:00AM NEUTS-87.1* BANDS-0 LYMPHS-8.8* MONOS-3.2
EOS-0.8 BASOS-0.1
[**2178-3-4**] 11:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2178-3-4**] 11:00AM PLT SMR-NORMAL PLT COUNT-338
[**2178-3-4**] 11:00AM SED RATE-22*
.
WBC scan: IMPRESSION:
Mild asymmetrical uptake at the lumbosacral junction and left
sacroiliac regionwhich could represent inflammation given
extensive changes seen on CT and MRI.
No definite source of infection is identified
.
LENI: IMPRESSION: No evidence of fempop DVT bilaterally.
.
ECHO: Conclusions:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is normal (LVEF>55%).
2. Right ventricular chamber size and free wall motion are
normal.
3.There are simple atheroma in the descending thoracic aorta.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve.
5.The mitral valve appears structurally normal with trivial
mitral
regurgitation. No mass or vegetation is seen on the mitral
valve.
6.There is no pericardial effusion.
.
CT spine: IMPRESSION: Stable appearance to multiple
abnormalities in the cervical spine as compared to [**2175**]. No
clear evidence of paraspinal abscesses.
.
MRI spine: IMPRESSION: Extremely limited exam. Multiple
abnormalities as described above, which do not appear to be new.
Superimposed acute inflammatory processes could be overlooked on
this study. If clinical concern persists, other imaging
modalities, such as a radionuclide scan, may be helpful for
further evaluation.
.
[**3-25**] MR spine -Somewhat motion limited study. No definite
evidence of alteration in appearance compared to the previous
examination of [**3-5**]. Persistent abnormalities in the lower
cervical, upper thoracic, lower thoracic, and upper lumbar
region.
Brief Hospital Course:
.
# Fever: Given her back pain and absence of other focus, there
was concern was for epidural abcess or spinal stimulator
infection. CT and MRI of spine were unrevealing although they
were limited studies as artifact from surgical hardware obscured
imaging. U/A was sterile. CXR showed no pneumonia despite repeat
studies. Blood cx drwan in ED eventually grew coag neg staph [**2-24**]
bottles. She was then started on Vancomycin and had persistent
fevers. ID consulted. Pt received ceftazidime ([**Date range (1) 59224**]),
vancomycin and gentamycin ([**Date range (1) 91453**]). Eventually all
antibiotics were discontinued except Vancomycin once
sensitivities were back. Surveillance blood cultures from [**3-16**],
[**3-17**] and [**3-22**] all grew coag negative staph but all with
different sensitivties with the [**3-17**] cultures growing 2
different morphologies. She has persistent fevers warrenting
further workup. Differential diagnosis also included viral
etiology, though no signs to suggest it and influenza a/b was
negative. TEE on [**3-6**] was negative for endocarditis. Pt had WBC
scan after MRI and CT scan negative which showed minimal uptake
at stimulator suggestive of inflammation but no evidence of
infection or abscess. Dr [**Last Name (STitle) 363**] from ortho spine felt that the
stimulator may be infected so she was taken to the OR for
removal of the battery pack of the stimulator and most of the
wires on [**3-19**] although grossly it didn't appeat infected. LENI
were negative for infected thrombus. ID recommended a full 6
week course of vancomycin as there was no clear source of
infection. The possibility of drug fever was also raised due to
the possibility of the culture data being contaminant so on [**3-20**]
she was changed to daptomycin. Fevers improved over the next 48
hours. Repeat MRI on [**2178-3-24**] revealed continued discitis in L2-3
and L3-4 so plan was made to dicontinue PICC line and continue
Linezolid for the remainder of her 6 week course. Pt will
follow-up in [**Hospital **] clinic on [**4-13**].
.
# resp failure - intubated for CT and MRI and severe back pain
extubated after procedures. Pt likely over sedated for
procedures and intubated in the ED.
.
# hypotension -Due to oversedation during CT. Pt required
levophed for under 12 hours. Echo revealed EF>55% no WMA or
valvular dysfcn. Cortisol stimulation test was negative for
adrenal insuficiency and it resolved with fluids.
.
# Back pain: Was concerning for infection as pain seemed to be
worse than usual. Pain seemed to me paraspinal as pt had no
point tenderness. Pain service was consulted and started her on
Oxycontin to 20 TID with oxycodone 5mg PRN for breakthrough. She
was on tizanidine at home, which increased to 4mg on this
admission and then weaned back down as pain improved. PT was
consulted to assist with mobility and they felt the patient
would benefit from rehab. She was weaned down on amytriptylline
and tizanidine and topiramate was discontinued on discharge.
.
HTN:We continued her home BP meds but held her ACE-I due to low
SBP and bout of acute renal failure as below
.
#. hypothyroid: We continued replacement at 125mg qd but
increased dose to 150mcg since she reported this was her home
dose
.
# ARF-Pt had baseline creat 0.6 which increased to 1.2 with
decreased GFR with poor PO intake and hypotension. Urine
eosinophils were negative, FENa showed no prerenal state. Her
intermittent tachycardia suggested possible volume depletion
which resolved with IVF. Her creat continued to improve with
holding ACE-I stopping vancomycin, and holdin NSAIDS so it
remained unclear which was the offending [**Doctor Last Name 360**].
.
Medications on Admission:
1. Atorvastatin 10 mg by mouth every day.
2. Amitriptyline 100 mg by mouth at hour of sleep.
3. Levothyroxine 125 mcg by mouth every day.
4. Docusate 100 mg by mouth twice per day.
5. Multivitamin one by mouth every day.
6. Calcium carbonate 1000 mg by mouth three times per day.
7. Atenolol 25 mg by mouth once per day.
8. Oxycodone 5 mg to 10 mg by mouth q.4h.
9. Zanaflex 2 mg by mouth three times per day.
10. Enteric coated aspirin 325 mg by mouth once per day.
11. Oxycodone 5 mg by mouth q.4-6h. as needed (for breakthrough
pain).
12. Celebrex 200 mg by mouth once per day.
13. Glucosamine 750 mg by mouth twice per day.
14. Fosamax 70 mg by mouth every week.
15. Diovan 80 mg by mouth once per day.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): Until fully ambulatory.
.
2. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every
4 hours) as needed.
7. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD (): 12 hours on
and 12 hours off. .
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q8H (every 8 hours).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
15. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 3 weeks: patient will have to have CBC checked q3d
while on this medication.
16. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
17. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
Bacteremia
Discitis
Discharge Condition:
[**Name (NI) 97288**] pt with difficulty with ambulation and being discharged
to rehab for PT.
Discharge Instructions:
Pleae return to the hospital if you experience chest pain,
shortness of breath, dizziness/lightheadedness, severe
nausea/vomiting/diarrhea or any other severe symptoms. Please
call your doctor if you have any questions about your symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2178-4-30**] 2:10.
You schould call [**Telephone/Fax (1) 3329**] to confirm an appointment for [**4-1**] at 3pm with the covering doctor for Dr. [**Last Name (STitle) 931**] for post
hospitalization follow-up.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16881**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2178-4-13**] 10am
Please follow-up with Dr. [**Last Name (STitle) 363**] on Thursday [**4-9**] 4:30 pm and
can call [**Telephone/Fax (1) 3573**] to confirm the appointment.
|
[
"722.93",
"584.9",
"458.29",
"V45.4",
"272.0",
"038.19",
"996.63",
"401.9",
"E937.9",
"518.81",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"86.05",
"96.04",
"03.94",
"96.6",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10854, 10919
|
4724, 8405
|
291, 374
|
10983, 11080
|
2159, 4701
|
11368, 12058
|
1694, 1845
|
9163, 10831
|
10940, 10962
|
8431, 9140
|
11104, 11345
|
1860, 2140
|
235, 253
|
402, 1116
|
1138, 1544
|
1560, 1678
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,300
| 110,122
|
11171
|
Discharge summary
|
report
|
Admission Date: [**2177-8-11**] Discharge Date: [**2177-8-18**]
Date of Birth: [**2125-8-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Paxil
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain, DOE
Major Surgical or Invasive Procedure:
[**2177-8-14**] CABG x 3 (LIMA->LAD, SVG->OM, SVG->PDA)
History of Present Illness:
52 yo Female with PVD, DM presented with chest pain and dyspnea,
cardiac cath showed LM and RCA disease.
Past Medical History:
Left femoral-DP bypass with in-situ greater saphenous vein
CVA X 2 on coumadin
Asthma
RAS
HTN
myofascial pain syndrome
Social History:
35 pack year smoking history, lives with boyfriend
Family History:
n/c
Physical Exam:
NAD, flat after cath
lungs CTAB ant/lat
RRR
Abdomen benign, obese
Extem warm, no edema, healed LLE incision
Pertinent Results:
[**2177-8-18**] 04:34AM BLOOD Hct-32.1*
[**2177-8-16**] 02:30PM BLOOD WBC-14.4* RBC-3.49* Hgb-10.4* Hct-30.8*
MCV-88 MCH-29.8 MCHC-33.8 RDW-15.2 Plt Ct-219
[**2177-8-18**] 04:34AM BLOOD PT-26.4* INR(PT)-2.7*
[**2177-8-17**] 10:15AM BLOOD PT-21.3* INR(PT)-2.1*
[**2177-8-16**] 07:00AM BLOOD PT-14.2* PTT-29.3 INR(PT)-1.3*
[**2177-8-18**] 04:34AM BLOOD UreaN-11 Creat-0.6 K-3.9
[**2177-8-16**] 02:30PM BLOOD Glucose-168* UreaN-11 Creat-0.8 Na-134
K-4.4 Cl-100 HCO3-24 AnGap-14
Brief Hospital Course:
She was seen by neurology preoperatively to assess stroke risk.
She awaited several days off of plavix prior to be taken to the
operating room on [**2177-8-14**] where she underwent a CABG x 3. She
was transferred to the ICU in critical but stable condition on
neosynephrine, propofol and insulin. She was extubated later
that same day. She was transferred to the floor on POD #1. On
POD #2, she vomited, KUB showed no obstruction and LFTs were
normal. Her vomiting rosolved with IV protonix. She did well
postoperatively and was ready for discharge home on POD #4.
Medications on Admission:
lovastatin, plavix, hydroxyzine, actos, metoprolol, coumadin,
lisinopril, theophylline, glipizide, clonidine, flexeril,
albiuterol, percocet, nitro
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
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:*0*
7. Theophylline 200 mg Tablet Sustained Release 12 hr Sig: One
(1) Tablet Sustained Release 12 hr PO BID (2 times a day).
8. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] [**Hospital 2256**]
Discharge Diagnosis:
CAD
HTN
lipids
CVA x 2
PVD s/p L SFA stent & L fem-dp bypass c/b infection& dehiscence
renal srtery stenosis s/p stent
asthma
lung nodule
migraines
fatty liver
right hand tendonitis
myofascial pain syndrome
s/p left hand tendon surgery
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds or driving until follow up with
sutgeon or while taking narcotic pain medicine.
Shower, no baths, no lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] 4 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**First Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] (thoracic surgery). Please call to arrange
follow up for lung nodules.
Already Scheduled appointments:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2177-8-20**]
11:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2177-8-20**] 11:45
Completed by:[**2177-8-18**]
|
[
"V58.61",
"443.9",
"440.1",
"305.1",
"438.89",
"401.9",
"250.00",
"272.0",
"571.8",
"433.10",
"729.1",
"493.90",
"414.01",
"346.90",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.15",
"88.56",
"39.61",
"36.13",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
3348, 3417
|
1353, 1920
|
286, 344
|
3697, 3705
|
854, 1330
|
4043, 4578
|
705, 710
|
2118, 3325
|
3438, 3676
|
1946, 2095
|
3729, 4020
|
725, 835
|
231, 248
|
372, 478
|
500, 620
|
636, 689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,358
| 143,503
|
38732
|
Discharge summary
|
report
|
Admission Date: [**2115-7-18**] Discharge Date: [**2115-7-19**]
Date of Birth: [**2075-8-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory failure; neurologic catastrophy, SDH
Major Surgical or Invasive Procedure:
none- pt arrived intubated with burr hole in place
History of Present Illness:
Mr. [**Name13 (STitle) **] is a 39 yo M w/ h/o ETOH cirrhosis and
thrombocytopenia who presented to OSH after being found down and
unresponsive in bloody vomitus at home by his mom. At OSH, he
was found to have a large left SDH with midline shift and a burr
hole was placed prior to transfer here. In our ED, he was noted
to have decerebrate posturing and CT head showed Sub falcine and
left transtentorial herniation. CT C spine also didn't show any
fracture.
.
In the ED, neurosurgical c/s thought "extent and severity of the
injury is not amenable to neurosurgerical intervention ".
Neurology was then consulted for possible medical management and
recommended [**Hospital1 **] IV keppra (first dose given in ED)
.
GI was also consulted in ED for GI bleed. Octreotide was
started, pantoprazole IV 40mg and the pt was typed and crossed
x4. He recieved 1u PRBCS and 2 u plt in ED. In the ED, he got
propofol briefly for shakes. NEOB was called from [**Location **] for
possible organ donation eligibility. Of note, pt was
persistently tachy to 120s in ED with transfer vitals: 129
106/66 100% on vent 23.
.
On arrival to the floor, pt is intubated off all pressors and
unresponsive. Pts mom states pt was c/o headache last few days.
Was seen the night of [**7-17**] and then she found him roughly [**1-4**]
hrs later.
.
Review of systems:
unable to obtain at this time
Past Medical History:
EtOH abuse--2 pints of vodka daily
Hx of alcohol withdrawal
Thrombocytopenia [**2-19**] liver cirrhosis
Cirrhosis x 2 years
Hx of biliary sludge
S/p fusion of right elbow 3-4 weeks ago
S/p remote jaw surgery
Social History:
Lives alone, recently feels lonely. States that family lives
close by. Drinks [**1-19**] pints of vodka daily. Currently does not
work, retired from department of corrections.
Family History:
Mother with hypertension and osteoporosis
Physical Exam:
Tmax: 38.1 ??????C (100.5 ??????F)
Tcurrent: 38 ??????C (100.4 ??????F)
HR: 120 (120 - 144) bpm
BP: 88/43(55) {87/43(55) - 130/73(87)} mmHg
RR: 20 (16 - 25) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
Respiratory
O2 Delivery Device: Endotracheal tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 500 (500 - 500) mL
Vt (Spontaneous): 496 (496 - 496) mL
RR (Set): 10
RR (Spontaneous): 2
PEEP: 5 cmH2O
FiO2: 50%
PIP: 17 cmH2O
Plateau: 15 cmH2O
Compliance: 50 cmH2O/mL
SpO2: 100%
ABG: 7.40/40/69/21/0
Ve: 9.4 L/min
PaO2 / FiO2: 138
Physical Examination
General Appearance: Well nourished
Eyes / Conjunctiva: No(t) PERRL, Pupils dilated, Sclera edema,
pupils midline, fixed and dilated
Head, Ears, Nose, Throat: Endotracheal tube, burr hole over left
lateral scalp- dressing with blood c/w active ooze
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : at bases bilat)
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+
Skin: Warm, No(t) Rash: , Jaundice
Neurologic: Responds to: Unresponsive, Movement: Non
-purposeful, Tone: Increased, pt with periodic shaking. Cold
calorics without any appreciated eye mvmt. no corneal reflex.
Pertinent Results:
Admission labs:
[**2115-7-18**] 05:25PM BLOOD WBC-10.3 RBC-3.31* Hgb-10.7* Hct-31.6*
MCV-96 MCH-32.2* MCHC-33.7 RDW-17.6* Plt Ct-41*
[**2115-7-18**] 05:25PM BLOOD PT-15.0* PTT-74.4* INR(PT)-1.3*
[**2115-7-18**] 05:25PM BLOOD Plt Ct-41*
[**2115-7-18**] 05:25PM BLOOD Fibrino-245
[**2115-7-18**] 07:04PM BLOOD UreaN-6 Creat-0.7 Na-146* K-3.0* Cl-103
HCO3-22 AnGap-24*
[**2115-7-18**] 07:04PM BLOOD ALT-17 AST-216* AlkPhos-212*
[**2115-7-18**] 05:25PM BLOOD Lipase-25
[**2115-7-18**] 05:25PM BLOOD ASA-NEG Ethanol-269* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2115-7-18**] 07:05PM BLOOD Type-ART Rates-/14 Tidal V-500 O2
Flow-100 pO2-541* pCO2-47* pH-7.38 calTCO2-29 Base XS-2
-ASSIST/CON Intubat-INTUBATED
[**2115-7-18**] 05:31PM BLOOD Glucose-138* Lactate-5.3* Na-151* K-3.0*
Cl-103 calHCO3-26
[**2115-7-18**] 05:31PM BLOOD Hgb-11.5* calcHCT-35 O2 Sat-96 COHgb-2.3
MetHgb-0.1
[**2115-7-18**] 05:31PM BLOOD freeCa-0.89*
[**2115-7-18**] CT head: 1. Large left-sided extra-axial hematoma which
is actively bleeding, with small foci of left subarachnoid and
intraventricular blood.
2. Massive rightward shift of midline structures with subfalcine
and downward transtentorial herniation.
3. Comminuted focal left temporal bone fracture and subgaleal
hematoma.
[**2115-7-18**]
CT c SPINE: No acute cervical spine fractures or malalignment is
detected
Brief Hospital Course:
Mr. [**Name13 (STitle) **] is a 39 yo M w/ h/o ETOH cirrhosis and
thrombocytopenia who presented to OSH after being found down in
bloody vomitus at home by his mom
.
CT head in this pt on admission showed a large, extensive SDH
with several shades suggesting possible old as well as new
blood. Pt on admission without many cranial nerve reflexes on
exam c/w herniation seen on CT. However, he continued to
demonstrate spontaneous respiratory efforts, breathing in excess
of the set ventialtory rate (i.e. did not fulfill criterion for
brain death). After discussion with ICU team, pt's mother made
him DNR shortly after arrival to the ICU. [**Location (un) 511**] Organ Bank
was referred this case from the ED and on board to start
preparations for possible organ donation.
Neurology contact[**Name (NI) **] by the ICU team did not think mannitol would
help pt at this late stage. Neurosurgery didn't think surgical
intervention appropriate either. Cefazolin was ordered given
burr hole in place. Overnight, he recieved supportive tx
including electrolyte repletion, IVF and blood products, PPI and
octreotide gtts for likely GIB.
Unfortunately, at about 6am, the pt became tachycardic to 150s
and abruptly became bradycardic and then had a cardiac arrest.
His mother (who is next of [**Doctor First Name **]) was at the bedside. He was
pronounced at 6:10am with causes of death listed as brain
herniation, SDH, ETOH cirrhosis with thrombocytopenia however
the case was accepted by the medical examiner so this could
changed on the official death certificate. NEOB states they will
likely still try to harvest tissue from the pt and will arrange
this with his mother and the Medical Examiner.
Medications on Admission:
Unknown
Discharge Medications:
pt deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
brain herniation
SDH
ETOH cirrhosis
GIB
thrombocytopenia
Discharge Condition:
pt deceased.
Discharge Instructions:
pt deceased.
Followup Instructions:
pt deceased.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
Completed by:[**2115-7-19**]
|
[
"571.2",
"303.91",
"518.81",
"780.01",
"285.1",
"578.0",
"V45.4",
"348.4",
"276.0",
"432.1",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7017, 7026
|
5226, 6922
|
364, 416
|
7127, 7141
|
3844, 3844
|
7202, 7371
|
2258, 2301
|
6980, 6994
|
7047, 7106
|
6948, 6957
|
7165, 7179
|
2316, 3825
|
1784, 1816
|
276, 326
|
444, 1765
|
4799, 5203
|
3861, 4790
|
1838, 2048
|
2064, 2242
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,504
| 138,692
|
31434
|
Discharge summary
|
report
|
Admission Date: [**2114-3-16**] Discharge Date: [**2114-3-19**]
Service: MEDICINE
Allergies:
Prednisone / Isordil / Ace Inhibitors
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 29250**] is a [**Age over 90 **] year old male with history of CHF and
previous admissions for acute heart failure who presents with
acute onset dyspnea, without any chest pain. He has had multiple
admissions to [**Hospital1 18**], [**Hospital1 882**], and [**Hospital 100**] rehab within past
several months for CHF, C. difficile, and GI bleeding, the
latter two necessitating diuretic dose reduction with resultant
CHF exacerbations. Patient presents today after dyspnea while
getting up to go to the bathroom. He denied any chest pain
associated with this. EMS was called and administered 50mg IV
furosemide on initial evaluation and placed on non-rebreather
for decreased oxygen saturation. Patient was then brought to the
emergency room, where he was noted to also be hypertensive to
225/110. He was then placed also on a nitroglycerin gtt and for
his hypoxia, he was also started on BiPAP. Eventually, his blood
pressure improved to systolic 140s and his oxygenation improved
so that he was transitioned from BiPAP to nasal cannula and his
nitroglycerin gtt was turned off. He did receive a dose of
levofloxacin empirically prior to chest x-ray.
Of note, patient has been on long-standing oral vancomycin and
metronidazole for which the duration needs to be clarified by
discussion with [**Hospital 100**] Rehab.
Past Medical History:
CAD s/p at least 2 MIs per patient, first at age 58
CHF with past hospital admissions for this
Chronic Kidney Disease
DM II
COPD - Smoked 4ppd for 50 years, on 2 litres Home O2
Peptic Ulcer Disease s/p rx for H.pylori
HTN
h/o Testicular cancer
h/o pancreatitis
s/p cholecystectomy
s/p L parotidectomy complicated by facial nerve paralysis
Social History:
no current alcohol/tobacco, lives with wife but most recently
from STR. The patient lives with his wife in a senior
housing where they have their own apartment. He is a retired
truck driver. He smoked tobacco for about 50 years at two to
four packs per day and quit in [**2080**] after his first myocardial
infarction. No ETOH. He has two daughters and four
grandchildren and six great grandchildren with one on the way.
Family History:
He has multiple other relative with hypertension, coronary
artery disease, and diabetes.
Physical Exam:
Discharge physical exam
BP:150s/70s, HR:90s, O2Sat:94% on 2L, Weight 67.9kg
Neck: Supple with JVP 12 cm
Lungs: CTAB
Ext: 1+ lower extremity bilateral edema
Pertinent Results:
[**2114-3-16**] 06:05PM BLOOD WBC-8.5 RBC-4.29*# Hgb-13.5*# Hct-40.4#
MCV-94 MCH-31.5 MCHC-33.5 RDW-15.7* Plt Ct-230
[**2114-3-17**] 04:28AM BLOOD WBC-5.0 RBC-3.59* Hgb-11.6* Hct-33.1*
MCV-92 MCH-32.2* MCHC-34.9 RDW-15.7* Plt Ct-207
[**2114-3-19**] 06:15AM BLOOD WBC-4.3 RBC-3.31* Hgb-11.1* Hct-30.6*
MCV-93 MCH-33.5* MCHC-36.2* RDW-15.9* Plt Ct-213
[**2114-3-16**] 06:05PM BLOOD Glucose-150* UreaN-77* Creat-3.8* Na-142
K-4.5 Cl-101 HCO3-29 AnGap-17
[**2114-3-17**] 04:28AM BLOOD Glucose-92 UreaN-79* Creat-3.7* Na-141
K-4.3 Cl-101 HCO3-28 AnGap-16
[**2114-3-18**] 04:37AM BLOOD Glucose-82 UreaN-76* Creat-3.7* Na-141
K-4.5 Cl-100 HCO3-31 AnGap-15
[**2114-3-18**] 05:30PM BLOOD Glucose-112* UreaN-76* Creat-3.6* Na-142
K-3.9 Cl-99 HCO3-32 AnGap-15
[**2114-3-19**] 06:15AM BLOOD Glucose-94 UreaN-72* Creat-3.7* Na-141
K-4.4 Cl-99 HCO3-32 AnGap-14
[**2114-3-16**] 06:05PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2114-3-17**] 04:28AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2114-3-16**] 06:05PM BLOOD CK(CPK)-54
[**2114-3-17**] 04:28AM BLOOD CK(CPK)-28*
[**2114-3-17**] 04:28AM BLOOD Calcium-9.0 Phos-4.9*# Mg-2.3 Cholest-118
[**2114-3-18**] 04:37AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.4
[**2114-3-17**] 09:38AM BLOOD %HbA1c-5.8
[**2114-3-17**] 04:28AM BLOOD Triglyc-101 HDL-27 CHOL/HD-4.4 LDLcalc-71
Chest x-ray [**2114-3-16**]:
UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette is
unchanged, and
appears to be within normal limits. Diffuse opacification of the
right
hemithorax with haziness of the pulmonary vascular markings is
compatible with pulmonary edema. Similar findings are seen
within the left lung, but not as severe in extent, compatible
with asymmetric edema. Bibasilar opacities are also
demonstrated, compatible with atelectasis. Small pleural
effusions are likely present. The aorta demonstrates
calcifications at its arch. No pneumothorax.
Chest x-ray [**2114-3-18**]:
FINDINGS: Compared to the prior study, there are worsening
pleural effusions bilaterally, but right more so than left.
Retrocardiac density is unchanged. Upper lungs remain clear. No
evidence for progressive distention of the pulmonary vessels. No
definite new consolidations. A stable well-circumscribed 2 cm
mass is seen right lower lobe which has been seen back to a CT
scan of [**2112**].
Renal artery ultrasound:
1. Small shrunken kidneys, more so on the right, with cortical
thinning and increased echogenicity consistent with chronic
kidney disease. Findings unchanged.
2. Multiple renal cysts as previously demonstrated.
3. Very limited Doppler examination due to patient's inability
to hold
breath. Normal arterial upstroke demonstrated at right renal
hilum.
Brief Hospital Course:
1) Acute on chronic systolic CHF - Thought secondary to worse
hypertension (presented with blood pressure 225/110). Patient
transiently required nitroglycerin drip and non-invasive
positive pressure ventilation with BiPAP but this had been
titrated off by the time patient arrived in the CCU. He
required a few more doses of IV furosemide, and was transitioned
back to his outpatient regimen of furosemide 60mg PO daily.
Patient was ruled out for MI with serial cardiac enzymes,
telemetry and EKG. In addition, patient was started on
Isosorbide dinitrate for afterload reduction. Records had
listed this medication as causing adverse effects (headache) but
patient tolerated it well while in the hospital. Plan is to
continue furosemide, hydralazine, Isosorbide dinitrate and
follow-up with [**Hospital 1902**] clinic, Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] on [**2114-4-2**] at 1:00
PM. Likely ischemic cardiomyopathy given history of MI, no
coronary angiographies per our records, perhaps due to patients
advanced chronic renal failure. This exacerbation likely
precipitated by uncontrolled hypertension and flash pulmonary
oedema.
.
2) Hypertension - Given dramatic elevation of blood pressure,
patient required nitroglycerin gtt temporarily. He underwent
renal artery ultrasound to rule-out stenoiss, but this was a
limited evaluation. He was started on Isordil in addition to
his other anti-hypertensives, and his blood pressure improved to
systolic of 150s.
.
3) Coronary artery disease - patient with previous history of
two MIs. No cardiac catherization reports recorded. Patient is
already on full dose statin, aspirin, carvedilol as outpatient.
Continued aspirin, statin, and carvedilol.
.
4) Rhythm - Patient had normal sinus rhythm with left bundle
branch block.
.
5) COPD: Extensive smoking history, though no documented
obstructive disease by PFTs. Dyspnea secondary to CHF as above,
but can consider inhalers in addition if needed.
.
6) Diabetes: Patient with good control (repeat A1C this
admission was 5.8%) maintained on outpatient glipizide.
.
7) Chronic Renal insufficiency: Patient with admission Cr of 3.8
which appears to be his baseline. Patient not treated with an
ACE inhibitor as outpatient because on an allergy. Has refused
dialysis in the past, but potassium was stable during this
admission and there were no signs of uremia.
.
8) C. difficile colitis - Patient continued his Vancomycin taper
and metronidazole which he was receiving at home, with plan to
complete this course on [**2114-3-20**].
.
9) Prophylaxis: Patient written for heparin subcutaneous for VTE
prophylaxis.
.
10) Code status: DNR/DNI
.
11) Communication: with daughter [**Telephone/Fax (1) 74022**] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 73985**]
Medications on Admission:
Atorvastatin 80 mg PO daily
Calcitriol 0.25 mcg capsule PO daily
Calcium Acetate 667 1 capsule PO TID with meals
Carvedilol 6.25 mg PO BID
Folic acid 1 mg PO daily
Lasix 20 mg PO daily
lasix 40 mg PO daily
Gabapentin 300 mg PO daily
Glipizide 5 mg PO BID
Hydralazine 25 mg PO TID
Flagyl 500 gm PO TID
Vanco 125 mg PO QID
Tylenol 325 mg PO PRN
Aspirin 81 mg PO daily
Polysaccharide Irone complex 150 mg capsule PO daily
Vit B 1 capsule PO daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
9. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days: To complete last day on [**2114-3-20**], for C.
difficile.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days: To complete last day on [**2114-3-20**].
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
13. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
16. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
with meals.
17. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
18. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): hold for SBP < 100, HR < 55.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Acute on chronic systolic congestive heart failure.
Secondary diagnoses:
Chronic renal failure
Diabetes mellitus
Discharge Condition:
Stable, on 2 litres of oxygen which is same amount patient uses
at home.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
You were admitted for shortness of breath due to heart failure.
You received a medication called Lasix to help remove some fluid
out of your lungs. Please continue to take medications as
detailed below. You were also started on isosorbide dinitrate
for the prevention of further episodes. You were monitored
closely when starting this because of note in previous records
that you experienced headaches. You tolerated the Isosorbide
dinitrate (Isordil) without adverse effects. Please discuss
with Dr. [**First Name (STitle) 437**] whether it would be helpful for you to stay on
this medication.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) 437**] on Monday [**2114-4-2**] at 1:00 PM.
Completed by:[**2114-3-19**]
|
[
"428.0",
"414.8",
"585.9",
"008.45",
"496",
"412",
"250.00",
"403.00",
"V10.47",
"428.23"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10306, 10385
|
5406, 8226
|
253, 260
|
10543, 10618
|
2730, 5383
|
11367, 11491
|
2449, 2539
|
8721, 10283
|
10406, 10459
|
8252, 8698
|
10642, 11344
|
2554, 2711
|
10480, 10522
|
206, 215
|
288, 1631
|
1653, 1994
|
2010, 2433
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,965
| 165,958
|
50724
|
Discharge summary
|
report
|
Admission Date: [**2191-6-18**] Discharge Date: [**2191-6-20**]
Date of Birth: [**2117-2-27**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Ambien
Attending:[**First Name3 (LF) 105518**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Name14 (STitle) 105519**] is a 74 year-old female with ESRD, DM2 who was at
HD on [**2191-6-18**] when she developed acutely altered mental status.
Per EMS report, she had sBP in the 70s after HD that lasted for
about 4 hours. Blood glucose was 168. She was confused and
unable to answer questions. She was transported to [**Hospital1 18**] and at
that time her SBP increased to 90s without intervention.
.
In the ED, vitals were 97.1, 94/64, 74, 20, 100% RA. The patient
could answer questions well but did not know her location. She
was noted to have a positive UA. Blood cultures were obtained
and she was started on Meropenum (for history of ESBL UTI). EKG
showed deepening ST depresssions in V1-V5, I, II. Troponin WAS
0.02 (at baseline = 0.03). She was admitted to the ICU for for
rule-out MI and monitoring of UTI in setting of hypotension. She
was given 2L of NS.
.
She denied any pain, cheat pain, shortness of breath, nausea,
numbness/tingling, diarrhea. She stated she is anueric and
denies dysuria or burning. Per report she has a history of C
diff.
Past Medical History:
1. Diabetes mellitus type 2, complicated by gastroparesis with
chronic nausea, ESRD from nephropathy, peripheral neuropathy
2. Hypertension
3. Hypercholesterolemia
4. Dual chamber pacemaker placement [**4-23**] for sick sinus syndrome
5. Paroxysmal atrial fibrillation, not on Coumadin
6. Echo [**6-29**] with EF 55%, mild AS, mild PulmHTN
7. Chronic urinary tract infections
8. Depression
9. Peripheral [**Month/Year (2) 1106**] disease status post left tarsal
amputation, left [**Doctor Last Name **]-plantar bypass [**8-26**]
10. Possible renal artery stenosis
11. Nephrolithiasis and staghorn calculus
12. Gastritis with history of gastrointestinal bleed
13. Internal hemorrhoids
14. History of catheter-associated DVT in right upper extremity
15. Focal high grade dysplasia in cecal polyp in [**2185**]
16. ERSD on HD with history of tunnelled line infection
17. History of C.Diff
18. Recurrent line infection: Last in [**3-30**] with sensitive
K.Pneumonia
19. History of ESBL E. coli infection
Social History:
[**Last Name (un) 27474**] [**Telephone/Fax (1) 105520**] (C), Daughter- and health care proxy
Lives at [**Hospital 100**] Rehab.
Speaks Russian--all communication was via interpreter
Non-smoker, no alcohol, no illicit drugs, no history of IV drug
use.
Family History:
Father died from lung cancer, mother died at age [**Age over 90 **].
Physical Exam:
VSS 106/43, 66, 20, 97% NC 2L
Gen: Sleeping comfortably
HEENT: Sclera anicteric; noncooperative with EOMI or OP
examination
Neck: JVD to earlobe at approximately 30 degrees
CV: Regular; normal S1/ pronounced S2; I/VI early systolic
murmur LUSB
Chest: Respirations unlabored; no accessory muscle use; CTA
bilaterally without wheezes/rales/rhonchi, although examination
limited
Abd: Hypoactive bowel sounds; soft, non-tender, non-distended
Ext: L foot w/ toes amputated; left foot cool; unable to palpate
DP/PT pulse left foot, otherwise reduced pulses bilaterally, DP
and radial
Skin: Tunneled line site C/D/I; unstageable sacral decubitus
ulcer without circumferential erythema or warmth
Neuro: Not cooperative with CN or strength examinations
Pertinent Results:
Labs on admission:
[**2191-6-18**] 04:00PM WBC-7.4 RBC-4.51 HGB-13.2 HCT-42.5 MCV-94
MCH-29.3 MCHC-31.1 RDW-17.0*
[**2191-6-18**] 04:00PM NEUTS-79.7* LYMPHS-12.9* MONOS-5.9 EOS-1.1
BASOS-0.3
[**2191-6-18**] 04:00PM PLT COUNT-210
[**2191-6-18**] 04:00PM PT-12.9 PTT-29.1 INR(PT)-1.1
[**2191-6-18**] 04:00PM GLUCOSE-151* UREA N-11 CREAT-1.4* SODIUM-141
POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-24 ANION GAP-17
[**2191-6-18**] 05:16PM LACTATE-1.5
[**2191-6-18**] 04:00PM cTropnT-0.02*
[**2191-6-18**] 03:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2191-6-18**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2191-6-18**] 03:30PM URINE RBC-0-2 WBC-[**12-10**]* BACTERIA-MOD
YEAST-NONE EPI-0-2 TRANS EPI-<1
Imaging:
CXR: [**2191-6-17**]
1. Patient is rotated to the right.
2. The patient's pacer battery pack overlies the left mid lung
and a small
consolidation in this region is not excluded. Otherwise, the low
volume lungs are clear.
CT head: [**2191-6-17**]
1. No acute intracranial pathology.
2. Chronic small vessel ischemic disease, lacunar infarcts and
age-related
involutional changes are present.
Brief Hospital Course:
# Hypotension: On arrival the ICU, patient reported feeling
well. She was given a total of 1.2 L fluid over the length of
stay and her BP remained in the 110s to 150s. There was initial
concern that she had a urosepsis due to pyuria and bacteruria on
UA and she was started on antibiotics with meropenem. However,
her urine culture was negative and the antibiotics were stopped.
Blood cultures also remained negative. It was thought that her
hypotension was from hemodialysis and poor po intake. She
remained in the ICU overnight and was hemodynamically stable.
She was transferred out of the unit to the medicine floor and
continued to be normotensive. Her lisinopril and metoprolol
were restarted and she continued to do well. There were no
other changes to her medications prior to discharge.
.
# AMS: Upon admission, the patient was oriented to person and
"hospital" and "[**2191**]" but did not know the exact place or month.
She had a CT scan of her head in the ED which did not show
evidence of acute pathology. Her mirtazepine and oxycodone were
initially held. She was given IV fluids and her blood pressure
normalized. Her mental status also improved. She can restart
her home medications as her altered mental status was thought to
be due to her hypotensive event after hemodialysis.
.
# EKG changes: The patient was found to have worsening of known
ST depressions in lateral leads with hyperacute T waves on EKG.
Cardiac enzymes were cycled times 5 and remained stable (0.02 -
0.05). There were no evolving q waves and the patient denied
any chest pain, shortness of breath, nausea, tingling,
diaphoresis or other symptoms consistent with acute coronary
syndrome. She was continued on aspirin 325 mg and monitored on
telemetry. She had no events. Her last exercise Stress test in
[**2187**] showed no anginal symptoms or additional ECG changes noted
during the procedure and normal myocardial perfusion on nuclear
imaging. She may need to have another perfusion stress test in
the future to assess her coronary artery status.
.
# ESRD: The patient is on HD, T/Th/Sat. Last dialysis was
[**2191-6-18**] prior to admission. She was not dialyzed during this
admission. She was continued on Sevelamer and Sensipar.
.
# DM2: The patient was placed on insulin sliding scale and given
a diabetic diet.
.
# Sacral Decubitus ulcer: Noted on arrival. A wound consult and
nutrition consult were pending at the time of discharge. She
should continue to get wound care with daily dressing changes,
- would cleanse the wound, apply iodosorb and change dressing
daily
- patient will need step 1 mattress
- turn the patient every 2 hrs while in bed
- Up to the chair [**Hospital1 **], provide pressure reducing surface and
shift weight q 1 hr while in a chair.
.
# PVD: With recent finding occlusion of left
popliteal-to-plantar artery bypass graft on [**2191-5-5**]. The
patient was continued on [**Date Range **] and Simvastatin.
.
# Chronic CHF: No evidence of volume overload at this time. Last
Echo with perserved EF but with mild pulmonary hypertension. The
patient's lisinopril was initially held in the setting of
hypotension, but was restarted prior to discharge.
.
# Paroxysmal AF: Not anticoagulated for unclear reasons. The
patient was continued on metoprolol for rate control and
aspirin. Her anticoagulation should be addressed to clarify the
cost/benefits of coumadin therapy.
.
# HTN: As stated above, the patient's lisinopril and metoprolol
were initially held in the setting of hypotension. But after
this resolved, they were both restarted at her usual dose.
.
# Gastritis: Denies current abdominal pain. The patient was
continued on her outpatient omeprazole.
.
# Depression / Anxiety: The patient's Mirtazpine and lorazepam
were both initially held given her altered mental status.
However they can be restarted at discharge.
.
Medications on Admission:
Oxycodone 10 mg Q6hr PRN
Aspirin 325 mg Qday
Omeprazole 20 mg Q day
Bisacodyl 5 mg Q day
Sevelemer 1200 mg TIDAC
Metoprolol tartrate 50 mg [**Hospital1 **]
Buproprion 150 mg [**Hospital1 **]
Acetominophen 650 mg [**Hospital1 **]
Cyanocobalamin 1000 mcg Q month
Senna 17.2 mg [**Hospital1 **]
Mirtazepine 30 mg QHS
Lisinopril 10 mg Q day
Simvastatin 20 mg Q pm
Polyethylene glycol 17 gm QBID
Discharge Medications:
1. Oxycodone 5 mg Capsule Sig: [**1-22**] Capsules PO every six (6)
hours.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. Sevelamer HCl 400 mg Tablet Sig: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
once a month.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
15. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnosis:
Hypotension after hemodialysis
Altered mental status during hypotension
Secondary diagnosis:
Diabetes type II
Sacral decubitus ulcer
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 came to the hospital because you were having confusion and
low blood pressure after hemodialysis. You were given IV fluids
and your blood pressure returned to [**Location 213**]. Your urine was
checked for an infection but there was none.
There were no changes to your medications. You should plan to
have dialysis again tomorrow at your regularly scheduled time
and location.
Please follow up with your doctor at your rehab.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please go to the following already scheduled appointments
Department: [**Name8 (MD) **] SURGERY
When: WEDNESDAY [**2191-6-22**] at 3:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"427.31",
"250.40",
"V45.01",
"272.0",
"458.21",
"443.81",
"V45.11",
"250.70",
"585.6",
"707.25",
"707.03",
"250.60",
"536.3",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10445, 10511
|
4821, 8695
|
306, 313
|
10708, 10708
|
3577, 3582
|
11433, 11811
|
2727, 2797
|
9137, 10422
|
10532, 10532
|
8721, 9114
|
10884, 11410
|
2812, 3558
|
245, 268
|
341, 1414
|
4634, 4798
|
10645, 10687
|
10551, 10624
|
3597, 4625
|
10723, 10860
|
1436, 2440
|
2456, 2711
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,277
| 198,836
|
34777
|
Discharge summary
|
report
|
Admission Date: [**2156-10-6**] Discharge Date: [**2156-10-9**]
Date of Birth: [**2129-6-30**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Codeine / Oxycodone
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
progression of L5/S1 spondylolisthesis
Major Surgical or Invasive Procedure:
1. Anterior interbody arthrodesis through a posterior
interbody approach at L5-S1.
2. Application of interbody cage L5-S1.
3. Posterolateral fusion.
4. Posterolateral instrumentation to L5 and S1 with pedicle
screw construct.
5. Open treatment of fracture dislocation of L5 on S1 with
traumatic spondylolisthesis grade 1/grade 2.
6. Posterior L5 laminectomy with medial facetectomy of L5-
S1 and foraminotomy bilaterally.
7. Bilateral laminotomies of L4 with L4-L5 medial
facetectomy and bilateral far lateral decompressions of
the L4 nerve roots with removal of the pars bilaterally
and complete far lateral decompression of the L4 nerve
roots.
8. Left iliac crest bone graft with morcellized graft
placed in interbody position.
History of Present Illness:
This gentleman was admitted to [**Hospital1 18**] following highspeed
motorcycle accident with multiple injuries. He was evaluated at
that time by the Spine service for multiple spinous
procress/transverse process fractures of the lower lumbar spine,
L5/S1 disc herniation and MRI findings concerning for
ligamentous injury. He was treated initially with bracingin
TLSO. In following him in the postoperative period, he had
development of a grade 1 spondylolisthesis followed by a grade 2
spondylolisthesis with significant kyphosis and
spondylolisthesis on flexion-extension views. Therefore, the
risks and benefits of surgical stabilization with possible
extension from an L4-S1 fusion were discussed with him in
detail.
Past Medical History:
s/p highspeed motorcycle crash [**8-6**]:
Injuries:
Bilateral retroperitoneal renal lacerationss (R Grade 1, L Grade
2), Left flank laceration (open)
S1 spinous process fractures
L5 spinous fracture
L4 comminuted left transverse process fracture
L3 bilateral transverse process fracture (comminuted on left)
Left non-displaced distal clavicle fracture
Left femur fracture
Pulmonary contusion
Left pleural effusion
Acute blood loss anemia
s/p IMN L femur, I&D L flank wounds with abdominal wall
reconstruction
Social History:
noncontributory
Family History:
Noncontributory
Physical Exam:
Well appearing, NAD
Prior left thigh surgical incisions well healed
Kyphotic deformity with palpable step-off lower lumbar spine
[**5-3**] motor strength bilateral adductors/quads/HS/TA/GS - [**4-3**] R
[**Last Name (un) 938**] (old finding per patient from prior injury) [**5-3**] [**Last Name (un) 938**] on left
SILT L2-S1
Nl rectal tone
2+ quad/achilles reflexes - no clonus
Pertinent Results:
[**2156-10-6**] 10:33PM HCT-33.9*
Brief Hospital Course:
27 yoM with multiple lumbar spinous processes and
transverse process fractures with disc herniation at L5-S1. He
was placed in a brace for concern of ligamentous injury. Upon
follow-up slip was noted to progress radiographically and
patient was admitted following scheduled/elective procedure
listed above. Post-operative course was without complication.
He received routine perioperative antibiotics and DVT
prophylaxis throughout hospitilization with teds/pneumoboots.
He was noted to have no change in neurologic examination
post-operatively. Pain was controlled with IV and then po
narcotics. Hemovac was d/c'ed when output was <30cc/8 hours.
Incisions were noted to be clean/dry/intact upon discharge.
Physical therapy evaluated the patient during hospitilization.
He was made activity as tolerated, warm and form brace for
comfort with no bending/twisting or lifting >5 lbs. He was
discharged to home in stable condition when cleared by PT and
medically stable.
Medications on Admission:
famotidine 20 mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
traumatic L5/S1 spondylolisthesis
Discharge Condition:
stable
Discharge Instructions:
You have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: You may have been given a brace. This brace is to be
worn when you are walking. You may take it off when sitting in a
chair or while lying in bed.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
o We will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
2 weeks
|
[
"738.4",
"722.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.08",
"03.09",
"80.51",
"77.79",
"84.51",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
4268, 4274
|
2922, 3896
|
323, 1091
|
4352, 4361
|
2862, 2899
|
6708, 6719
|
2430, 2447
|
3980, 4245
|
4295, 4331
|
3922, 3957
|
4385, 4463
|
2462, 2843
|
4725, 5183
|
6200, 6685
|
4497, 4707
|
245, 285
|
5195, 6188
|
1119, 1846
|
1868, 2381
|
2397, 2414
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,104
| 113,352
|
44052
|
Discharge summary
|
report
|
Admission Date: [**2187-2-17**] Discharge Date: [**2187-2-25**]
Date of Birth: [**2148-11-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Cellulitis/fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
38 yo with known hypertension/hyperlipidemia/Diabetes Mellitus
presents with a 4 day history of cellulitis RLE, started
cephalexin and bactrim the day prior to presentation without
improvement. On the day of admission, the temperature increased
to 101.4 at home and he called PCP who advised to go to ER.
Temperature at ED: 101, wbc 24, creat 2.7 (baseline 1.7). Pan
cultured, started iv vanco and unasyn, iv rehydration. u/s and
xray of RLE prelim were negative. The patient was admitted after
discussion with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
.
ROS
Denied any precipitant of cellulitis; no falls/abrasion, trauma.
No other complaints: No CP, SOB, palpitations. No GI/GU
complaints.
Past Medical History:
DIABETES TYPE 2 ([**First Name8 (NamePattern2) **] [**Last Name (un) **]; in [**Last Name **] problem list says type 1)
HYPERCHOLESTEROLEMIA
HYPERTENSION
OBESITY
ASTHMA; never been intubated
TOBACCO ABUSE
S/P APPY
TO THE ER
Chronic RENAL INSUFFICIENCY
OTITIS
Obesity
Social History:
He lives in [**Location 686**] with his wife, their 11 [**Name2 (NI) **] son and two
step sons. Pt states he is a long-time smoker, but has quit
several times in the past and does not see smoking as a problem
for him. Occasional EtOH at parties, no IVDU.
Family History:
Diabetes
Physical Exam:
T: 98.0 BP: 126/72 P: 86 RR: 22 O2 sats: 92RA FS: 181
Gen: NAD
HEENT: NC/AT, EOMI
Neck: supple, no [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: RRR, no m/r/g
Resp: CTAB
Abd: obese, soft, NT/ND
Ext:
- RLE with areas of blanching erythema bordered with pen on
anterior aspect. No erythema over posterior aspect. Warm and
tender on palpation. Proximal leg with trace erythema/swelling.
- LLE wnl.
Neuro: grossly wnl
Sensation: wnl
Strength: [**2-22**] dorsi/plantar flexion of R foot; 5/5 strength on L
Reflexes: 1+ b/l DTR
Pertinent Results:
[**2187-2-16**] 03:45PM BLOOD WBC-12.9* RBC-4.83 Hgb-13.1* Hct-38.9*
MCV-81* MCH-27.1 MCHC-33.7 RDW-13.8 Plt Ct-308
[**2187-2-17**] 01:30PM BLOOD WBC-23.6*# RBC-4.48* Hgb-12.4* Hct-35.7*
MCV-80* MCH-27.7 MCHC-34.8 RDW-14.5 Plt Ct-256
[**2187-2-18**] 06:55AM BLOOD WBC-15.9* RBC-4.04* Hgb-11.0* Hct-32.4*
MCV-80* MCH-27.3 MCHC-34.1 RDW-14.5 Plt Ct-261
[**2187-2-19**] 07:35AM BLOOD WBC-15.8* RBC-4.00* Hgb-10.4* Hct-32.4*
MCV-81* MCH-26.0* MCHC-32.1 RDW-14.4 Plt Ct-262
[**2187-2-17**] 01:30PM BLOOD Neuts-83.7* Lymphs-11.4* Monos-4.4
Eos-0.3 Baso-0.2
[**2187-2-19**] 01:05PM BLOOD PT-12.0 PTT-45.7* INR(PT)-1.0
[**2187-2-17**] 01:30PM BLOOD Glucose-186* UreaN-37* Creat-2.7* Na-135
K-4.1 Cl-96 HCO3-30 AnGap-13
[**2187-2-18**] 06:55AM BLOOD Glucose-172* UreaN-48* Creat-3.7* Na-136
K-4.1 Cl-97 HCO3-27 AnGap-16
[**2187-2-19**] 07:35AM BLOOD Glucose-133* UreaN-59* Creat-4.0* Na-137
K-4.3 Cl-100 HCO3-27 AnGap-14
[**2187-2-18**] 06:55AM BLOOD Calcium-8.3* Phos-4.3 Mg-1.9 Cholest-207*
[**2187-2-19**] 07:35AM BLOOD calTIBC-225* VitB12-440 Ferritn-269
TRF-173*
[**2187-2-18**] 06:55AM BLOOD Triglyc-201* HDL-42 CHOL/HD-4.9
LDLcalc-125
[**2187-2-19**] 07:35AM BLOOD Vanco-8.8*
[**2187-2-19**] 03:59AM BLOOD Type-ART pO2-62* pCO2-56* pH-7.34*
calTCO2-32* Base XS-2 Intubat-NOT INTUBA Comment-NON-REBREA
[**2187-2-17**] 01:32PM BLOOD Lactate-1.1
- UNILAT LOWER EXT VEINS RIGHT [**2187-2-17**] 3:48 PM
FINDINGS: Color Doppler son[**Name (NI) 1417**] of the right common femoral,
superficial femoral, and popliteal veins were performed. There
was normal flow, augmentation, and waveforms demonstrated. There
was no intraluminal thrombus identified. Due to the patient body
habitus, compression images of the common and superficial
femoral arteries could not be obtained.
IMPRESSION: No evidence of right lower extremity deep vein
thrombosis. Somewhat limited study.
- RADIOLOGY TIB/FIB (AP & LAT) RIGHT [**2187-2-17**]
FINDINGS: There is a marked soft tissue edema and density, in
the proximal right lower extremity. There is no gas noted in the
subcutaneous tissue. There is no sign of fracture or dislocation
or degenerative change. There is no underlying cortical
reaction. There are no radiopaque foreign bodies.
IMPRESSION: Marked density and edema of soft tissues of the
proximal right lower extremity. Please note that absence of gas
does not rule out necrotizing fasciitis.
- RADIOLOGY CHEST (PA & LAT) [**2187-2-17**]
PA AND LATERAL CHEST RADIOGRAPH: The lung volumes are low.
Cardiomediastinal silhouette is unchanged. There is no evidence
of central lymphadenopathy. Lungs are clear, with the exception
of bibasilar atelectasis. There is no pleural effusion.
Pulmonary vascularity is normal.
IMPRESSION: No acute cardiopulmonary process
- RADIOLOGY Final Report CHEST (PORTABLE AP) [**2187-2-18**]
IMPRESSION: Stable appearance to the chest with no acute process
seen.
- RENAL U.S. [**2187-2-18**]
FINDINGS: Study is very limited secondary to large body habitus.
The left kidney measures 11.9 cm. The right kidney measures 10.7
cm. No hydronephrosis identified within the kidneys. No definite
mass lesion or stones identified.
IMPRESSION: Limited study secondary to increased body habitus.
No hydronephrosis identified and no definite mass lesion or
renal stones identified.
- LUNG SCAN [**2187-2-19**]
INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol
in 8 views
demonstrate mild decrease in tracer uptake in the posterobasilar
segment of the right lower lobe. Perfusion images in the same 8
views show a matched defect in the posterior right lower lobe.
No other perfusion defects are identified.
Chest x-ray shows an air space opacity in the right lower lobe
corresponding to the area of matched tracer defect.
IMPRESSION: Decreased perfusion and ventilation in the posterior
right lower lobe corresponding to an infiltrate on CXR. These
findings would be entirely compatible with air space disease,
but in the face of CXR findings, the possibility of pulmonary
embolism can not be fully excluded. No other segmental perfusion
defects are present.
- BILAT LOWER EXT VEINS [**2187-2-19**]
BILATERAL LOWER EXTREMITY ULTRASOUND: Compared to DVT study of
just two days prior. Grayscale and Doppler son[**Name (NI) 867**] were
performed of the bilateral lower extremity veins including the
greater saphenous, common femoral, superficial femoral,
popliteal, and deep tibial veins. Venous structures demonstrate
normal compression, flow, waveforms, and augmentation without
intraluminal thrombus. Note is made of large right groin lymph
nodes measuring up to 2.8 cm in long axis, demonstrating a
benign-appearing fatty hila, likely reactive given history of
cellulitis.
IMPRESSION:
1) No evidence of DVT.
2) Right groin adenopathy, likely reactive.
- CHEST (PORTABLE AP) [**2187-2-19**]
PORTABLE AP CHEST RADIOGRAPH: There is a new area of faint
opacity within the right lower lobe in comparison to the prior
study. The cardiac and mediastinal contours are stable. The
remainder of lungs are clear. There is no pulmonary vascular
congestion. No pleural effusions or pneumothorax seen.
IMPRESSION: New faint opacity in the right lower lobe may
represent an area of aspiration and/or consolidation.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2187-2-24**] 3:52 PM
LIVER OR GALLBLADDER US (SINGL; DUPLEX DOP ABD/PEL LIMITED
Reason: evaluate for evidence of hepatitis, gallbladder disease,
por
[**Hospital 93**] MEDICAL CONDITION:
38 year old man with diabetes, hypercholesterolemia, HTN, CRI
admitted for PE and ? cellulitis, now with elevated LFTs (new
since [**2187-2-15**]).
REASON FOR THIS EXAMINATION:
evaluate for evidence of hepatitis, gallbladder disease, portal
vein thrombosis
INDICATION: Diabetes, chronic renal failure, and admitted for
PE. Now with elevated LFTs. Evaluate for hepatitis, gallbladder
disease, portal vein thrombosis.
COMPARISON: [**2185-6-17**].
ABDOMINAL ULTRASOUND: The liver is diffusely echogenic
consistent with fatty infiltration. No focal lesions are seen.
The gallbladder is unremarkable with no stones or wall
thickening. The common hepatic duct measures 4 mm. There is no
intrahepatic biliary dilatation. The portal vein is patent with
anterograde flow. There is no ascites. The pancreas was not well
visualized due to overlying bowel gas. Limited views of the
right kidney demonstrate no hydronephrosis.
IMPRESSION: Echogenic liver consistent with fatty infiltration.
Other forms of liver disease including significant
fibrosis/cirrhosis cannot be excluded. Additionally, ultrasound
is not very sensitive for detection of hepatitis. Please
correlate clinically.
TIB/FIB (AP & LAT) RIGHT [**2187-2-24**] 1:39 PM
TIB/FIB (AP & LAT) RIGHT
Reason: eval for evidence of osteomyelitis
[**Hospital 93**] MEDICAL CONDITION:
38 year old diabetic male with cellulitis, pain on RLE (anterior
shin).
REASON FOR THIS EXAMINATION:
eval for evidence of osteomyelitis
EXAMINATION: Tibia and fibular, right.
INDICATION: Diabetes. Pain. Possible osteomyelitis.
Views of the right tibia and fibula show normal bony alignment
with no acute bony injury. No plain film findings are seen to
suggest osteomyelitis. No soft tissue gas or foreign material is
visualized. There is mild soft tissues swelling anterior to the
proximal tibia.
IMPRESSION:
No plain final film findings to suggest osteomyelitis. If this
remains a clinical concern, then a nuclear medicine study or MRI
would be more sensitive.
Brief Hospital Course:
# Cellulitis
Pt was started on keflex and bactrim as an outpatient on the day
prior to admission, but had called PCP because of fevers on day
of admission. On arrival to [**Name (NI) **], pt had LENIs, R TIB/FIB XR, and
CXR performed, which were all negative. He received vanco and
unasyn in ED and continued on floor. Temperatures were
monitored, and noted to spike despite antibiotics. Blood
cultures were drawn for each spike. His wbc trended downwards
from 26->15. Pt received dilaudid for pain control.
Subsequently he was switched to a regimen of vancomycin,
levofloxacin and flagyl. He was discharged on keflex x one week
and asked to finish his course of levo and flagyl.
# Hypoxia
Pt had desaturated to the 66% on RA while sleeping on routine
vital sign check on HD#2. Pt's lungs were clear, without
wheeze/rales/crackles. Given his asthma hx, albuterol/atrovent
nebs were provided. An EKG and CXR were also performed which
showed no change from prior. His temperature was also elevated
at the time, and thus another set of blood culture was sent.
Blood cultures from [**2-19**] were again negative, and ASO negative as
well.
The patient then had an episode of shortness of breath early
morning of HD#3. Pt was noted to be saturating at 76% on RA
when he ambulated to the use the bathroom. Pt was placed on NC,
and was 85%. Thus, was placed on NRB and saturating 93%. He
was without CP, palpitations, or any other complaints. SOB was
improved on NRB. His vitals at the time of incident was: 102.3
108 118/70 22. Another CXR and LENIs were ordered, which were
negative, ABG was done: 7.34/56/62. Repeat EKG showed no acute
changes. Moreover, his creatinine had increased up to 4.0.
On exam, the patient's lungs had crackles, and thus lasix was
given with renal consult.
Pt had a V/Q scan performed and he was found to have decreased
perfusion and ventilation in the posterior right lower lobe
corresponding to an infiltrate on CXR. These findings would be
entirely compatible with air space disease, but in the face of
CXR findings, the possibility of pulmonary embolism could not be
fully excluded. No other segmental perfusion defects were
present. Pt remaind on NRB and was achieving low 90s. MICU
consult was obtained, and the patient was transferred to the
MICU for persistent hypoxia. Because the patient had remained
relatively immobile with his cellulitis, clinical suspicion for
PE warranted the initiation of anticoagulation with heparin
bridge to coumadin. Heparin was d/c on [**2-23**]. Coumadin was
initially given at 7.5 mg, then 5 mg, and he was discharged on 3
mg with instructions to see his PCP within [**Name Initial (PRE) **] day or two to
address the need for continued anticoagulation.
The patient was put on BIPAP for OSA in the ICU, and prior to
discharge it was arranged that he would get a BIPAP machine that
same day. He did not like the BIPAP but it was explained to him
that he required it for sleep apnea.
Prior to discharge, he ambulated on the floor and maintained his
oxygen sats >95% at all times.
.
# Acute renal failure
The patient has known chronic renal insufficiency with bsl
creatinine of 1.7-2.1. On admission at [**Name (NI) **], pt's creatinine was
elevated to 2.7. It was remeasured on the following day and
showed an increase to 3.7. Urinary Na, creatinine, osm,
protein, eos were measured, and results were suggestive of
prerenal picture. Renal U/S was performed, which was a limited
study secondary to increased body habitus, but no hydronephrosis
identified and no definite mass lesion or renal stones
identified. IVF was started overnight of HD#2. Renal consult
was obtained. Recommendations included: Holding ACE-I,
continuing to Vanco dose was obtained was 8.8. Vancomycin was
continued until the day of discharge, at which time he was put
on Keflex for one week.
# DIABETES TYPE II, followed at [**Last Name (un) **], the patient's sugars
were well controlled on sliding scale insulin.
.
# HYPERCHOLESTEROLEMIA - Stable; Pt was continue on Lipitor.
Fasting lipids were drawn which were reasonable.
.
# HYPERTENSION - Stable; Pt was initiated on HCTZ, Cardia,
Lisinopril. Lisinopril was later held.
.
# TOBACCO ABUSE - offer nicotine patch prn
.
#.
# FEN: The patient was maintained on a regular - diabetic diet.
.
# PPX: SC hep
.
# CODE: FC
Medications on Admission:
Bupropion 100"
keflex, bactrim
insulin NPH
- 62u in AM, 52 in PM
HCTZ 50'
Cartia 180'
Lisinopril 40'
question other meds?
Discharge Medications:
1. Bupropion 100 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
2. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days: Last doses on [**3-1**].
Disp:*14 Tablet(s)* Refills:*0*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days: Last dose 4/12.
Disp:*4 Tablet(s)* Refills:*0*
7. Coumadin 3 mg Tablet Sig: Three (3) Tablet PO at bedtime:
Please take 3 mg daily, follow-up with your PCP on [**Month/Year (2) 3816**] for
dose adjustment. .
Disp:*5 Tablet(s)* Refills:*0*
8. Keflex 500 mg Tablet Sig: One (1) Tablet PO every six (6)
hours for 7 days: Last doses on [**2187-3-3**].
Disp:*28 Tablet(s)* Refills:*0*
9. Please continue to take insulin as you were prior to
admission
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute respiratory failure - Possible Pulmonary Embolism/
pneumonia
Right Lower Extremity Cellulitis
Acute on Chronic Renal Failure
Secondary Diagnosis:
DM type II
Hypercholesterolemia
Hypertension
Obesity
Asthma
Discharge Condition:
Good. Ambulatory and no need for oxygen.
Discharge Instructions:
You were in the hospital for an infection in your right leg. We
also were unable to exclude a blood clot in your lungs, and are
treating you for this condition. You were given medicine to make
your blood thinner and antibiotics. It is ESSENTIAL that you see
your doctor [**First Name (Titles) **] [**Last Name (Titles) 3816**] [**2-27**] at the latest as your blood can get
too thin and not thin enough and this can cause very serious
health problems.
You need to complete the course of antibiotics as prescribed.
Flagyl and Levofloxacin until [**3-1**], and Keflex until [**3-4**].
You need to use a CPAP machine at home for your obstructive
sleep apnea (breathing problems at home). You also need to
discuss this problem with your PCP during your next visit.
Please note that we have stopped hydrochlorothiazide, and
started a new blood pressure medication called Metoprolol.
Please take it as prescribed. Please note that we have also
stopped Lisinopril. Please discuss this with your PCP when you
see him on [**Month/Year (2) 3816**].
Followup Instructions:
With Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**]. Please
call and schedule an appointment with him for Monday or [**Telephone/Fax (1) 3816**]
([**2-27**]) at the latest.
Should he not be available, please schedule an appointment with
a different provider in the clinic (episodic), but it is
ESSENTIAL that you be seen within the next two days.
|
[
"799.02",
"272.0",
"493.90",
"V15.82",
"250.01",
"V58.67",
"278.00",
"682.6",
"327.23",
"V46.2",
"486",
"415.19",
"584.9",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
15433, 15439
|
9763, 14101
|
333, 339
|
15715, 15758
|
2259, 7701
|
16848, 17272
|
1671, 1681
|
14273, 15410
|
9072, 9144
|
15460, 15460
|
14127, 14250
|
15782, 16825
|
1696, 2240
|
277, 295
|
9173, 9740
|
367, 1090
|
15632, 15694
|
15479, 15611
|
1112, 1380
|
1396, 1655
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,278
| 155,573
|
34768
|
Discharge summary
|
report
|
Admission Date: [**2191-9-8**] Discharge Date: [**2191-9-18**]
Date of Birth: [**2130-2-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Neuroendocrine Tumor
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Duodenotomy with excision of two lesions for gastrinoma.
3. Antrectomy with Billroth II gastroenterostomy.
4. Open cholecystectomy.
5. Regional lymphadenectomy of the portal lymphatic system.
6. Intraoperative ultrasound.
History of Present Illness:
This 61-year-old man has hypergastrocnemia in the setting of
sporadic gastrinoma. He has not had MEN syndrome. Workup for
this has revealed a 3-cm
lesion in the peripancreatic area which has been biopsied,
proven to be a neuroendocrine tumor. There is no evidence of any
other disease on endoscopic ultrasound or octreotide scanning
preoperatively. He has been controlled for his
gastrin level through proton pump inhibitors quite well, but
realizes that he has a potentially metastatic lesion and that an
operative intervention would be warranted for oncologic
purposes.
His gastrin levels have been documented over [**2183**].
He has had nausea and vomiting with this as well as diarrhea for
over seven years now. This was worked up by an endoscopic
ultrasound at our institution and a close to 3 cm mass has been
found in his porta hepatis, which is consistent with a
neuroendocrine tumor based on a fine needle aspirate. CAT scans
from both here and [**Hospital1 498**] show this lesion quite distinctly. It
has all the [**Hospital1 **] features of a neuroendocrine tumor
radiographically. Also of interest is that the right hepatic
artery is replaced off of the superior mesenteric artery and
this courses directly next to the mass superior to it.
Past Medical History:
Zollinger-[**Doctor Last Name 9480**] syndrome
HTN, hypercholesterolemia, GERD, CAD s/p angioplasty
Social History:
Retired from [**Country 11150**]. Brother and son are part of support network.
Physical Exam:
On physical exam, his abdomen is soft, nontender, and
nondistended with positive bowel sounds. He is slightly obese
in
the abdominal area only. His inguinal and genital region shows
no evidence of any hernias or masses. Rectal exam was deferred
today. The rest of his physical exam is entirely normal.
Pertinent Results:
[**2191-9-9**] 05:01AM BLOOD WBC-11.3* RBC-3.62* Hgb-11.2* Hct-32.5*
MCV-90 MCH-31.0 MCHC-34.5 RDW-15.1 Plt Ct-147*
[**2191-9-12**] 01:24AM BLOOD WBC-10.8 RBC-3.42* Hgb-10.8* Hct-30.5*
MCV-89 MCH-31.6 MCHC-35.4* RDW-14.8 Plt Ct-103*
[**2191-9-15**] 04:30AM BLOOD PT-16.1* PTT-48.2* INR(PT)-1.4*
[**2191-9-13**] 04:18AM BLOOD Glucose-124* UreaN-21* Creat-1.4* Na-136
K-4.2 Cl-104 HCO3-22 AnGap-14
[**2191-9-13**] 04:18AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.2
[**2191-9-11**] 02:22AM BLOOD TSH-3.4
[**2191-9-11**] 02:22AM BLOOD Free T4-0.95
.
SPECIMEN SUBMITTED: gallbladder, duodenal lesion, duodenal
lesion-2, stomach and pylorus, whipples node, portal lymph node.
DIAGNOSIS:
I. Gallbladder, cholecystectomy (A-B):
Cholelithiasis and chronic cholecystitis.
II. Soft tissue, duodenum, excision (C-D):
Fragment of duodenum and pancreatic tissue with ductal
epithelium. No malignancy identified.
III. Soft tissue, "duodenal lesion-2," excision (E-F):
Malignant neuroendocrine tumor (clinically gastrinoma), 0.3 cm,
invasive of duodenal submucosa.
IV. Stomach, duodenum and omentum, partial gastrectomy (G-N):
Malignant neuroendocrine tumor (clinically gastrinoma), two foci
each 0.2 cm, present in duodenal mucosa.
The surgical margins are free of tumor.
V. "Whipple node," resection (O-Q):
Metastatic neuroendocrine tumor in one ([**1-11**]) lymph node.
VI. "Pleural lymph nodes," resection (R-U):
No lymph nodes identified, entire specimen submitted.
No malignancy identified.
.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2191-9-10**] 5:23 PM
IMPRESSION:
1. Negative for PE.
2. Bilateral dependent atelectasis and bilateral trace pleural
effusions.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2191-9-11**] 5:35
AM
IMPRESSION: Development of atelectasis in the lower right lung.
Atelectasis or consolidation at the left base, unchanged.
Evidence of small right effusion.
.
Radiology Report PORTABLE ABDOMEN Study Date of [**2191-9-13**] 8:08 AM
IMPRESSION: Unremarkable bowel gas pattern with no evidence for
ileus or
obstruction.
.
Brief Hospital Course:
The patient is a 61-year-old man who has hypergastrocnemia in
the setting of sporadic gastrinoma. On [**2191-9-8**], he [**Date Range 1834**]
exploratory laparotomy, duodenotomy with excision of two lesions
for gastrinoma, antrectomy with Billroth II gastroenterostomy,
open cholecystectomy, regional lymphadenectomy of the portal
lymphatic system, and intraoperative ultrasound. During the
procedure, there were no evidence of any hemodynamic compromise
or overt complications.
On HD 3, he was transferred to the ICU for possible pulmonary
embolism and with suspected atrial fibrillation with rapid
ventricular rate. He was placed on an amio drip but after
consulting Cardiology, it was recommended to be stopped and
amiodarone 400mg TID started. A variety of imaging was also done
while in the ICU and are detailed as follows:
CXR ([**9-11**])Development of atelectasis in the lower right lung.
Atelectasis or consolidation at the left base, unchanged.
Evidence of small right effusion.
CXR ([**9-10**]) IMPRESSION: No change in left base patchy opacity.
CXR ([**9-10**]) A heterogeneous infrahilar opacification, new since
an abdomen CT [**2191-8-19**], could represent either pneumonia
or atelectasis. Upper lungs clear aside from pulmonary vascular
engorgement. Heart mildly enlarged. Pleural effusion, if any, is
minimal. Nasogastric tube ends in the stomach, right jugular
line tip projects over the upper right atrium. Thoracic aorta is
generally large, not necessarily aneurysm.
([**9-10**]) CTA IMPRESSION:
1. Negative for PE.
2. Bilateral dependent atelectasis and bilateral trace pleural
effusions.
On HD5, Mr. [**Known lastname **] was transferred back to the floor with a
Holter monitor and his amio drip replaced by po amiodarone as
per cardiology consult. A Heparin drip was begun on HD7, along
with continuing his beta blocker and undergoing an Echo on the
same day as per cardiology recommendations. A PT consult was
also done on HD 7 and they continued to follow him until
discharge. On HD 8, Mr. [**Known lastname **] doses of both heparin and
metoprolol were adjusted and his PTT continued to be followed.
On HD9, the patient was placed on po pain medicines and po
Lopressor. On HD 10, Mr. [**Known lastname **] [**Last Name (Titles) 1834**] another episode of SVT
and so cardiology's approval was requested before his discharge.
After clearance by cardiology on HD 11, his JP drain and staples
were removed and he was discharged home.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed.
Disp:*40 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day:
Please take as directed by your primary care provider.
7. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Medication
Please continue all other medications as directed by your
primary care provider.
Discharge Disposition:
Home
Discharge Diagnosis:
Neuroendocrine Tumor
Reentrant tachycardia
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**10-26**] lbs) for 6 weeks.
* You may shower and wash. No tub baths or swimming.
* Monitor your incision for signs of infections
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 3 weeks. To make an
appointment, call [**Numeric Identifier 66571**].
Also please follow up with Cardiac electrophysiology in their
clinic as soon as possible. To make an appointment, call
[**Telephone/Fax (1) 62**].
Completed by:[**2191-9-18**]
|
[
"151.8",
"272.0",
"V45.82",
"251.5",
"197.4",
"518.0",
"574.10",
"530.81",
"401.9",
"E878.6",
"198.89",
"997.1",
"427.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.7",
"45.31",
"51.22",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
7837, 7843
|
4542, 7002
|
332, 586
|
7929, 7936
|
2436, 4519
|
9445, 9749
|
7025, 7814
|
7864, 7908
|
7960, 9422
|
2109, 2417
|
272, 294
|
614, 1875
|
1897, 1998
|
2014, 2094
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,368
| 100,139
|
5262
|
Discharge summary
|
report
|
Admission Date: [**2111-9-29**] Discharge Date: [**2111-10-5**]
Date of Birth: [**2050-1-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ampicillin / Amoxicillin / Ativan
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
OP CABGx2(LIMA-LAD,SVG-OM)[**10-1**]
History of Present Illness:
61 yo M with 2 month decline in energy and malaise who was
walking at home, unable to sleep and tripped/lost balance and
fell against the bath tub and developed SOB. At OSH, Was found
to have R ptx and rib fx. Was also found to have pulmonary edema
with elevated trops.Had known CAD, uncerwent repeat cath which
showed significant CAD. Tansferred to [**Hospital1 18**] for further eval.
Past Medical History:
Acute on Chronic systolic heart failure
DM
HTN
[**Hospital1 18048**]
ESRD - on HD (MWF) - last dialysis [**11-8**]; [**11-11**]
Thrombectomy L arm fistula [**12-22**]
Hypercholesterolemia
GIB [**10-20**] in prepyloric area by EGD (? [**12-19**] NSAIDS)
Gastritis [**12-22**] (EGD)
Anemia
Hip surgery [**6-21**] - on coumadin
Prostate adenocarcinoma
Chronic low back pain
Social History:
Occasional EtOH, No tobacco, No drugs
Family History:
Mother: [**Name (NI) 18048**]
Physical Exam:
Obese M in NAD
Neuro A&O, forgetful train of though, wanders, grip strenth L
[**3-21**], R [**2-19**] PERRL
CV RRR 2/6 SEM
Resp crackles thoughout Right, Left clear
GI obese, soft/NT
Right groin macerated/fungal infection
Pertinent Results:
[**2111-10-4**] 08:20AM BLOOD WBC-8.0 RBC-2.74* Hgb-8.4* Hct-24.9*
MCV-91 MCH-30.5 MCHC-33.6 RDW-16.4* Plt Ct-130*
[**2111-10-3**] 08:35AM BLOOD WBC-7.9 RBC-3.03* Hgb-9.4* Hct-27.5*
MCV-91 MCH-31.1 MCHC-34.2 RDW-16.9* Plt Ct-127*
[**2111-10-4**] 08:20AM BLOOD Plt Ct-130*
[**2111-10-3**] 08:35AM BLOOD Plt Ct-127*
[**2111-10-1**] 01:33PM BLOOD PT-19.9* PTT-39.1* INR(PT)-1.9*
[**2111-10-4**] 08:20AM BLOOD Glucose-155* UreaN-38* Creat-6.8*#
Na-129* K-4.4 Cl-89* HCO3-30 AnGap-14
[**2111-10-3**] 08:35AM BLOOD Glucose-123* UreaN-22* Creat-5.2* Na-135
K-4.2 Cl-92* HCO3-31 AnGap-16
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 21518**] (Complete)
Done [**2111-10-1**] at 10:54:10 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2050-1-9**]
Age (years): 61 M Hgt (in): 70
BP (mm Hg): 137/74 Wgt (lb): 235
HR (bpm): 68 BSA (m2): 2.24 m2
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 410.91, 440.0
Test Information
Date/Time: [**2111-10-1**] at 10:54 Interpret MD: [**Name6 (MD) 3892**]
[**Name8 (MD) 3893**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% >= 55%
Left Ventricle - Peak Resting LVOT gradient: 3 mm Hg <= 10 mm
Hg
Aorta - Annulus: 2.3 cm <= 3.0 cm
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.9 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 11 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 7 mm Hg
Aortic Valve - LVOT pk vel: 0.[**Age over 90 **] m/sec
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *2.0 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the LA/LAA or the RA/RAA. All four pulmonary
veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Dynamic
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity.
Moderate regional LV systolic dysfunction. Mildly depressed
LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Simple atheroma in aortic arch. Mildly dilated descending aorta.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-revascularization:
1. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is mildly dilated. There is moderate to
severe regional left ventricular systolic dysfunction of the
inferior, septal and anterior walls. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened with focal calcification of
left coronary cusp causing aorto sclerosis. There is no aortic
valve stenosis. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
7. There is no pericardial effusion.
Post revascularization:
Pt on phenylephrine infusion in intrinsic sinus rhythm:
1. Normal Rv function. LVEF 40%
2. No new regional wall motion abnormalites, valves as listed
pre-revascularization.
3. Thoracic aortic contour is intact
CHEST (PORTABLE AP) [**2111-10-2**] 4:28 PM
CHEST (PORTABLE AP)
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p cabg and ct removal
REASON FOR THIS EXAMINATION:
r/o ptx
HISTORY: Status post CABG with chest tube removal; to assess for
pneumothorax.
FINDINGS: In comparison with the study of [**9-21**], the endotracheal
tube, Swan-Ganz catheter, and nasogastric tube have all been
removed. Left chest tube has also been removed and there is no
evidence of pneumothorax. There is probably some residual
atelectatic change at the left base as well as in the right
upper zone, both of which are decreasing.
Brief Hospital Course:
He was admitted to cardiac surgery. He was seen by renal to
continue his HD. He was taken to the operating room on [**10-1**]
where he underwent an OPCABG x 2. He was transferred to the ICU
in critical but stable condition. He was given vancomycin
perioperative prophylaxis as he was in house preoperatively. He
was extubated the morning of POD #1. He continued on HD postop.
He was transferred to the floor on POD #1. He was started on
renagel per renal. He did well postoperatively and was ready for
discharge to rehab on POD #4.
Medications on Admission:
crestor 40', colace 150", zoloft 100', lisinopril 40', norvasc
10', asprin 81', thiamin 100', plavix 75', protonix 40', toprol
xl 200', ambien 10', folate 1", sensipar 180', lovaza 1""
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
5. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Cinacalcet 30 mg Tablet Sig: Six (6) Tablet PO DAILY
(Daily).
12. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehab [**Location (un) 1110**]
Discharge Diagnosis:
CAD now s/p CABG
Acute on Chronic systolic heart failure
ESRD on HD(L AV fist), CAD s/p MI, HTN, ^lipids, DM2 , s/p L
THR, prostate CA s/p cryo/lupron, h/o gastric ulcer
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions,creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 20764**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2111-10-5**]
|
[
"807.01",
"V58.66",
"E849.0",
"E888.8",
"585.6",
"518.0",
"724.2",
"403.91",
"428.23",
"250.00",
"V45.1",
"272.4",
"428.0",
"278.00",
"V58.61",
"414.01",
"285.21",
"412",
"753.12",
"V10.46",
"V43.64"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"88.72",
"89.64",
"36.15",
"99.00",
"39.95",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
9286, 9361
|
7479, 8012
|
306, 345
|
9575, 9583
|
1516, 5462
|
9881, 10085
|
1227, 1258
|
8247, 9263
|
6942, 6982
|
9382, 9554
|
8038, 8224
|
9607, 9858
|
5511, 6905
|
1273, 1497
|
259, 268
|
7011, 7456
|
373, 761
|
783, 1155
|
1171, 1211
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
923
| 151,107
|
44626
|
Discharge summary
|
report
|
Admission Date: [**2137-1-29**] Discharge Date: [**2137-2-7**]
Date of Birth: [**2088-4-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Excertional Chest Pain
Major Surgical or Invasive Procedure:
CABGx2(LIMA->LAD, SVG->OM) [**2137-1-31**]
Lymph node biopsy of LUL [**2137-1-31**]
History of Present Illness:
Mr. [**Known lastname 95516**] is a 48 y/o Spanish speaking male with a
h/o of HTN, DM2, hyperlipidemia, tobacco abuse, CAD, recently
diagnosed lung cancer who presented with chest pain over the
last several weeks, described as pressure with radiation to both
arms and associated with SOB, associated wqith excertion but
also occuring at rest. It is not associated with diaphoresis,
nausea, or vomiting. Last chest pain was this morning. Currently
he is chest pain free.
He underwent ETT on day of admission during which he developed
SSCP and dyspnea after 2.5 min which was [**6-29**] and progressed to
[**10-29**] and then resolved with oxygen after 6 minutes. Rhythm
remained sinus without ectopy. 0.5mm downsloping ST depressions
were noted on lead II, aVF at 5.5 minutes exercise that
resaolved 2 min into recovery stage. Hemodyanmic response to
limited exercise was appropriate. Nuclear report showed
moderate to severe reversible perfusion defects in the septum
and anterior wall extending to the apex with associated
hypokinesis consistent with a proximal LAD lesion, LVEF 45%.
He had a cardiac cath at [**Hospital1 18**] in [**2-23**] which showed 1 vessel CAD
with a distal LM stenosis of 30%, LAD 50% proximal disease, LCx
40% proximal disease. RCA was small, non-dominant, and without
lesions. LVEDP measured at 25 mmHg, EF 54%.
After stress results patient underwent cath which showed 2
vessel disease with 60-70% LM disease, 70% pLAD, and 70% pLCx.
He had no intervention.
Past Medical History:
Hypertension
Diabetes
Hyperlipidemia
CAD
Non-small-cell Lung Ca, diagnosed in past 1-2 weeks; T3 N2
disease making him stage IIIa lung cancer.
Low back pain, multiple herniated disks
Social History:
From prior note. Lives in [**Location 86**] with his wife. [**Name (NI) **] three
children. Prior tobacco abuse of [**2-22**] ppd x 34 years; currently
smoking one to [**1-21**] pack cigarettes/day. Originally from [**Country **]
[**Country **], moved to US in [**2122**]. Previously worked at a paper
recycling factory but stopped approximately 10 years ago after a
work related injury. Denies etoh and recreational drug use.
Family History:
not elicited
Physical Exam:
Lying in bed, comfortable but tearfull
T 98.5 BP 146/93 HR 96 RR 20 SAT 98% on RA
HEENT: sclera anicteric, mm moist
Neck: good carotid pulses, no bruits
Chest: Lungs clear
Heart: RRR. No m/g/r.
Abd: +bs, soft, NT, ND
Ext: Warm, well perfused, equal femoral pulses without bruits,
2+ popliteal pulses, 1+ DP pulses
Pertinent Results:
[**2137-1-29**] 05:26PM GLUCOSE-133* UREA N-9 CREAT-0.7 SODIUM-138
POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-27 ANION GAP-13
[**2137-1-29**] 05:26PM ALT(SGPT)-19 AST(SGOT)-17 AMYLASE-34 TOT
BILI-0.3
[**2137-1-29**] 05:26PM ALBUMIN-4.1
[**2137-1-29**] 05:26PM %HbA1c-6.9* [Hgb]-DONE [A1c]-DONE
[**2137-1-29**] 05:26PM WBC-11.4* RBC-4.57* HGB-13.9* HCT-38.6*
MCV-85 MCH-30.3 MCHC-35.9* RDW-14.8
[**2137-1-29**] 05:26PM PT-12.4 PTT-23.5 INR(PT)-1.0
[**2137-1-29**] 05:26PM PLT COUNT-333
[**2137-2-5**] 04:45AM BLOOD WBC-7.7 RBC-3.41* Hgb-10.1* Hct-29.1*
MCV-85 MCH-29.5 MCHC-34.6 RDW-14.9 Plt Ct-367#
[**2137-2-5**] 04:45AM BLOOD Plt Ct-367#
[**2137-2-5**] 04:45AM BLOOD Glucose-117* UreaN-10 Creat-0.7 Na-141
K-4.1 Cl-102 HCO3-25 AnGap-18
[**2137-1-29**] Cardiac Catheterization
1. Two vessel coronary artery disease.
2. Significant left main stenosis.
[**2137-1-29**] Exercising MIBI
Moderate to severe reversible perfusion defects in the septum
and
anterior wall extending to the apex with associated hypokinesis
consistent with a proximal LAD lesion. Left ventricular cavity
size is slightly larger on exercise images consistent with
transient ischemic dilatation.
[**2137-1-30**] Head MRI
Nearly uninterpretable study due to gross patient motion.
Possible left frontal developmental venous anomaly. Perhaps the
patient would be better able to tolerate a CT scan of the brain
with resultant less image degradation due to motion artifacts.
[**2137-1-31**] ECHO
he left atrium is normal in size. No mass/thrombus is seen in
the left atrium or left atrial appendage and the right atrium or
the 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. There is mild regional left
ventricular systolic dysfunction. Overall left ventricular
systolic function is mildly depressed. Resting regional wall
motion abnormalities include mild hypokinesis in the apical
anteroseptal and anterior walls. Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
[**2137-2-5**] Head CT
No evidence of intracranial hemorrhage or acute territorial
infarction.
[**2137-2-4**] CXR
Left apical lung mass and pneumothorax are relatively unchanged
when compared to [**2137-2-2**]. Patient is again noted to be status
post CABG. Bibasilar atelectasis is slightly worse on the left
when compared to the previous study. Shift of the trachea from
the midline to the right is unchanged from the previous exam.
[**2137-1-31**] Mediastinal Lymph Node Biopsy
I. Lymph node, mediastinal level five (A):
Mediational poorly differentiated carcinoma with squamous
features, present within one lymph node (+[**1-20**]).
II. Lymph node, mediastinal level six (B):
One lymph node, no malignancy identified (0/1).
Brief Hospital Course:
Mr. [**Known lastname 95516**] was admitted to the [**Hospital1 18**] on [**2137-1-29**] following an
exercise tolerance test for a cardiac catheterization. This
revealed a 70% stenosed left main, a 70% stenosed left anterior
descending artery and a 70% stenosed left circumflex artery.
Heparin was started for anticoagulation. Given the severity of
his disease, the cardiac surgical service was consulted. Mr.
[**Known lastname 95516**] was worked-up in the usual preoperative manner. Given
his history of lung cancer, the thoracic surgery service was
consulted for a mediastinal lymph node biopsy at the time of his
surgery. A head MRI was performed to rule out metastatic disease
which was not interpretable due to motion artifact. On [**2137-1-31**],
Mr. [**Known lastname 95516**] was taken to the operating room where he underwent
coronary artery bypass grafting to two vessels as well as a
mediastinal lymph node dissection. Postoperatively he was taken
to the cardiac surgical intensive care unit for monitoring. On
postoperative day one, Mr. [**Known lastname 95516**] [**Last Name (Titles) 5058**] and was extubated.
Beta blockade and aspirin were resumed. As he was experiencing
significant pain, the pain service was consulted who started a
dilaudid PCA pump. He was then transferred to the cardiac
surgical intensive care unit for further recovery. He was gently
diuresed towards his preoperative weight. The physical therapy
service was consulted for assistance with his postoperative
strength and mobility. On [**2137-2-3**], Mr. [**Known lastname 95516**] became somewhat
agitated and anxious. Clonopin was given with good effect and a
psychiatry consult was obtained. Haldol was recommended as
needed and a head CT was obtained. This revealed no evidence of
intracranial hemorrhage or acute territorial infarction. His
narcotics were discontinued with subsequent stabilization of his
delirium. Vancomycin was started for mild sternal serous
drainage. The pathology results of Mr. [**Known lastname 95517**] mediastinal
lymph node biopsy revealed mediational poorly differentiated
carcinoma with squamous features, present within one lymph node
(+[**1-20**]). Mr. [**Known lastname 95516**] continued to make steady progress and was
discharged home on postoperative day seven. He will follow-up
with Dr. [**Last Name (STitle) **], hiss cardiologist, Dr. [**Last Name (STitle) 95518**] of the
thoracic surgery service and his primary care physician as an
outpatient.
Medications on Admission:
Allergies: NKDA
Meds:
Motrin 800 mg po TID
Atenolol 50 mg po daily
HCTZ 25 mg po daily
ASA 81 mg po daily
Gemfibrozil 600 mg po BID
Elavil 50 mg po daily
Actos 15 mg po daily
Zantac 150 mg po BID
Albuterol 2 puffs [**Hospital1 **]
Fioricet prn
Flexeril 10 mg po prn
Percocet 1-2 tabs Q8h prn
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
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. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO three times a day.
Disp:*135 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
You may not lift more than 10 lbs. for 3 months.
You may not drive for 4 weeks.
You should shower daily, let water flow over wounds, pat dry
with a towel.
Do not use powders, lotions, or creams on wounds.
Call our office for sternal drainage, temp>101
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in four weeks [**Telephone/Fax (1) 170**]
Follow up with Dr. [**Last Name (STitle) **] for Tues. [**2137-2-12**], [**Telephone/Fax (1) 170**]
Follow up with Dr. [**Last Name (STitle) **] for 1-2 weeks
Completed by:[**2137-2-7**]
|
[
"401.9",
"196.1",
"414.01",
"272.4",
"293.0",
"250.00",
"305.1",
"413.9",
"722.10",
"162.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.56",
"37.22",
"39.61",
"99.04",
"40.29",
"34.1",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
9844, 9902
|
6101, 8584
|
344, 430
|
9970, 9977
|
2985, 6078
|
10323, 10599
|
2616, 2631
|
8928, 9821
|
9923, 9949
|
8610, 8905
|
10001, 10300
|
2646, 2966
|
281, 306
|
458, 1948
|
1970, 2155
|
2171, 2600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,962
| 114,707
|
24106
|
Discharge summary
|
report
|
Admission Date: [**2145-7-10**] Discharge Date: [**2145-7-14**]
Date of Birth: [**2088-9-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Hypotension at dialysis
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
56 year-old male with HCV cirrhosis, ESRD on HD, recent
hypotension in the setting of large-volume paracentesis or
dialysis presenting with hypotension to 56/32 15 minutes into
dialysis the day of admission. The patient states he was "a
little dizzy" at the time, however, denied presyncope, chest
pain, shortness of breath, palpitations. The patient also
complained of the gradual onset of sharp LUQ pain, nonradiating,
after being placed in Trendelenberg. The pain resolved when
taken out of Trendelenberg. He denied fevers, chills, sweats,
nausea, vomiting, hematemesis, change in [**4-14**] BM/day on
lactulose, melena, recent hematochezia - he had one episode of
BRBPR only with wiping a few weeks prior. He was given 1L NS and
transferred to the ED for further evaluation.
.
In the ED, initial VS: T 97.8 HR 110 BP 91/53 RR 20 SaO2 98%RA.
Blood pressure subsequently dropped to 74/45. EKG unchanged from
prior. Chest x-ray showed question LLL pneumonia. Abdominal CT
showed ascites but was otherwise negative for acute pathology.
The patient received 4L NS with improvement in SBP to 90-100s. A
therapeutic paracentesis was attempted but unsuccessful. The
patient was given zosyn.
.
Currently, the patient has no complaints.
.
ROS: As above. Denies headache, vision changes, rhinorrhea,
congestion, pharyngitis, cough, myalgias. Patient is anuric.
Review of systems otherwise negative in detail.
Past Medical History:
1. Hepatitis C and alcoholic cirrhosis:
- Complicated by encephalopathy, portal HTN w/ portal
hypertensive gastropathy, grade I varices, and ascites requiring
q2-3weekly paracentesis
- Followed at the [**Hospital3 2358**] for liver transplantation
- Also followed by Dr. [**Name (NI) **]
2. ESRD:
- On HD T/Th/Sa
- Followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Hospital1 3494**]
3. Hypertension/Hypotension
- The patient had several anti-hypertensives discontinued as the
patient easily becomes hypotensive with dialysis
4. History of IVDU
5. Neuropathy
6. Osteoarthritis
7. Seizures:
- Patient with a history of two seizures - once in [**2141-4-11**],
seizure in the setting of new diagnosis of renal failure,
pneumonia, and alcohol use, second seizure in [**10-18**] with
generalized tonic-clonic seizure while at HD
- MRI in [**10-18**] remarkable for localized area of encephalomalacia
secondary to trauma
- EEG in [**10-18**] unremarkable
8. Tobacco Abuse
9. Type 2 Diabetes Mellitus:
- Not taking medication currently
- Presented with DKA in [**2144**]
- Followed at [**Last Name (un) **]
Social History:
Lives on his own. Currently unemployed. Smokes [**2-12**] pack per day.
History of alcohol abuse in the past, non recently. History of
IVDU, none recently.
Family History:
Non-contributory
Physical Exam:
On admission-
.
GENERAL: Alert, NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. OP clear. MMM.
NECK: Supple, no LAD.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally. No dullness to
percussion or egophony in the LLL.
ABDOMEN: NABS. Mildly distended, bulging flanks, shifting
dullness. No tenderness to palpation.
EXTREMITIES: Trace edema b/l, 2+ dorsalis pedis/posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: AAOx3. CN 2-12 are intact. Normal strength in all four
extremities. No asterixis.
Pertinent Results:
===========
Micro
===========
Blood culture 5/30x2 - No growth to date at time of discharge
.
===========
Labs
===========
[**2145-7-10**] 07:40AM BLOOD WBC-7.1 RBC-4.00* Hgb-12.9* Hct-39.3*
MCV-98 MCH-32.2* MCHC-32.7 RDW-19.6* Plt Ct-155#
[**2145-7-11**] 01:10AM BLOOD WBC-6.6 RBC-3.53* Hgb-11.3* Hct-35.0*
MCV-99* MCH-32.2* MCHC-32.5 RDW-20.5* Plt Ct-71*
[**2145-7-12**] 04:55AM BLOOD WBC-7.0 RBC-3.64* Hgb-11.6* Hct-36.0*
MCV-99* MCH-31.8 MCHC-32.2 RDW-20.7* Plt Ct-72*
[**2145-7-14**] 04:50AM BLOOD WBC-7.5 RBC-3.66* Hgb-11.7* Hct-36.2*
MCV-99* MCH-31.9 MCHC-32.3 RDW-19.2* Plt Ct-78*
[**2145-7-10**] 08:54AM BLOOD Glucose-93 UreaN-23* Creat-8.5*# Na-141
K-3.1* Cl-110* HCO3-16* AnGap-18
[**2145-7-11**] 01:10AM BLOOD Glucose-92 UreaN-34* Creat-12.9*# Na-137
K-4.1 Cl-99 HCO3-22 AnGap-20
[**2145-7-12**] 04:55AM BLOOD Glucose-83 UreaN-48* Creat-15.9*# Na-142
K-4.2 Cl-103 HCO3-19* AnGap-24*
[**2145-7-13**] 04:55AM BLOOD Glucose-87 UreaN-30* Creat-12.0*# Na-144
K-3.4 Cl-104 HCO3-25 AnGap-18
[**2145-7-14**] 04:50AM BLOOD Glucose-77 UreaN-35* Creat-13.8*# Na-141
K-3.5 Cl-102 HCO3-22 AnGap-21*
[**2145-7-10**] 08:54AM BLOOD ALT-29 AST-70* AlkPhos-131* TotBili-2.3*
[**2145-7-11**] 01:10AM BLOOD ALT-40 AST-82* AlkPhos-192* TotBili-2.9*
[**2145-7-13**] 04:55AM BLOOD ALT-35 AST-71* AlkPhos-159* TotBili-3.3*
[**2145-7-14**] 04:50AM BLOOD ALT-40 AST-82* AlkPhos-208* TotBili-2.9*
[**2145-7-10**] 08:55AM BLOOD Ammonia-162*
.
===========
Radiology
===========
RUQ u/s [**7-12**] -
Cirrhotic liver with a moderate amount of ascites. Patent portal
vein.
.
CT Abdomen and pelvis [**7-10**]
1. Nodular liver compatible with underlying cirrhosis. There is
moderate
ascites.
2. No evidence for bowel obstruction or bowel ischemia. There is
a single
non-specific loop of mildly prominent fecalized small bowel in
the left lower
quadrant, which demonstrates normal mucosal enhancement and no
distinct
transition points.
3. Atrophic kidneys compatible with underlying renal disease.
4. Atherosclerotic disease of the abdominal aorta with
aneurysmal dilatation.
.
CXR [**7-11**]
PA AND LATERAL VIEWS. Comparison with [**2145-7-10**]. The lungs now
appear clear.
The heart is normal in size. Mediastinal structures are
otherwise
unremarkable. The bony thorax is grossly intact. A possible
focal area of
increased density at the left base is no longer identified.
IMPRESSION: Clear lungs.
Brief Hospital Course:
# Hypotension: The patient has a recent history of hypotension
as an outpatient thought due to fluid shifts or aggressive fluid
removal during dialysis or large-volume paracentesis. His
episode on admission may be due to hypovolemia or fluid shifts.
SBP was back to 90-100s, which is his baseline per HD records
after 5L NS, without evidence of fluid overload. Also on the
differential is infection, with possible sources spontaneous
bacterial peritonitis versus pneumonia. The patient remains
afebrile and without leukocytosis, however. Culture data
remained negative. Hematocrit was down from baseline, however,
the patient denies gastrointestinal bleeding. Weight now 102.6
kg from recorded dry weight 95 kg (recent post-HD weight 99.2
kg). Patient was treated transiently with vancomycin and zosyn
which were stopped after 3 days and patient remained afebrile.
He was discharged without antibiotics.
.
# Abdominal pain: Resolved. Unclear etiology - may be due to
reversible ischemia in the setting of hypotension as positional.
CT abdomen negative for acute pathology. Was treated with zosyn
for potential SBP, but since pain resolved this felt to be an
unlikely culprit.
.
# Metabolic acidosis: The patient has a chronic metabolic
acidosis likely due to renal failure, as well as lactic acidosis
with baseline lactate 2.1-2.7, likely due to liver disease.
.
# Anemia: Macrocytic. Recent hematocrit mid-to-high 30s, now 30
on admission. No evidence of active bleeding. Baseline anemia
likely due to underlying liver and renal disease. Last EGD
[**5-/2144**] with only grade I varices. Initial ED laboratories were
likely laboratory error. Hct was stable and patient did not
require any transfusions while in house.
.
# HCV and EtOH cirrhosis: Complicated by encephalopathy, portal
HTN with portal hypertensive gastropathy, grade I varices, and
ascites requiring q2-3 weekly paracentesis. INR was elevated
from recent baseline, however, other liver function tests
stable. RUQ u/s was unchanged, with comparable ascites and
cirrhosis. Patient is on the transplant list through [**Hospital1 3343**]
.
# ESRD: Continued on HD while in house.
.
Medications on Admission:
Pregabalin 75 mg PO DAILY on HD days and 50 mg DAILY on non-HD
days
Lactulose 30 ML PO BID
Paricalcitol 1 mcg IV QHD
Epoetin Alfa 10,000 unit SC QHD
B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
Calcium Acetate 1337 mg PO TID W/MEALS
Folic acid 0.8 mg PO DAILY
Oxycodone 5 mg Q12H:PRN pain
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO 4X/WEEK
([**Doctor First Name **],MO,WE,FR).
4. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO 3X/WEEK
(TU,TH,SA).
5. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q6H
(every 6 hours): Please increase or reduce dose as needed to
ensure 3 bowel movements daily.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection QHD.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypotension with dialysis
Hepatic Encephalopathy
.
Secondary:
End stage liver disease [**3-15**] hepatitis C cirrhosis
End stage kidney disease on dialysis [**3-15**] diabetes
Discharge Condition:
vitals signs stable, afebrile
Discharge Instructions:
You were admitted because of low blood pressure with dialysis.
We treated you with IV fluids and antibiotics and your blood
pressure improved. We also treated you for confusion thought
secondary to your liver failure. Your confusion improved with
lacutlose. Your antibiotics were stopped because your blood
cultures did not reveal an infection.
.
Please continue to follow at the [**Hospital3 **] for possible
transplant.
.
If you develop any of the following, chest pain, shortness of
breath, cough, fever, chills, nausea, vomiting, diarrhea,
headache, confusion or dizziness, please call your primary care
doctor or go to your local emergency room.
[**Hospital3 **] yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Please follow up with Dr. [**Last Name (NamePattern4) **], MD
Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2145-7-14**] 9:10
.
Please follow up with Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2145-10-25**] 1:25
.
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2146-2-21**] 1:00
.
Please follow up with Dr. [**First Name (STitle) 1382**] [**Name (STitle) 1383**], MD
Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2145-7-19**] 10:10
.
Please follow up with Dr. [**Last Name (STitle) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2977**]
Date/Time:[**2145-7-26**] 11:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2145-7-15**]
|
[
"585.6",
"572.3",
"250.00",
"403.91",
"276.2",
"458.21",
"293.0",
"571.2",
"285.21",
"070.44",
"V45.11",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
9401, 9407
|
6246, 8392
|
339, 354
|
9636, 9668
|
3840, 6223
|
10497, 11360
|
3135, 3153
|
8731, 9378
|
9428, 9615
|
8418, 8708
|
9692, 10474
|
3168, 3821
|
276, 301
|
382, 1786
|
1808, 2946
|
2962, 3119
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,607
| 170,007
|
47159
|
Discharge summary
|
report
|
Admission Date: [**2185-10-24**] Discharge Date: [**2185-10-31**]
Service: MEDICINE
Allergies:
Penicillins / A.C.E Inhibitors
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
EGD.
History of Present Illness:
This is 91-year old female with little pmhx who was brought to
the ED today by her son after 1 week of increasing somnolence,
incontinence, s/p fall, and dyspnea. Pt poor historian, most of
history obtained through son [**Name (NI) 518**], who is HCP. [**Name (NI) **] states
that pt had been in usual state of health up until about one
week prior when she began requesting to go to bed multiple times
throughout the day, was agitated, and had multiple episodes of
urinary incontinence. Pt has also had multiple episodes of
"heavy breathing" both at rest and with activity. Denies recent
fevers/ chills, pt has chronic cough, no recent change in sputum
production. Pt also w/ chronic LE edema and gout, but son feels
legs have recently looked "worse". Pt does not c/o pain, but son
reports she always denies any pain. No known sick contacts. At
baseline, pt is coherent and talkative; has significant hearing
loss but refuses hearing aid. Son denies any recent signs to
suggest confusion, no known dementia.
.
In [**Name (NI) **], pt was found to have hypothermic to 93.5 with elevated
WBC and lactate, code sepsis initiated. [**Name (NI) 1094**] son refused [**Name (NI) 14938**],
however, and pt made DNR/DNI. Pt became tachycardic with likely
a-fib rhythm, IV lopressor administered with resolution of HR to
100's. Pt also received 500 cc NS and dose of Nafcillin for
likely cellulitis of LE.
Past Medical History:
1. Atrial fibrillation
2. Hypertension
3. Peripheral Vascular Disease
4. Peptic Ulcer Disease
5. Iron deficiency anemia
6. Umbilical hernia
7. h/o ARF secondary to ACE inhibitors
8. Chronic LE edema
9. Gout
10. Hearing loss
Social History:
Lived alone up until this past [**Month (only) 205**], now lives with son and
nephew. [**Name (NI) **] tobacco, no ETOH, no illicit drug use.
Family History:
non-contributory at present.
Physical Exam:
Vitals: T 98 BP 120-126/70 P 94-99 R 22-24 Sat 97-98%3LNC
Gen: elderly woman, sitting up in bed, dyspneic and tachypneic,
unable to complete a full sentence
HEENT: NCAT, sclerae anicteric/noninjected, pupils equal, OP
clear, uvula midline, dry MM
Neck: JVP difficult to assess, no LAD
CV: irregular, tachycardic, distant heart sounds, no m/r/g noted
Lungs: unable to get pt to take deep breath, but pt has
decreased breath sounds at the bases, no rales or wheezing
Ab: soft, NTND, NABS, large umbilical hernia, no HSM by
percussion, no rebound or guarding
Extrem: wwp, 3+ pitting edema up to the knees bilaterally and
2+edema in the thighs; 1 +pitting edema LUE and trace pitting
edema RUE; erythema on BL calves symmetrically
Neuro: a and ox3, MAFE
Pertinent Results:
[**2185-10-24**] 03:30PM BLOOD WBC-16.0*# RBC-5.42* Hgb-15.2 Hct-45.4
MCV-84 MCH-28.2 MCHC-33.6 RDW-16.7* Plt Ct-276
[**2185-10-25**] 03:50AM BLOOD WBC-13.5* RBC-4.68 Hgb-13.3 Hct-39.6
MCV-85 MCH-28.3 MCHC-33.5 RDW-16.7* Plt Ct-204
[**2185-10-26**] 04:08AM BLOOD WBC-17.4* RBC-4.86 Hgb-13.6 Hct-40.7
MCV-84 MCH-27.9 MCHC-33.4 RDW-16.8* Plt Ct-203
[**2185-10-27**] 05:45AM BLOOD WBC-13.1* RBC-4.83 Hgb-13.2 Hct-41.4
MCV-86 MCH-27.2 MCHC-31.8 RDW-16.7* Plt Ct-167
[**2185-10-28**] 05:55AM BLOOD WBC-12.3* RBC-4.96 Hgb-13.6 Hct-41.5
MCV-84 MCH-27.5 MCHC-32.9 RDW-16.4* Plt Ct-193
[**2185-10-25**] 03:50AM BLOOD Neuts-89.3* Lymphs-6.5* Monos-3.7 Eos-0.5
Baso-0
[**2185-10-24**] 03:30PM BLOOD PT-14.7* PTT-27.0 INR(PT)-1.3*
[**2185-10-28**] 05:55AM BLOOD Glucose-82 UreaN-23* Creat-0.9 Na-143
K-3.7 Cl-108 HCO3-26 AnGap-13
[**2185-10-24**] 03:30PM BLOOD Glucose-120* UreaN-31* Creat-1.6* Na-141
K-4.9 Cl-104 HCO3-23 AnGap-19
[**2185-10-24**] 03:30PM BLOOD CK(CPK)-43
[**2185-10-24**] 03:30PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier **]*
[**2185-10-24**] 03:30PM BLOOD cTropnT-0.02*
[**2185-10-27**] 05:45AM BLOOD CK-MB-3 cTropnT-0.02*
[**2185-10-24**] 03:30PM BLOOD Calcium-9.7 Phos-3.8 Mg-2.4
.
CXR [**10-24**] - IMPRESSION: Density at the right lung base, that
could represent airspace disease versus atelectasis, left-sided
pleural effusion.
.
Orophyaryngeal Swallow Study [**10-25**]: Video oropharyngeal swallow
exam was performed in conjunction with the speech and swallow
therapy department. Various consistencies of barium were
administered under constant video fluoroscopic monitoring.
Several times, premature spillover of liquids from the oral
cavity into the valleculae, piriform sinuses, and airway was
noted. Aspiration did occur before the swallow of the
administered teaspoon of thin liquid due to premature spillover.
The patient did have a reflexive cough, however, was not
effective in clearing the aspirated material. Penetration was
also noted during the swallow of thin liquids. Of note,
evaluation of the esophagus revealed visible _____ of barium
material that did not readily pass into the stomach.
.
Echo: Moderate left ventricular and severe right ventricular
systolic
dysfunction. Moderate to severe mitral regurgitation. Moderate
tricuspid
regurgitation. Mild aortic regurgitation. Mild pulmonary
hypertension.
Moderately dilated ascending aorta.
.
CT chest: 1. Right middle and lower lobe consolidation with
moderate-sized
pleural effusion; no bronchial obstruction or [**Location (un) 21851**].
Right pleural
effusion may impinge on the esophagus.
2. Small left pleural effusion.
3. Atherosclerotic coronary and aortic calcification.
4. Moderate cardiomegaly.
.
EGD: EGD showed narrowing at GE junction without mucosal
abnormality.
Scope could traverse the GE junction. Distal esophagus was
tortuous. Upper esophagus had external pulsatile mass. Stomach
had severe erosive gastritis and acute duodenal ulcer, neither
of
which were bleeding. Suggest; chest CT scan to exclude external
compression of both distal and proximal esophagus. Continue
PPI. Stop ASA if possible after discussion with Cardiology. If
ASA is continued, she should take PPI lifelong because of
appearance of stomach at endoscopy.
Brief Hospital Course:
A/P: [**Age over 90 **] yo F with afib and gout who originally presented after
her son noted she had increased somnolence, SOB, and a fall.
Treated for community aqcuried and presumed aspiration PNA.
.
## Pneumonia: consolidation on right side on CT with. Subjective
dyspnea at baseline, but no home O2 requirement. Was treated
with levofloxacin (500 mg qd now that renal function has
improved) for a course that ios to end on [**11-6**] and
metronidazole 500 gm tid for a course that is to end [**11-6**]. She
was also treated with standing ipratropium nebs and prn
albuterol nebs.
.
## Cardiomyopathy: EF 30% by echo. She was diuresed slowly and
started on digoxin for her CMPY and a-fib. Her ACE inhibitor was
held due to renal dysfunction. She was started on metoprolol
short acting and then changed over to the long-acting
formulation on the day of discharge. Hydralazine was also begun
for blood pressure and afterload control. A long-acting nitrate
should be added to her regimen this week once she is tolerating
the change to long-acting metoprolol.
.
## Dementia: pt is currently at her baseline per son and
daughter.
.
## LE Cellulitis vs. venous stasis: concern in unit, primary
team here questioning presence of cellulitis. Holding on vanco.
Findings c/w chronic venous stasis dermatitis.
.
## ARF: unsure of patient's baseline. Cr 1.6 on admission,
currently 0.9. CrCl by MDRD is in mid-50s. Dosed meds
appropriately.
.
## Hypernatremia: pt's baseline may be elevated. Primary
finding that does not support CHF component but likely effected
by decreased PO intake and possible intermittent contraction
alkalosis.
.
## Gout: Had a 5-day course of prednisone that has now been
stopped. She was without joint complaint on the day of
discharge.
.
## Atrial fibrillation: h/o afib, rate controlled. She was
maintained on short-acting metoprolol and then changed to
long-acting version for management of her CMPY and rate control.
Not on warfarin. Kept on aspirin.
.
## Impaired Swallowing: swallow evaluation performed twice in
past week with same results. Nectar thick suggested. EGD
revealed external compression of the esophagus, however, CT
chest not revealing in terms of etiology esophageal compression.
Medications on Admission:
aspirin
pt recently self-d'c'd cardiac medication (? atenolol) for
unknown reasons per son.
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days: To cease on [**11-6**] to complete 10 day
course for treatment of pneumonia.
Disp:*6 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*6 Tablet(s)* Refills:*0*
8. Ipratropium Bromide 0.02 % Solution Sig: Two (2) puffs
Inhalation Q6H (every 6 hours).
Disp:*qs qs* Refills:*2*
9. Albuterol Sulfate 0.083 % Solution Sig: Two (2) puffs
Inhalation Q3-4H (Every 3 to 4 Hours) as needed for shortness of
breath or wheezing.
Disp:*qs qs* Refills:*2*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center
Discharge Diagnosis:
1. Pneumonia
2. Atrial fibrillation
3. Hypertension
4. Peripheral Vascular Disease
5. Peptic Ulcer Disease
6. Iron deficiency anemia
7. Umbilical hernia
8. ARF secondary to ACE inhibitors
9. Chronic LE edema
10. Gout
11. Hearing loss
Discharge Condition:
Patient discharged to home in stable condition, tolerating foods
and fluids, without pain, and without fever with stable vital
signs.
Discharge Instructions:
Patient is advised to come to the emergency room if she
experiences chest pain, shortness of breath, lightheadedness,
fevers, chills, nausea, vomiting, or pain that is out of the
ordinary for her.
Patient is advised to take all of her prescriptions as
prescribed.
Followup Instructions:
1. Patient is advised to follow-up with her primary care
physician [**Name Initial (PRE) 176**] 3-5 days to address these medical issues.
2. Patient is advised to see a cardiologist - we have set up an
appointment for you - Friday, [**11-18**], 10am, Dr. [**Last Name (STitle) **],
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**].
|
[
"280.9",
"274.9",
"425.4",
"276.0",
"401.9",
"427.31",
"535.50",
"584.9",
"682.6",
"532.30",
"424.0",
"290.3",
"459.81",
"397.0",
"443.9",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
9896, 9952
|
6210, 8434
|
259, 266
|
10239, 10375
|
2943, 6187
|
10688, 11045
|
2126, 2156
|
8576, 9873
|
9973, 10218
|
8460, 8553
|
10399, 10665
|
2171, 2924
|
200, 221
|
294, 1693
|
1715, 1950
|
1966, 2110
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,093
| 115,737
|
5409
|
Discharge summary
|
report
|
Admission Date: [**2188-2-4**] Discharge Date: [**2188-2-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Endoscopy with clips, epinephrine injection, and Bicap thermal
therapy to site of bleeding gastric ulcers.
History of Present Illness:
84M with lymphoma s/p CHOP last week, h/o GIB, dilated CMP, who
originally presented from home with hematemesis x2, after taking
high dose prednisone during chemotherapy as well as Bufrin for
arthritis. Patient denied melena, abdominal pain, hematochezia,
chest pain, shortness of breath, fever, chills or chest pain.
Patient has had UGIB in past with NSAID use. Patient came to ED,
with VS 96.8, 100, 119/65, 18, 100%RA and A and O times 3.
At home, patient is functional in his ADLs, grocery shopping and
driving on his own, and taking care of his wife with [**Name (NI) 2481**]
disease. Patient is very noncompliant at home.
He was given PPI, received NGT lavage, which did not clear after
1L, and patient was fluid resuscitated prior to transfer to the
MICU for emergent endoscopy. In the MICU, patient had endoscopy
showing multiple gastric ulcers, which were clipped, injected
with epinephrine, and Bicapped. He remained hemodynamically
stable. Patient was also found to have an evolving STEMI, with
isolated ST elevation in V3, as well as CE with peak troponin of
1.48 on [**2188-2-6**]. Patient remained chest pain free. Cardiology
was consulted, and patient was medically managed with a beta
blocker, ACE inhibitor, and advised to follow up for an
outpatient stress test. Patient was taken off his home digoxin
and amlodipine. Patient is transferred to OMED.
Past Medical History:
1. Lymphoma - Biopsy [**2-24**] showing B-cell non Hodgkins lymphoma c
difficult subclassification. Originally felt to be a small
lymphocytic lymphoma but new, more aggressive behavior is
suggestive of NHL. Tx c XRT [**8-26**]-on CHOP-R- last chemo last
Friday
2. Dilated cardiomyopathy, EF 20%
3. Chronic afib, has refused coumadin in past for side effects
4. HTN
5. Migraines
6. Arthritis
7. question OSA
8. GI bleed - [**2184**] c hgb 7.7 [**1-24**] NSAID/aspirin use, EGD showing
gastritis/ulcers in fundus.
9. Hearing loss
10. ARF from hydronephrosis due to lymphoma
Social History:
No smoking, rare ETOH, married, lives in [**Location **], former prof.
chemistry c hx exposure to organic compounds. Lives at home with
his wife who has [**Name (NI) 2481**] disease.
Family History:
Mother c asthma, CHF, daughter died in childhood [**1-24**]
neuroblastoma
Physical Exam:
Tc 97.5 BP 120/70 HR 73 O2sat 99%RA.
Gen: NAD.
HEENT: NCAT, EOMI. No cervical LAD. No oral ulcers or exudates.
CV: Irregularly irregular. 2/6 SEM.
Lungs: CTAB. Decreased BS at bases/
Abd:+BS, soft, NT, ND. Guaiac positive in the ED.
Ext: WWP. No CCE.
Neuro:CN II-XII intact, strength 5/5 bilat
Pertinent Results:
132 97 52 / 186 AGap=14
------------
4.4 25 1.0
.
CK: 38 MB: Notdone Trop-*T*: 0.02
Ca: 8.3 Mg: 2.0 P: 4.1
ALT: 10 AP: 98 Tbili: 0.5 Alb: 3.1
AST: 12 LDH: 151
[**Doctor First Name **]: 33 Lip: 18
Dig: 0.3
.
86
10.5 \ 7.1 / 339
-------
20.8 D
N:96.9 Band:0 L:2.0 M:0.9 E:0.2 Bas:0.1
.
Conclusions:
The left atrium is dilated. The right atrium is moderately
dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is
moderately dilated. Overall left ventricular systolic function
is moderately
depressed. Resting regional wall motion abnormalities include
mid to distal
anteroseptal and anterior akinesis/hypokinesis and basal to mid
inferior/inferolateral hypokinesis akinesis. The apex is not
fully visualized
but appears hypokinetic/akinetic. Right ventricular chamber size
and free wall
motion are normal. The ascending aorta is moderately dilated.
The aortic valve
leaflets are moderately thickened. There is a minimally
increased gradient
consistent with minimal aortic valve stenosis. Moderate (2+)
aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened.
There is moderate thickening of the mitral valve chordae.
Moderate (2+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is
seen. Significant pulmonic regurgitation is seen. There is no
pericardial
effusion.
Compared with the prior study (images reviewed) of [**2187-12-21**],
left
ventricular systolic function is now significantly worse with
new anteroseptal
and anterior akinesis/hypokinesis.
.
EKG [**2188-2-6**]:
Atrial fibrillation
Ventricular premature complex
Modest nonspecific intraventricular conduction delay
Left ventricular hypertrophy with ST-T abnormalities
Anteroseptal myocardial infarct, age indeterminate - possible
acute/recent/in
evolution
Diffuse ST-T wave abnormalities
Since previous tracing of [**2188-2-5**], further ST-T wave
abnormalities present
.
Endoscopy:
Findings: Esophagus:
Lumen: A sliding small size hiatal hernia was seen.
Mucosa: A salmon colored mucosa suggestive of Barrett's
Esophagus was found. Biopsy not performed due to bleeding.
Stomach:
Excavated Lesions Multiple ulcers were found in the antrum and
stomach body. A large 3-4 cm cratered ulcer with a necrotic
center and adherent clot on the incisura was seen. There was a
pulsating vessel seen after the clot was removed. Two resolution
clips were applied to the vessel with persistent oozing. 9cc of
1:10,000 epinephrine was injected with successful hemostasis.
Bicap thermal therapy was then applied to the area at the
setting of 28. No bleeding was seen at the completion of
therapy. Much of the body and fundus was not well-visualized due
to blood and clot obscuring the view.
Duodenum:
Other lymphoid hyperplasia in the duodenal bulb.
Other
findings: An opening that is either a diverticulum or accessory
duct was seen in the second portion of the duodenum.
Impression: Ulcers in the antrum and stomach body
Lymphoid hyperplasia in the duodenal bulb.
Small hiatal hernia
An opening that is either a diverticulum or accessory duct was
seen in the second portion of the duodenum.
Mucosa suggestive of Barrett's esophagus
Brief Hospital Course:
84 yo male with PMHx sx for lymphoma, upper GIB, cardiomyopathy,
who presented with an upper GI bleed with multiple gastric
ulcers seen on endoscopy, likely secondary to NSAID use and
recent high dose prednisone with CHOP therapy for lymphoma.
Patient was also found to have a silent STEMI, with V3 elevation
and elevated CE.
.
Upper GI bleed: Patient's UGI bleed was likely [**1-24**] NSAID use
combined with recent prednisone for CHOP. Patient was transfused
several units while in the MICU for hematocrit drop from 29.9 to
20.8 on presentation. Patient had an NG lavage performed, which
did not clear after 1000cc NS were infused. An emergent upper
endoscopy demonstrated ulcers in the antrum and stomach body,
lymphoid hyperplasia in the duodenal bulb, and mucosa suggestive
of Barrett's esophagus. Patient's ulcers were clipped, injected
with epinephrine, and had thermal therapy which stopped the
bleeding. Biopsy wasn't performed at the time due to concern for
increased bleeding.
On transfer to OMED, patient was hemodynamically stable, but
then began to have drop in hematocrit. He received three units
of blood, without an appropriate increase in hematocrit. He
remained guaiac positive, had two large bore pIVs for access,
and continued on [**Hospital1 **] pantoprazole. He had serial hematocrits
checked, and was stable for 48 hours prior to discharge.
Patient was scheduled for outpatient endoscopy to reassess the
ulcers, and for biopsy of the lymphoid hyperplasia. Patient was
advised to avoid all NSAIDs. He will have serial hematocrits
checked by home VNA.
.
STEMI: Patient was admitted with initial STE in V3, but with a
progressive rise in cardiac enzymes. He was noted to have
evolving ST changes since admission with peak troponin, and was
diagnosed as having a STEMI. A cardiology consult was obtained,
and recommended stopping patient's amlodipine and digoxin, and
starting atorvastatin, lisinopril and metoprolol, which were
started when patient was hemodynamically stable from a GI bleed
perspective. Patient's cardiac enzymes were trended, and he was
found to have continued upward trend in troponin to peak 2.24,
with gradual decrease in CK and CKMB. Cardiology was
reconsulted, and felt that elevation in troponin was not an
indication for cardiac catheterization, and opted for medical
management. Patient was not placed on heparin due to bleeding
risk. He was not anticoagulated for his atrial fibrillation due
to bleeding risk, and due to concern for poor compliance as an
outpatient.
A repeat echocardiogram was performed, which showed global
hypokinesis and a depressed EF from 40% to 30-35%, possibly from
stunned myocardium. He will need to have follow up with his
outpatient cardiologist. He remained on telemetry with no
events. He will need a stress test as an outpatient. He remained
chest pain free through his admission.
.
Lymphoma: Patient's lymphoma was stable. He received one dose of
neupogen as an inpatient, but had a leukocytosis. He will be
seen in [**Hospital 20722**] clinic for consideration of further
chemotherapy. Patient will be seen by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 5565**]
as an outpatient.
.
Patient remained full code. His diet was advanced as tolerated.
His electrolytes were monitored carefully and repleted.
Communication was with patient, and son Dr. [**Last Name (STitle) 2578**] [**Known lastname **]. C:
[**Telephone/Fax (1) 21950**] H: [**Telephone/Fax (1) 21951**]. Patient was seen by physical and
occupational therapy. He will be seen by physical therapy at
home for services.
Medications on Admission:
Amlodipine
Digoxin
Bufferin
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*56 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*28 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*28 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
1. Upper gastrointestinal bleeding
2. Gastric ulcers
3. ST elevation MI
4. Lymphoma s/p R-CHOP
5. Leukopenia
6. Lymphoid hyperplasia in duodenal bulb
Discharge Condition:
Stable
Discharge Instructions:
If you develop nausea, vomiting, shortness of breath, blood in
your stool, vomiting blood, dizziness on standing, black stools,
chest pain, please call your primary care doctor or go to the
emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 5566**] [**Name Initial (NameIs) **]. HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2188-3-6**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2188-3-6**] 2:30
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Location (un) 2788**] CARDIOLOGY-PRIVATE
Date/Time:[**2188-5-6**] 11:30
Please follow up with Dr. [**Last Name (STitle) 21952**], your primary care doctor, in
the next 1-2 weeks. The number to call is [**Telephone/Fax (1) 4775**].
|
[
"E935.9",
"E932.0",
"427.31",
"530.85",
"531.40",
"397.0",
"288.0",
"425.4",
"410.71",
"202.80",
"424.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
10283, 10332
|
6215, 9794
|
271, 379
|
10526, 10535
|
2996, 6192
|
10789, 11376
|
2592, 2667
|
9872, 10260
|
10353, 10505
|
9820, 9849
|
10559, 10766
|
2682, 2977
|
220, 233
|
407, 1777
|
1799, 2374
|
2390, 2576
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,371
| 106,552
|
45991
|
Discharge summary
|
report
|
Admission Date: [**2186-11-29**] Discharge Date: [**2187-1-26**]
Date of Birth: [**2127-6-10**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Benzocaine
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
Left foot swelling x 2 weeks
Major Surgical or Invasive Procedure:
Incision and dranage and debridement of ankle
Thoracotomy, Left, with Debridement and Internal fixation and
grafting L1-L2, partial vertebrectomy
Posterior spinal fusion with instrumentation T8-L2
History of Present Illness:
59 yo NIDDM with left ORIF (25 years ago), chronic BLE edema,
chronic back pain s/p hardware placement and neuropathy who
presented with left medial malleolus pain x 2 weeks. Notes that
this was a site where he had a recent ulcer. He states that he
has chronic LE edema, but awoke this AM with increased pain and
swelling in his left leg and was unable to bear weight on the
leg. Denies trauma. Has had fevers at home to 101. The patient
was intially admitted to medicine for a cellulitis and started
on zosyn.
The initial presentation was followed by a very complicated
hospital course.
- [**12-4**] the pt underwent incision and drainage with hardware
removal from his left ankle. Subsequent TTE and TEE were
negative for endocarditis.
- [**12-15**], the pt had an episode of desaturation and
methemoglobinemia during TEE secondary to the use of benzocaine.
This required [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] admission but the pt returned to the floor
on [**12-16**]. During this time, the pt was experiencing increased
back pain.
- [**12-19**] Spine MR [**First Name (Titles) 654**] [**Last Name (Titles) 97910**]/osteomyelitis with an adjasent
psoas infection. L spine films obtained on [**12-21**] were highly
suggestive of osteomyelitis/diskitis at L1-2 with accompanying
indistinct appearance of the vertebral bodies from L2 to S1.
- [**1-9**], the pt was taken to the OR for hardware removal from
the back secondary to these findings. This debridment was
accompanied by L1 vertebrectomy and L1-L2 fusion. He received 3
U PRBC intraop and 1 U PRBC following the procedure. Initially,
the pt did well overnight in the PACU on SIMV.
- [**1-10**], he became tachypnic when his sedation was decreased.
Other hemodynamic markers were stable. Pt was seen by the pain
clinic at that time and he was changed to a dilaudid drip for
pain control. The pt also spiked to 102.4 in the PACU. He was
pan cultured. At that time, the pt was transferred to the MICU
for further care.
- The pt self extubated in the early morning hours of [**1-12**].
- Transferred to floor where his course was unremarkable
- Taken back to OR for posterior stabilization on [**1-16**].
- Uneventful post op course until [**1-23**] PM when he was found
transiently unresponsive, hypotensive and hypoxic - all of which
spontaneously resolved within minutes. Transferred to medicine
for ROMI and further w/u; thought to have had a mucous plug.
- Ruled out, no PE, did have UTI
Past Medical History:
1. Diabetes II
2. Hypertension
3. GERD
4. Mild anemia
5. Lower back pain s/p multiple back surgery (L4-S1 fusion '[**80**],
[**4-/2183**] he had a L3 laminectomy and medial fasciectomy with L3
to L4 bilateral fusion with pedicle screws and bone grafting. On
[**2184-9-27**] he had a left L2-L3 microdiscectomy and right L2-L3
laminectomy. On [**2185-10-3**] he underwent decrompression at L2 to L3
and an L2, L3 fusion using pedicle screws and iliac crest line
graft.)
6. Dyslipidemia
7. Hypertension
8. S/P retinal detachment repair in [**2176**]
Social History:
Lives alone, denies etoh, rare pipe, no illicit drug use
Family History:
Father w/ MI at age 72
Physical Exam:
T 98.6 (Tm 103.6 in ED) BP 130/84 HR 96 96% RA
General: NAD
Pulm: cta B
CV: s1 s2 reg
Abd: NABS, soft, NT
Ext: no edema
2+ DP on right and 1+ on left. Erythema from midfoot to shin
with tenderness at ankle and with dorsiflexion.
Pertinent Results:
Initial labs:
CBC
[**2186-11-29**] 04:15AM WBC-15.1*# RBC-3.63* HGB-11.6* HCT-34.5*
MCV-95 MCH-32.0 MCHC-33.7 RDW-14.5, NEUTS-79* BANDS-13*
LYMPHS-2* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-1*, PLT
COUNT-228
Chemistries
[**2186-11-29**] 04:15AM GLUCOSE-141* UREA N-45* CREAT-1.7* SODIUM-138
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-29 ANION GAP-14
[**2186-11-29**] 01:10PM GLUCOSE-150* UREA N-34* CREAT-1.3* SODIUM-139
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-25 ANION GAP-18
Micro
- Resp culture ([**1-10**]) Strep, not group A, but repeat on [**1-11**] OP
flora
- Swab ([**12-4**]) strep not group A, MSSA
- BCx ([**11-30**] and [**11-29**]) MSSA
- [**2187-1-17**] L1 gross diagnosis "osteomyelitis"
- [**1-24**] U/A negative, UCx Gram negative rods
L foot xray:
1. Old fractures of the distal tibia and fibula.
2. Marked abnormality of the tibiotalar joint which requires
additional
clinical information for full assessment. Differential diagnosis
includes
posttraumatic, Charcot neuropathy, and changes related to
infection and
inflammation.
3. Fracture involving the first proximal phalanx extending to
the IP joint,
ECHO
Conclusions:
1. The left atrium is mildly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
normal
(LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic root is moderately dilated. The ascending aorta is
moderately
dilated.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation. 6.The mitral valve
leaflets are mildly
thickened. Trivial mitral regurgitation is seen.
7.There is mild pulmonary artery systolic hypertension.
8.There is a small pericardial effusion. There are no
echocardiographic signs
of tamponade.
9. No echocardiographic evidence of endocarditis. Would
recommend a TEE if
clinically indicated.
TEE
IMPRESSION: Mild aortic valve sclerosis. Trace aortic
regurgitatio. No echo evidence of endocarditis.
MR [**Name13 (STitle) **]
IMPRESSION:
Abnormal signal at the L1-L2 level and within the L1 vertebral
body with abnormal enhancement in the adjacent psoas muscles,
consistent with a [**Name13 (STitle) 97910**]/osteomyelitis with adjacent psoas
infection. Limited evaluation of the spinal canal suggests
epidural infection at L1-2. If there is a decline in neurologic
function, a repeat study is recommended.
MR Hip
IMPRESSION:
1) Bilateral psoas abscesses, worse on the left than the right,
unchanged. Erosion of the anteroinferior aspect of the body of
L1 likely relates to infection and is unchanged in appearance.
Paraspinal collection in the posterior paraspinal soft-tissues,
unchanged.
Right iliac [**Doctor First Name 362**] fracture, unchanged.
Unremarkable bilateral hip joints. No hip effusion.
CT LE
IMPRESSION:
1) Status post debridement in the medial malleolar region, with
a VAC dressing in place, contacting the distal tibia.
2) Erosive and destructive changes involving the distal tibia
and fibula, talus, and calcaneus; osteomyelitis is not. In
particular, there are foci of gas and fluid in the lateral
aspect of the foot (distant from the VAC dressing), raising the
concern for presence of a gas-producing infection or abscess
formation.
3) Scattered tiny pockets of fluid with no drainable fluid
collection.
[**1-23**] CT LE
IMPRESSION:
1) Erosive and destructive changes involving the ankle, which
may be consistent with the stated history of osteomyelitis. No
discrete fluid collections are identified. The soft tissue
defect at the medial malleolus is grossly unchanged when
compared to the prior study.
Brief Hospital Course:
Ankle and Lumbar Spine Osteomyelitis
The patient initially presented with what was thought to be a
left ankle cellulitis and was started on unasyn with vancomycin
given risk for MRSA. When the sensitivities grew out MSSA,
antibiotics were changed to oxacillin. He had hardware in place
from a prior injury of his left ankle. He continued to have
fevers and given staph bacteremia was at risk of osteomyelitis
or hardware seeding. Orthopaedic service consulted and
proceeded with a left ankle I&D with removal of hardware on
[**12-4**]; wound cultures grew out MSSA. The wound was kept open
with temporary VAC dressing and plastics followed the patient
during hospitalization; he will follow up after discharge for
VAC removal and flap coverage.
The patient was also thought to have osteomyelitis of L1 based
on MRI and underwent debridement and spinal fusion of T12 to L2
on [**1-9**]; vertebral tissue sent from the OR was consistent with
infection. He was taken back to the OR for posterior fusion on
[**2187-1-16**]. Ortho spine and neurosurgery followed the patient while
admitted. He was treated with oxacillin and rifampin added per
ID recommendations for osteomyelitis in his ankle as well as his
spine. These antibiotics should continue until his appointment
with Dr. [**Last Name (STitle) 11382**] in [**Month (only) 958**].
CV
Pt with h/o hypertension and had been on univasc at last visit.
Initially the patient remained on moexipril and labetolol with
good control. During his hospitalization, he was transitioned
to metoprolol and continued on this until discharge. He had an
episode of hypotension on [**2187-1-23**] that spontaneously resolved
after minutes. But given flattening of T waves laterally on
EKGwith this, he was ruled out for a myocardial infarction with
three sets of cardiac enzymes. He was started on 325mg aspirin.
Other ID issues
The patient had diarrhea off and on during his hospitalization;
c difficile toxins were negative consistently. Given this, he
was started on imodium prn for symptoms. Additionally, a urine
culture was sent on [**1-24**] and grew gram negative rods (U/A
negative). His foley was removed and he was started on
ciprofloxacin for a 5 day course (ID felt this could be
colonization); on discharge further speciation and sensitivities
were pending. A urine culture will be repeated [**Hospital **] rehab once
the cipro is completed.
Heme
Pt with anemia of unclear cause. SPEP is negative as are his B12
and folate levels. Followed by PCP; baseline 29-35 which
remained stable during most of his hospital stay. After his
third surgery, his HCT fell to 26 and remained stable between
26-28. Because of his history of transfusion reactions, he was
not transfused but rather was started on tid iron
supplementation.
Derm
Pt with right arm and bilateral thigh (left > right) ulcers and
excoriations. Dermatology consulted who were of the impression
that the lesions were consistent with neurotic excoriations and
purigo nodules from chronic excoriation. Management goals were
to prevent secondary infection. Bactroban cream started [**Hospital1 **]
with clean dressings. Further along during his hospitalization,
he was also placed on nystatin and miconazole treatments.
Psychiatry
The patient had a h/o depression treated with home regimen of
Paxil 30mg po qd. After his third surgery he was restarted on
paxil at10mg daily and this can be titrated up. Social work was
consulted regarding patient's concerns over financial issues
given his long hospital stay.
NIDDM
On admission, he stated that he was taking glyburide 7.5mg po
qAM and 5mg po qPM. He was initially continued on this regimen
with an additional RISS, but during his course was NPO and was
then kept only on the sliding scale with a goal of tight
glycemic control.
FEN
After his first spinal surgery, the patient was kept NPO except
meds with water as he was unable to sit upright. He was briefly
given TPN via his PICC line until his second spinal surgery.
After that surgery, once extubated his diet was advanced without
difficulty.
Proph
The patient was maintained on a PPI; DVT prophylaxis; bowel
regimen; and the pain service followed him to ensure appropriate
pain control. His pain meds were tapered off after his final
surgery. On discharge he was on prn tylenol and prn [**Hospital1 **]
(but was not requiring it).
Access
The patient had a CVL and arterial line while in the ICU; he
then had a PICC inserted for long term IV antibiotics and was
discharge to rehab with this in place.
FULL CODE.
Medications on Admission:
MS [**First Name (Titles) **]
[**Last Name (Titles) 1756**]
Lodine
Glyburide
Paxil
Moexipril
Discharge Medications:
1. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
2. Multi-Vitamin Hi-Po Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Glutamine 10 g Packet Sig: 0.5 Packet PO BID (2 times a
day).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
units per sliding scale Injection ASDIR (AS DIRECTED).
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
14. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
15. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
16. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): hold for diarrhea.
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
20. [**Last Name (Titles) 1756**] HCl 5 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for pain.
21. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: hold for diarrhea.
23. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
24. Oxacillin 2 gm IV Q4H
25. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO once a
day.
26. Imodium 2 mg Capsule Sig: One (1) Capsule PO four times a
day as needed for diarrhea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses
MSSA Osteomyelitis of the Spine L1-L2
MSSA Ankle Pyarthrosis and chronic wound left ankle
MSSA bacteremia
Secondary Diagnoses
Diabetes II
Hypertension
GERD
Mild anemia
Low back pain s/p multiple surgeries
Dyslipidemia
Discharge Condition:
Hemodynamically stable and neurologically intact. Wounds from
spinal surgery healing primarily. Resumed oral intake. Vac
dressing in place left foot per plastics until flap procedure.
Discharge Instructions:
Keep wounds clean and dry. Use topicals for rash.
Please alert your care providers if you have fevers, chills,
nausea, vomiting, persistent diarrhea, worsening chest or
abdominal pain, worsening ankle pain, or any other symptoms
concerning to you.
Followup Instructions:
Dr. [**Last Name (STitle) 363**] (orthopedic surgery) on Wednesday [**2-21**] 9:15AM
for X-Ray, [**Hospital Ward Name 23**] [**Location (un) **], [**Telephone/Fax (1) **]
Dr. [**Last Name (STitle) 11382**] (ID) on Tuesday [**3-6**] 11AM, [**First Name8 (NamePattern2) **]
[**Hospital Ward Name **] Bldg, Suite G, [**Telephone/Fax (1) **]
Plastic surgery followup on Tuesday [**2-6**] at 10AM,
[**Telephone/Fax (1) **], Hand and [**Hospital 3595**] clinic
|
[
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"682.6",
"289.7",
"730.28",
"401.9",
"826.0",
"790.7",
"518.5",
"250.60",
"730.27",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.06",
"96.6",
"88.72",
"78.69",
"99.04",
"86.22",
"80.87",
"38.93",
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] |
icd9pcs
|
[
[
[]
]
] |
14820, 14890
|
7706, 12265
|
311, 512
|
15171, 15359
|
3976, 7683
|
15658, 16118
|
3682, 3706
|
12409, 14797
|
14911, 15150
|
12291, 12386
|
15383, 15635
|
3721, 3957
|
243, 273
|
540, 3019
|
3041, 3591
|
3607, 3666
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,889
| 187,942
|
4809
|
Discharge summary
|
report
|
Admission Date: [**2181-4-16**] Discharge Date: [**2181-4-18**]
Date of Birth: [**2134-9-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46yo M w/ h/o alpha-1 anti-trypsin deficiency, and asthma, w/
recent gastric band placed in [**Month (only) **]. who now p/w hemptysis x7-10d.
He was in his USOH, w/ his baseline DOE from walking the
distance of east to [**Hospital Ward Name **] or 1 flight of stairs, good
appetitie, and rare dry cough. Then 7-10d ago pt developed a
productive cough w/ bloody sputum, not at any point bright red
blood by itself or clots, or changed over this wk. Pt has been
having this cough all day and all night, and worsening over the
course of the wk. Pt has been producing a little over a cup's
worth/day. The coughing is worse at night when lying flat, and
better right now after 02 given. Pt does have wheezing, no CP,
but does have b/l pleuritic pain behind ribs w/ deep breaths.
Did not try any cough/cold medicatons. No sick contacts. Pt
denies any fevers/chills/rhinorrhea/congestion/sore throat. Also
denies epistaxsis, hematemesis, melana, hematochezia. Today his
SOB became significantly worse, where he could walk about half
his baseline distance. He called his PCP who told him to come
in.
In the emergency department: P/w 97.5, 115/79, 64, 18, 96%RA. HR
was into 140s, sinus - got 2L IVF, HR down to 110s-120s. O2 sat
mid-90s on 2L. CTA was ordered intially prelim read showed b/l
PEs. Pt was started on heparin gtt. This was re-read by
attending to no PE, and heparing stopped. IP team - no immediate
scope. Transferred w/ 96% RA, BPs 90s-100s. Guaiac neg, no
fevers, no pain.
In the MICU, his cough is better.
ROS: lost 63 lbs s/p gastric bypass banding at [**Hospital1 2177**] in [**Month (only) **].
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:
1. Alpha-1 Anti-Trypsin Deficiency
2. Asthma
3. cirrhosis [**2-26**] AAT
Social History:
Significant for a 20-pack-year history of tobacco use. Quit 15
years. Denies etoh He lives with his mother who is also a smoker
and has a pet dog. Worked as a truck-driver delivering trucks up
anddown the East Coast, now on disability.
Family History:
Father died in late 60s from thyroid cancer. Mother is a smoker
but otherwise healthy.
Physical Exam:
Vitals: 97.4, 120, 100/74, 95%RA
General: No acute distress, conversing w/ incr work of breathing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: b/l rales at lower lung fields, RLL rhonchi, expiratory
wheezes throughout
CV: irregular, irregular, tachycardic, no m/g/r
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, no gross focal deficits
Pertinent Results:
[**2181-4-16**] 02:40PM BLOOD WBC-8.2 RBC-4.59* Hgb-14.1 Hct-40.8
MCV-89 MCH-30.7 MCHC-34.5 RDW-12.9 Plt Ct-185
[**2181-4-16**] 02:40PM BLOOD Neuts-63.5 Lymphs-30.8 Monos-3.2 Eos-1.9
Baso-0.6
[**2181-4-17**] 04:02AM BLOOD PT-16.0* PTT-34.6 INR(PT)-1.4*
[**2181-4-17**] 04:02AM BLOOD Glucose-78 UreaN-8 Creat-0.5 Na-144 K-3.9
Cl-112* HCO3-23 AnGap-13
[**2181-4-17**] 04:02AM BLOOD ALT-35 AST-41* LD(LDH)-186 AlkPhos-137*
TotBili-0.5
[**2181-4-17**] 04:02AM BLOOD Albumin-3.4 Calcium-8.7 Phos-3.7 Mg-2.0
[**2181-4-16**] 02:51PM BLOOD Lactate-1.2
Blood cultures pending
[**2181-4-16**] CTA chest:
1. No evidence of PE. or acute aortic process.
2. Stable extensive bronchiectasis, with regions of saccular
ronchiectasis and air-fluid levels and wall thickening in the
right lower lobe. Stable emphysema.
3. Unchanged pulmonary nodules. Recommend attention to these
areas on f/u
exams.
4. Cirrhotic liver with splenomegaly.
[**2181-4-17**] 9:16 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2181-4-17**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.
[**2181-4-18**] 05:35AM BLOOD WBC-4.4 RBC-3.91* Hgb-11.8* Hct-35.4*
MCV-91 MCH-30.1 MCHC-33.3 RDW-13.1 Plt Ct-113*
[**2181-4-17**] 04:02AM BLOOD WBC-5.1 RBC-4.08* Hgb-12.5* Hct-37.0*
MCV-91 MCH-30.6 MCHC-33.8 RDW-13.0 Plt Ct-123*
[**2181-4-18**] 05:35AM BLOOD PT-15.7* PTT-30.2 INR(PT)-1.4*
[**2181-4-18**] 05:35AM BLOOD Glucose-95 UreaN-12 Creat-0.5 Na-141
K-3.8 Cl-108 HCO3-27 AnGap-10
[**2181-4-18**] 05:35AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
[**2181-4-17**] 04:02AM BLOOD ALT-35 AST-41* LD(LDH)-186 AlkPhos-137*
TotBili-0.5
Brief Hospital Course:
46yo M w/ h/o alpha-1 anti-trypsin deficiency, and asthma, w/
recent gastric band placed in [**Month (only) **]. who now p/w hemptysis x7-10d
#) Hemoptysis- cough w/ sputum x1wk. Pt likely had acute
worsening of bronchiectasis [**2-26**] tracheobronchitis. He was
initially admitted to the [**Hospital Unit Name 153**] and placed on IV Levaquin,
prednisone, cough suppressants and nebulized albuterol and
ipratropium. His hemoptysis resolved and he was transferred to
my service on the floor. He did well monitored overnight, sats
>95% on room air, no respiratory distress. He was discharged
with a 5 day course of Levaquin, and a prednisone taper. He is
scheduled to follow up with Dr. [**Last Name (STitle) **] in one week.
.
#) transient atrial fibrillaion - on presentation, but
spontaneously converted after initiation of treatment. He was
monitored on telemetry with no recurrence and has no previous
history of heart disease or arhythmia.
.
#) Coagulopathy- secondary to cirrhosis, INR 1.4 - given vit K
x1
.
#) FEN: No IVF, replete electrolytes, NPO overnight
Medications on Admission:
Active Medication list as of [**2181-1-29**]:
Medications - Prescription
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled
q 4-6h as needed for Chest tightness/SOB - No Substitution
ALPHA-1 PROTEINASE INHIB.(HUM) [ZEMAIRA] - 1,000 mg Suspension
for Reconstitution - 125 mg/kg +/- 10 % qo week
CLOBETASOL - 0.05 % Cream - apply to affected area twice a day
FLUTICASONE - 50 mcg Spray, Suspension - 2 squirts nasally once
daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250-50 mcg/Dose Disk
with Device - 1 whiffs inhaled twice a day
LEVOFLOXACIN [LEVAQUIN] - 500 mg Tablet - 1 Tablet(s) by mouth
for 1st 5 days of each month
MONTELUKAST [SINGULAIR] - 10 mg Tablet - one Tablet(s) by mouth
once a day
PREDNISONE - 20 mg Tablet - 2 Tablet(s) by mouth daily taper per
instructions
ZOLPIDEM [AMBIEN] - 10 mg Tablet - 1 Tablet(s) by mouth at
bedtime as needed for sleeplessness
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for sob/wheezing.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
6. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day:
taper as follows: 4 tabs (40 mg) for 4 days, then 2 tabs (20
mg) for 4 days, then 1 tab (10mg) for 4 days, then discontinue.
Disp:*QS Tablet(s)* Refills:*0*
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 14 days: take
while on prednisone.
Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. acute exacerbation of bronchiectasis
2. alpha 1 antitrypsin deficiency
3. transient atrial fibrillation, resolved
Discharge Condition:
stable, on room air, no further hemoptysis
Discharge Instructions:
You were hospitalized with blood in your sputum. This resolved
after initiation of antibiotics and steroids. Please finish
your antibiotics and steroid taper as prescribed. Follow up
with Dr. [**Last Name (STitle) **] as scheduled below.
If you have fever, increased cough or sputum production,
recurrence of blood in your sputum, difficulty breathing, or any
other concerns, please contact your primary physician or return
to the hospital.
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2181-5-3**] 9:10
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2181-5-3**] 9:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2181-5-3**] 9:30
|
[
"286.7",
"571.5",
"V45.86",
"494.1",
"427.31",
"786.3",
"493.90",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8019, 8025
|
5026, 6105
|
325, 331
|
8185, 8230
|
3156, 4418
|
8723, 9157
|
2495, 2584
|
7043, 7996
|
8046, 8164
|
6131, 7020
|
8254, 8700
|
2599, 3137
|
4456, 5003
|
275, 287
|
359, 2128
|
2150, 2225
|
2241, 2479
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,849
| 120,039
|
48447
|
Discharge summary
|
report
|
Admission Date: [**2108-12-12**] Discharge Date: [**2108-12-15**]
Date of Birth: [**2036-3-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
lower extremity weakness and twitching
Major Surgical or Invasive Procedure:
Central line placement, RIJ
History of Present Illness:
72 y/o F with hx of CAD, HTN, bipolar disorder, baseline tardive
dyskinesia, recent admission in [**11-2**] for pneumonia and severe
constipation who presents with "whole body twitching." Hx on the
morning of admission, her husband found pt in bathroom c/o
inability to move her legs. Pt was noted to be shaking/twtiching
different from baseline tardive dyskinesia. She was aware and
alert. Per her daughter, these symptoms are not new and are
usualy a sign that she is getting sick. First episode dates back
in OMR as early as [**2105**]. Patient presented at least 3 prior
episodes with similar symptoms followed later by an infection
and has been worked up extensively by neurology (EEG, video
monitoring, Dr. [**Last Name (STitle) **] examined patient). Per daughter, at
baseline, she is fully functional with ADLs except for bathing
limited by shoulder OA.
.
In the ED, initial T 102.2, HR 90, BP 195/90, RR 30, 95%RA,
lactate 4.2. Sepsis protocol was activated, RIJ was placed, and
she was given 4L NS, Flagyl 500 IV, Levaquin 500 IV, ativan 2
mg, and benadryl.
Past Medical History:
- Hypertension
- Hypothyroidism
- Bipolar d/o (h/o psych admits)
- Tardive dyskinesia
- Cervical spine dz s/p surgery C5/C6
- Hypercholesterolemia
- Anemia
- Right elbow arthritis
- Lacunar infarcts
- Diverticulosis
- LLL pneumonia [**11-2**] rx with cefpodoxime / azithromycin
- Lithium toxicity [**11-2**]
- Swallowing difficulty- recent eval [**2108-11-12**], only eats soft
foods-
- [**8-/2108**]: she had a colonoscopy for diarrhea and spotting which
revealed an adenoma, which was partially removed.
Social History:
The patient denies tobacco, alcohol or IV drug use. She is
independent of all activities of daily living but receives
frequent visits and support from her 7 children. The patient is
married and lives with her husband.
Family History:
NC
Physical Exam:
Vs- 97.6 109/67 P 78 RR 20 99% RA
Gen- conversant, mild twitching, no acute distres
Heent- pupils not equal (L assymmetric), EOM intact, MM slightly
dry, tongue
Neck- JVP flat, bruise from last night's central line
Cv- RRR, no M/R/G
Chest- CTAB, good air entry, poor effort
Abd- +BS, soft, NT/ND no hepatomegaly
Ext- warm, well perfused, + DP pulses
Neuro- oriented to place and person, knows where she is, able to
give history of what has happened to her over last few weeks
Skin- no rash or lesions
Pertinent Results:
[**2108-12-12**] 12:45PM WBC-11.8*# RBC-3.23* HGB-10.2* HCT-31.8*
MCV-98 MCH-31.6 MCHC-32.2 RDW-13.4
[**2108-12-12**] 12:45PM NEUTS-85.3* BANDS-0 LYMPHS-10.9* MONOS-2.4
EOS-1.1 BASOS-0.4
[**2108-12-12**] 12:45PM PLT COUNT-463*
[**2108-12-12**] 12:45PM PT-11.7 PTT-26.2 INR(PT)-1.0
.
CK 148 (hemolyzed)
.
[**2108-12-12**] 12:44PM LACTATE-4.2*
[**2108-12-12**] 03:41PM LACTATE-0.7
[**2108-12-12**] 12:45PM LITHIUM-1.0
[**2108-12-12**] 12:45PM CRP-0.8
[**2108-12-12**] 12:45PM CORTISOL-36.8*
.
[**2108-12-12**] 12:45PM CALCIUM-10.5* PHOSPHATE-4.1# MAGNESIUM-2.1
[**2108-12-12**] 12:45PM LIPASE-44
[**2108-12-12**] 12:45PM ALT(SGPT)-48* AST(SGOT)-63* CK(CPK)-148* ALK
PHOS-106 AMYLASE-56 TOT BILI-0.2
[**2108-12-12**] 12:45PM GLUCOSE-192* UREA N-32* CREAT-0.9 SODIUM-136
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-19* ANION GAP-19
.
[**2108-12-12**] 01:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2108-12-12**] 01:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2108-12-12**] 01:20PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
.
serum tox: negative
urine tox: negative
.
BLOOD CX [**2108-12-12**]: NGTD
.
EKG: sinus brady at 49 bpm, pseudonormalization of Ts in V3-6
and aVF
.
CXR:
FINDINGS: Upright radiograph of the chest. The right internal
jugular line appears to be in more appropriate positioning,
likely at the atriocaval junction. Cardiomediastinal silhouette
is stable. Left basilar retrocardiac opacity remains
representing atelectasis versus airspace consolidation.
Pulmonary vascularity is unremarkable. Again, no large pleural
effusions are seen. No pneumothorax is identified.
IMPRESSION: Satisfactory positioning of right internal jugular
line. No pneumothorax. Stable or left basilar retrocardiac
opacity representing atelectasis/consolidation.
.
REPEAT CXR S/P 4 L NS:
Right jugular CV line is in distal SVC. No pneumothorax. There
are low lung volumes with elevation of the right hemidiaphragm
and associated mild atelectasis at the right lung base and a
small right pleural effusion. There is persistent discoid
atelectasis in the left lower lobe. Degenerative changes post
glenohumeral joint.
IMPRESSION: Small right pleural effusion with atelectasis at
right lung base. Persistent discoid atelectasis left lower lobe.
Artifact opacity overlies right upper lobe.
.
KUB:
FINDINGS: No dilated loops of small bowel are evident. There has
been relative decompression of the more proximal colon. The
descending colon, in particular, is of relative normal caliber.
Minimal stool is noted within the region of the rectal vault and
in the ascending colon. The bones are osteopenic. There is a
dramatic dextroconvex curvature at the thoracolumbar junction.
Phleboliths are seen at the pelvis.
IMPRESSION: Residual stool with relative decompression of the
colon. No radiographic evidence suggestive of small bowel
obstruction. Also, there is no intraperitoneal air.
Brief Hospital Course:
# Fever: No source identified. Patient remained afebrile and
WBC returned to [**Location 213**] off antibiotics (only received one dose
levo/flagyl in ED [**2108-12-12**]). Blood cultures no growth to date.
Urinalysis negative. KUB shows no free air and significantly
improved constipation. LFTs normal. CXR with minimal
atelectasis and small effusion post IVF resuscitation but was
without focal infiltrate and patient denied any cough or
persistent shortness of breath to suggest pneumonia. CK normal
on admission so low suspicion for NMS. She was continued on her
seroquel. This could have been an aspiration event but unlikely
given she was standing up. Nevertheless, I have recommended
that she follow-up outpatient for a video swallow evaluation.
She denies any choking episodes and has had a normal bedside
evaluation on her most recent admission [**2108-11-13**].
.
# Twitching: Patient has had extensive work-up previously for
this, including ambulatory EEG which has shown no epileptiform
activity. On my evaluation, she reported lower extremity
weakness without loss of consciousness. Her history regarding
twitching was variable. She denied this to me. She did report
intermittent right toe numbness without any complaints of
claudication. Neurology was consulted given patient has not
been seen since [**2106**] and their exam was consistent with
radiculopathy at C5, L5 and perhaps S1. They recommended MRI
C-spine (outpatient, if patient ready for discharge) and
subsequent neurology follow-up. They also reiterated the
importance of the patient wearing her soft cervical collar.
Patient had no recurrence of symptoms in house.
.
# Chronic constipation: Patient was started on qd miralax by
her PCP following her last discharge. Family reports this is
working well. Follow-up KUB this admission much improved.
Patient reminded she needs to schedule her barium enema to
follow-up her colonoscopy. She was given the number to schedule
this exam.
.
# Bipolar disorder: Lithium level within normal limits.
Patient's home meds continued.
.
# Anemia: Stable hematocrit. PCP [**Name9 (PRE) 702**] for low retic count
with negative SPEP/UPEP to consider bone marrow biopsy for
further evaluation. This may be due to bone marrow suppression
from her medications.
.
# Hypertension: Patient brady to hr 49 on admission and had sbp
as low as 90 on her home dose of beta blocker. She was thus
instructed to discontinue this medication and follow-up with her
PCP [**Name Initial (PRE) 176**] 1-2 weeks for a repeat blood pressure check.
.
# Hypothyroidism: Patient was continued on Levothyroxine at home
dose.
.
# FEN: Soft diet. Aspiration precautions.
.
# PPX: SQ heparin
.
# Dispo: Patient discharged home.
.
# Communication: [**Doctor First Name **] [**Telephone/Fax (1) 102007**] - I
personally reviewed my discharge instructions with the patient's
daughter at discharge.
Medications on Admission:
Levothyroxine 75 mcg PO once daily.
Lithium carbonate 300 mg PO b.i.d.
Toprol XL 25 mg PO once daily.
Aggrenox 25 mg PO b.i.d.
Seroquel 25 mg PO q a.m. and 100 mg PO q.p.m.
Cyanocobalamin 100 mcg PO once daily.
Pyridoxine 50 mg PO once daily.
Ensure shakes, one shake t.i.d.
Lipitor 10 mg QD
Tylenol arthritis
Polyethylene glycol
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
3. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
5. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO BID (2 times a day).
6. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for arthritis.
10. Polyethylene Glycol 3350 100 % Powder Sig: One (1) scoop PO
once a day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Fever, no source identified
Cervical spondylosis
Secondary:
Tardive dyskinesia
Bipolar disorder
Hypertension
Hypothyroidism
Anemia
Chronic constipation
Discharge Condition:
Good: No further twitching episodes, patient at baseline mental
status, taking good PO intake, afebrile
Discharge Instructions:
Please call Dr. [**First Name (STitle) 1395**] or go to the emergency room if you
experience temperature > 101, headache, or other concerning
symptoms.
Please STOP taking your toprol XL as this may be making your
blood pressure go too low.
Please make all recommended follow-up appointments. Please
contact Dr. [**First Name (STitle) 1395**] if you are having issues getting any of these
procedures scheduled in the recommended time frame.
Please wear your cervical collar ALWAYS at night when you go to
bed and as much as you can tolerated during the day.
Please continue to take ensure shakes 3 times per day to ensure
adequate caloric intake.
Followup Instructions:
Please call to schedule an MRI of your cervical spine which
needs to be done within 1-2 weeks. Phone: [**Telephone/Fax (1) 327**]
Please call to schedule an appointment to see the neurologist,
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10927**], within 1 week of your MRI to discuss the
results of this test. Phone: ([**Telephone/Fax (1) 2528**]
Please call to schedule your video swallow evaluation to be done
within 1-2 weeks. Phone: ([**Telephone/Fax (1) 25326**]
Please call to schedule your barium enema to be done within 1
month. Phone: [**Telephone/Fax (1) 327**]
Please call to schedule an appointment to see Dr. [**First Name (STitle) **] [**Name (STitle) 1395**]
within 1 week of your barium enema to discuss the results.
Please also see Dr. [**First Name (STitle) 1395**] within 1-2 weeks to have your blood
pressure rechecked off of your toprol XL. Phone: [**Telephone/Fax (1) 2936**]
|
[
"244.9",
"285.9",
"333.85",
"721.1",
"296.7",
"272.0",
"401.9",
"E947.9",
"276.2",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9964, 9970
|
5827, 8730
|
356, 386
|
10176, 10282
|
2805, 5804
|
10981, 11912
|
2263, 2267
|
9110, 9941
|
9991, 10155
|
8756, 9087
|
10306, 10958
|
2282, 2786
|
278, 318
|
414, 1483
|
1505, 2012
|
2028, 2247
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,655
| 187,826
|
35080
|
Discharge summary
|
report
|
Admission Date: [**2175-11-21**] Discharge Date: [**2175-11-24**]
Date of Birth: [**2104-8-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Right carotid stenosis
Major Surgical or Invasive Procedure:
[**2175-11-21**] Right carotid endardarectomy
History of Present Illness:
72-y.o F currently resides in a skilled nursing facility. She
is a poor historian and much of the history is obtained from the
records. Patient was just discharged from our hospital on
[**2175-10-30**] after a nine-day stay
for a stroke. She was found at home by her daughter with
slurred speech and disorientation. The patient had no
recollection of what had happened. She was noted to have left
hemiparesis. Initially, she was treated at the [**Hospital6 48708**] and transferred here to our stroke neurology service.
CT scan showed a subacute watershed-type infarct in the right
cerebral hemisphere. CT scan done after transfer here suggested
multifocal lesions of ischemia involving multiple vascular
territory, suggestive of subacute infarct, it is possibly
embolic in origin with no hemorrhage. A CT angiogram of the
arch and neck showed a very irregular atherosclerotic aortic
arch involving the great vessels with partial occlusion of the
left common carotid and subclavian arteries and there is
significant stenosis of the right internal carotid artery with
minimal stenosis on the left. Transthoracic echocardiogram
showed no evidence of intraluminal thrombus within the cardiac
[**Doctor Last Name 1754**]. Had office visit with Dr. [**Last Name (STitle) **] and was advised
to have a right carotid endarterectomy.
Past Medical History:
-arthritis
-no prior hospitalizations
-has not seen a doctor in a "while"
-former [**Last Name (STitle) **], no hx of seizures, ? blackouts, but no hx of
DT's; stopped using 14 years ago
-hx of "legs crippled from EtOH" now recovered
-varicose veins
Social History:
-lives with her daughter, [**Name (NI) **] [**Name (NI) **] at [**Female First Name (un) 80127**], [**Location (un) **], (h) [**Telephone/Fax (1) 80128**], the patients son in law is [**Name (NI) **]
[**Name (NI) **] (cell) [**Telephone/Fax (1) 80129**])
-independant in ADLS
-widow
-HCP: none designated
-EtOH: former
-tobacco: +, long standing 1 PPD x 50+
-drugs: none
Family History:
-mother: ? cancer, unknown type
-father: [**Name (NI) **], burned in fire
Pertinent Results:
[**2175-11-24**] 06:20AM BLOOD WBC-6.8 RBC-2.82* Hgb-9.0* Hct-25.4*
MCV-90 MCH-31.9 MCHC-35.3* RDW-15.1 Plt Ct-215
[**2175-11-24**] 06:20AM BLOOD Plt Ct-215
[**2175-11-24**] 06:20AM BLOOD Glucose-105 UreaN-22* Creat-1.0 Na-144
K-4.1 Cl-111* HCO3-25 AnGap-12
[**2175-11-23**] 03:59AM BLOOD CK(CPK)-180*
[**2175-11-24**] 06:20AM BLOOD Calcium-9.5 Phos-2.5* Mg-2.0
Brief Hospital Course:
71 y.o F admitted from Nursing Home for a scheduled R CEA.
Patient tolerated procedure, recoverred in the PACU.Placed on
Nitro to maintain SBP<130. Transfered to CVICU for tight BP
management.
[**11-22**]. Transfered 1uPRBCs for acute blood loss anemia/HCT 22
(post 26.9.
[**11-23**]: Transfered to [**Wardname **], Oral doses of Lisinopril and
Metoprolol increased, Norvasc started. Foley discontinued.
[**11-24**] VSS, afebrile. Restarted Coumadin until Neurology follow
up. Incsion with small opening, steristrips placed (staples
removed). Discharged to rehab. FOllow up with Dr. [**Last Name (STitle) **]
scheduled for 1 month with carotid duplex.
Medications on Admission:
Aspirin 81 mg po qd
Metoprolol Tartrate 25 mg po qd
Lisinopril 5 mg po qd
Atorvastatin 80 mg po qd
Humalog Insulin Sliding Scale
Acetaminophen 325 qid prn
Colace 100 ng [**Hospital1 **]
Senna 8.6 mg po bid
Bisacodyl 5 mg po QHS prn
Miconazole Nitrate 2 % Powder Topical tid
Nystatin 100,000 unit/mL Suspension po qid
Coumadin 3 mg po qd(stopped [**11-16**] and placed on Lovenox)
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Warfarin 3 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
adjust to maintain INR 2-2.5.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for SBP < 100 .
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day): Hold HR<55, SBP<100.
7. Amlodipine 5 mg 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 pain.
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day): Until INR >1.8.
12. Humalog Sliding Scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-70 mg/dL 4 oz. Juice
and 15 gm crackers
71-120 mg/dL 0 Units
121-140 mg/dL 2 Units
141-160 mg/dL 4 Units
161-180 mg/dL 6 Units
181-200 mg/dL 8 Units
201-220 mg/dL 10 Units
221-240 mg/dL 12 Units
241-260 mg/dL 14 Units
261-280 mg/dL 16 Units
> 280 mg/dL Notify M.D.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
14. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab Hospital
Discharge Diagnosis:
Primary:
R carotid stenosis
Secondary:
arthritis
DM II
anxiety
depression
hypercholesterolemia
varicose veins
heavy cigarette smoking (still smokes)
hiatal hernia
renal cysts
former EtOH-stopped using 14 years ago
Discharge Condition:
Cr 1.0
Ca: 9.5 Mg: 2.0 P: 2.5
H/H:, plt 9.0/25.4, 215
Coumadin restarted [**11-24**]
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Carotid Endarterectomy Surgery Discharge Instructions
What to expect when you go home:
1. Surgical Incision:
?????? It is normal to have some swelling and feel a firm ridge along
the incision
?????? Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
?????? Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
?????? Try ibuprofen, acetaminophen, or your discharge pain
medication
?????? If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeon??????s office
4. 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
?????? 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!
5. 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
?????? No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
?????? You may shower (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:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2175-12-11**] 3:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2175-12-26**] 2:30
-------------- Dr. [**Last Name (STitle) **]
Phone:[**Telephone/Fax (1) 3121**] Date/Time:[**2175-12-28**] 1:30, carotid dupex and ov
with Dr. [**Last Name (STitle) **]
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2175-12-11**] 3:00
Completed by:[**2175-11-24**]
|
[
"272.4",
"715.90",
"285.1",
"454.9",
"729.89",
"433.10",
"300.4",
"250.00",
"401.1",
"438.89",
"438.83",
"433.30",
"553.3",
"440.0",
"753.10",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"99.04",
"38.12"
] |
icd9pcs
|
[
[
[]
]
] |
5557, 5618
|
2913, 3567
|
338, 386
|
5877, 5965
|
2527, 2890
|
8845, 9460
|
2432, 2508
|
3998, 5534
|
5639, 5856
|
3593, 3975
|
5989, 8250
|
8276, 8822
|
276, 300
|
414, 1752
|
1774, 2027
|
2043, 2416
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,173
| 151,265
|
4936+55622
|
Discharge summary
|
report+addendum
|
Admission Date: [**2164-11-25**] Discharge Date: [**2164-12-7**]
Service: NEUROLOGY
Allergies:
Enalapril
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Change in mental status, weakness on the right, nystagmus, and
b/l deviated eyes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 y RHM originally from [**Country **], who lives with his wife and
son [**Doctor Last Name **]. At around 23:00 h on [**11-25**], his son noticed that
he was slumping on his right side in bed, his eyes were in
"weird" positions with "funny" movements. Mr [**Known lastname **]' speech was
also slurred, however, his son thought that it was just fatigue.
However, at 6 am, the symptoms persisted, and his son then
called 911. The EMS services came around 8 am. Mr [**Known lastname **]
complained of nausea, when he arrived in the ED at 9am, he
vomited once.
Systems review: He complained of diplopia, nausea, slight
dyspnea, otherwise the rest of the ROS was negative.
Past Medical History:
HTN
glaucoma (R)
DM2 c/b neuropathy and possibly retinopathy
Depression
Dementia (etiology unknown)
Hypokalemia
Hypercholesterolemia
2nd degree AV block s/p PCM
CRI likely [**2-18**] DM, HTn. Baseline 1.3
Decreased vision-Right homonymous hemianopsia
B12 deficiency
BPH
Social History:
Lives with wife and son who does most of his medications. He is
originally from [**Country **] and a retired farmer. denies ETOH,
tobacco use, IVDU
health-care-proxy (son, [**Doctor Last Name **]: [**Telephone/Fax (1) 20510**].
PCP: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**]
Family History:
Has a sister with type 2 diabetes mellitus, and who has needed
amputations. History about the parents is unknown.
Physical Exam:
VS: T 98.4, HR 74, BP 191/98 (systolic range 224-186, DBP range
98-110), RR 18, SpO2 97% on air, sugars 120
General:
HEENT:no lymphadenopathy
Neck:no meningismus
CV:PPM scar, S1+2, no added sounds, JVD difficult to assess as
he has a very short neck
Chest:Lung bases are clear
Abd: Distended, with normal bowel sounds, could not turn him
effectively to check for ascites
Ext: Tense edema all the way up the legs, with eczematous skin
changes in both shins.
Neurologic examination:
Mental status: Drowsy, attempting to cooperative with exam,
normal affect. Oriented to person, knows that he is in a
hospital, and does not know the date date. Not attentive, cannot
even do simple digit spans backwards. Speech is fluent with
normal comprehension and repetition; naming intact when he can
see the object. No dysarthria. Could not read any letters below
20/60 line. Registers [**3-19**], recalls 0/3 in 5 minutes. No
right-left confusion. Apraxic b/l hand movements or uses his
left hand preferentially, even though he is right handed,
however, he is connected to multiple things on his right. He
perseverates with tasks.
Cranial Nerves: Fundoscopic examination reveals extensive
changes consistent with diabetic retinopathy. Pupils are 3 mm
bilaterally, do not appear to constrict with light. Visual
fields were difficult to check, as he kept turning his head, he
complained of diplopia in both his eyes with images side by
side,
but a formal cover test could not be performed due to his
perseveration. Extraocular movements: right eye resting position
is down and out (6th and 4th), left eye appears to be deviating
towards his nose (6th nerve), he has nystagmus to the left.
Sensation intact V1-V3. Slight nasolabial flattening on the
right. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. Sternocleidomastoid and trapezius full
strength bilaterally. Tongue midline, movements intact.
Motor: Normal bulk bilaterally, tone slightly increased on the
right. No observed myoclonus, asterixis, or tremor. No pronator
drift. He did not comply with formal muscle group testing due to
drowsiness, however, he appeared to have normal power on the
left, and on his right side, he appeared more ataxic than weak.
Sensation: Unreliable sensory exam as he said "yes" to
everything, he does have peripheral neuropathy as evidenced by
skin changes and his long standing diabetes. No extinction to
DSS.
Reflexes: 2 and symmetric throughout. Toes mute bilaterally.
Coordination: finger-nose-finger, finger-to-nose, fine finger
movements, and [**Doctor First Name **] were ataxic in his right hand.
Gait and Romberg not assessed.
Pertinent Results:
[**2164-11-25**] 08:15AM BLOOD WBC-6.6 RBC-4.80 Hgb-14.2 Hct-43.7 MCV-91
MCH-29.6 MCHC-32.6 RDW-13.6 Plt Ct-189
[**2164-11-25**] 08:15AM BLOOD Neuts-75.3* Lymphs-20.7 Monos-3.2 Eos-0.5
Baso-0.2
[**2164-11-25**] 08:15AM BLOOD PT-13.6* PTT-28.0 INR(PT)-1.2*
[**2164-11-25**] 08:15AM BLOOD Glucose-125* UreaN-17 Creat-1.0 Na-143
K-3.7 Cl-103 HCO3-31 AnGap-13
[**2164-11-25**] 08:15AM BLOOD CK(CPK)-243*
[**2164-11-25**] 06:46PM BLOOD CK(CPK)-323*
[**2164-11-26**] 04:41AM BLOOD CK(CPK)-367*
[**2164-11-30**] 08:00AM BLOOD ALT-23 AST-40 LD(LDH)-312* CK(CPK)-549*
AlkPhos-85 TotBili-0.7
[**2164-11-27**] 02:08AM BLOOD CK-MB-20* MB Indx-2.7 cTropnT-0.04*
[**2164-11-25**] 08:15AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.1
[**2164-11-26**] 04:41AM BLOOD %HbA1c-9.8*
[**2164-11-27**] 02:08AM BLOOD Triglyc-35 HDL-59 CHOL/HD-1.9 LDLcalc-46
[**2164-12-2**] 11:19AM BLOOD Type-ART pO2-97 pCO2-59* pH-7.41
calTCO2-39* Base XS-9
[**2164-11-25**] 08:37AM BLOOD Glucose-110* Lactate-3.6* Na-144 K-3.7
Cl-99* calHCO3-30
[**2164-12-7**] 06:50AM BLOOD WBC-7.3 RBC-4.29* Hgb-12.8* Hct-38.7*
MCV-90 MCH-29.8 MCHC-33.0 RDW-13.6 Plt Ct-225
[**2164-12-7**] 06:50AM BLOOD Plt Ct-225
[**2164-12-7**] 06:50AM BLOOD Glucose-173* UreaN-17 Creat-1.1 Na-143
K-3.4 Cl-102 HCO3-32 AnGap-12
[**2164-12-1**] 07:19PM BLOOD ALT-21 AST-50* AlkPhos-79 TotBili-0.8
Brief Hospital Course:
-Likely brainstem small vessel disease
-Initially admitted to NeuroICU due to hypertension
-CT Head:
1. No acute intracranial hemorrhage, edema or mass. MR [**First Name (Titles) 151**] [**Last Name (Titles) 4639**]n-weighted imaging is more sensitive for detection of
acute ischemia,
particularly in setting of underlying chronic microvascular and
lacunar infarction.
2. Left occipital cystic encephalomalacia and bilateral thalamic
and left internal capsule lacunes, unchanged.
-CTA Head/Neck:
1. No evidence of hemorrhage, or acute infarction, or aneurysm.
2. Bilateral internal carotid 35% stenoses. Left vertebral
artery stenosis at its origin. Severe vascular calcifications
consistent with atherosclerotic disease.
-TTE: LVEF 55%, moderate symmetric left ventricular hypertrophy.
Due to suboptimal technical quality and patient lack of
cooperation, a focal wall motion abnormality cannot be fully
excluded.
-Repeat CT/CTA head:
1. Short segment mild-to-moderate stenosis of the proximal and
the mid poritons of the basilar artery, without flow limitation
and unchanged.
2. Paranasal sinus disease as described above.
-CXR: No acute intrathoracic process.
-AXR: Non-specific bowel gas pattern without evidence for ileus
or
obstruction. No free air.
-Cont. telemetry
-Discontinued ASA, started Plavix 75 mg daily
-CEs: CK 243-323-367-751-549, CKMB [**2072-8-29**], TropT
0.03-0.04-0.04-0.04; HgA1c 9.8%; FLP Chol 112, TG 35, HDL 59,
LDL 46
-Increased Atenolol to 75 daily, Cont. Lisinopril 20 daily, HCTZ
25 mg daily, Labetalol PO prn
-Cont. Atorvastatin 10 daily
-Appreciate urology recs for ? penile laceration: Bacitracin prn
-Diabetic diet
-PPx: Pneumoboots, Tylenol prn, ISS, Brimonidine Tartrate 0.15%,
Dorzolamide 2%
- Pt's BP remained difficult to control. Lisinporil was
increased to 40 Qday [**12-4**], and then Norvasc 5 mg Qday was added
[**12-5**]. This seemed to improved his SBP to the 160 range.
- Pt was attempetd to be placed back on his home DM regimen of
insulin, but had an episode of hypoglycemia, likely because his
PO intake amount and proportion carbs is different here in hosp.
Subsequently placed on a reduced standing [**Hospital1 **] insulin regimen
with continued ISS coverage.
-Contacts: Son, [**Name (NI) **] [**Telephone/Fax (1) 20511**] (cell), [**Telephone/Fax (1) 20512**]
(work), [**Location (un) **] [**Telephone/Fax (1) 20513**], [**Telephone/Fax (1) 20514**]
Medications on Admission:
Albuterol Sulfate 5 mg/mL, 1-2 Puffs Inh q4-6 hours prn
Aspirin EC 325 mg daily
Atenolol 50 mg daily
Docusate Sodium 100 mg daily
Doxazosin 2 mg PO HS
Ergocalciferol (Vitamin D2) 50,000 unit Capsule QMON
Hydrochlorothiazide 25 mg PO DAILY
Lisinopril 20 mg PO DAILY
Lipitor 10 mg daily
Insulin
Brimonidine 0.15 % Drops 1 drop Ophthalmic [**Hospital1 **] prn
Dorzolamide-Timolol 2-0.5 % Drops 1 drop Ophthalmic [**Hospital1 **] prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H
(Every 12 Hours).
3. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
7. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed: PRN for SBP > 180.
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Insulin Asp Prt-Insulin Aspart 100 unit/mL (70-30) Insulin
Pen Sig: Fifteen (15) units Subcutaneous QAC breakfast.
16. Insulin Asp Prt-Insulin Aspart 100 unit/mL (70-30) Insulin
Pen Sig: Seven (7) units Subcutaneous QAC dinner.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
small vessel infarct to brainstem
Discharge Condition:
stable
Discharge Instructions:
You were admitted with new aberrant eye movements causing some
double vision, and we suspected that this resulted from a small
vessel infarct, or stroke, to your brainstem. You were started
on Plavix, which is a more potent anti-platelet drug, and should
continue on that. It will be important to control your blood
pressure, your diabetes, and your high cholesterol in order to
further minimize your future stroke risk.
Followup Instructions:
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
Neurology ([**Telephone/Fax (1) 2574**]) on [**2164-2-1**] at 1:00 in the [**Hospital Ward Name 23**]
Center, [**Location (un) 858**].
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**]
within 1-2 weeks of discharge. Phone: [**Telephone/Fax (1) 250**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2164-12-7**] Name: [**Known lastname 76**],[**Known firstname 3422**] Unit No: [**Numeric Identifier 3423**]
Admission Date: [**2164-11-25**] Discharge Date: [**2164-12-7**]
Date of Birth: [**2078-11-20**] Sex: M
Service: NEUROLOGY
Allergies:
Enalapril
Attending:[**First Name3 (LF) 608**]
Addendum:
see expanded Brief Hosp Course
Chief Complaint:
see prior
Major Surgical or Invasive Procedure:
see prior
History of Present Illness:
see prior
Past Medical History:
see prior
Social History:
see prior
Family History:
see prior
Physical Exam:
see prior
Pertinent Results:
see prior
Brief Hospital Course:
Mr. [**Known lastname **] was admitted with dysconjugate eye movements thought
to be consistent with a 4th nerve palsy vs ocular tilt, and was
felt to have a small-vessel infarct affecting his brainstem,
though this was never apprecitated on CT, and because of his
pacemaker, could never get an MRI. His A1C was 9.8 indicating
poor prior glycemic control from his DM, however his lipid panel
was relatively normal. His TTE was normal. He remained quite
hypertensive during his admission, and his lisinopril was
increased to 40 mg Qday, Atenolol increased to 75 mg Qday, and
Norvasc started at 5 mg Qday. This combination eventually
allowed his SBP to remain in the 150-160 range, which we felt
was an appropriate goal for him given his longstannding HTN. His
glycemic control was also attempted to be optimized and, after
having been off his home regimen initially, we placed him back
on his insulin 70/30, and titrated his dose to its current 15 U
QAC breakfast and 7 U QAC dinner (given that both the amount and
content of his diet in hospital is likely differnet from what he
was eating at home). He had some ongoing problems with
sundowning, and we found that wrist restraints and redirection
were most successful. He responded very poorly to
benzodiazepines. Zyprexa was moderately effective. On discharge,
his eye skew deviation as well as his old bilateral 6th nerve
palsy remained, but his sensory and strength exam were normal.
He is able to tolerate an oral diet, but has a tendency to eat
too quickly, causing at times some coughing. Speech/swallow
recommended supervised feeding.
Medications on Admission:
see prior
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H
(Every 12 Hours).
3. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
7. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed: PRN for SBP > 180.
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Insulin Asp Prt-Insulin Aspart 100 unit/mL (70-30) Insulin
Pen Sig: Fifteen (15) units Subcutaneous QAC breakfast.
16. Insulin Asp Prt-Insulin Aspart 100 unit/mL (70-30) Insulin
Pen Sig: Seven (7) units Subcutaneous QAC dinner.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
Discharge Diagnosis:
small vessel infarct to brainstem
Discharge Condition:
stable
Discharge Instructions:
You were admitted with new aberrant eye movements causing some
double vision, and we suspected that this resulted from a small
vessel infarct, or stroke, to your brainstem. You were started
on Plavix, which is a more potent anti-platelet drug, and should
continue on that. It will be important to control your blood
pressure, your diabetes, and your high cholesterol in order to
further minimize your future stroke risk.
Followup Instructions:
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) 55**] [**Last Name (NamePattern1) 3424**] in
Neurology ([**Telephone/Fax (1) 1482**]) on [**2164-2-1**] at 1:00 in the [**Hospital Ward Name **]
Center, [**Location (un) **].
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
within 1-2 weeks of discharge. Phone: [**Telephone/Fax (1) 23**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**]
Completed by:[**2164-12-7**]
|
[
"294.8",
"V45.01",
"250.60",
"266.2",
"585.9",
"250.40",
"378.53",
"600.00",
"V58.67",
"272.0",
"434.91",
"357.2",
"403.90",
"365.9",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14958, 15028
|
11931, 13524
|
11715, 11726
|
15106, 15115
|
11897, 11908
|
15584, 16169
|
11841, 11852
|
13584, 14935
|
15049, 15085
|
13550, 13561
|
15139, 15561
|
11867, 11878
|
11666, 11677
|
11754, 11765
|
2928, 4434
|
5897, 8205
|
2289, 2912
|
2274, 2274
|
11787, 11798
|
11814, 11825
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,057
| 168,188
|
53269
|
Discharge summary
|
report
|
Admission Date: [**2158-12-22**] Discharge Date: [**2159-1-2**]
Date of Birth: [**2095-6-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Cardiac Catheterization with placement of bare metal stent in
OM1
Repeat Cardiac Catheterization
Cardiopulmonary Resuscitation and Defibrillation
History of Present Illness:
In brief this is a 63yo M PMHx HD dependent ESRD s/p failed
allograft, CAD s/p CABG ([**2156**] - LIMA to LAD, SVG to RPDA, SVG to
OM1, SVG to ramus), PVD, HTN, HLD, sCHF (EF 20-30%) who was
admitted for elective cardiac catheterization [**12-22**], notable for
occluded OM graft, patent LIMA, SVG-PDA and SVG-ramus grafts,
OM1/Circ w flow-limiting disease, Circ not able to be wired,
BMSx2 to OM1 takeoff, complicated by circ jailing, course
further c/b femoral pseudoaneurysm at and hypotension during
post-cath HD. Night prior to transfer, patient with continued
slow bleeding from cath site (changing dressing q30-60minutes),
abciximad held (given psuedoaneurysm). Next AM patient
developed hypotension to 60s/30s while at HD, as well as
dizziness and mental status changes that did not initially
resolve with fluid bolus; HD stopped, patient given 2 units of
pRBCs w resolution of pressures to 100s
.
At time of initial exam in HD, patient w HR 60s, SBP 108,
mentating well and without complaint of chest pain, shortness of
breath, dizziness, EKG with ST depressions in II,III,avF similar
to prior EKG. Patient transferred to CCU for further
management.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: sCHF (EF 20-30%), CAD
-CABG - ([**2156**]) LIMA to LAD, SVG to RPDA, SVG to OM1, SVG to
ramus.
-PCI - ([**2158-12-22**]) BMS to OM1 x2 c/b jailed circ
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- ESRD [**3-15**] interstitial nephritis versus post-infectious
glomerulonephritis s/p allograft ([**2138**]), c/b failure ([**2156**]), HD
dependent
- Secondary hyperparathyroidism with hypercalcemia.
- GERD w Barrett's esophagus ([**2152**])
- Peripheral vascular disease
- Colonic polyps
- Prostate adenocarcinoma ([**2156-5-12**]) s/p CyberKnife therapy
- s/p appendectomy.
- s/p hernia repair.
Social History:
Former engineering consultant, now on disability; married with
two children, rare alcohol use, former smoker quit in [**2156**].
Family History:
Mother with CABG at 60. Father with CABG at 70. Brother with
CAD status post PCI in 62.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.4 132/82 91 21 100% on RA
GENERAL: pleasant gentleman, laying comfortably in bed, NAD,
alert and appropriate
HEENT: NCAT. EOMI. MMM.
NECK: Supple, JVP not appreciated
CARDIAC: RR, normal S1, S2, no S3, S4. I/VI systolic murmur
heard throughout the precordium.
LUNGS: CTAB, no increased WOB, no wheezes, rales, rhonchi.
ABDOMEN: Soft, NTND. NABS, kidney transplant palpable in RLQ
Groin: R groin cath site; slight tenderness to palpation, soft
EXTREMITIES: No c/c/e. LUE fistula with thrill
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
NEURO: A/Ox3, CN II-XII intact. Non focal.
.
DISCHARGE PHYSICAL EXAM:
VS 97, 74, 128/63, 21, 94RA at rest, desats as low as mid 70's
when ambulating on RA which resolves with 2-4L O2 by NC
GENERAL: pleasant gentleman, laying comfortably in bed, NAD,
alert and appropriate
HEENT: NCAT. EOMI. MMM.
NECK: Supple, JVP not appreciated
CARDIAC: RR, normal S1, S2, no S3, S4. I/VI systolic murmur
heard throughout the precordium.
LUNGS: slight bibasilar crackles, but otherwise lung fields
clear to auscultation b/l
ABDOMEN: Soft, NTND. NABS, kidney transplant palpable in RLQ
EXTREMITIES: No c/c/e. LUE fistula with thrill
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
NEURO: A/Ox3, CN II-XII intact. Non focal.
Pertinent Results:
ADMISSION LABS:
.
[**2158-12-22**] 07:12AM BLOOD WBC-9.4 RBC-3.50* Hgb-11.0* Hct-33.0*
MCV-94 MCH-31.4 MCHC-33.3 RDW-17.9* Plt Ct-216
[**2158-12-22**] 01:10PM BLOOD Glucose-107* UreaN-53* Creat-9.7*#
Na-130* K-5.9* Cl-92* HCO3-19* AnGap-25*
[**2158-12-22**] 06:45PM BLOOD CK-MB-38*
[**2158-12-22**] 06:45PM BLOOD CK-MB-38*
[**2158-12-22**] 01:10PM BLOOD Calcium-9.7 Phos-4.3 Mg-2.6
.
PERTINENT LABS:
.
[**2158-12-23**] 10:04AM BLOOD CK-MB-319* MB Indx-24.0* cTropnT-2.47*
[**2158-12-23**] 10:11AM BLOOD CK-MB-324* MB Indx-24.1* cTropnT-2.30*
[**2158-12-24**] 02:32AM BLOOD CK-MB-204* MB Indx-19.1* cTropnT-6.21*
[**2158-12-28**] 06:49AM BLOOD CK-MB-10 MB Indx-5.1 cTropnT-12.17*
[**2158-12-28**] 04:55PM BLOOD CK-MB-9 cTropnT-13.07*
[**2158-12-31**] 01:30AM BLOOD Cortsol-14.0
[**2158-12-30**] 04:40PM BLOOD Lactate-0.7
.
DISCHARGE LABS:
.
[**2159-1-2**] 04:37AM BLOOD WBC-8.0 RBC-2.67* Hgb-8.4* Hct-24.7*
MCV-93 MCH-31.3 MCHC-33.9 RDW-16.0* Plt Ct-284
[**2159-1-2**] 04:37AM BLOOD Glucose-80 UreaN-61* Creat-7.9*# Na-137
K-4.4 Cl-93* HCO3-28 AnGap-20
[**2159-1-2**] 04:37AM BLOOD Calcium-9.3 Phos-6.2*# Mg-2.3
.
MICRO/PATH:
.
MRSA Screen [**12-25**]: Negative
MRSA Screen [**12-27**]: Negative
.
IMAGING/STUDIES:
.
C.CATH [**12-22**]:
FINAL DIAGNOSIS:
1. Severe native three vessel coronary artery disease.
2. Patent LIMA-LAD, SVG-RI.
3. Occluded SVG-OM.
4. Normal systemic arterial blood pressure.
5. Successful PCI of OM1 with two overlapping BMS.
6. Unsuccessful attempt to revascularize AV groove LCx.
7. Hemodialysis post-procedure.
8. Ongoing optimal medical therapy for CAD and CHF.
9. Repeat echocardiogram to evaluate for improvement in LVEF
after
revascularizing the OM1. If not, consider repeat viability study
(Dobutamine echo) and re-assess the need to open the LCx.
.
Extremity U/S [**12-23**]:
IMPRESSION: 1.2 x 1.1 cm right groin pseudoaneurysm.
.
TTE [**12-25**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is 0-5
mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is severe regional left ventricular systolic
dysfunction with severe hypokinesis of the inferior and
inferolateral walls. The remaining segments contract well (LVEF
30-35%). No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is mild-moderate pulmonary
artery systolic hypertension. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD. Pulmonary artery hypertension.
Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2158-8-9**],
left ventricular systolic dysfunction is now regional and global
systolic function is preserved. Left ventricular cavity size is
now normal.
.
C.CATH [**12-25**]:
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Jailed AV groove Lcx with delayed flow.
3. Patent OM bare metal stents.
4. Unsuccessful attempt at PCI of AV groove Lcx due to inability
to
cross lesion with wire.
.
CXR PA/LAT [**12-27**]:
FINDINGS: As compared to the previous radiograph, pre-existing
pleural
effusions have minimally decreased in extent. However,
bilateral, right more than left subtle reticular opacities are
seen on both the frontal and the lateral radiograph. Given the
small overall lung volumes the findings are suggestive of a
fibrotic process. CT could be performed to clarify this
suspicion. Moderate cardiomegaly without evidence of acute
pulmonary edema.
Status post CABG.
.
CXR Portable [**12-27**]:
IMPRESSION:
1. Worsening congestive heart failure.
2. No residual pneumothorax identified.
Brief Hospital Course:
63M with ESRD on HD, CAD s/p CABG ([**2156**] - LIMA to LAD, SVG to
RPDA, SVG to OM1, SVG to ramus), sCHF (EF 20-30%) admitted after
elective PCI c/b inability to Circ, psuedoaneurysm, and
hypotension in the setting of HD who experienced in-hospital
Vfib arrest greater than 48 hours after NSTEMI.
.
ACTIVE DIAGNOSES:
.
# NSTEMI/VFib Cardiac Arrest In-Hospital: Mr. [**Known lastname **] was
admitted for elective cardiac catheterization for optimization
of cardiac function in preparation for possible renal
transplant. During the procedure he was noted to have severe
native vessel disease, 2 patent grafts (LIMA-LAD, SVG-RI), and
one occluded graft (SVG-OM). During the procedure OM1 was
successfully stented with BMS x 2, but there was an unsuccessful
attempt to revascularize AV groove LCx. Following the procedure
the patient developed chest pain with ST depressions in
II/III/aVF and positive CKMB and troponins (CKMB peak of 24.1).
On arrival to the CCU he was continued no aspirin, plavix,
heparin drip, abciximab, and atorvastatin. Echo after the
procedures was significant for increase in estimated LVEF
(30-35% from 20-30% on prior) with preserved global systolic
function but severe regional left ventricular systolic
dysfunction with severe hypokinesis of the inferior and
inferolateral walls. A second cardiac catheterization was
conducted which was significant for a jailed AV groove Lcx with
delayed flow and an unsuccessful attempt at PCI of AV groove Lcx
due to inability to cross lesion with wire. His condition
improved steadily and he was called out of the CCU to the floor.
Five days following this patient's NSTEMI, he experienced a VT
-> Vfib arrest (caught on telemetry) and was rapidly coded
receiving chest compressions and defibrillator shocks with rapid
ROSC. He was transferred back to the CCU for continued
evaluation and treatment and was loaded with IV then PO
amiodarone. He was evaluated by the EP team who offered the
possibility of an ICD prior to discharge or a lifevest to assess
EF in 4 weeks and further discussion regarding need for ICD. He
was fitted with a [**Hospital1 **] lifevest and was discharged home with
close follow-up with his PCP, [**Name10 (NameIs) 2085**], electrophysiologist,
and nephrologist.
.
# Femoral Pseudoaneurysm: Following initial catheterization the
patient was found to have a pseudoaneurysm reported as 1.2x1.1cm
by radiology, read as 0.7cm by interventional radiology. Per
discussion with interventional, thrombin injection of
psuedoanuerysm was felt to be of low utility given its small
size. On transfer to the CCU, abciximab was initially restarted,
then held. The patient would benefit from repeat ultrasound in
two weeks to assess the status of this finding.
.
# Symptomatic Hypotension: Pt was hypotensive in dialysis
following his initial catheterization to the 60's systolically
with mild light-headedness which resolved quickly with fluids
and 2 units of PRBCs. There was initial concern for hemorrhage
from his cath site but this was felt to be less likely given the
reassuring doppler findings and quick resolution. He continued
to be mildly hypotensive mostly to the high 80's-low 90's during
subsequent dialysis sessions but this continued to improve until
he was able to tolerate full dialysis with significant fluid
removal.
.
# Acute on Chronic Anemia of CKD: Pt experienced a gradual crit
drop from 33 to 25 despite receiving 3 units of blood during his
hospitalization. He had no active sources for bleeding (although
there was initial concern related to his femoral pseudoaneurysm
as mentioned above). Perhaps it is multifactorial given his ESRD
and more frequent but shorter dialysis sessions perhaps leading
to sequestration of RBC's within the tubing. This should be
followed as an outpatient to ensure his crit does not continue
to drop.
.
#Hypoxia: This patient was hypoxic on RA at rest to the high
80's on occasion. He was never free of rales or pulmonary edema
but also desaturated on room air to the mid-70's when walking
even after he was dialyzed to his estimated goal dry weight. It
was thought that given his prior smoking history, he likely had
a component of chronic lung disease. It did not become apparent
until just prior to discharge that this patient was previously
on home oxygen for the same reason. He was discharged with home
oxygen.
.
#Chronic Systolic CHF: ECHO during this admission demonstrated
an LVEF of 30-35% up from 20-30% on prior. He did not have
clinical evidence of CHF exacerbation on admission and was
dialyzed to his dry weight. His home metoprolol and lisinopril
were held for a period following his NSTEMI due to hypotension
as above. He was re-started on lower doses of both medications
prior to discharge. He will likely benefit from spironolactone
in the future when his blood pressures are more robust.
.
CHRONIC DIAGNOSES:
.
#Atrial Fibrillation: Stable. He was intermittently in sinus
rhythm and afib during this admission. His warfarin was held for
a period of time given elevated levels and possibility of
placing an ICD. He was continued on his home warfarin dose at
the time of discharge and instructed to follow-up as usual with
coumadin clinic.
.
# ESRD s/p Kidney Transplant: Stable. He was dialyzed frequently
during this admission due to his borderline blood pressures and
inability to tolerate longer sessions. By the end of his
hospitalization he was back to his baseline of tolerating
dialysis. We increased his sevelamer per renal recs given
chronically elevated phosphate. He will need continue dialysis
and prednisone QOD as an outpatient.
.
# GERD: Stable. Continued on home omeprazole.
.
TRANSITIONAL ISSUES:
# Groin U/S in 2 weeks: To assess for pseudoaneurysm
.
#Need for ICD?: He will be following up with Dr. [**Last Name (STitle) **] for
discussion of his treatment options. He currently has a lifevest
and is being loaded on amiodarone.
.
#Blood Pressure: His blood pressures have been a little soft,
especially following dialysis which has caused us to lower his
home BP regimen (metoprolol succinate 75mg PO daily ->
metoprolol succinate 25mg PO daily, and lisinopril 20mg PO daily
-> lisinopril 10mg PO daily). We will leave it to you to
uptitrate these as tolerated as an outpatient.
.
#Atorvasatin: We have lowered his lipitor dose from 80mg PO
daily -> 40mg PO daily due to the addition of amiodarone
.
#Coumadin: This is followed by his PCP/outside coumadin clinic.
We anticipate he will have lower coumadin requirements going
forward given the amiodarone.
.
#Renal Transplant: He is naturally quite concerned that having
an ICD/arrest may affect his chances for a renal transplant. He
will surely have questions regarding this during his renal
follow-up.
Medications on Admission:
- ATORVASTATIN 80mg daily
- NEPHROCAPS 1mg daily
- LISINOPRIL 20mg daily
- METOPROLOL SUCCINATE 75mg daily
- OMEPRAZOLE 20mg daily
- PREDNISONE 5mg qod
- SEVELAMER HCL 1600mg TID
- WARFARIN 4mg daily
- ASPIRIN 81mg daily
- MAGNESIUM OXIDE 400mg [**Hospital1 **]
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
7. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
Disp:*20 Tablet(s)* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: As needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day: As
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
13. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
14. Home oxygen order
Home oxygen for exertion when oxygen saturations fall below 88%.
We have found that you desaturate to below 88% on room air when
walking short distances. Titrate up to 4L's for oxygen
saturations less than 88%.
15. triamcinolone acetonide 0.1 % Cream Sig: One (1) application
Topical twice a day as needed for itching: Apply to affected
areas on chest. Please do not apply for more than 2 consecutive
weeks.
Disp:*1 pound jar or large trade* Refills:*0*
16. atorvastatin 80 mg Tablet Sig: 0.5 Tablet PO once a day.
17. amiodarone 200 mg Tablet Sig: as directed Tablet PO as
directed: Please take two tablets twice a day until [**1-4**], then
you should take one tablet three times a day until [**1-11**], then
you should take one tablet twice daily until [**1-18**], then you
should take 200mg daily Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Allcare VNA
Discharge Diagnosis:
Primary Diagnosis:
Coronary Artery Disease s/p cardiac cath with BMS to OM1
Non ST Elevation Myocardial infarction
Monomorphic VT with VF arrest
Hypotension
End Stage Renal Disease
.
Secondary Diagnoses:
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Chest pain free.
Discharge Instructions:
Dear Mr. [**Known lastname **],
.
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You had a cardiac catheterization with a placement of
a bare metal stent. After the procedure, you started having some
chest pain that we believe was from a heart attack. We did
another heart catheterization, but no further interventions were
able to be made.
.
Later your heart went into an unstable rhythm called ventricular
fibrillation. We performed CPR and shocked your heart three
times back into a normal rhythm. We considered implanting a
device that could shock you back into a normal rhythm if this
was to happen again but decided against it, as this irregular
rhythm is likely a result of your heart attack. Once you
recover from your heart attack, you should not be at risk for
this rhythm and you may not need a internal defibrillator.
Instead you should wear a LifeVest which is an external device
that will stop a dangerous irregular heart rhythm if it occurs
again. You should follow up with Dr. [**Last Name (STitle) **] as scheduled to
arrange to have further studies and potential implantation of a
defibrillator device at a later time. We also started a
medication called amiodarone which will help prevent this
arrhythmia.
.
You will need to take Aspirin 325mg daily indefinitely. You
will need to take Plavix 75mg daily for minimum of one year.
Stopping these medications prematurely can put you at risk for
in stent clot and subsequent heart attack. You should NOT stop
these medications unless Dr. [**First Name (STitle) 437**] tells you otherwise.
.
weight goes up more than 3 lbs in one day or more than 5 lbs in
one week.
.
Your oxygen levels have been low in the hospital, especially
when you move around. As a result, we are sending you home on
oxygen for you to use when you walk. This may be temporary and
you should follow up with your PCP and your kidney specialist to
reevaluate this need in the future. Ideally your oxygen
saturation levels should be greater than 94%.
.
Your blood levels are also lower than normal. Your kidney
doctor may want to give you blood transfusions at dialysis.
.
The following changes have been made to your medication regimen:
-START amiodarone 400mg twice a day until [**1-4**], then you should
take 200 mg three times a day until [**1-11**], then you should take
200mg twice daily until [**1-18**], then you should take 200mg daily
-START oxycodone 5mg every 6 hours as needed for pain.
-START docusate 1 pill twice daily as needed for constipation
-START senna 1 pill as needed for constipation
-START Plavix 75mg PO daily - Do NOT stop this unless Dr. [**First Name (STitle) 437**]
instructs you to!
-START Triamcinolone 0.1% cream twice daily as needed to
affected areas. This medication can thin or discolor your skin
so please only use it for two weeks at a time.
-INCREASE Aspirin 325mg by mouth once daily - Do not stop this
medication unless Dr. [**First Name (STitle) 437**] instructs you otherwise!
-INCREASE Sevelamer (PhosLo) to 2400mg by mouth three times
daily
-DECREASE Lisinopril to 10mg once daily (this can be increased
to your home dose by your primary care doctor or cardiologist)
-DECREASE atorvastatin to 40 mg daily
-DECREASE Metoprolol Succinate 25mg PO daily
-Continue your other home medications as previously directed
.
Please follow-up with the appointments below.
.
It is VERY important that you wear your life vest at all times
and follow the instructions provided by the company. You can
take off your life vest when you shower but you have to make
sure someone is present with you AT ALL TIMES when you have your
lifevest off. You should not drive or operate heavy machinery
because if you were to have an abnormal heart rhythm at that
time you could serious harm yourself or others.
Followup Instructions:
Please attend the following appointments:
.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: THE MEDICAL GROUP
Address: [**Last Name (un) 15488**] [**Apartment Address(1) 31103**], [**Hospital1 420**],[**Numeric Identifier 15489**]
Phone: [**Telephone/Fax (1) 10508**]
*We are working on a follow up appointment with your primary
care provider [**Name Initial (PRE) 176**] 1 week. The office will contact you at home
with an appointment. If you have not heard within 2 business
days please call the office.
.
You will need continued follow-up with your coumadin clinic as
arranged through your PCP. [**Name10 (NameIs) 2172**] last INR was 1.6 on [**2159-1-1**].
You are being discharged on 4mg Warfarin PO daily.
.
Department: TRANSPLANT CENTER
When: FRIDAY [**2159-1-12**] at 8:00 AM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2159-1-24**] at 10:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: FRIDAY [**2159-1-26**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2159-1-4**]
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11,600
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21716
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Discharge summary
|
report
|
Admission Date: [**2151-9-16**] Discharge Date: [**2151-9-29**]
Service: [**Doctor First Name 147**]
Allergies:
Aspirin / Vioxx / Celebrex
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain, some nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 84 year old male transferred from [**Hospital3 **] for management of undetermined biliary tree injury.
Patient was originally admitted on [**2151-6-23**] with
chest pain. Cardiac cath revealed LAD and LCX disease. Pain
continued and patient was diagnosed with acute cholecystitis.
Patient underwent a laproscopic cholecystectomy [**2151-7-1**] which
was complicated by small bowel enterotomy. The procedure was
converted to open, with repair of the enterotomy and completion
of the cholecystectomy. Postoperatively, a intrabdominal bile
collection was diagnosed and a 7mm stent was placed on [**2151-7-14**].
Patient presented again to [**Hospital3 15402**] on [**2151-8-28**], and underwent
a CT guided percutaneous drain placement for a RUQ abscess. At
that time patient was still having seropurulent drainage.
Patient was readmitted to [**Hospital3 15402**] a third time on [**2151-9-12**]
with low grade fevers, and RUQ pain. He was found to have a WBC
count of 26.2 with a left shift. Abdominal/pelvic CT showed no
fluid collection or free air, but some slight inflammatory
changes around the drain. The stent was in place, with no
duodenal erosion. Patient was placed on unasyn and flagyl
empirically. Patient underwent an ERCP to remove the biliary
stent on [**2151-9-14**]. Following this, he had copious drainage from
the pigtail catheter, suggesting an ongoing bile leak, possibly
from the R hepatic duct. Patient was transferred to [**Hospital3 **]
Deconess for further evaluation and treatment. Urinalysis and
culture was negative, chest xray revealed bibasilar atelectasis
vs scarring. Blood cultures remained negative after 48 hrs.
Past Medical History:
1. status post cholecystectomy complicated by right upper
quadrant abcess
2. coronary artery disease, status post myocardial infarction:
[**5-28**] c. cath showed 99% dLAD, pLAD stenosis, mLCX stenosis,
mild RCA stenosis; ejection fraction 25-30% with anteroapical
AK.
3. COPD
4. Depression
5. anxiety
6. htn
7. chronic back pain
Social History:
resident at [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 57090**] NH, previous heavy smoker, no history
of excessive drug abuse
Physical Exam:
PE: V- 98.8, 182/77, 76, 18, 99% on RA
gen - NAD
HEENT - PERRLA, EOMI, anicteric. O/P clear, MMM
neck - supple, no JVD, minimal L sided carotid upstroke, no
bruits
lungs - CTAB
c/v - RRR, II/VI SEM at base
abd - s/nt/nd, NABS, no HSM, AAA incision is c/d/i
extr - no c/c/e
neuro - A+Ox3, no focal signs
Pertinent Results:
[**2151-9-16**] 11:08PM GLUCOSE-74 UREA N-6 CREAT-0.7 SODIUM-139
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12
[**2151-9-16**] 11:08PM ALT(SGPT)-8 AST(SGOT)-13 LD(LDH)-198 ALK
PHOS-95 AMYLASE-17 TOT BILI-0.3
[**2151-9-16**] 11:08PM LIPASE-12
[**2151-9-16**] 11:08PM ALBUMIN-2.6* CALCIUM-8.5 PHOSPHATE-3.3
MAGNESIUM-1.7 IRON-13*
[**2151-9-16**] 11:08PM calTIBC-133* VIT B12-418 FOLATE-15.8
FERRITIN-440* TRF-102*
[**2151-9-16**] 11:08PM DIGOXIN-1.0
[**2151-9-16**] 11:08PM WBC-12.2* RBC-3.51* HGB-9.6* HCT-31.2* MCV-89
MCH-27.2 MCHC-30.6* RDW-15.7*
[**2151-9-16**] 11:08PM NEUTS-76.4* LYMPHS-15.0* MONOS-6.7 EOS-1.7
BASOS-0.2
[**2151-9-16**] 11:08PM HYPOCHROM-2+
[**2151-9-16**] 11:08PM PLT COUNT-346
[**2151-9-16**] 11:08PM PT-16.9* PTT-31.2 INR(PT)-1.8
[**2151-9-16**] 11:08PM FIBRINOGE-728*
Brief Hospital Course:
Patient was admitted to [**Hospital1 **] [**First Name (Titles) **] [**2151-9-16**] with the above complaints. Patient was started on zosyn for
bilary coverage. CT on [**2151-9-17**] demonstrated small residual
fluid/air collection in the gallbladder fossa around the
pigtail catheter. The plan itially was repeat the ERCP, but the
patient improved clinically. Repeat CT on [**9-23**] showed no change.
The pigtail cathater was pulled the next day and the zozyn was
discontinued.
Throughout admission, patient consistantly refused to eat. He is
without his dentures and although a soft mechanical diet was
ordered, he ate very little A picc line was placed on [**9-20**] and the patient has been getting his daily caloric needs
with peripheral nutrition. Towards the end of the admission,
with encouragement he does drink some of his boost shakes. His
dentures and glasses, turns out, are in pocession by a
friend/family member.
Patient also was followed by pyschiatry during this admission
for symptoms of depression/anxiety. Patient was started on
Risperdal for these symptoms.
Medications on Admission:
zozyn
digoxin
metoprolol
ecitalopram
protonix
senna/colace
percocet
moprhine
coumadin
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*1 inhalation* Refills:*2*
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*1 inhalation* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QD (once a day).
Disp:*30 Suppository(s)* Refills:*2*
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
Disp:*1 application* Refills:*2*
11. Risperidone 0.5 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime).
Disp:*1 Tablet(s)* Refills:*2*
12. Morphine Sulfate 10 mg/5 mL Solution Sig: One (1) 10mg/5ml
PO Q4H (every 4 hours) as needed.
Disp:*60 10mg/5ml* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 54351**] - [**Location (un) 5503**]
Discharge Diagnosis:
bilary sepsis
depression
coronary artery disease
history of myocardial infarction
hypertension
Discharge Condition:
good
Discharge Instructions:
increase food intake
Followup Instructions:
Patient to follow up with Dr. [**Last Name (STitle) 57091**]
|
[
"496",
"414.01",
"E878.8",
"998.59",
"300.4",
"997.4",
"576.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.93",
"89.64",
"38.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
6356, 6431
|
3689, 4772
|
280, 287
|
6570, 6576
|
2841, 3666
|
6645, 6709
|
4908, 6333
|
6452, 6549
|
4798, 4885
|
6600, 6622
|
2518, 2822
|
213, 242
|
315, 1985
|
2007, 2338
|
2354, 2503
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,063
| 167,762
|
40848
|
Discharge summary
|
report
|
Admission Date: [**2114-6-19**] Discharge Date: [**2114-6-28**]
Date of Birth: [**2046-8-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina and progressive dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2114-6-19**] Coronary bypass grafting x3: Left internal mammary
artery graft to left anterior descending, reverse saphenous vein
of diagonal branch and the marginal branch.
History of Present Illness:
This is a 67 year old Parkinsonian male with several months of
progressively increasing angina and dyspnea on exertion. Recent
stress test demonstrated the inability to go beyond one minute
of Stage I of the [**Doctor First Name **] protocol secondary to dyspnea while
there was echocardiogram evidence suggestive of intra-left
ventricular obstructive pathophysiology. Subsequent cardiac
catheterization revealed multivessel coronary artery disease and
he was referred surgical revascularization.
Past Medical History:
-Coronary artery disease
-Possible Hypertrophic obstructive cardiomyopathy
-Possible Bicuspid Aortic Valve
-Dyslipidemia
-Parkinson's disease
-Hypertension
-Hemorrhoids
- Left Middle finger amputation secondary to trauma
- Right Lower Leg trauma s/p ORIF
Social History:
Race: Caucasian
Lives with: Wife
Cigarettes: Smoked no [] yes [x] last cigarette 50 yrs ago Hx:
Other Tobacco use:
ETOH: Denies
Illicit drug use: Denies
Family History:
Denies premature coronary artery disease. Mother underwent CABG
in her 70's.
Physical Exam:
Physical Exam
Pulse: 58 Resp: 18 O2 sat: 98%
B/P Right: Left: 132/77
General: Elderly male in no acute distress
Skin: Dry [x] intact [x] - well healed scar on RLE
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] systolic murmur noted
along left sternal border
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema [x] trace / Varicosities: None [x]
Neuro: alert and oriented / resting tremor noted in left arm and
hand / shuffle gait / grossly normal motor function and strength
equal bilaterally
Pulses:
Femoral Right: 2 Left: 2 - right groin hematoma noted
without bruit
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 1 Left: 1
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2114-6-19**] Intraop TEE:
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. There is [**Month/Day/Year 1192**] symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). No definite evidence for
asymmetric LVH. There is a mild septal knuckle (1.5cm) 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. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is a long
anterior leaflet. After the coaptation, the remaining anterior
mitral leaflet curves into LVOT causing chordal [**Male First Name (un) **]. At a HR of
40 to 50/min, there was no noticeable resting gradients with
trivial to mild MR> Given this anatomy, the chance of [**Male First Name (un) **] at a
higher HR was readily apparent. However, given his CAD history,
it was decided not to increase HR> Surgeon informed and agreed
with the decision. An eccentric, posteriorly directed jet of
Mild (1+) to [**Male First Name (un) 1192**] mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results before surgical incision. POST-BYPASS:
Normal RVEF. Overall LVEF 55%. Intact thoracic aorta. At a HR of
more than 70min (by atrial pacing), MR [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] becomes readily
apparent. MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] to severe under these conditions. At HR
less than 70/min, MR is mild to [**Last Name (Titles) 1192**] with [**Male First Name (un) **]. There is no
AI. No other new findings.
.
[**2114-6-25**] Chest X-ray:
As compared to the previous examination, [**Month/Day/Year 1192**] bilateral
pleural
effusions are seen on today's radiograph. The effusions are
better
appreciated on the lateral than on the frontal view. Otherwise,
the
radiograph is unchanged. [**Month/Day/Year **] cardiomegaly with basal areas
of
atelectasis. Status post CABG, right central venous access line.
No interval appearance of focal parenchymal opacity suggesting
pneumonia.
.
[**2114-6-26**] WBC-6.4 RBC-2.97* Hgb-9.1* Hct-27.0* Plt Ct-193
[**2114-6-25**] WBC-6.3 RBC-3.08* Hgb-9.7* Hct-28.0* Plt Ct-168
[**2114-6-24**] WBC-5.7 RBC-2.92* Hgb-9.1* Hct-26.4* Plt Ct-142*
[**2114-6-23**] WBC-6.5 RBC-3.07* Hgb-9.9* Hct-27.6* Plt Ct-121*
[**2114-6-22**] WBC-8.7 RBC-3.48* Hgb-11.0* Hct-31.1* Plt Ct-106*
[**2114-6-26**] PT-31.7* PTT-30.0 INR(PT)-3.1*
[**2114-6-25**] PT-19.9* INR(PT)-1.8*
[**2114-6-24**] PT-15.8* PTT-32.2 INR(PT)-1.4*
[**2114-6-23**] PT-13.6* PTT-28.3 INR(PT)-1.2*
[**2114-6-26**] Glucose-97 UreaN-34* Creat-1.3* Na-142 K-4.1 Cl-104
HCO3-29
[**2114-6-25**] Glucose-100 UreaN-31* Creat-1.2 Na-142 K-4.1 Cl-105
HCO3-29
[**2114-6-24**] Glucose-107* UreaN-24* Creat-1.1 Na-143 K-4.0 Cl-105
HCO3-30
[**2114-6-23**] Glucose-123* UreaN-22* Creat-1.0 Na-140 K-4.0 Cl-107
HCO3-25
[**2114-6-22**] Glucose-121* UreaN-16 Creat-1.0 Na-142 K-3.9 Cl-110*
HCO3-25
[**2114-6-26**] Mg-2.3
[**2114-6-27**] 05:24AM BLOOD WBC-5.9 RBC-2.92* Hgb-9.0* Hct-25.9*
MCV-89 MCH-31.0 MCHC-34.9 RDW-14.2 Plt Ct-226
[**2114-6-27**] 05:24AM BLOOD PT-29.1* INR(PT)-2.8*
[**2114-6-27**] 05:24AM BLOOD Glucose-90 UreaN-36* Creat-1.3* Na-141
K-3.9 Cl-104 HCO3-30 AnGap-11
[**2114-6-28**] 05:25AM BLOOD WBC-5.8 RBC-2.93* Hgb-9.2* Hct-26.4*
MCV-90 MCH-31.3 MCHC-34.7 RDW-14.4 Plt Ct-302
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2114-6-19**] where the patient underwent CABGx 3
(LIMA-LAD, RSVG-Om and diag. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. Kefzol
was used for surgical antibiotic prophylaxis. His blood pressure
was labile immediately out of the OR and he was noted to have
Systolic Anterior Motion by echocardiogram, therefore diuresis
was minimized and he remained in the unit for a few days due to
Neo-Synephrine requirement. He developed atrial fibrillation
soon out of the OR and was started on Amiodarone. Low dose
Lopressor was eventually started once he was off Neo-Synephrine.
Patient was slow to wake and narcotics were minimized. He was
restarted back on his Carbidopa-Levodopa. He awoke
neurologically intact and was extubated on POD #1. His renal
function remained stable, and his Foley was removed without
difficulty. His CVICU was otherwise unremarkable and he was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
He remained in atrial fibrillation and was eventually started on
Warfarin with a goal INR between 2.0 - 2.5. He remained on beta
blockade while Amiodarone was titrated accordingly. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. By the time of discharge to the
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] rehab on POD # 9 the patient was ambulating with
walker and assistance. His wounds were healing well and pain
was controlled with oral Tylenol. The patient was discharged to
rehab in good condition with appropriate follow up instructions.
Medications on Admission:
Medications at home: ** Patient unsure of medications and did
not
bring a list ** Below medications are based on outside notes **
Atenolol 50 mg daily
Diovan HCT (160 mg/ 12.5 mg) daily
Doxazosin 2 mg daily
Lipitor 10 mg daily
Sinemet 10/100 mg TID
Mirapex 0.25 mg TID
ASA 81 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. ranitidine HCl 150 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. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. carbidopa-levodopa 10-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Take 200mg [**Hospital1 **] for one week then reduce to 200mg daily
until stopped by cardiologist. Tablet(s)
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
12. potassium chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 2 weeks.
13. Coumadin 1 mg Tablet Sig: 0.5 Tablet PO once a day for 1
days: Dose for INR goal of [**12-27**].5.
14. Mirapex 0.25 mg Tablet Sig: One (1) Tablet PO three times a
day.
Discharge Disposition:
Extended Care
Facility:
Roscommon vs. [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
Coronary artery disease - s/p Coronary artery bypass graft x 3
Post-op atrial fibrillation
Past medical history:
Dyslipidemia
Parkinson's disease
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2114-7-18**] 1:45
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14522**] will call pt. with appointment.
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 89228**] [**Name (STitle) **] in [**11-26**] weeks [**Telephone/Fax (1) 30837**]
**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: [**2114-6-29**](day after discharge). Please monitor 3x
weekly and titrate Warfarin accordingly. Prior to discharge from
rehab, please arrange outpatient Warfarin followup with PCP or
cardiologist.
Completed by:[**2114-6-28**]
|
[
"411.1",
"285.9",
"287.5",
"414.01",
"V15.82",
"746.4",
"272.4",
"427.31",
"458.29",
"332.0",
"425.1",
"401.9",
"V70.7",
"780.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"38.93",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9929, 10038
|
6448, 8258
|
352, 531
|
10240, 10469
|
2524, 6425
|
11309, 12236
|
1521, 1599
|
8593, 9906
|
10059, 10150
|
8284, 8284
|
10493, 11286
|
8305, 8570
|
1614, 2505
|
270, 314
|
559, 1057
|
10172, 10219
|
1351, 1505
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,219
| 138,802
|
34833
|
Discharge summary
|
report
|
Admission Date: [**2183-9-30**] Discharge Date: [**2183-10-17**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
PROCEDURE:
1. Total percutaneous repair of aortic aneurysm with
endovascular method.
2. Zenith 36-95 graft right 22-71 limb, left 22-54 limb
with 12-54 bridge
History of Present Illness:
This is an 89 y.o M transferred from [**Hospital6 5016**] with
c/o mid back pain since last night, seen at his PCP this morning
for routine visit, he happened to mention about the back pain.
An
abdominal US was taken that showed 8x8 cm AAA. Patient was sent
to the [**Hospital3 **] Caritas ED for further evaluation. Patient
was
pain free when he arrived at the [**Hospital6 5016**]. An
abdominal CT was taken-that showed no leakage of AAA, routine
labs and was R/O for MI. Patient denies any pain, chest
pain/discomfort, breathing difficulty, fever, chills or
generalized body malaise.
Past Medical History:
PMH:
HTN
Glaucoma
Emphysema
Anxiety
PSH: s/p CABGx3, s/p prostatectomy, s/p hernia repair
Social History:
Social Hy: currently non-smoker h/o 25 pky smoking, denies ETOH
abuse
Family History:
N/C
Physical Exam:
PE: VS wt. 170 lbs. P 64 169/90 O2 sat 100 on 2 L
Gen: AAOx3, NAD
HENT: NCAT, EOMI, MMM
Lungs: CTA
Heart: RRR S1, S2
Abd: soft, obese, no rebound, active bowel sounds, no abdominal
masses palpable,
Ext:
B/L edema 1 Plus
palpable bilateral dp, pt, popliteal and femoral
Pertinent Results:
[**2183-10-17**] 05:40AM BLOOD WBC-12.5* RBC-3.16* Hgb-8.7* Hct-27.4*
MCV-87 MCH-27.5 MCHC-31.8 RDW-15.8* Plt Ct-444*
[**2183-10-8**] 08:24PM BLOOD PT-14.6* PTT-32.7 INR(PT)-1.3*
[**2183-10-17**] 05:40AM BLOOD Glucose-65* UreaN-28* Creat-1.8* Na-141
K-3.7 Cl-97 HCO3-35* AnGap-13
[**2183-10-17**] 05:40AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0
[**2183-10-17**] 05:40AM BLOOD
%HbA1c-6.1*
[**2183-10-13**] 11:10AM BLOOD
TSH-4.6*
[**2183-10-13**] 11:10AM BLOOD
T4-5.6
[**2183-10-3**] 01:52PM
URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.011
URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
URINE RBC->50 WBC-[**2-5**] Bacteri-FEW Yeast-NONE Epi-0-2
[**2183-10-3**] 11:52 am STOOL CONSISTENCY: WATERY Source:
Stool.
FECAL CULTURE (Final [**2183-10-5**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2183-10-5**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2183-10-6**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2183-10-4**]):
Feces negative for C.difficile toxin A & B by EIA.
Cardiology Report ECG Study Date of [**2183-10-14**] 4:30:26 AM
Sinus rhythm
Right bundle branch block
Since previous tracing of [**2183-10-13**], atrial ectopic activity not
seen
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 150 138 416/440 86 -10 24
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.0 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.5 m/s
Left Atrium - Peak Pulm Vein D: 0.6 m/s
Left Atrium - Peak Pulm Vein A: 0.2 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: *6.2 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% >= 55%
Left Ventricle - Lateral Peak E': 0.10 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 13 < 15
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *2.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 18 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 10 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.22
Mitral Valve - E Wave deceleration time: 198 ms 140-250 ms
TR Gradient (+ RA = PASP): *39 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
Lipomatous hypertrophy of the interatrial septum. Normal IVC
diameter (<2.1cm) with <35% decrease during respiration
(estimated RA pressure indeterminate).
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. Low normal LVEF. No
resting LVOT gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function. Paradoxic septal motion consistent with prior cardiac
surgery.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild
AS (AoVA 1.2-1.9cm2). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Calcified tips of papillary muscles. Mild to moderate
([**12-4**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate [[**12-4**]+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PS.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. The right atrial pressure is indeterminate.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is probably normal but the inferolateral wall is not
adequately visualized and there may be hypokinesis in this
territory. Overall left ventricular systolic function is low
normal (LVEF 50-55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic valve
leaflets are moderately thickened. There is at least mild aortic
valve stenosis (area 1.2-1.9cm2) which may be underestimated.
There is no aortic regurgitation. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-4**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: At least mild aortic stenosis (velocity across valve
may be underestimated). Low normal left ventricular systolic
function. Mildly dilated right ventricle with normal function.
Mild to moderate mitral and tricuspid regurgitation. Moderate
pulmonary hypertension.
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2183-10-13**]
1:14 PM
BILAT LOWER EXT VEINS
Reason: b/l sweeling in legs s/p EVAR. Please evaluate for DVT
FINDINGS: Grayscale, color and Doppler son[**Name (NI) 1417**] of bilateral
common femoral, superficial femoral, popliteal and tibial veins
are performed. There is normal flow, compression and
augmentation seen in all of the vessels.
IMPRESSION: No evidence of deep vein thrombosis in either leg.
CHEST (PA & LAT)
FINDINGS: Two views. Comparison with [**2183-10-10**]. Bilateral
subsegmental
atelectasis and/or scarring increased density in the right lung
base are
unchanged. Bilateral pleural thickening and/or fluid is stable.
The patient is status post median sternotomy as before.
Mediastinal structures are stable in appearance. A right
subclavian central venous catheter remains in place.
IMPRESSION: No significant interval change. There is no definite
evidence of volume overload.
Radiology Report CT PELVIS W/O CONTRAST Study Date of [**2183-10-10**]
9:01 PM
CT ABDOMEN WITHOUT CONTRAST: There is a moderate right pleural
effusion with associated consolidation, likely atelectasis. A
small focus of consolidation is present within the left lower
lobe which may represent rounded atelectasis.
Evaluation of intra-abdominal and intrapelvic organs is limited
given lack of IV contrast administration. However, no focal
liver lesions are identified. The gallbladder demonstrates
intraluminal stones, without pericholecystic fluid or wall
thickening. The spleen, stomach, pancreas, and visualized
abdominal large and small bowel are unremarkable. There is no
evidence of obstruction. No free fluid or free air is present
within the abdomen. There are multiple bilateral renal
hypodensities, not appreciably changed over the short interval.
The largest cystic lesion at the lower pole of the left kidney
currently measures 4.3 cm and is consistent with a simple cyst.
There is a large infrarenal abdominal aortic aneurysm measuring
7.8 x 7.5 x 8.6 cm. There is little change since recent
comparison with now intraluminal aortic stent graft with a short
segment of the graft extending into the proximal iliac veins.
Evaluation of leak cannot be performed given lack of IV contrast
administration.
CT PELVIS WITHOUT CONTRAST: There is diffuse circumferential
wall thickening involving the rectum and distal sigmoid colon.
Region of sigmoid colon with diverticulosis is within normal
limits without evidence of inflammatory stranding. There is
inflammatory stranding within the ischiorectal fossa with small
amount of free fluid in the presacral region (series 2: image
75).
There is diffuse anasarca. A small amount of intraluminal air
within the
bladder is likely related to recent Foley placement. Coarse
calcification is noted within the prostate gland.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
identified. There is loss of disc heights and multiple
osteophytes within the lumbar spine, most marked at L2-3
consistent with degenerative change.
IMPRESSION:
1. New circumferential thickening of the rectum and distal
sigmoid colon
consistent with proctocolitis. Differential includes infection,
ischemia and inflammatory causes. Given recent graft placement
an ischemic etiology
involving branches of the superior rectal artery/[**Female First Name (un) 899**] must be
considered.
2. Large infrarenal aortic aneurysm with new endograft placement
in which
evaluation of leak cannot be assessed given lack of IV contrast
administration.
3. Moderate right pleural effusion with bibasilar
consolidations, likely
representing atelectasis.
4. Dense calcification of the aortic valve with uncertain
hemodynamic
significance.
5. CT evidence of anemia.
6. Anasarca.
Brief Hospital Course:
[**9-30**] 89 transfered from OSH with symptomatic AAA. Pt in
Respiratory acidosis. [**Hospital **] transfered to the ICU.
The patient is an elderly male with an 8-cm aneurysm who
developed back pain symptoms. He felt better with blood
pressure control but then we took him fairly
urgently to the operating room.
[**10-1**] Operation performed:
PROCEDURE:
1. Total percutaneous repair of aortic aneurysm with
endovascular method.
2. Zenith 36-95 graft right 22-71 limb, left 22-54 limb with
[**11/2129**] bridge.
Pt extubated in the [**Hospital **] Transfered to the [**Hospital 13042**] in stable
condition. WHile in the [**Name (NI) 13042**] pt became acidotic, He was
reintubated. (respiratory failure secondary to acidosis)
Once recovered from anesthesia. He was sent to the CVIU in
sstable condition.
Notes missing from chart [**10-2**] - [**10-6**]
[**Name (NI) 3916**] pt 3 BM since 2 2PM which were Guaiac neg. Trasplant
Consult for flex sig obtained. Scope showed no ischemic bowel,
but however scope was suspicious for colitis. Flagyl and cipro
started empirically. to note no acidosis and normal lactate.
Pt did have an elevation in his creatinine to 2.1 (baseline 1.3.
This was secondary to contrast induced nephropathy. ON DC his
creatinine is 1.8. He is making good urine. While in the
hospital his creatinine was as low as 1.4. But with diuresis it
climbed bac up to 1.8.
[**10-7**] Pt transfered to the VICU in stable condition. OOB to
chair. Sips. abdomen distended. Hypoactive BS. c/w PT. Foley
DC'd. Clear liquid diet. Off pressors.
[**10-8**] illeus by KUB. Remains distended, Nutrition Consult, PT.,
A - Line removed
[**10-9**] illeus, clears, pos flatulance, loose stools, increase in
WBC
[**10-10**] Nebs started, IV fluids DC, diet advanced - illeus
improved. c/w PT. Given IV lasix. CXR obtained. BNP elevated
[**10-11**] Transfered to floor status. Tele DC'd. decresed in WBC.
Cipro and flagyl DC'd.
Cardiology consult. CHF exacerbation
[**10-12**] Increase in WBC off antibiotics. CT scan obtained.
Thickening of rectum and distal sigmoid. Emperic flagyl and
cipro started. This is for 30 days. Cdiff negative. from cx on
[**10-9**].
[**10-13**] - [**10-15**] Pt vigourously diuresed with lasix IV and
zaroxylyn. Echo obtained. See pertinant results, BNP trending
down after diuresis. Fluid restriction. On AB WBC trending down.
Bowel regime started. With Diuresis pt creatinine climbed back
up to its current 1.8.
Heart Failure acute on chronic diastolic dysfunction
[**10-16**] Pt did recieve SQ insulin for new found DM. [**Last Name (un) **] consult
obtained. They recommended PO glimeride, DM teaching. This will
be follwed by his PCP.
[**10-17**] Cleared to go home with [**Month/Year (2) 269**]
Medications on Admission:
Meds: ECASA 325, Diltiazem 240, Pravachol 40, Avapro 150, Paxil
20
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
2. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
[**Month/Year (2) **],VARTAN[**Telephone/Fax (1) 12551**], to fill.
Disp:*30 Tablet(s)* Refills:*6*
3. Glucocard X-Meter Kit Sig: One (1) Glucocard X-Meter
(Miscellaneous) Kit Miscellaneous once a day: check fasting
blood sugar.
Disp:*1 Glucocard X-Meter (Miscellaneous) Kit* Refills:*0*
4. Glucosource Misc Sig: One (1) Glucosource (Miscellaneous)
LANCETS
LANCETS Miscellaneous once a day: LANCETS
[**Telephone/Fax (1) **],VARTAN[**Telephone/Fax (1) 12551**], to fill.
Disp:*60 Glucosource* Refills:*6*
5. Glucostix Test Strip Sig: One (1) TEST STRIPS In [**Last Name (un) 5153**]
once a day: test strips
[**Last Name (un) **],VARTAN[**Telephone/Fax (1) 12551**], to fill.
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*28 Tablet(s)* Refills:*0*
7. Zaroxolyn 5 mg Tablet Sig: One (1) Tablet PO once a day for
14 days: 10 minutes before lasix dose in the am.
Disp:*14 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): [**Telephone/Fax (1) **],VARTAN[**Telephone/Fax (1) 12551**], to fill.
Disp:*60 Capsule(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: [**Telephone/Fax (1) **],VARTAN[**Telephone/Fax (1) 12551**], to fill.
Disp:*60 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 14
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
13. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
TID (3 times a day).
14. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1,5
Tablet Sustained Release 24 hr PO once a day:
[**Telephone/Fax (1) **],VARTAN[**Telephone/Fax (1) 12551**], to fill.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*6*
16. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 1 months.
Disp:*90 Tablet(s)* Refills:*0*
18. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
19. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: One
(1) Drop Ophthalmic PRN (as needed).
20. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
21. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
all care [**Last Name (LF) **], [**First Name3 (LF) **]
Discharge Diagnosis:
Aortic anuerysm
Anemia post op requiring blood transfusions
ARF secondary to contrast load. Improved
Atrial fibrillation
Intubation to protect airway / Symptomatic abdominal aortic
aneurysm
New onset DM - - [**Last Name (un) **] Consult
CHF diastolic chronic
PMH:
HTN
Glaucoma
Emphysema
Anxiety
Discharge Condition:
good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? 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
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and 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:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-9**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2183-10-24**] 10:30
[**Last Name (un) 79765**] Dr [**Last Name (STitle) **] and follow up in 1 week. His number is [**Telephone/Fax (1) 7960**].
You should call your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 12551**].
Schedule an appointment for 1 week. You have a new diagnosis of
DM. He will teach you nutritional and DM teaching.
Completed by:[**2183-10-17**]
|
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icd9cm
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,412
| 128,694
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21700+57254
|
Discharge summary
|
report+addendum
|
Admission Date: [**2145-4-3**] Discharge Date: [**2145-5-25**]
Date of Birth: [**2114-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zosyn / Gentamicin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
fevers/chills, gastrointestinal distress
Major Surgical or Invasive Procedure:
[**2145-5-7**] Fifth time redo sternotomy and aortic root replacement,
Bentall procedure, with a size #25 St. [**Male First Name (un) 923**] composite graft
History of Present Illness:
30 year old male well known to cardiac surgery with a history of
AV endocarditis with MSSA in [**2137**] and [**2140**], enteroccocus in
[**2142**], s/p AVR x 2 in [**2140**] and [**2142**] who presented to [**Hospital 57051**]
medical center on [**2145-4-2**] with 1 week of
intermittent crampy abdominal pain, fatigue, chills, diarrhea,
loose stools, headache and neck pain. He states his pain
originated 5-7 days ago, is sharp and constant in intensity, and
was not relieved by over the counter analgesics. The pain in his
head and neck with worse with changing positions. Upon arrival
to the OSH, he was febrile to 100.7, found to have a WBC of 9
wtih bandemia to 18%, with blood cultures growing GNR in [**4-11**]
bottles. He was started on vancomycin amikacin and cefepime
(vancomycin was discontinued after GNR were discovered on
culture). TTE demonstrated EF 55% with LVF, AV not well
visualized, but no vegetations observed. Now found to have most
likely recurrent
endocaridits given progression on TEE, continuing to spike
fevers and dital embolism secondary to vegetation. He was
referred to cardiac surgery for redo AVR x4/+/-possible Bentall.
Past Medical History:
1. Bicuspid Aortic Valve- s/p Aortic Valvuolplasty at age 15
2. MSSA Recurrent Aortic Valve Endocarditis, ([**2137**], [**2139**])
----[**12/2137**]: MSSA endocarditis: with a 6 week course of
nafcillin and ultimately [**Year (4 digits) 1834**] a Bentall procedure utilizing
homograft along with VSD closure and debridement of aortic root
abscess.
----[**3-/2140**]: MSSA? Endocarditis: Redo aortic valve replacement
with a size 27 mm Onyx mechanical valve and ascending aortic
interposition graft with a size 24 mm Dacron graft
3. History of Septic Emboli to Spleen, Kidney and Cerebrum;
hepatic pseudoaneurysm embolization in [**2137**]
4. Intravenous Drug Abuser; patient states last time used IVDs
was prior to his last surgery in [**2139**].
5. History encephalomalacia of the right parietal lobe from a
prior infarct, and minimal chronic microvascular ischemic
changes.
6. Chronic systolic heart failure
Social History:
Quit tobacco just prior to admission h/o [**2-8**] ppd for 12 years.
Denies ETOH over the last year. He currently lives with his
parents. Several years of IVDU but denies since last AVR.
Family History:
Patient adopted and does not know family history.
Physical Exam:
Pulse:90 Resp:18 O2 sat:98/RA
B/P 117/74
Height:5'[**43**]" Weight:100.9 kgs
General: AAOx3 NAD
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: strongly dop Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2145-5-7**]:
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 moderate symmetric left ventricular hypertrophy. The
left ventricular cavity is moderately dilated. There is mild
regional left ventricular systolic dysfunction with focalities
in the septal wall. Overall left ventricular systolic function
is mildly depressed (LVEF= 40)
The right ventricular cavity is moderately dilated with moderate
global free wall hypokinesis.
The appearance of the ascending aorta is consistent with a
normal tube graft.
A mechanical aortic valve prosthesis is present. The transaortic
gradient is normal for this prosthesis. There is a
moderate-sized vegetation (1.4 cm x 1.8 cm on the aortic valve.
An aortic annular abscess is seen at the junction of the aortic
and anterior mitral leafllet. There is no flow within the
abscess. There are no flow connections from the cavity to
outside [**Doctor Last Name 1754**]. Mild (1+) aortic regurgitation is seen.
No mass or vegetation is seen on the mitral valve. Mild (1+)
mitral regurgitation is seen.
There is no pericardial effusion.
POST-BYPASS:
The patient is in sinus rhythm. The patient is on epinephrine,
norepinephrine, and vasopressin infusions.
Left ventricular function is moderately depressed (LVEF =
30-35%). The septum and inferior wall remain severely
hypokinetic.
Right ventricular function remains moderately depressed.
There is a mechanical prosthetic valve in the aortic position.
No paravalvular leak is seen. There is a mean gradient of 6 mmHg
at a cardiac output of 7.0 L/min. The aortic valve vegetation is
no longer present.
An ascending aortic tube graft is seen.
Mitral regurgitation is unchanged.
The aortic arch and descending aorta are intact
post-decannulation
.
[**2145-5-23**] 05:50AM BLOOD WBC-5.6 RBC-3.21* Hgb-9.2* Hct-28.4*
MCV-88 MCH-28.6 MCHC-32.4 RDW-15.1 Plt Ct-508*
[**2145-5-22**] 06:45AM BLOOD WBC-5.9 RBC-3.31* Hgb-9.4* Hct-29.4*
MCV-89 MCH-28.3 MCHC-31.9 RDW-15.3 Plt Ct-555*
[**2145-5-25**] 05:50AM BLOOD PT-22.9* INR(PT)-2.2*
[**2145-5-24**] 06:23AM BLOOD PT-18.1* PTT-68.8* INR(PT)-1.7*
[**2145-5-24**] 12:05AM BLOOD PT-17.2* PTT-78.0* INR(PT)-1.6*
[**2145-5-23**] 05:50AM BLOOD PT-15.4* PTT-86.9* INR(PT)-1.4*
[**2145-5-22**] 06:45AM BLOOD PT-13.9* PTT-106.9* INR(PT)-1.3*
[**2145-5-21**] 05:41AM BLOOD PT-13.8* PTT-68.5* INR(PT)-1.3*
[**2145-5-20**] 01:04AM BLOOD PT-14.5* PTT-51.9* INR(PT)-1.4*
[**2145-5-19**] 06:33PM BLOOD PT-15.1* PTT-68.8* INR(PT)-1.4*
[**2145-5-19**] 12:35PM BLOOD PT-14.4* PTT-56.6* INR(PT)-1.3*
[**2145-5-19**] 03:11AM BLOOD PT-14.5* PTT-49.9* INR(PT)-1.4*
[**2145-5-23**] 05:50AM BLOOD Glucose-122* UreaN-27* Creat-1.0 Na-135
K-3.9 Cl-98 HCO3-27 AnGap-14
[**2145-5-22**] 06:45AM BLOOD Glucose-91 UreaN-23* Creat-0.9 Na-135
K-4.3 Cl-98 HCO3-27 AnGap-14
[**2145-5-21**] 05:41AM BLOOD Glucose-111* UreaN-23* Creat-1.0 Na-137
K-4.1 Cl-99 HCO3-31 AnGap-11
Brief Hospital Course:
This is a 30 year old man with a past medical history
significant for bicuspid AV, AVR x 2, Endocarditis x 3(MSSA and
enteroccocus) last AVR in [**2142**] who presents with shortness of
breath, cough, fevers, diarrhea/nausea and gram negative
bacteremia.
Initially, Mr. [**Known lastname 57041**] was treated with gram negative
bacteremia/possible PNA with zosyn and levaquin. However he
developed a diffuse erythematous maculopapular rash and severe
eyelid swelling following his first dose of zosyn. Zosyn was
discontinued given apparent allergy and cefepime/Flagyl were
started instead. Blood and urine cultures were repeated and were
negative. TEE was obtained which initially did not show
vegetations, but on repeat studies, small echo densities were
seen on the aortic leaflets. These were serially monitored and
were noted to increase. As below, the patient developed sudden
severe foot pain which was felt to be secondary to a septic
embolic. Repeat imaging confirmed that the vegetation had
decreased in size. He was continually monitored and the size of
his vegetation remained stable, however on a study from [**2145-5-4**],
it was noted that there was liquid pocket near the aortic root,
c/w an abscess. He was taken to the OR for an aortic valve
replacement on [**2145-5-7**]. He [**Date Range 1834**] a fifth time redo
sternotomy and aortic root replacement, Bentall procedure, with
a size #25 St. [**Male First Name (un) 923**] composite graft. See operative note for
full details. Overall the patient tolerated the procedure well
and was transferred to the CVICU in stable condition. He was
weaned off all vasoactive medications by POD # 1 and within 24
hours he was extubated without incident. The patient was
neurologically intact and hemodynamically stable on POD 1. 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.
He developed shortness of breath and echo revealed a moderate to
large pericardial effusion. There were no signs of tamponade.
Coumadin was stopped and he was bridged with heparin. He
received a pericardial drain in the cath [**Male First Name (un) **]. This was removed
days later without incident.
He was continued on Meropenem per the Infectious disease team
via left sided PICC. Final antibiotic recommendations were
Ertapenem for 6 weeks from the date of surgery
([**Date range (3) 57052**]). He should have weekly safety labs with this
which will include a CBC with differential, chemistry panel, ESR
and C-reactive protein. Results should be faxed to ([**Telephone/Fax (1) 10739**]. Acute pain service was consulted for aid in pain
management. His pain was well controlled with Dilaudid,
Gabapentin and Ativan at the time of discharge. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 18 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to his parents' home in good condition with appropriate follow
up instructions. Dr. [**Last Name (STitle) 24127**] will continue to follow the INR and
dose coumadin. Home infusion will assist with antibiotic
administration and he will have VNA services.
Medications on Admission:
Carvedilol 12.5mg [**Hospital1 **]
ASA 81mg daily
Ferrous sulfate 325mg daily
Warfarin 10mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*100 Capsule(s)* Refills:*2*
3. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
4. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q2H (every 2
hours) as needed for pain for 2 weeks.
Disp:*50 Tablet(s)* Refills:*0*
5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO three
times a day.
Disp:*135 Tablet(s)* Refills:*2*
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): 1/2 hour before Dilaudid.
Disp:*60 Tablet(s)* Refills:*2*
7. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Coumadin 5 mg Tablet Sig: as directed Tablet PO once a day:
Disp:*100 Tablet(s)* Refills:*2*
10. Outpatient [**Hospital1 **] Work
ESR, CRP,Chem 7, CBC w3/ diff weekly begin [**5-31**], through
[**2145-6-18**].
Fax results to [**Hospital1 18**] Infectious Diseases at [**Telephone/Fax (1) 1419**]
11. ertapenem 1 gram Recon Soln Sig: One (1) Intravenous once a
day for 23 days: through [**2145-6-18**].
Disp:*qs * Refills:*0*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
13. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for insomnia.
14. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
15. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
16. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 5 days.
Disp:*10 Tablet Extended Release(s)* Refills:*0*
17. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**2-8**]
Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea.
Disp:*qs * Refills:*0*
18. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
19. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*qs * Refills:*2*
20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA
Discharge Diagnosis:
Enterobacter Bacteremia
recurrent aortic valve Endocarditis
Aortic root abscess
congenital bicuspid aortic valve
s/p aortic valvuloplasty age 15
s/p redo sternotomy,homograft aortic valve
replacement,ventricular septal defect closure [**2137**]
s/p redo sternotomy,Bentall(Onxy) [**2140**]
s/p Bentall ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Mechanical) [**2142**]
s/p evacuation of tamponade [**2142**]
s/p redo(5th) sternotomy, Bentall(25mm St. [**Male First Name (un) **] mechanical
composite)
MSSA Endocarditis [**2137**] with septic emboli to spleen,
kidney,cerebrum in [**2137**],
s/p hepatic psuedoaneurysm embolization
Recurrent MSSA endocarditis [**2140**]
prosthetic Aortic Insufficiency
Congestive Heart Failue
h/o IV drug abuse
Gentamycin induced Right ototoxicity
prior occipital blindness-prior to 1st heart surgery
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid, Ativan
Incisions:
Sternal - healing well, no erythema or drainage
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**First Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2145-6-15**] @ 1:15pm in the
[**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name (STitle) 437**] ([**Telephone/Fax (1) 62**]) on [**2145-6-2**] at9:20am
Infectious Disease: Dr. [**Last Name (STitle) 7443**] ([**Telephone/Fax (1) 457**]) on [**2145-5-28**] at
10:00am
and Dr.[**Last Name (STitle) **] on [**2145-6-18**] at 10:30a
-Check CBC, BMP,LFTs weekly and fax results to [**Telephone/Fax (1) 1419**]
Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-8**] weeks ([**Telephone/Fax (1) 57053**])
Local Cardiologist: Dr. [**Last Name (STitle) 24127**] [**0-0-**]
**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 AVR
(to be drawn at Dr.[**Name (NI) 57054**] office)
Goal INR 2.5-3.5
First draw [**2145-5-26**]
Results to: Dr. [**Last Name (STitle) 24127**] phone: [**0-0-**], [**Hospital **] clinic
fax: [**Telephone/Fax (1) 57055**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2145-5-25**] Name: [**Known lastname 10622**],[**Known firstname **] Unit No: [**Numeric Identifier 10623**]
Admission Date: [**2145-4-3**] Discharge Date: [**2145-5-25**]
Date of Birth: [**2114-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Zosyn / Gentamicin
Attending:[**First Name3 (LF) 265**]
Addendum:
Of note, the patient demonstrated an elevated right
hemi-diaphragm post-operatively. He remained stable from a
clinical standpoint. Dr. [**First Name (STitle) **] is aware of the finding. He is
discharged home with detailed follow-up instructions.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 10624**] VNA
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2145-5-25**]
|
[
"276.1",
"287.5",
"423.0",
"038.49",
"428.0",
"995.92",
"428.32",
"V12.54",
"285.29",
"693.0",
"996.61",
"338.18",
"E930.0",
"423.3",
"V58.61",
"280.9",
"444.22",
"E930.8",
"584.9",
"449",
"309.24",
"682.7",
"V12.51",
"008.63",
"421.0",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.45",
"39.61",
"37.21",
"37.0",
"88.72",
"38.97",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
16585, 16765
|
6577, 9987
|
324, 483
|
13535, 13711
|
3568, 6554
|
14551, 16562
|
2823, 2874
|
10135, 12556
|
12655, 13514
|
10013, 10112
|
13735, 14528
|
2889, 3549
|
244, 286
|
511, 1669
|
1691, 2602
|
2618, 2807
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,101
| 177,078
|
41768
|
Discharge summary
|
report
|
Admission Date: [**2192-10-1**] Discharge Date: [**2192-12-24**]
Date of Birth: [**2123-3-25**] Sex: M
Service: [**Year (4 digits) **]
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Speech disturbance, Right sided weakness, Transferred from OSH
for higher level of care
Major Surgical or Invasive Procedure:
Intubation
Tracheostomy and PEG
PICC line
History of Present Illness:
69yoM w/hx of HTN and hyperlipidemia who presents from OSH with
ischemic stroke (L-PCA infarction involving L-occipital and
posterior temporal lobes with conversion to hemorrhagic stroke).
Pt is from [**Country 11150**] and was brought to [**Hospital6 28728**] Center
by
his son. [**Name (NI) **] reports that patient vomitted in his sleep and was
unable to speak. On admission to [**Location (un) 1121**] patient was
arousable, but 'non verbal,' unable to follow commands and
'flaccid' in R-upper and lower exremities as per ED note.
.
Hosp Course at [**Hospital1 3597**].
[**9-19**] presented at OSH with aphasia, R-sided weakness
8/25 MRI showed acute ischemic change of L occipital, parietal
and temporal lobes - left thalamus diffusely involved.
Hemorrhage was noted in area of thalamus.
[**9-24**] TEE showed no obvious source of embolus, with normal EF, no
PFO. Continued to have confusion/vomitting. CT showed L-PCA
territory infarction with areas of hemorrhage. Mass effect and
midline shift present. Pt started on Aspirin 325mg, vomitting
resolved.
[**9-25**] Pt started to improve (per family) prior to increasing
somnolence on [**9-29**] (see below). Pt had fluent speech, required 2
people to help stand, 1 to help sit, weaker on R side, mild
R-facial droop, was not oriented to date, but knew he was in
hospital.
[**9-29**] . Pt became drowsy. CT of head showed increasing acute
intracranial hemorrhage within large L PCA territory, increasing
mass effect and midline shift compared with [**9-24**]. Neurosrug
consulted, recommended transfer to [**Hospital1 2025**]. Family decided to keep
pt at [**Hospital3 7362**] and decline neurosurgical intervention. Pt
transferred to ICU.
[**9-30**] pt became more delirious and agitated. Able to speak but as
per son and wife, his wording was not making any sense
[**10-1**] neuro exam remained the same, Head CT showed increased
hemorrhage and surrounding edema in L hemisphere with slight
increase in shift of midline. Possibly interventricular
hemorrhages as well. Pt reaffirmed decision to decline
neurosurgical intervention, but agreed to transfer pt to [**Hospital1 18**].
.
Of note per OSH report BP remained 'in good control' throughout
hosp course.
.
Past Medical History:
1. L-ischemic stroke conversion into hemorrhagic stroke with
increasing ICP midline shifts
2. Hyponatremia most likely secondary to SIADH
3. Newly Dx'd DM on OSH admission
5. Hyperlipidemia
6. Hypertension
7. Left Thyroid Nodule - found incidentally on Head CT.
Social History:
Lives with in [**Country 11150**] came to visit son at beginning of [**Month (only) **].
Planning to go home [**10-30**]. Prior to stroke, walking at
home, speaking fluently, had a retail business. Native language
is Tamil. Denies tobacco, alcohol, illicits.
Married w/ 3 children.
Family History:
Fam Hx: Mother died of cervical cancer ?age, father died of 'old
age'.
Physical Exam:
Physical Exam on Admission:
VS: 97.2, HR 99, BP 150/68, RR 21, 97%RA
GEN: elderly male lying in bed intermittently agitated
HEENT: OP clear, neck supple
CV: RRR, no m/r/g
PULM: CTA-B laterally
ABD: soft, NT, ND
EXT: no peripheral edema
.
Neurological Exam:
Mental Status: Awakens to voice, answers in "nonsens words" (per
his family who were translating) when asked the date, where he
was. Per family speech not slurred. Pt able to repeat short
phrases, but not long phrases (longer than 3 words). Pt uses
"made up words" on confrontation naming, and got more agitated
with each question. He was unable to read, unable to write.
However, at the very end of the exam he said "don't disturb me I
want to sleep" fluently. He can follow midline, appendicular
and
x-body commands. No evidence of neglect
.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils post-surgical bilaerally, reactive 2->1.5mm, VFF to
confrontation. Pt unable to cooperate with fundoscopic exam
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: R sided facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, but unable to get past bottom
lip.
.
-Motor: Normal bulk throughout, increased tone in RLE. Pt unable
to cooperate with pronator testing. No adventitious movements,
such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 1 2 2 1 3 1 2 2 2 2 2 2 3 3
.
-Sensory: No deficits to light touch, but pt unable to cooperate
with rest of sensory exam.
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 2 2 2 1
R 3 2 2 3 1
Plantar response was upgoing on the R, down on the L.
.
-Coordination: Pt unable to cooperate with FNF
.
-Gait: Deferred
__________________________________________________________
DISCHARGE EXAM
HEENT: AT/NC, trach in place - capped
CV: RRR, no m/r/g
PULM: CTA-B laterally
ABD: soft, NT, ND
EXT: no peripheral edema
Neurological: Awake, alert, oriented to self only. Language is
fluent (speaks Tamil). Follows simple axial and appendicular
commands.
PERRL, EOMI, right facial droop.
LUE and LLE has 3-4/5 strength throughout. RUE has 2/5 strength
throughout; RLE toes wiggle.
He is able to sit with zero to moderate assistance. He is able
to stand with 1-2 person assist.
Pertinent Results:
Labs on Admission:
[**2192-10-1**] 09:05PM BLOOD WBC-6.0 RBC-5.04 Hgb-15.0 Hct-43.2 MCV-86
MCH-29.8 MCHC-34.7 RDW-12.1 Plt Ct-368
[**2192-10-1**] 09:05PM BLOOD PT-14.5* PTT-27.7 INR(PT)-1.3*
[**2192-10-1**] 09:39PM BLOOD ESR-52*
[**2192-10-1**] 09:05PM BLOOD Glucose-164* UreaN-16 Creat-0.8 Na-136
K-4.1 Cl-104 HCO3-19* AnGap-17
[**2192-10-1**] 09:05PM BLOOD ALT-27 AST-68* LD(LDH)-534* CK(CPK)-301
AlkPhos-46 TotBili-0.4
[**2192-10-1**] 09:05PM BLOOD CK-MB-22* MB Indx-7.3* cTropnT-0.49*
[**2192-10-1**] 09:39PM BLOOD CK-MB-21* MB Indx-7.0* cTropnT-0.49*
[**2192-10-2**] 05:20AM BLOOD CK-MB-14* MB Indx-6.4* cTropnT-0.55*
[**2192-10-1**] 09:05PM BLOOD Albumin-4.0 Calcium-9.4 Phos-2.7 Mg-2.2
[**2192-10-1**] 09:39PM BLOOD %HbA1c-8.3* eAG-192*
[**2192-10-2**] 05:20AM BLOOD Triglyc-59 HDL-36 CHOL/HD-3.1 LDLcalc-64
[**2192-10-1**] 09:05PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.5 Leuks-TR
[**2192-10-1**] 09:05PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
[**2192-10-7**] 08:45PM URINE CastHy-3*
[**2192-10-1**] 09:05PM URINE Mucous-RARE
[**2192-10-2**] 01:57PM URINE Hours-RANDOM Creat-73 Na-178 K-50 Cl-201
No labs were done prior to discharge as pt was clinically
stable.
EEG:
[**2192-10-5**] This is an abnormal EEG due to the presence of bursts
of
generalized slowing superimposed upon an asymmetry of background
activity. The first finding is suggestive of a mild to moderate
encephalopathy of toxic, metabolic, or anoxic etiologies. The
second
abnormality suggests a widespread area of subcortical
dysfunction
involving the left hemisphere. No evidence of ongoing or
potential
seizure activity was seen at the time of this recording.
[**2192-10-8**] Markedly abnormal portable EEG due to the background
voltage suppression on the left side, particularly posteriorly,
and due
to the additional slowing and occasional suppression on the left
side.
These findings suggest a focal structural abnormality on the
left, but
the tracing cannot specify its etiology. In addition, the
background
was slow in all areas, suggesting a concomitant widespread
encephalopathy. Medications, metabolic disturbances, and
infections are
among the most common causes of these encephalopathies. There
were no
epileptiform features or electrographic seizures in the
recording.
[**2192-10-13**] This telemetry captured no pushbutton activations.
There
were no electrographic seizures. The record showed an
encephalopathic
pattern throughout. For about an hour on the morning of [**10-13**],
the blunted sharp waves were particularly rhythmic at about 1.3
Hz in
the right frontal region. Their resolution later that morning
was
likely to have followed administration of phenytoin as described
by the
clinical teams. The encephalopathy persisted.
[**2192-10-14**] This telemetry captured no pushbutton activations.
It
showed a slow or suppressed background throughout, particularly
in the
left posterior quadrant. The focal voltage suppression indicates
some
cortical dysfunction there. Some of the record appeared to
suggest
ongoing sleep, but most indicated an encephalopathy, with the
faster
regular alpha frequencies suggesting medication effect. There
were no
clearly epileptiform features or electrographic seizures.
[**2192-10-16**] This extended routine EEG over the morning of [**10-16**]
showed a very suppressed background over the left side,
particularly
posteriorly. The faster alpha frequencies on the right were
widespread
and suggested medication effect rather than normal wakefulness.
There
were no epileptiform features or electrographic seizures.
Neuroimaging:
[**2192-10-2**] Suboptimal MRI study secondary to patient motion.
Hemorrhagic
infarction seen in the left posterior cerebral artery territory
with
involvement of the splenium of corpus callosum. There is
surrounding edema
causing partial effacement of left lateral and third ventricles
along with a midline shift of 1 cm towards the right side.
[**2192-10-2**]
Large left hemispheric acute infarction, also involving the left
thalamus
and cerebral peduncle, with extensive hemorrhagic
transformation. Partial effacement of the left lateral and third
ventricles. Dilated temporal [**Doctor Last Name 534**] of the right lateral ventricle
suggests trapping.
[**2192-10-7**]
Evolving left PCA territory infarct with hemorrhagic conversion.
Stable mass effect and rightward shift of midline structures. No
significant interval increase in the hemorrhage.
[**2192-10-13**]
No significant change from the prior exam- see details above in
the left temporal and callosal lesion and edema . However, there
is a small hypodense focus in the right lentiform nucleus that
is more conspicuous since the prior study and not seen on more
earlier studies and may represent a focus of evolving acute
infarct.
[**2192-10-15**]
No appreciable change from prior examination. No new areas of
hemorrhage.
[**2192-10-20**]: Expected evolution of blood products within the left
PCA infart, with slightly decreased mass effect. No evidence of
new intracranial abnormalities.
ECG [**2192-10-22**]:
Sinus tachycardia. Probable prior anteroseptal myocardial
infarction. Diffuse non-specific ST-T wave flattening. Compared
to the previous tracing of [**2192-10-17**] no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
102 134 82 318/391 58 0 95
TTE - ECHO [**2192-10-26**]:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with distal septal and apical hypokinesis
(distal LAD). The remaining segments contract normally (LVEF =
45-50%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. No PFO, ASD or cardiac source of embolism seen.
Other Radiology:
[**2192-10-21**] ABDOMEN SUPINE PORTABLE:
Gastrostomy tube appears to be in a satisfactory position. The
stomach is not dilated. There is gas throughout the bowel as far
as the rectum. No dilated loops of small bowel are present.
Bowel gas [**Doctor Last Name 5926**] is therefore unremarkable. There is no evidence
either
obstruction or ileus.
[**2192-10-26**] CTA Chest with and without contrast:
IMPRESSION:
1. No evidence of pulmonary embolism to the subsegmental levels
bilaterally.
2. Minimal bilateral dependent atelectasis.
3. Left hepatic lobe hypodensities too small to characterize but
not
significantly changed compared to prior CT.
[**2192-11-13**] Renal Ultrasound:
IMPRESSION:
1. Bilateral caliceal diverticula. Small renal stone in the left
lower pole. Simple cyst in the mid portion of the right kidney.
No hydronephrosis.
[**2192-12-6**] Video Oropharyngeal Swallow:
IMPRESSION:
1. Weakness at the base of the tongue.
2. No evidence of aspiration or penetration.
Brief Hospital Course:
Mr. [**Known lastname 90726**] was admitted to the [**Hospital1 18**] NeuroICU as a transfer from
[**Hospital 3597**] [**Hospital 12018**] Hospital. His outside hospital course was
described above. Briefly, his problems began when following
dinner one night, he vomitted while in bed and was poorly
responsive. At the OSH, he was found to have a dense right
hemiparesis with global aphasia and left gaze preference and was
started on a large aspirin therapy. While his CT scan showed an
evolving left PCA stroke, he did have some punctate hemorrhagic
regions in the thalamaus on the left. He initially did well,
participated in rehabilitation and speech therapy, and was
showing improvement. His A1c returned elevated (newly diagnosed
diabetic) and both a TEE/TTE were unrevealing for a thrombus. On
[**2192-9-29**], he developed an acute worsening in his mental status
with delirium and drowsiness. A NCHCT at that time showed
worsening of his edema and hemorrhagic conversion. His ASA was
held and he was transferred to the ICU where over the next two
days, his examination remained stable. He remained
hemodynamically stable during his course, but for some mild
hyponatremia, he was started on hypertonic saline (3%).
The family eventually agreed to be transferred to the [**Hospital1 18**] for
a higher level of care. On arrival to us, his examination was
such that he had a profound right homonymous hemianopia with
right sided neglect, right hemiparesis and facial droop, a
largely expressive aphasia (language had to be tested in Telugu
(Tamil) through his son/family). Throughout the course of his
stay, this was his best examination. Over the course of the next
several days, his examination deteriorated to the point where he
was poorly responsive to sternal rub, he started to display
weakness of the left lower and upper extremities. Through his
deterioration, he was initiated on a variety of therapies to
reduce his intracranial pressure, including high dose IV
mannitol, hypertonic saline (3% or 23%) and IV steroids. He
developed fevers during this period (thought to be of a
pulmonary source) and was initiated on cooling blankets and
broad spectrum IV antibiotics. At the peak of his diminished
consciousness, he had an episode where he frankly aspirated his
tube feeds. Following this he was sedated and intubated. Under
the guidance of Dr. [**Last Name (STitle) 87490**] of the Neuro-ICU, we undertook an
intravascular cooling protocol to reduce ICP. He attained a core
body temperature of 34C for at least 24 hours and during this
period, his shivering was controlled with high doses of
fentanyl/propofol. He was slowly warmed, and following regaining
normothermia, he remained intubated for a few days. Off
sedation, his examination was quite poor: intact brainstem
reflexes, but with no response to calling his name, no
spontaneous eye opening, no movements of his lower extremities.
His steroids were slowly tapered.
We had at least two formal family meetings where we discussed
his grave prognosis. On the final family meeting on [**10-16**], the family wished to pursue a full code and trach/PEG. Their
ultimate goals were to have the patient transported back to
[**Country 11150**] for continued care. He was shown to be having
electrographic seizure activity on EEG, and was started on
pheytoin, which stopped the seizure activity. He received his
tracheostomy/gastrostomy tube on Setmeber 23, [**2192**] and was
tolerating trach collar well the next day. He started to spike
fevers to 103 shortly therafter and was found to have MRSA
colonization of his trach. He was started on linezolid on [**10-20**],
but continued to spike through this antibioic so he was
broadened to zosyn also on [**10-21**]. He had some transient episodes
of hypotension, felt to be from likely sepsis, and he was put on
pressors for <24 hours. These were weaned without issue, and he
was started on IVF to help with volume status. His UCx then
grew out klebseilla, which was sensitive to zosyn, so his ABx
were not changed. His phenytoin levels were difficult to
control and so he was switched to keppra on [**10-25**].
Ultimately he was transferred out of the ICU on [**10-25**] when he was
afebrile x 24hrs, was more alert, was intermittently responding
to commands and was able to be sat up in the chair without
issue. His neurologic exam had improved such that he was able to
open his eyes to voice and tracked relatively well, primarily to
the left. He was able to move his LUE spontaneously and
purposefully. He continued to have dense weakness of the RUE and
RLE but did show very small movements of the right hand. He was
able to speak phrases with the Passy-Muir valve in place. He
remained mildly tachycardic to the 90s-120s and was maintained
on Lopressor 25 mg PO q6h and continuous normal saline IV fluids
which attenuated this. An echocardiogram was performed which
showed mild regional left ventricular systolic dysfunction
consistent with CAD with an EF of 45-50%. A CTA was also
performed due to concern for PE which was negative. He completed
a 10 day course of linezolid and piperacillin-tazobactam for his
MRSA tracheobronchitis and UTI. He had another fever on [**11-8**]
which was likely secondary to continued infection from
Klebsiella which grew in a urine culture from that day; we
replaced his Foley catheter (which was required for urine output
monitoring, avoid exacerbating pressure ulcers, and
transitioning of care to another facility/travel).
Mr. [**Known lastname 90726**] remained medically stable over the next 4 weeks. He
was re-evaluated by the swallow therapists and found to be safe
for all consistencies po after a video swallow exam on [**2192-12-6**].
He continues to receive nighttime tube feeds until he is able to
take in a full diet. His trach has been capped intermittently
and he is able to tolerate it capped for 48 hours without
difficulty. He continues to make strides with physical therapy
and is now able to stand with 1-2 person assitance.
On day of dispo, at the request of the transporting doctor, we
changed his DVT prophylaxis from heprain SQ to lovenox. Pt was
sent with 6 doses of [**Hospital1 **] dosed lovenox as well as a week supply
of heparin in case his transport took longer than expected. He
was also sent with 2 doses of dextrose in case his blood sugar
dipped too low.
PENDING LABS:
Viral Cx final read [**2192-12-3**]
TRANSITIONAL CARE ISSUES:
Patient's transportation to [**Country 11150**] has been arranged and plan is
to have patient go to a rehab facility once in [**Country 11150**].
Medications on Admission:
atorvastatin 10mg PO
incorandil 5mg [**Hospital1 **]
metoprolol 25mg [**Hospital1 **]
flavedon mr [**First Name (Titles) 31366**] [**Last Name (Titles) **]
Aspirin EC 150mg
ramipril 2.5mg [**Hospital1 **]
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
3. senna 8.8 mg/5 mL Syrup Sig: Five (5) ML PO BID (2 times a
day).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*7 Tablet(s)* Refills:*0*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*14 Tablet(s)* Refills:*0*
6. levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID
(2 times a day).
Disp:*14 doses* Refills:*0*
7. ascorbic acid 500 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 dry skin.
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
Disp:*28 Tablet(s)* Refills:*0*
10. benzoyl peroxide 10 % Gel Sig: One (1) Appl Topical DAILY
(Daily): for neck folliculitis.
11. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous Q breakfast.
Disp:*7 doses* Refills:*0*
12. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
Two (22) units Subcutaneous Q dinner.
Disp:*7 doses* Refills:*0*
13. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous QAHS: Titrate to sliding scale with QAHS finger
sticks.
14. Insulin Syringe 1 mL 30 x [**6-11**] Syringe Sig: One (1)
syringes Miscellaneous twice a day.
Disp:*20 syringes* Refills:*0*
15. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 6 doses.
Disp:*6 syringes* Refills:*0*
16. dextrose 50% in water (D50W) Syringe Sig: Two (2)
syringes Intravenous once a day for 2 doses.
Disp:*2 doses* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 90727**] Nursing Facility
Discharge Diagnosis:
Primary: Acute Ischemic Stroke, Intracerebral hemorrhage
Secondary: Urinary Tract Infection (bacterial, Klebsiella),
Seizure (electrographic), MRSA Tracheobronchitis
Discharge Condition:
Mental Status: Awake and alert, able to speak in native
language.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro: awake, alert, and able to communicate with his family
with spontaneous speech in his native language and follow basic
commands. He has a tracheostomy as well as a PEG tube, but
recently passed a swallow evaluation and is tolerating food by
mouth. His pupils are reactive, extraocular movements are
intact, and has a right facial droop. He is able to lift his
left arm and leg antigravity (approximately 4/5 strength, but
formal assessment is difficult due to cooperation). His right
arm and leg are 1-2/5. He is able to stand with two-person
assist.
Discharge Instructions:
Dear Mr. [**Known lastname 90726**],
You were seen in the hospital for a large ACUTE ISCHEMIC STROKE
which was complicated by HEMORRHAGIC CONVERSION (bleeding).
While here you needed to be on a ventilator (breathing machine)
for a very long time. Because of this, we had to place a
tracheostomy and a PEG tube to help you breath and get
nutrition. Your hospital course was complicated by a URINARY
TRACT INFECTION and TRACHEOBRONCHITIS, both of which were
treated and have resolved.
We made the following changes to your medications:
INCREASED metoprolol from 25mg po bid to 25mg po EVERY 6 HOURS
STOPPED atorvastatin 10mg PO
STOPPED incorandil 5mg [**Hospital1 **]
STOPPED flavedon mr [**First Name (Titles) 31366**] [**Last Name (Titles) **]
INCREASED Aspirin EC 150mg to Aspirin 325MG DAILY
STOPPED ramipril 2.5mg [**Hospital1 **]
STARTED famotidine 20mg po BID
STARTED Keppra (levetiracetam) 1000MG po BID
STARTED INSULIN NPH 5 UNITS subcut qAM and 22 UNITS subcut qPM
STARTED LOVENOX 30mg subcutaneously every 12 hours
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
It is hoped that Mr. [**Known lastname 90726**] will soon be traveling back to [**Country 11150**]
to follow up with the accepting physician:
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **]
MD, DM (AIIMS)
Assistant Professor [**First Name (Titles) **] [**Last Name (Titles) 878**]
National Institute of Mental Health and Neurosciences (NIMHANS)
[**Location (un) 90727**]- [**Numeric Identifier 90728**]
Office- [**Numeric Identifier 90729**]
Home- [**Numeric Identifier 90730**]
Fax- +91-[**Numeric Identifier 90731**]
Email-[**Company 90732**]
[**Last Name (un) 90733**].in
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
[
[]
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21918, 21987
|
13324, 19735
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406, 450
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22197, 22197
|
6031, 6036
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|
22968, 23476
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4227, 6012
|
3403, 3417
|
23505, 24180
|
3660, 3660
|
279, 368
|
19761, 19908
|
478, 2711
|
6050, 13301
|
22212, 22944
|
2733, 2997
|
3013, 3299
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,912
| 171,954
|
19786
|
Discharge summary
|
report
|
Admission Date: [**2127-1-22**] Discharge Date: [**2127-2-1**]
Date of Birth: [**2062-4-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
renal cell CA
Major Surgical or Invasive Procedure:
1. Placement of central venous catheter.
2. Placement of inferior vena caval filter device.
3. Exploratory laparotomy.
4. Extensive resection of tumor from retroperitoneum.
5. Gastro-enterostomy.
6. Small bowel resection with anastomosis.
7. Appendectomy.
8. J tube placement.
History of Present Illness:
64 hx of renal cell Ca s/p R nephrectomy recently admitted [**11-25**]
for pSBO and GI bleed which was resolved with medical
management. Pt presents for attempt at resection of mass in OR
that lays in close association to the duodenum, vena cava and
aorta with vascular surgery involed to place an IVC filter and
possible caval reconstruction.
Past Medical History:
Onc Hx: RCC dx [**8-27**] s/p nephrectomy, [**8-27**]. Lesions in liver
thought to be cysts. Also with lytic lesion on L5 which was
thought to cyst vs. metatsasis. Biopsy of this lesion was
non-diagnostic so followed with scans. Mass growing and
symptomatic starting [**4-30**] and patient tx with gamma knife, [**6-30**]
with improvement.
.
PMH:
Hypercholesterolemia
Social History:
SH: rare tob, etoh
lives with wife and kids
Family History:
FH: NC
Physical Exam:
100.0 99.2 77 121/82 20 96%RA FS129-157
GEN: NAD
CARD: RRR
PULM: CTAB
ABD: SOFT, NONTENDER, NONDISTENDED
WOUND: C/D/I, NO SIGNS OF INFECTION
EXT: 1+EDEMA
NEURO: AAOX3
Pertinent Results:
[**2127-1-22**] 08:00AM PT-14.5* PTT-34.2 INR(PT)-1.3*
[**2127-1-22**] 10:40AM HGB-9.3* calcHCT-28
[**2127-1-22**] 10:40AM GLUCOSE-112* LACTATE-1.1 NA+-135 K+-4.6
CL--105
[**2127-1-22**] 10:40AM TYPE-ART PO2-195* PCO2-39 PH-7.43 TOTAL
CO2-27 BASE XS-2 INTUBATED-INTUBATED
[**2127-1-22**] 06:18PM WBC-11.6* HCT-31.9*
[**2127-1-22**] 09:14PM HCT-28.9*
[**2127-1-22**] 11:44PM TYPE-ART PO2-138* PCO2-32* PH-7.36 TOTAL
CO2-19* BASE XS--6
[**2127-1-30**] 06:20AM BLOOD WBC-13.8* RBC-3.79* Hgb-11.1* Hct-32.8*
MCV-87 MCH-29.2 MCHC-33.7 RDW-14.9 Plt Ct-455*
[**1-26**] CXR:
IMPRESSION: Persistent bilateral pleural effusions, right
greater than left, stable since the prior day's radiograph
Brief Hospital Course:
During his procedure there was an estimated blood loss of 4L. In
the OR he received autologous blood 250, crystalloid 10 liters,
FFP 1165, PRBCs 3750, Plt 245.
[**1-23**] Following his procedure the pt was transferred to the ICU
where he remained intubated and sedated on full assist vent
support, on fentanyl and midazolam with aggresive rescusication.
[**1-24**] no major changes, pt remained on vent with plan for weaning
vent the next day [**12-27**] for increase in secretions and temp. Plan
was for vent to removed the next AM. Pt remained on Vanc, Zosyn.
[**1-25**] extubated, levophed stopped and lopressor started, sputum
cultures showed GNR, GPC, GPR. HCt remained stable, OOB and swan
was dc'd.
[**1-26**] ABx were stopped, diuresis was continued, OOB to [**Last Name (un) **] as
tolereated and trophic TF, sputum culture final read showed
contamination, pt remained afebrile, NGT to LWCS had bilious
output
[**1-27**] NGT d/c'd, Pt was 3L negative(gaol was 2-3L), A line
removed,
[**1-28**] transferred to floor in stable condition, TF restarted
[**1-29**] episode of bilious vomitting x 2, TF held; continued with
diuresis
[**1-30**] TF restarted, fiber repleted [**11-26**] stren 20cc/hr, po meds
restarted
[**1-31**] and [**2-1**]: pt continued to improve, diet ADAT to regular and
tolerated well. Diuresis was continued, staples were removed
from wound and steri-strips placed to incision site. Pt sent
home with VNA services to remove neck suture on Monday, J-tube
left in place orders given to VNA to flush. Pt is to see Dr.
[**Last Name (STitle) **] in 3 weeks and Dr. [**Last Name (STitle) **] in 4 weeks
Medications on Admission:
pain meds
MVI
calcium supplementation
Discharge Medications:
none
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
Renal cell cancer
Discharge Condition:
Stable
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath,fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, or any other symptoms which are
concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing. Leave
white strips above your incisions in place, allow them to fall
off on their own.
Activity: No heavy lifting of items [**9-8**] pounds until the
follow up
appointment with your doctor.
Medications: Resume your home medications.
Followup Instructions:
Please call and schedule an appointment with Dr. [**Last Name (STitle) **] to be
seen in 4 weeks.
Pleae call and schedule an appointment to be by [**Name6 (MD) **] [**Name8 (MD) 53472**], MD Phone:[**Telephone/Fax (1) 22**] before you see Dr. [**Last Name (STitle) **]
Completed by:[**2127-2-3**]
|
[
"997.4",
"560.1",
"V15.82",
"198.89",
"V45.73",
"272.4",
"197.6",
"V10.52",
"568.81",
"543.9",
"537.3",
"196.2",
"197.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.98",
"44.39",
"54.59",
"38.7",
"99.05",
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icd9pcs
|
[
[
[]
]
] |
4131, 4169
|
2384, 4014
|
325, 604
|
4231, 4240
|
1660, 2361
|
4962, 5262
|
1448, 1456
|
4102, 4108
|
4190, 4210
|
4040, 4079
|
4264, 4939
|
1471, 1641
|
272, 287
|
632, 978
|
1000, 1370
|
1386, 1432
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,522
| 170,534
|
52932
|
Discharge summary
|
report
|
Admission Date: [**2204-8-9**] Discharge Date: [**2204-8-15**]
Service: NEUROSURGERY
Allergies:
Tetanus Toxoid / Oxycontin / Ace Inhibitors /
Hydrochlorothiazide / Quinidine;Quinine Analogues / Nitro-Dur /
Beta-Adrenergic Blocking Agents / Calcium Channel Blocking
Agents-Benzothiazepines
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
worsening pain
Major Surgical or Invasive Procedure:
1. Extracavitary decompression T2, T3 and T4.
2. Fusion C7-T7.
3. Instrumentation C7-T7.
4. Autograft.
History of Present Illness:
81 yr old pt is known to Dr. [**Last Name (STitle) **]. Pt has NSCL cancer which
was treated with XRT and Chemotherapy in [**12-26**]. In [**6-24**] pt saw
Dr. [**Last Name (STitle) **] for T3 compression fracture from metastatic lesion.
At that time it was decided to treat conservatively as it was
felt that his cancer was not well controlled at that time and pt
was braced. Pt presents with worsening pain and ?urinary
incontinence. Recent PET shows abnormal uptake at T3. Also
abnormal uptake in left upper lobe, right middle lobe which
could be tumor vs. post radiation changes. Pt presents now for
pain control and probable surgical intervention for palliative
pain/symptom control.
Past Medical History:
PAST MEDICAL HISTORY:
1. Status post myocardial infarction in [**2180**].
2. Coronary artery disease.
3. Hypercholesterolemia.
4. Hypothyroidism.
5. Status post gunshot wound to the arms.
6. Status post kidney stones.
7. Hypertension.
PAST SURGICAL HISTORY:
1. Status post olecranon bursectomy in [**2199-2-17**].
2. Status post cystoscopy and bladder biopsy in [**2196-12-19**].
3. Status post coronary artery bypass graft x 4 in [**2195-6-19**].
4. Status post septoplasty in [**2194**].
Social History:
Lives with wife
Family History:
unknown
Physical Exam:
Exam on admission:
T:99.7 BP:102/59 HR:67 RR:16 O2Sats: 97%RA
Gen: WD/WN, comfortable; grimaces in pain w/ movement
HEENT: PERRL@4mm EOMIs
Neck: Supple.
Lungs: Coarse
Cardiac: RRR. S1/S2.
Abd: Soft, some tenderness w/ palpation
Extrem: Warm and well-perfused. No C/C/E.
.
Neuro:
Mental status: Awake and alert, cooperative with exam; appears
distracted. Oriented to person, place; not to date.
.
Motor:
D B T WE FE IP Q H DF PF [**Last Name (un) 938**]
R 3 3 4 5 5 4 4+ 5 5 5 5
L 3 3 4 5 5 4 4+ 5 5 5 5
Areas of weakness appear to be secondary to pain.
.
Sensation: Intact to light touch. Unable to acccurately
identify propioception.
.
Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+
.
Propioception not intact
Toes downgoing bilaterally
Decreased rectal tone
.
Pertinent Results:
Admission labs:
WBC: 4.9 Na: 143
Hgb: 9.6 K: 4.2
Hct: 29 Cl: 104
Plts: 332 CO2: 29
PT: 12.9 BUN: 32
PTT: 31.6 Cr: 2.1
INR: 1.1 U/A: negative
.
CXR [**8-9**]: Region of left upper lobe radiation fibrosis which
progressed substantially between [**Month (only) 205**] and earlier today, is
subsequently stable, obscuring the aortic knob. There is no
pneumothorax or pleural effusion. Heart is normal size.
Stabilization rods have been placed in the cervicothoracic
spine. Tip of the right jugular line projects over the right
brachiocephalic vein. No pneumothorax.
.
T & L-spine xray [**8-9**]: Lateral views of the thoracic and lumbar
spines were performed. There is again seen posterior fusion from
L3-S1 without signs for hardware complications or interval
change. There is bony fusion at L3-4. There is retrolisthesis of
L2 over L3 which is unchanged. There is again noted a prominent
compression deformity of the L1 vertebral body which is
unchanged. There is a lowest marker seen posteriorly is at the
level of the L3 vertebral body. The next superior marker is seen
at the level of the T9 vertebral body, and the superior-most
marker is seen at the likely the T2 vertebral body, however,
this is poorly evaluated due to technique. Please refer to the
procedure note for further details.
.
CT T-spine [**8-10**]: Status post posterior fusion of C7 through T8
with laminectomies at T2 through T4. There is soft tissue
prominence at the level of the laminectomy, which may represent
postop changes or recurrence of disease depending on time course
of surgery which is not given on history.
.
Brief Hospital Course:
81yo man with small cell lung cancer with metastases to the
spine presented with increased back pain due to a T3 metastatic
lesion. He was taken to the OR for extracavitary decompression
of T2-T4, fusion of C7-T7, and autografting. He was extubated on
POD #1 and decadron stopped. On POD #2 he was transferred to the
floor. He had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36323**] collar ordered which he received on
[**2204-8-13**].
.
Palliative care became involved on [**2204-8-13**] because his wife
expressed wish for hospice care. However, he is being evaluated
for rehab because his surgery was done to help prolong his life
and improve his quality of life. After further discussions with
the patient and his wife, all were in agreement with the plan
for rehab to improve his activity and likely pain as well, with
possible future chemotherapy depending on how he progressed,
with goals to include increased functionality and longer life.
.
The patient was found on the floor the evening of [**2204-8-13**]. It is
unclear whether he hit his head, but he complained of shoulder,
hip, and left ankle pain at the time. The plain films showed no
fractures.
.
On [**2204-8-14**] he complained of bilateral ear pain. He was examined
and no sign of infection or perforation was appreciated.
.
On [**2204-8-15**], the patient was doing well and had no furthur
complaints. He was discharged in a stable condition and was
tolerating a regular diet at time of discharge. He was full
strenght motor exam and his pain was now well controlled he
started on Megace to stimulate his appetite and resumed Effexor
for depression
Medications on Admission:
Norvasc 5mg qam
Levothyroxine 88mcg qd
Prilosec 10mg qd
Lipitor 20mg Qd
Hydromorphone 12mg q4hrs
Fentanyl patch 200mcg q72 hrs
Vit B complex w/ iron
Vit C qd
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain;fever.
2. Fentanyl 100 mcg/hr Patch 72HR Sig: Two (2) Patch 72HR
Transdermal Q72H (every 72 hours).
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units 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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
14. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
15. Megace Oral 40 mg/mL Suspension Sig: Four Hundred (400) mg
PO twice a day.
16. Venlafaxine 37.5 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Metastatic lung cancer, cord compression and kyphosis secondary
to fracture at T2 and T3.
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as instructed. Please follow up with your
PCP and neurosurgery as described.
Please call your doctor or return to the ER for any of the
following:
* Redness, swelling, bleeding at the incision site.
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 100.4 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
1)Please follow up with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1669**]) on [**2209-9-11**]:45am. You will need to have x-rays taken just prior to this
appointment.
2)You have the following appointment already scheduled:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) 147**] SPEC SURGERY- [**Doctor Last Name **] [**Doctor First Name 147**] SPEC (NHB)
Date/Time:[**2204-11-5**] 9:30
Completed by:[**2204-8-15**]
|
[
"401.9",
"412",
"198.5",
"V45.81",
"414.00",
"272.0",
"244.9",
"737.19",
"733.13",
"V10.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"81.05"
] |
icd9pcs
|
[
[
[]
]
] |
7758, 7830
|
4452, 6090
|
418, 526
|
7964, 7973
|
2800, 2800
|
9086, 9519
|
1824, 1833
|
6299, 7735
|
7851, 7943
|
6116, 6276
|
7997, 9063
|
1536, 1774
|
1848, 1853
|
364, 380
|
554, 1248
|
2816, 4429
|
1867, 2144
|
2159, 2781
|
1292, 1513
|
1790, 1808
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,526
| 128,688
|
38606
|
Discharge summary
|
report
|
Admission Date: [**2114-3-16**] Discharge Date: [**2114-3-21**]
Date of Birth: [**2058-7-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Increasing dyspnea and chest pain on exertion
Major Surgical or Invasive Procedure:
[**2114-3-16**] - coronary artery bypass grafts x 4(Left internal mammary
artery->Left anterior descending artery, Saphenous vein
graft(SVG)->Diagonal artery, SVG->Obtuse marginal artery,
SVG-Posterior descending artery).
History of Present Illness:
This 55 year old amle was admitted for for cardiac
cathetr=erization. He complained of noted to have chest pressure
intermittently upon exertion. He describes it as
substernal/leftchest and in elbow lasting minutes and relieves
with rest. He states it started about 6 months ago and has not
increased in
frequency or severity. His job involves lifting all day,
however, he does not always experience chest pain.
With concern for anginal pain, a stress test was performed in
the
outpatient which showed a partially fixed, mostly reversible
inferior defect. He was admitted for prehydration due to
elevated
creatinine of 2.0.
Past Medical History:
insulin dependent diabetes mellitus
hyperlipidemia
hypertension
peripheral vascular disease
Social History:
Works in delivery for Enteman's bakeries. Smokes 2 ppd for the
past 42 years. Denies alcohol and illicit drug use
Family History:
Father had MI and died at age 68
Physical Exam:
Admission:
Pulse:64 Resp: O2 sat: 98
B/P Right: 118/64 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
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:cath site Left:+2
DP Right: doppler Left:doppler
PT [**Name (NI) 167**]: doppler Left:doppler
Radial Right: +2 Left:+2
Carotid Bruit -no bruit Right: +2 Left:+2
Pertinent Results:
[**2114-3-16**]
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Top
normal/borderline dilated LV cavity size. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
Physiologic MR (within normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is top normal/borderline dilated. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits).
POSTBYPASS
Biventricular systolic function is preserved. The study is
unchanged from the prebypass period.
[**2114-3-20**] 05:20AM BLOOD WBC-14.9* RBC-4.02* Hgb-12.0* Hct-35.5*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.0 Plt Ct-220
[**2114-3-20**] 05:20AM BLOOD PT-15.5* PTT-25.5 INR(PT)-1.4*
[**2114-3-20**] 05:20AM BLOOD Glucose-129* UreaN-43* Creat-1.9* Na-136
K-4.5 Cl-97 HCO3-29 AnGap-15
[**2114-3-19**] 01:03AM BLOOD Glucose-66* UreaN-41* Creat-1.9* Na-135
K-4.5 Cl-102 HCO3-27 AnGap-11
[**2114-3-17**] 03:03AM BLOOD Glucose-80 UreaN-51* Creat-2.0* Na-140
K-5.3* Cl-111* HCO3-25 AnGap-9
[**2114-3-16**] 01:37PM BLOOD UreaN-56* Creat-2.0* Cl-112* HCO3-24
[**2114-3-18**] 01:48AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.7*
Brief Hospital Course:
Mr. [**Known lastname 85813**] was admitted as a same day admission for coronary
revascularization. On [**3-16**] he underwent a coronary artery bypass
grafting x4 with left internal mammary artery to left anterior
descending artery and saphenous vein grafts to diagonal, obtuse
marginal and posterior descending arteries. See operative note
for full details.
His post operative course was complicated by pulmonary issues
(patient had significant tobacco history) and multiple episodes
of rapid atrial fibrillation, which converted to sinus rhythm
after an amiodarone bolus and drip. He was transitioned to oral
amiodarone. He was started on Coumadin on post operative day 3
due to the atrial dysrhythmia. [**Last Name (un) **] was also consulted and
followed his blood sugars throughout his hospital course. He
was discharged on his home insulin and oral [**Doctor Last Name 360**] regimen and is
to follow up as an outpatient.
Chest tubes and pacing wires were removed per cardiac surgery
protocol. He was transferred to the step down unit on post
operatvie day 3 in stable condition. He continued to work with
Physical Therapy for increased strength and endurance. His
incisions were healing well, he was tolerating a full oral diet
and he was ambulating without assistance. Coumadin is to be
followed by Dr. [**Last Name (STitle) 24862**] with a goal INR of [**2-13**].5. An appointment
was made for 48 hours after discharge to draw labs and adjust
the Coumadin dose.
He was discharged home with visiting nurse services on post
operative day 5 in stable condition. precations, instructions
and medications were discussed with the patient prior to leaving
the hospital.
Medications on Admission:
Atenolol 25 mg daily
Atorvastatin 20 mg daily
Clopidogrel 75 mg daily - advised to stop today
Duloxetine 30 mg Capsule, Delayed Release qhs
Furosemide 40 mg Tablet, 2 tabs in AM and 1 tab in PM
Glargine 100 unit/mL Solution 55 units once a day/am
Lisinopril 5 mg daily
Minoxidil 2.5 mg Tablet, 5 mg [**Hospital1 **]
Pioglitazone [Actos] 30 mg daily
Verapamil 240 mg Tablet Sustained Release daily
Aspirin 325 mg Tablet
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*0*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO as directed
for 2 months: 400 mg [**Hospital1 **] x 2 weeks then 200 mg [**Hospital1 **] x 2 weeks
then 200 mg daily x 1 month then discontinue.
Disp:*100 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
10. Combivent 18-103 mcg/Actuation Aerosol Sig: [**1-13**] Inhalation
four times a day as needed for shortness of breath or wheezing.
Disp:*1 1* Refills:*0*
11. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 55 units
Subcutaneous q AM.
Disp:*1 55 units* Refills:*1*
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for temperature >38.0.
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
14. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: Take daily as directed by Dr. [**Last Name (STitle) 24862**].
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
s/p coronary artery bypass grafts
Coronary artery disease
insulin dependent diabetes mellitus
hypertension
dyslipidemia
peripheral vascular diseas
unilateral kidney
chronic renal insufficiency
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon: Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]on [**4-16**] at
1:00 PM
Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24862**] in [**1-13**] weeks ([**Telephone/Fax (1) 64296**]on
Fri., [**3-23**] at 1030am for blood test
Cardiologist: Dr. [**Last Name (STitle) 7047**] in [**1-13**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2114-3-21**]
|
[
"272.4",
"403.90",
"443.9",
"305.1",
"V58.67",
"753.0",
"427.31",
"250.80",
"585.9",
"V58.66",
"458.29",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8179, 8235
|
4084, 5772
|
367, 591
|
8472, 8568
|
2220, 4061
|
9109, 9740
|
1509, 1543
|
6243, 8156
|
8256, 8451
|
5798, 6220
|
8592, 9086
|
1558, 2201
|
281, 329
|
619, 1245
|
1267, 1361
|
1377, 1493
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,130
| 138,525
|
46893
|
Discharge summary
|
report
|
Admission Date: [**2147-10-21**] Discharge Date: [**2147-11-7**]
Date of Birth: [**2068-10-24**] Sex: M
Service: MEDICINE
Allergies:
Tetracyclines / Lisinopril
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
increasing back pain and failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 78 yo retired plastic surgeron with a history
of metastatic prostate cancer currently on taxotere who presents
with worsening back pain. He was initially diagnosed with
prostate CA in [**2132**] and has failed hormonal therapy now on cycle
12 of taxotere rec'd on [**2147-10-17**]. He presents to the ER with
worsening back pain. The patient states his back pain is lower
back and has been worsening for the past 24 hours. He has also
had some subjective lower extremity weakness for the past [**4-12**]
months without any change. No fecal incontinence or urinary
retention or incontinence. No saddle anesthesia. He has known
bony mets throughout his spine. Over the past 3-4 days he also
has noted a decrease in his urine output as well as a darkening
of his urine. He has been slightly confused from time to time
only over the past few days and much more somnolent and with
generalized weakness. No other symptoms. Denies fevers.
.
In the ED, initial vs were: T 97.5 HR 75 BP 121/64 RR 18 O2 sat
100. He was noted to have paroxysmal afib w/ RVR and rec'd 2x
15mg IV boluses of dilt and 30mg po dilt without much effect and
then started on a dilt drip. He also was noted to have a
retrocardiac opacity so was given 250mg IV levofloxacin (given
ARF cr 5.6). He was given 250cc of IVF for his ARF. He
underwent a renal u/s which was negative for stone or
hydronephrosis. He was noted to have lower extremity stregnth
[**5-14**] bilaterally; his MRI of his spine was deferred until he
arrived on the floor.
.
VS prior to transfer were: T 97.5 HR 120 BP 139/74 RR 19 98%
on 2L
Past Medical History:
ONCOLOGIC HISTORY:
- Diagnosed [**2132**] s/p prostatectomy
- Multilevel osseous metastatic changes in the cervical and
thoracic spine without epidural disease or cord compression.
Posterior disc protrusion at level C4- C5.
- Previously received on casodex and finasteride
- Now on C12 taxotere ([**2147-10-17**])
.
PMH:
-Metastatic prostate cancer: known [**Last Name (un) 2043**] metastases s/p 6 cycles
of docetaxel last on [**4-17**]
-Paroxysmal atrial fibrillation on coumadin and flecainide s/p
cardioversion attempts [**7-/2147**]
-Hypertension
-Hyperlipidemia
-H/O nephrolithiasis
-S/P appendectomy
-s/p left inguinal hernia repair
-s/p ventral hernia repairs (now recurred)
Social History:
He is the former Chief of Plastic Surgery at [**Hospital1 18**] but is now
retired and lives with his wife. [**Name (NI) **] does not smoke, drink
alcohol, or use any drugs.
Family History:
Noncontributory
Physical Exam:
Vitals: T: BP: 174/73 P: 143 (afib) R: 12 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, conjunctiva
pale
Neck: supple, JVP 8cm, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, irregularly irregular, SEM at the LUSB
Abdomen: soft, non-tender, mild to mod distension, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, no asterixis, able to hold a normal conversation,
no saddle anesthesia, 4+/5 stregnth in lower extremities-
bilaterally symmetric quad, hamstring, dorsiflex, plantarflex,
abduction, adduction.
Pertinent Results:
ADMISSION:
WBC-10.6 RBC-3.43* Hgb-9.7* Hct-29.6* MCV-86 MCH-28.3 MCHC-32.8
RDW-18.8* Plt Ct-56*#
Neuts-93.4* Lymphs-3.6* Monos-2.6 Eos-0.1 Baso-0.4
PT-26.2* PTT-31.5 INR(PT)-2.5*
Fibrino-411*
D Ret Aut-0.4*
Glucose-129* UreaN-100* Creat-5.6*# Na-139 K-4.7 Cl-104 HCO3-21*
AnGap-19
ALT-18 AST-37 LD(LDH)-554* CK(CPK)-223* AlkPhos-83 TotBili-0.7
DirBili-0.2 IndBili-0.5
Calcium-8.4 Phos-6.2*# Mg-2.2
Hapto-<20*
Lactate-0.9
[**2147-10-21**] CXR: Increased retrocardiac density at the left base,
with corresponding basilar opacity on the lateral view,
concerning for left lower lobe pneumonia. Low lung volumes.
[**2147-10-21**] Renal US: No hydronephrosis. Potentially partially
septated cyst.
Recommend attention paid to these cysts on presumed followup
imaging.
[**2147-10-22**] CT abd/pelvis without contrast:
1. No evidence of hydronephrosis or hydroureter. No findings to
account for
acute renal failure. Left non- obstructing renal
calculus/calculi.
2. Right pelvic wall mass and non-pathlogically enlarged right
external iliac
node have increased in size compared to 5 months prior. Status
post
prostatectomy.
3. Bilateral renal cysts, several of which are hyperdense, and
liver cysts;
the enhancement pattern of these is not evaluated due to lack of
IV contrast.
4. Diffuse bony metastases redemonstrated, without acute
fracture identified.
5. Small left greater than right pleural effusions are new, with
associated
atelectasis.
MRI L, T, C Spine [**2147-10-24**]:
1. Progression of osseous metastases in the cervical, thoracic
and lumbar
spine. No new compression fractures.
2. Unchanged small anterior epidural lesion at the level of L5,
without
evidence of definite nerve root involvement.
3. No evidence of new epidural lesions. No cord compression.
4. Unchanged spondylosis as described above.
CT Head [**2147-11-2**]:
1. No intracranial hemorrhage. No mass effect.
2. No non-contrast CT evidence for metastases. MR is more
sensitive in the
detection of small masses and acute stroke.
LE U/S [**2147-10-26**]
No evidence of DVT in the left lower extremity.
Brief Hospital Course:
78 yoM w/ a h/o metastatic prostate cancer and afib presents
with worsening back pain, found to have thrombocytopenia and
severe acute renal failure as well as afib with RVR- admitted to
the ICU as he was requiring a diltiazem drip for rate control.
# Acute renal failure: Patient's ARF peaked at creatinine of
6.4, just barely made it without requiring dialysis. Etiology
remained unclear. [**Name2 (NI) 227**] thrombocytopenia, low haptoglobin,
anemia, TTP/HUS and DIC remained on the differential, however
smear was without evidence of microangiopathic hemolytic anemia
making these diagnoses less likely. Hypotension leading to
ischemic insult secondary to a fib in RVR is another
possibility, however patient has had a fib for years making this
also less likely. Nonetheless, his ARF resolved with fluids and
time. Renal was following. Last creatinine at 1.7. Renal
recommended continuing his IV fluids until his PO intake
increases.
# Anemia: Hct was slightly lower than baseline, as above labs
were consistent with hemolysis but smears failed to show
abundant schistocytes. Baseline was in the low 30s and based on
iron studies from [**5-18**] consistent with anemia of chronic
disease. vitB 12 low at 147, folate was normal. Patient was
started on B12 repletion of 1 week of injections, which did not
yet resolve his anemia but his B12 levels returned to [**Location 213**].
# Afib with RVR: Patient's a fib in RVR was difficult to control
with dilt in the ICU. Metoprolol was used instead with good
affect. However, pt developed fatigue, increased depression, and
bradycardia with high dose metoprolol concerning for beta
blocker toxicity. His metoprolol was titrated down while being
uptitrated on diltiazem. His heart rate remained well controlled
throughout the admission.
# Delerium: Pt developed delerium secondary to most likely a
combination of mirtazapine and reglan use. This cleared after 2
days. Infectious w/u remained negative.
# Abdominal pain/nausea vomitting: KUB was negative, these
symptoms resolved with BMs and were thought to be related to
constipation.
# Back pain: Patient's back pain was associated with a few
months of lower extremity weakness. Last imaging of his spine
was [**5-18**] with an MRI of his C, T and L spine which demonstrated
diffuse metastasis to the spine and no cord compression. Patient
was put on oxycontin 10mg po bid with prn PO oxycodone and prn
IV morphine prn pain.
Code: Full (discussed with patient). Patient's PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], had a long conversation with the patient on his code
status, and patient decided to keep the code as full for now.
Medications on Admission:
Allopurinol 300 mg daily
Citalopram 10 mg daily
Dexamethasone 1 mg daily
Immodium
Lupron
Oxycodone 5 mg Q4-6 PRN
Oxycontin 10 mg TID
Pravastatin 20 mg daily
Prochlorperazone 10 mg Q6H prn
Coumadin 2 mg Tablet - [**3-14**] Tablet(s) by mouth daily takes 4mg
Mon and Fri and 3mg all other days
Vitamin D
Lactobacillus
MOM
OM3FA
Ocuvite
Discharge Medications:
1. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
4. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) Injection
DAILY (Daily) for 5 days: Last dose [**2147-11-6**].
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for nausea.
9. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for gas, bloating.
10. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
12. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day:
Please only start when creatinine is <1.5. .
13. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO once a day.
14. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
15. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day.
16. Vitamin A-Vitamin C-Vitamin E Tablet Sig: One (1) Tablet
PO once a day.
17. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO once
a day.
18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
mL PO every six (6) hours as needed for constipation.
19. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for Nausea.
20. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
Hold of SBP<100 or HR<50 .
21. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Hold of SBP<100 or HR<50 .
22. IV fluid
20 mEq Potassium Chloride / 1000 mL D5 1/2 NS
Continuous at 50 ml/hr
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary:
1) Acute renal failure
2) Atrial fibrillation with rapid ventricular rate
3) Thrombocytopenia
Secondary:
Metastatic prostate cancer
Depression
Discharge Condition:
Stable vitals, afebrile.
Discharge Instructions:
You were admitted to the hospital for lower back pain and you
were found to have a very high heart rate, kidney failure, and
low platelet count. You were admitted to the ICU where they
controlled your heart rate with an IV diltiazem drip. We treated
your kidney failure by aggressive IV hydration. The cause of
your kidney failure was unclear, however, it might have been
related to your elevated heart rate leading to low blood flow to
the kidneys. Fortunately, your kidney function improved with IV
hydration. Your heart rate also came under control by increasing
your metoprolol dosage.
We have made the following changes to your medications:
START taking Diltiazem 30mg by mouth four times a day
START taking Lansoprazole 30mg by mouth once a day
START Metoprolol Succinate 50 mg by mouth every day
START Coumadin 2mg by mouth every day
You will be transported to your follow up appointments listed
below.
Please seek medical care if you develop chest pain, shortness of
breath, palpiations, syncope, fevers.
Followup Instructions:
You have an appointment with Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2147-11-7**] 12:00
You have an appointment with Provider: [**Name10 (NameIs) 17246**] [**Name11 (NameIs) **], RN
Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2147-11-7**] 1:00
You have an appointment with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2147-11-27**] 10:20
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
Completed by:[**2147-11-7**]
|
[
"298.9",
"V58.61",
"401.9",
"293.81",
"427.32",
"286.9",
"584.5",
"564.09",
"V87.41",
"276.0",
"272.4",
"198.5",
"427.31",
"E939.0",
"787.01",
"292.81",
"V10.46",
"287.5",
"285.22",
"311",
"E933.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.94"
] |
icd9pcs
|
[
[
[]
]
] |
11110, 11175
|
5788, 8493
|
332, 338
|
11372, 11399
|
3679, 5765
|
12463, 13146
|
2894, 2911
|
8878, 11087
|
11196, 11351
|
8519, 8855
|
11423, 12041
|
2926, 3660
|
12070, 12440
|
250, 294
|
366, 1979
|
2001, 2686
|
2702, 2878
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,866
| 155,052
|
53328
|
Discharge summary
|
report
|
Admission Date: [**2192-4-17**] Discharge Date: [**2192-4-23**]
Service: MEDICINE
Allergies:
Penicillins / Clindamycin
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
.
History of Present Illness:
88F h/o metastatic breast cancer c/b malignant pleural and
pericardial effusion s/p window, currently on chemotherapy,
initially presented on [**2192-4-18**] with SOB increased above chronic
baseline. Right pleurex catheter w/ increased drainage of
~300cc/day. +cough with minimal sputum.
.
In the ED, T 98.5, BP 91/31, HR 94, RR 20-24, 94% on 4L nc (91%
on 1L nc). CXR revealed reaccumulation of right pleural effusion
with possible superimposed PNA. Given CTX, azithro, and flagyl
initially, then changed to levofloxacin and flagyl on admission
to OMED. IP consulted, drained 150cc and thought effusions
unlikely etiology of increased dyspnea. Echo with normal cardiac
function, trivial pericardial effusion. CTA chest negative for
PE. LENIs negative for DVT. Portacath placed on [**4-19**] for
long-term access. Derm consulted for new rash at right pleurex
site concerning for cutaneous metastases of her breast cancer
(carcinoma erysiploides), a biopsy was performed.
.
On the floor this morning, became more dyspnic, hypoxic to 90%
on 100% shovel mask, and tachypnic to 30s. Newly tachycardic to
150s (ECG with ?afib). SBP mid-80s. Pulsus 10. ABG 7.39/27/76.
CXR with modest decrease in the size of the right pleural
effusion, but otherwise unchanged. Coarse breath sounds on exam
bilaterally (?upper airway). No response to nebs, morphine,
racemic epi, or deep suction (although suboptimal). Transferred
to [**Hospital Unit Name 153**].
Past Medical History:
POncH
# Metastatic breast CA (dx [**2153**])
- s/p mastectomy
- s/p malignant pleural effusion ([**5-/2190**])
- s/p pleurodesis, R pleurex catheter placement ([**6-/2190**])
- s/p fulvestran x4 cycles
- s/p malignant pericardial effusion ([**10/2190**]), d/c'd fulvestran
- pericardial window placed [**11-1**]
- s/p anastrozole, d/c'd [**2-/2192**] [**1-28**] progression
- s/p capecitabine, d/c'd [**1-28**] inability to swallow pills
- Current therapy: Navelbine x1 cycle ([**2192-4-5**])
.
PMH
# Hypothyroidism
# Hyperlipidemia
# Esophageal stenosis s/p dilation ([**2191-9-26**], [**2192-3-23**])
# R eye blindness [**1-28**] herpes keratitis
# s/p umbilical hernia repair ([**2191-8-8**])
Social History:
Other: # Personal: Lives alone
# Tobacco: Prior, quit > 50 yr ago
# Alcohol: Social
# Recreational drugs: Not elicited
Family History:
Non-contributory.
Physical Exam:
General Appearance: No acute distress, Thin, Anxious
Eyes / Conjunctiva: PERRL, right eye opacification
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Dullness : right lower [**12-28**]), (Breath Sounds: Bronchial:
bilateral, Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right: 1+, Left: 1+, No(t) Cyanosis
Musculoskeletal: Unable to stand
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
[**2192-4-17**] 04:30PM BLOOD WBC-3.9* RBC-4.93 Hgb-14.8 Hct-43.6
MCV-88 MCH-30.1 MCHC-34.0 RDW-14.4 Plt Ct-457*
[**2192-4-19**] 01:00AM BLOOD WBC-3.9* RBC-4.28 Hgb-13.1 Hct-38.3
MCV-89 MCH-30.6 MCHC-34.3 RDW-14.5 Plt Ct-355
[**2192-4-21**] 06:42AM BLOOD WBC-4.9 RBC-4.46 Hgb-13.7 Hct-39.7 MCV-89
MCH-30.7 MCHC-34.5 RDW-14.8 Plt Ct-371
[**2192-4-22**] 04:00AM BLOOD WBC-6.4 RBC-3.50* Hgb-10.8* Hct-32.9*
MCV-94 MCH-30.8 MCHC-32.8 RDW-15.1 Plt Ct-276
[**2192-4-22**] 04:00AM BLOOD Plt Ct-276
[**2192-4-22**] 04:00AM BLOOD PT-18.5* PTT-41.3* INR(PT)-1.7*
[**2192-4-22**] 02:47AM BLOOD PT-18.6* PTT-43.0* INR(PT)-1.7*
[**2192-4-21**] 07:40PM BLOOD PT-16.2* PTT-33.0 INR(PT)-1.4*
[**2192-4-17**] 04:30PM BLOOD Glucose-99 UreaN-24* Creat-1.2* Na-137
K-6.8* Cl-105 HCO3-23 AnGap-16
[**2192-4-18**] 07:20AM BLOOD Glucose-99 UreaN-26* Creat-1.2* Na-141
K-5.0 Cl-109* HCO3-23 AnGap-14
[**2192-4-20**] 05:37AM BLOOD Glucose-128* UreaN-26* Creat-1.2* Na-141
K-4.5 Cl-109* HCO3-23 AnGap-14
[**2192-4-21**] 07:40PM BLOOD Glucose-133* UreaN-28* Creat-1.4* Na-139
K-4.2 Cl-111* HCO3-16* AnGap-16
[**2192-4-22**] 04:00AM BLOOD Glucose-214* UreaN-26* Creat-1.3* Na-137
K-4.3 Cl-108 HCO3-13* AnGap-20
[**2192-4-17**] 04:30PM BLOOD CK-MB-3 proBNP-1143*
[**2192-4-22**] 04:00AM BLOOD CK-MB-9 cTropnT-0.15*
[**2192-4-17**] 04:30PM BLOOD cTropnT-0.01
[**2192-4-21**] 06:42AM BLOOD CK-MB-4 cTropnT-<0.01
[**2192-4-21**] 07:40PM BLOOD CK-MB-5 cTropnT-0.04*
[**2192-4-18**] 07:20AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.3
[**2192-4-19**] 01:00AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.1
[**2192-4-20**] 05:37AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.0
[**2192-4-21**] 06:42AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.1
[**2192-4-21**] 07:40PM BLOOD Calcium-7.7* Phos-3.4 Mg-2.0
[**2192-4-22**] 04:00AM BLOOD Phos-2.9 Mg-1.5*
[**2192-4-22**] 04:00AM BLOOD TSH-7.5*
[**2192-4-21**] 05:02PM BLOOD Type-ART FiO2-100 pO2-76* pCO2-27*
pH-7.39 calTCO2-17* Base XS--6 AADO2-620 REQ O2-100 Intubat-NOT
INTUBA
[**2192-4-22**] 02:45AM BLOOD Type-[**Last Name (un) **] pO2-30* pCO2-31* pH-7.26*
calTCO2-15* Base XS--12 Intubat-NOT INTUBA
[**2192-4-17**] 05:25PM BLOOD Lactate-1.9
[**2192-4-17**] 06:34PM BLOOD K-4.4
------------------
CT Chest:
IMPRESSION:
1. Overall progression of metastatic disease involving the
pleura and lung
interstitium (lymphangitic carcinomatosis) right greater than
left.
2. Similar-appearing chest wall metastases.
3. New left renal pelvis prominence, concerning for possible
hydronephrosis.
Consider ultrasound for confirmation/characterization, if
warranted
clinically.
4. Stable right 5th rib lesion, which could represent osseous
metastasis.
5. Prior granulomatous disease.
5.
The study and the report were reviewed by the staff radiologist.
REASON FOR EXAMINATION: Metastatic breast cancer and recurrent
pleural
effusion, assessment of change in pleural effusion.
Portable AP chest radiograph compared to [**2192-4-22**],
obtained at 02:15
a.m.
Bilateral pleural effusions, right significantly more the left,
are again
demonstrated with increased right lower lobe opacity consistent
with
consolidation, consistent with aspiration versus developing
pneumonia. There
is no significant change in bibasilar atelectasis. The left
upper lung is
unremarkable. The right chest tube is in unchanged position as
well as the
right subclavian line with its tip at the cavoatrial junction.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: TUE [**2192-4-24**] 9:46 AM
Brief Hospital Course:
88F h/o metastatic breast cancer (malignant pleural effusion,
pericardial effusion) on chemotherapy with acute on chronic
dyspnea, tachypnea, tachycardia, hypotension.
# Dyspnea, tachypnea: Acute worsening may be due to mucous
plugging in patient with little pulmonary reserve (effusions,
lobar collapse, extensive mets with lymphangitic spread),
compounded by tachycardia leading to CHF [**1-28**] decreased diastolic
filling and acute pulmonary edema. Pneumonia (post-obstructive,
aspiration pneumonitis) also possible especially given
immunosuppression from malignancy, although less likely. Recent
negative LENIs and CTA chest make PE lower on differential.
Dyspnea and hypoxia likely due to enlarging malignant pleural
effusion on CXR
Given High-flow O2, nebs prn
Treated atrial fibrillation per below
Continued levo/flagyl, added vanco for possible post-obstructive
PNA
Blood, urine, sputum, pleurex catheter cultured
Pleurex catheter for drainage of effusions.
# Atrial fibrillation: New onset in setting of acute illness,
may have been related to hypoxia and possible underlying
pneumonia. Normal atria by recent echo.
Amiodarone loaded given hypotension, temporarily converted.
# Hypotension: Likely volume depletion in the setting of poor
filling and CO due to tachycardia. Less likely sepsis,
cardiogenic, or adrenal etiology. No evidence bleeding or
tamponade (normal pulsus, JVP, and no effusion on recent echo).
Volume resuscitated with IVF bolus prn
Antibiotics per above
Cycled cardiac enzymes, increase in troponin likely rate
related. No evidence for ACS.
# Esophageal stenosis: Last dilation failed, with limited PO
intake [**1-28**] dysphagia.
-NPO in setting of AMS
# Metastatic breast CA: Last navelbine [**2192-4-5**].
- [**4-20**]: Received navelbine as inpatient starting [**4-20**].
# Hypothyroidism: Outpatient levothyroxine.
In setting of worsening respiratory failure and poor overall
prognosis decision was made to make patient DNR/DNI and
ultimately comfort measures only in family meeting. Pt passed
away from respiratory failure. Her family was present and
patient was comfortable. Please see official paper work for
details on official time of death.
Medications on Admission:
MEDS AT HOME:
# Levothyroxine 50mcg PO daily
# B12
# MVI daily
.
MEDS ON TRANSFER:
Ipratropium Bromide Neb 1 NEB IH Q6H
Levothyroxine Sodium 50 mcg PO DAILY
Levofloxacin 750 mg IV Q48H
Acetaminophen 325-650 mg PO Q6H:PRN
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H d1 = [**2192-4-17**]
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Morphine Sulfate 2 mg IV ONCE
Cyanocobalamin 500 mcg PO DAILY
Multiple Vitamins Liq. 5 ml PO DAILY
Diltiazem 10 mg IV ONCE
Ondansetron 4-8 mg IV Q8H:PRN
Guaifenesin [**5-5**] mL PO Q6H:PRN
Prochlorperazine 10 mg PO/IV Q6H:PRN nausea
Heparin 5000 UNIT SC TID
Racepinephrine 0.5 mL IH Q4H:PRN
Senna 1 TAB PO BID:PRN
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
breast cancer
respiratory failure
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"995.94",
"427.31",
"518.81",
"584.9",
"198.2",
"998.2",
"V10.3",
"272.4",
"197.2",
"038.9",
"530.3",
"E878.8",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"38.93",
"86.11",
"42.92"
] |
icd9pcs
|
[
[
[]
]
] |
9857, 9866
|
6939, 9138
|
237, 240
|
9943, 9952
|
3444, 6916
|
10008, 10147
|
2611, 2630
|
9825, 9834
|
9887, 9922
|
9164, 9229
|
9976, 9985
|
2645, 3425
|
194, 199
|
268, 1717
|
1739, 2455
|
2471, 2595
|
9247, 9802
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,505
| 106,933
|
50296
|
Discharge summary
|
report
|
Admission Date: [**2175-8-1**] Discharge Date: [**2175-8-9**]
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
sob and confusion s/p chlorine inhalation
Major Surgical or Invasive Procedure:
intubation with mechanical ventillation for 5 days
History of Present Illness:
88 yo M h/o CAD s/p CABG, HTN, brought in by EMS for
unresponsiveness and difficulty breathing. Pt was in USOH until
evening of presentation. After dinner he went to help his son
work on a leak in their pool's pump room. Per pt's wife, water
was spraying the room and its contents including containers of
granulated chlorine. The pt went inside the room and was there
for approximately three minutes. He walked from the room and was
stumbling/confused. He collapsed several minutes later and was
unresponsive, breathing shallowly. EMS was called. Pt
transported to [**Hospital1 18**].
.
In the ED vitals initially: t 99.9, hr 59, bp 154/71, rr 30, sat
98% on ? 02. Pt was intubated on presentation for airway
protection. In the ED CT head negative and CXR showed low lung
volumes. Pt transferred to MICU.
.
In the MICU pt was intubated for 5 days. Toxicology consult was
obtained and it was determined that pt's presentation was
chloride toxicity complicated by chemical pneumonitis.
Past Medical History:
nephrolithiasis, colon angioectasis, coronary artery disease,
hypertension, kidney stones, hyperlipemia, stable pulmonary
nodule, asthma (recently diagnosed)
Social History:
Pt is a lawyer. [**Name (NI) **] lives with his wife, with family members
nearby. [**Name2 (NI) **] drinks socially, no tobacco or drug use.
Family History:
non contributory
Physical Exam:
ON ADMISSION:
Temp 96.2
BP 146/56
Pulse 61
Resp 20
O2 sat 98% on vent AC 450X20 peep 10, fiO2 40%
Gen - Alert, no acute distress
HEENT - pupils pinpoint, anicteric, mucous membranes slightly
dry
Neck - no JVD, no cervical lymphadenopathy
Chest - diffusely wheezing
CV - Normal S1/S2, RRR, no murmurs appreciated
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - 1+ pitting edema to ankles b/l. 2+ DP pulses bilaterally
Neuro - intubated, sedated
Skin - No rash
Pertinent Results:
Chest X ray prior to discharge: The sternotomy wires and
mediastinal clips are unchanged from prior exam. The heart size
is normal. The aorta is heavily calcified. There is no
consolidation or vascular congestion in the lungs. There is
persistent blunting of the left costophrenic angle. Osseous
structures are unchanged.
IMPRESSION: No evidence of volume overload.
Brief Hospital Course:
1)Chemical pneumonitis due to chlorine. Pt presented to ED with
unresponsiveness and was intubated for airway protection and
difficulty breathing. A toxicology consult was obtained and pt
was treated with a course of steroids as per their
recommendations. After 5 days of mechanical ventillation pt was
extubated without difficulty. There was a minor component of
reactive airway disease and so pt was given tiotropium and
Advair. Because he has no history of COPD and was previously
without respiratory compromise, tiotropium was discontinued. As
he continued to have mild wheeze, Advair was continued with
instrution to discontinue after one more week.
2)Possible aspiration pneumonia in addition to pneumonitis: On
arrival to the MICU, there was concern that the pt may have
developed an aspiration pneumonia in the setting of decreased
consciousness. He was treated with 7 day course of antibiotics.
3)Renal failure: Pt had acute renal failure which resolved with
administration of IV fluids.
4)CAD s/p CABG: Continues on home asa/statin/bb. Confirmed with
pt and PCP that pt is no longer on plavix.
comm: wife/hcp [**Name (NI) **] [**Telephone/Fax (1) 104898**]
code: full (confirmed with wife)
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: Two (2) 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. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day) for 1 weeks.
7. Timoptic
continue home regimen
Discharge Disposition:
Home
Discharge Diagnosis:
chemical pneumonitis
Discharge Condition:
ambulating well, O2 sat 96% on room air, breathing without
difficulty, eating without difficulty
Discharge Instructions:
Please call your doctor or return to the emergency room with any
difficulty breathing or other concerning symptoms. Take advair
for one week and then finish.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 1313**] within the next few weeks.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2175-8-18**]
|
[
"584.9",
"518.81",
"491.22",
"506.0",
"401.9",
"E869.8",
"276.0",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4474, 4480
|
2628, 3843
|
273, 326
|
4545, 4644
|
2237, 2605
|
4851, 5088
|
1697, 1715
|
3866, 4451
|
4501, 4524
|
4668, 4828
|
1730, 1730
|
192, 235
|
354, 1340
|
1744, 2218
|
1362, 1521
|
1537, 1681
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,943
| 126,500
|
7511
|
Discharge summary
|
report
|
Admission Date: [**2104-9-4**] Discharge Date: [**2104-9-23**]
Date of Birth: [**2043-6-8**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
(R)UQ and epigastric abdominal pain and poor appetite.
Major Surgical or Invasive Procedure:
PICC line placement [**2104-9-5**].
.
Pancreatic pseudocyst gastrostomy with cholecystectomy and
cholangiogram [**2104-9-14**].
History of Present Illness:
Patient is a 61year old female, who works as a nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) **]
Hospital. The patient has a history of pacreatic divisum, and
was recently admitted at [**Hospital1 69**]
for abdominal pain [**2104-8-17**]. She was diagnosed with pacreatitis,
her lipase was found to be 6000 and an Ultrasound was negative
for cholecystitis or cholelithiasis. She was given antibiotics,
fluids and pain medications. The patient was discharged on the
19th in stable condition. She returns today after being seen at
an outside hospital on [**2104-9-3**]. The patient claims that she has
been not eating well and having increasing pain since last
Monday with worsening stabbing epigastric pain radiating to her
back. Also, she has developed (R)UQ abdominal pain. The patient
is having difficulty moving her bowels, but is pasing flatus.
No hematemesis, fevers, chills.
Past Medical History:
PMHx: Pancreas divisum, one episode of pancreatitis 3-4 years
ago, HTN, duodenal ulcer, hyperlipidemia, hypothyroid.
.
PSHx: Transvaginal hysterectomy, appendectomy, Tonsillectomy and
Adenoidectomy, Colonoscopy in [**2103-7-8**] with polypectomy.
Social History:
Nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] Hospital. Discontinued tobacco use 15 years
ago, no alcohol, no drugs.
Family History:
Non-contributory.
Physical Exam:
On Admission:
VS: Temp 96.3 BP 132/80 HR 65 RR18 O2sat 99%RA
GEN: Uncomfortable, awake, alert & oriented x3.
Lungs: CTA(B)
COR: RRR, S1 S2.
ABDOMEN: Firm in epigastric region, diffusely tender to
palpation, + guarding, abdomen is mildy distended.
EXTREM: warm and well perfused, pulses 2+.
.
At Discharge:
VS: 97.7 PO, 85, 114/56, 18, 95% RA
GEN: Appears well, comfortable in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **]. No JVD.
LUNGS: CTA(B)
COR: RRR
ABDOMEN: Incision OTA with steri-strips c/d/i. Appropriately
TTP. BSx4. Soft/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.
SKIN: As above, otherwise intact.
Pertinent Results:
ABD CT at [**Hospital6 8972**] [**2104-9-3**]:
Large complex cystic structure arising from and and replacing
much of the body of the pancreas, likely a large pseudocyst(16cm
X 10cm).
.
[**2104-9-5**] 09:30AM BLOOD WBC-7.4 RBC-3.83* Hgb-11.8* Hct-35.5*
MCV-93 MCH-30.7 MCHC-33.2 RDW-13.2 Plt Ct-725*#
[**2104-9-5**] 09:30AM BLOOD Plt Ct-725*#
[**2104-9-5**] 09:30AM BLOOD Glucose-88 UreaN-7 Creat-0.5 Na-137 K-4.1
Cl-98 HCO3-26 AnGap-17
[**2104-9-5**] 09:30AM BLOOD ALT-17 AST-20 AlkPhos-102 Amylase-79
TotBili-0.3
[**2104-9-5**] 09:30AM BLOOD Lipase-54
[**2104-9-5**] 09:30AM BLOOD Albumin-3.8 Calcium-9.2 Phos-4.0 Mg-1.9
Iron-28*
[**2104-9-5**] 09:30AM BLOOD calTIBC-269 Ferritn-938* TRF-207
[**2104-9-5**] 09:30AM BLOOD Triglyc-191*
.
[**2104-9-13**] 6:33 pm URINE Cx; Source: Catheter (FINAL REPORT):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML.
.
[**2104-9-14**] 11:47 am SWAB PSEUDOCYST (FINAL REPORT):
-GRAM STAIN (Final [**2104-9-14**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
-FLUID CULTURE (Final [**2104-9-16**]): NO GROWTH.
-ANAEROBIC CULTURE (Final [**2104-9-20**]): NO GROWTH.
.
[**2104-9-11**] CT ABD W&W/O CONTRAST:
1. Large pancreatic pseudocyst, with slight increase in size
compared to
prior study.
2. Hypodensity at the left kidney, which could be due to prior
infection or infarct; however, if further clinical investigation
is warranted, renal
ultrasound can be done. Smaller hypodensities in the left
kidney, too small to characterize.
.
[**2104-9-12**] CTA CHEST W&W/O C&RECON:
1. Technically limited scan with suboptimal bolus to evaluate
for PE. There is no large central PE. Please note that small
emboli might be missed due to suboptimal bolus.
2. Bibasilar atelectasis. Emphysema. Minimal apical scarring.
3. Few pulmonary nodules, largest in the left upper lobe
measuring 5 mm.
Followup chest CT in six months to document stability, if
clinically
warranted.
.
PATHOLOGY SPECIMEN SUBMITTED: pancreatic necrotum, Gallbladder.
DIAGNOSIS:
1. Pancreas necroticum (A):
Amorphous material with saponification.
2. Gallbladder, cholecystectomy (B):
Mild chronic cholecystitis.
Clinical: Pancreatic pseudocyst.
Gross:
The specimen is received fresh in two parts, both labeled with
the patient's name, "[**Known lastname 7046**], [**Known firstname **]", and the medical record
number.
Part 1 is additionally labeled "pancreatic necrosum." It
consists of multiple fragments of pale yellow to black soft
tissue measuring 3.7 x 3.0 x 1.0 cm in aggregate. Representative
sections of the specimen are submitted in cassette A.
Part 2 is additionally labeled "gallbladder." It consists of a
distended gallbladder measuring 2.5 x 5.4 x 3.0 cm. The cystic
duct is identified and is probe patent. A cystic duct lymph
node is not identified. The gallbladder is opened and contains
approximately 50 cc of bile. The mucosa is velvety and bile
stained. The gallbladder wall measures up to 0.2 cm in
thickness. No discrete lesions or masses are noted.
Representative sections are submitted in cassette B.
.
[**2104-9-21**] ABD/PELVIC CT W/CONTRAST:
1. Status post recent cyst gastrostomy. There is a small
residual cavity
at the site of the cyst containing fluid, contrast, and air
bubbles which are consistent with communication with the
stomach, as expected after such
operation. The residual collection appears largely decompressed.
2. Small elliptiform collection next to anterior abdominal wall.
3. The rest of the findings are similar to previous study from [**2104-9-11**].
Brief Hospital Course:
Ms. [**Known lastname 7046**] was admitted to the hospital, made NPO and hydrated
with IV fluids.
She was placed on Dilaudid for pain control, and had a PICC line
placed for TPN.
Attempts were made to advance her diet, but each attempt seemed
to cause her more abdominal pain and distension, therefore she
received all of her calories with TPN and simply took sips of
clears for comfort only.
Pain control was an issue as she described intermittent, severe
crampy pain which required a large amount of Dilaudid to control
prior to surgery. The Chronic Pain Service (CPS) was consulted
for recommendations for transitioning to oral medication, and
subsequently she was placed on OxyContin, then MS Contin 15 mg
PO BID with Dilaudid 2-4 mg PO q3hrs for breakthrough pain. She
was also started on a Lidoderm patch, Tylenol and gabapentin.
Due to nausea and constipation, MSContin was changed to a
Fentanyl patch with significantly improved pain control.
Hyperalimentation was tolerated well and eventually cycled over
a 12 hour period. Blood glucose monitoring took place throughout
hospitalization; the patient received insulin according to a
sliding scale, and the insulin was adjusted in the TPN. Prior to
discharge, the patient received glucose monitoring teaching and
was able to return demonstrate with ease. She was discharged
home on cyceled TPN, which will be managed by [**Known lastname 269**] in
consultation with [**Hospital1 18**] Hyperalimentation Services.
On [**2104-9-12**], the patient was transferred to the SICU for
tachycardia, SOB, hypotension with concern for pulmonary
embolus. CXR and CTA Chest did not identify a pulmonary embolus.
She was placed on a Phenylephrine drip. The patient remained in
the SICU until she went to the OR on [**2104-9-14**].
On [**2104-9-14**], the patient underwent pancreatic pseudocyst
gastrostomy with
cholecystectomy and cholangiogram, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful PACU stay, the patient
arrived on the floor NPO with an NG tube, on IV fluids, with a
foley catheter, and a Bupivacaine epidural and Dilaudid PCA for
pain control. The Fentanyl patch had been discontinued. The
patient was hemodynamically stable.
Post-operatively, her pain was well controlled on the Dilaudid
PCA and Bupivacaine epidural. The epidural was dicontinued on
POD#3, and the Dilaudid PCA was changed to oral pain medications
when the patient was tolerating a regular diet on POD#5 with
good pain control. The foley was discontinued after the epidural
was stopped. On POD#3, the NGT was discontinued. Her diet was
advanced as tolerated, but only with fair intake, which did not
meet her nutritional needs. As above, the patient continued on
TPN, which was ultimately cycled over 12 hours, and on which the
patient was discharged home.
Follow-up abdominal/pelvic CT performed on [**2104-9-21**] revealed a
small residual cavity
at the site of the cyst containing fluid, contrast, and air
bubbles which are
consistent with communication with the stomach, as expected
after such operation. The residual collection appeared largely
decompressed. The patient symptomatically improved
post-operatively as well.
A coag negative staph UTI diagnosed on [**2104-9-16**] was appropriately
treated with a course of Bactrim. By discharge, she was
asymptomatic.
At the time of discharge on [**2104-9-23**], the patient was doing well,
afebrile with stable vital signs. Staples were removed, and
steri-strips placed. The patient was tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. She was discharged home with [**Date Range 269**] services to manage
TPN administration. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Zestril 10mg PO daily, Synthroid 25mcg PO daily.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
5. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for nausea.
Disp:*120 Tablet(s)* Refills:*0*
6. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea: For use if Prochlorperazine
ineffective against nausea.
Disp:*14 Tablet(s)* Refills:*2*
10. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17)
gram in 8oz water or juice PO once a day as needed for
constipation.
Disp:*255 gm* Refills:*2*
11. One Touch Ultra 2 Kit Sig: One (1) kit Miscellaneous As
directed.
Disp:*1 kit* Refills:*0*
12. One Touch Ultra Test Strip Sig: One (1) strip In [**Last Name (un) 5153**]
twice a day.
Disp:*100 strips* Refills:*1*
13. Lancets,Ultra Thin Misc Sig: One (1) lancet
Miscellaneous As directed.
Disp:*1 box* Refills:*0*
14. Alcohol Pads Pads, Medicated Sig: One (1) pad Topical As
directed for glucose monitoring.
Disp:*1 box* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 269**] of Southeastern Mass
Discharge Diagnosis:
1. Pancreatic pseudocyst with acute cholecystitis.
2. Failure-to-thrive.
3. UTI - resolved.
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-15**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2104-10-3**] 11:45. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
Please call ([**Telephone/Fax (1) 27461**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) **] (PCP) in [**3-11**] weeks.
Completed by:[**2104-9-23**]
|
[
"041.10",
"783.7",
"575.0",
"599.0",
"458.9",
"272.4",
"785.0",
"401.9",
"244.9",
"249.00",
"751.7",
"577.0",
"577.2",
"786.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"87.53",
"99.15",
"51.22",
"52.4"
] |
icd9pcs
|
[
[
[]
]
] |
11831, 11907
|
6150, 10018
|
323, 453
|
12043, 12052
|
2547, 6127
|
14729, 15126
|
1826, 1845
|
10118, 11808
|
11928, 12022
|
10044, 10095
|
12076, 13531
|
13547, 14706
|
1860, 1860
|
2167, 2528
|
229, 285
|
481, 1385
|
1874, 2153
|
1407, 1656
|
1672, 1810
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,232
| 169,349
|
7901
|
Discharge summary
|
report
|
Admission Date: [**2176-7-5**] Discharge Date: [**2176-7-15**]
Date of Birth: [**2096-1-13**] Sex: M
Service: MEDICINE
Allergies:
Scopolamine / IV Dye, Iodine Containing / Levaquin
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
Hypotension, Urosepsis
Major Surgical or Invasive Procedure:
Central Venous Catheter Placement
History of Present Illness:
80 y/o M with PMHx significant for metastatic lung cancer,
CLL/SLL. Was found to be unresponsive, twitching, and
hypotensive at nursing home today. Was initially being brought
to [**Hospital3 **]; however, en route, BP's dropped to 55/P and he
was brought to [**Hospital1 18**].
.
On arrival to the ED, the patient's VS were 94/P, 108, 20, 100%
on 4L. Temp was 99.6, but then patient spiked to 102.8. CXR
showed ? retrocardiac consolidation. Given the pt's AMS, CT head
was performed and was negative for ICH. Labs were significant
for a UA with 11-20 RBCs, >50 WBCs. Given the high suspicion for
urosepsis, the patient was given vancomycin and zosyn. There was
some uncertainty regarding the patient's code status. Per
report, his wife and daughter reported that they felt that a DNR
was warranted; however, the patient wants to remain full code.
The decision was made to hold off on central line placement and
to start treatment with peripheral pressors in the ED. He was
given IVFs (5L total) as well as started on periperal levophed.
By the time of transfer to the ICU, the patient's BP had
improved to the low 100's. VS at the time of transfer: Temp 98.7
HR 101 P 106/52 RR 18 100% on 2L.
.
On arrival to the ICU, the patient's VS were: T: 99.3 BP: 137/88
P: 96 R: 16 O2: 98% on 4L. The patient was moaning and coughing
and was only oriented to person. He was not able to provide much
of a history. Per his wife, the patient has been less coherent
than his baseline recently. She reports that he is normally
quite coherent. She reports that she visited him today and that
he wasn't feeling well.
.
.
Review of sytems: Unable to obtain. The patient denies any
complaints.
Past Medical History:
(per [**Hospital3 **] records):
- h/o sepsis secondary to aspiration pneumonia
- h/o proteus mirabilis and [**Female First Name (un) **] albicans in drainage culture
of the abdomen
- h/o aspiration
- gastroesophageal reflux disease
- history of CLL and non-Hodgkin's lymphoma, also SLL lymphoma
- nonsmall cell lung cancer resected in [**2175-2-26**], later found
to be node positive. Patient was discovered to have metastatic
adenocarcinoma/recurrent lung cancer with lymphangitic spread.
He has progression of mediastinal lymphadenopathy, right upper
lobe and left lower lobe lung nodules, prominent periaortic
lymphadenopathy.
- bedbound at baseline with history of decubitus ulcer
- diverticulosis
- G-tube dependent
- depression
- anemia of chronic disease
- diabetes mellitus
- history of recurrent pneumonia
- right inguinal hernia repair.
- history of upper GI bleed in [**10/2175**], which showed esophagitis
on EGD in [**9-/2174**]
- rectosigmoid polypectomy in [**2172**]
- h/o appendectomy as a child
- h/o frx of pelvic bone after a fall in [**2172**]
- h/o facial abscess following dental work
Social History:
Married for 58 years. Currently living at [**Hospital1 599**] since [**3-6**]. Has
had some involvement with hospice there. Has not been living at
home since [**4-5**], which he had his lung resection. Per medical
records, pt has smoked in the part and drank occasionally (one
to two beers a week). No illicit drug use.
Family History:
Per medical records, he has an estranged brother. His mother is
deceased from old age. His father is deceased with a question of
leukemia but never diagnosed. He has three children.
Physical Exam:
Vitals: T: 99.3 BP: 137/88 P: 96 R: 16 O2: 98% on 4L
General: Moaning, coughing, oriented to person only
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: JVP not elevated
Lungs: exam limited by patient moaning; crackles noted in the
lower lung fields on the left
CV: exam limited by patient moaning; no murmurs, rubs, gallops
appreciated
Abdomen: gastric tube present and noted to be loose-fitting,
some drainage from g-tube noted, soft, non-tender,
non-distended, bowel sounds present
GU: foley in place
Ext: cool, 1+ radial pulses, no clubbing, cyanosis; trace
pitting edema in the lower extremities; some difficulty
palpating the pedal pulses
Pertinent Results:
Admission Labs
[**2176-7-5**] 08:10PM BLOOD WBC-8.0 RBC-3.80* Hgb-10.3* Hct-32.1*
MCV-84 MCH-27.2 MCHC-32.2 RDW-15.8* Plt Ct-174
[**2176-7-6**] 02:52AM BLOOD Neuts-90.0* Lymphs-6.1* Monos-3.5 Eos-0.2
Baso-0.2
[**2176-7-5**] 08:10PM BLOOD PT-13.1 PTT-27.2 INR(PT)-1.1
[**2176-7-5**] 08:10PM BLOOD Fibrino-466*
[**2176-7-6**] 02:52AM BLOOD Glucose-121* UreaN-31* Creat-0.9 Na-141
K-3.5 Cl-115* HCO3-17* AnGap-13
[**2176-7-6**] 02:52AM BLOOD ALT-25 AST-35 LD(LDH)-136 CK(CPK)-54
AlkPhos-163* TotBili-0.5
[**2176-7-5**] 08:10PM BLOOD Lipase-13
[**2176-7-6**] 02:52AM BLOOD CK-MB-4 cTropnT-0.03*
[**2176-7-5**] 08:10PM BLOOD Calcium-8.2* Phos-3.6 Mg-1.6
ABG on Admission
[**2176-7-6**] 03:18AM BLOOD Type-ART pO2-84* pCO2-36 pH-7.29*
calTCO2-18* Base XS--8
[**2176-7-5**] 08:21PM BLOOD Glucose-82 Lactate-2.2* Na-140 K-3.9
Cl-105 calHCO3-21
Urine Studies
[**2176-7-5**] 08:10PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.018
[**2176-7-5**] 08:10PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2176-7-5**] 08:10PM URINE RBC-[**11-16**]* WBC->50 Bacteri-MOD Yeast-NONE
Epi-0
Micro Data:
Blood Culture, Routine (Final [**2176-7-11**]): STAPHYLOCOCCUS,
COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY.
**No other positive blood cx's.
[**2176-7-5**] 8:10 pm URINE URINE CULTURE (Final [**2176-7-7**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2176-7-6**] 2:52 am URINE URINE CULTURE (Final [**2176-7-8**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML. PRESUMPTIVE
IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
CXR ([**2176-7-5**]) - IMPRESSION: Markedly limited study. It is unclear
to what extent interstitial opacities are acute versus chronic.
There are likely as well accentuated by the profound low lung
volumes. There is increased opacity at the retrocardiac left
lower lobe, which may indicate a focal consolidation such as
pneumonia if truly acute. It is difficult to place these
findings in context without pulmonary symptomology. Correlate
clinically.
CT Head ([**2176-7-5**]) - IMPRESSION:
1. No acute intracranial hemorrhage. Note that MRI is more
sensitive for ischemic process if clinical concern is high.
2. Non-contrast head CT is limited in evaluation of intracranial
metastasis. Gadolinium contrast-enhanced MRI is more sensitive.
3. Likely chronic paranasal sinus disease with a component of
fungal colonization, given high atenuatin of layering internal
secretions. No
osseous changes noted.
4. Age-related involutional change.
Brief Hospital Course:
MICU COURSE:
Given his hypotension and septic picture, the patient was
admitted to the ICU for further management. At the time of
transfer, he was on peripheral pressors. Given his positive UA,
he was started on vancomycin/zosyn as broad coverage for
suspected urosepsis. Weaning of peripheral pressors was
attempted overnight but was unsuccessful. On the following
morning, when the patient remained on pressors and after his
goals of care had been confirmed with his family, a central
venous catheter was placed. On antibiotics, the patient's
clinical status improved slightly. His pressors were weaned off.
Urine cx grew e.coli resistant to cipro. Given the poor
appearance of his CXR and his tenuous respiratory status, the
patient was continue of vancomycin/zosyn for an 8 day course to
cover for HCAP. After that, his antibiotics were changed to
ceftriaxone and then oral Cefpodoxime. He should complete a 14
day course of antibiotics to cover for urosepsis which is due to
end on [**2176-7-19**]. ICU course was also complicated by some initial
renal failure (which resolved with fluids) as well as delirium.
Multiple discussions were held with the patient's family
regarding his goals of care. It was decided based on discussion
with the patient, his wife and his daughter that he was DNR/DNI.
His respiratory status improved and he was discharged on 3L NC.
He was sent back to rehab for further care.
.
Code Status: Extensive discussion with the patient, his wife and
daughter. The patient wishes to be DNR/DNI. He would like to
return to the hospital for reversible causes of illness but
would not want aggressive measures to prolong suffering.
.
FOLLOW-UP:
Antibiotics are Cefpodoxime, to finish on [**2176-7-19**] for a total 14
day course.
Medications on Admission:
- Benadryl 25 mg q8hrs PRN
- Atropine 1% 2 drops SL q4hrs
- HISS
- Lantus 5 units qHS
- Baclofen 10 mg q8hrs (for hiccups)
- Pantoprazole 2mg/mL 20 mL [**Hospital1 **]
- Guaifenesin 10 mL TID
- Hyosyne 1mL SL q4hrs
- Levothyroxine 112 mch dialy
- Liquid Tylenol 640 mg q4hrs scheduled
- Neurontin 100 mg (250mg/mL soln) TID
- Sorbitol 70% solution 30mL daily
- Tramadol 50 mg QID
- Vitamin C 250 mg [**Hospital1 **]
- Acetylcysteine 10% vial, inhale 4 mL [**Hospital1 **] for SOB
- Artificial Tears
- Albuterol nebs
- Bisacodyl
- Fleet enema PRN
- Simethicone PRN
- Lorazepam 0.5 mg q6hrs PRN
- MOM 30 mL daily PRN
- Morphine Sulfate 2.5 mg (0.125 mL) SL q4hrs PRN
- Prochlorperazine suppository PRN
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: 2-8 units
Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
2. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: apply to each knee for 12 hours on, 12 hours
off each day for knee pain.
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 4 days: last dose on [**2176-7-19**].
7. Pantoprazole 40 mg Susp,Delayed Release for Recon Sig: Forty
(40) mg PO once a day.
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed for shortness of breath.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed for shortness of
breath; wheezing.
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-30**] Sprays Nasal
QID (4 times a day) as needed for dry nares.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
14. Lantus 100 unit/mL Solution Sig: Five (5) units Subcutaneous
at bedtime.
15. Baclofen 10 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for hiccups.
16. Morphine 10 mg/5 mL Solution Sig: 2.5 mg PO every four (4)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnoses:
1. Urosepsis
2. Health Care Associated Pneumonia
3. Acute Renal Failure, resolved
Secondary Diagnoses:
1. Metastatic Lung Cancer
2. Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital with a pneumonia and urinary
tract infection which caused you to be very sick with low blood
pressure. You were given antibiotics and improved. You need to
complete a course of antibiotics with Cefpodoxime for 4 more
days (last dose on [**2176-7-19**]).
You should follow-up with your doctors at rehab.
Followup Instructions:
Please follow-up with your primary care physician at rehab.
|
[
"162.8",
"196.1",
"562.10",
"285.29",
"590.10",
"507.0",
"293.0",
"204.10",
"331.0",
"785.52",
"486",
"787.20",
"038.42",
"V44.1",
"584.9",
"290.40",
"202.80",
"V66.7",
"276.4",
"995.92",
"V15.82",
"719.46",
"518.81",
"250.00",
"348.39",
"550.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12460, 12550
|
8169, 9930
|
333, 368
|
12753, 12753
|
4435, 8146
|
13254, 13317
|
3559, 3742
|
10680, 12437
|
12571, 12673
|
9956, 10657
|
12890, 13231
|
3757, 4416
|
12694, 12732
|
271, 295
|
2019, 2074
|
396, 2001
|
12768, 12866
|
2096, 3206
|
3222, 3543
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,126
| 148,913
|
48912
|
Discharge summary
|
report
|
Admission Date: [**2168-7-8**] Discharge Date: [**2168-9-3**]
Date of Birth: [**2098-9-25**] Sex: F
Service: MED
Allergies:
Penicillins / Phenobarbital / Heparin Agents
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Shortness of breath, R vocal cord paralysis
Major Surgical or Invasive Procedure:
PEG to GJ tube
Tracheostomy
Radiation therapy
History of Present Illness:
69 yo woman with h/o colon CA (s/p chemo and XRT), COPD, mitral
valve mechanical valve replacement, afib, recently diagnosed
with NSCLC. Patient with 2 month h/o hoarseness and dysphagia
and neck CT showing node compressing R recurrent laryngeal
nerve. Later found to have non small cell lung CA by bx.
Abdominal and head CT were negative for metastatic dz. Required
trach ([**2168-7-21**])and PEG ([**2168-7-15**])for vocal cord paralysis
secondary to b/l vocal cord paralysis and inability to protect
airway. Trach also placed for dyspnea and possible glotic
component.
[**2168-8-1**] patient found to have hemoptysis by tracheostomy tube,
hypoxemia--> 82% and hypotension. She was transferred to the
[**Hospital Unit Name 153**] where fluid was given and patient was started on
antibiotics for group b strep bacteremia as well as coag
negative staph. She was started on levoquin on [**2168-8-1**] for
questionable pneumonia and kept on levoquin for group b strep
bacteremia. Ruled in for MI by enzymes--presumed demand ischemia
in absence of CK elevation or ST elevations. A fib was rate
controlled with beta blocker (metoprolol) and amiodarone. Pt was
also placed on mechanical ventilation through her trach to
reduce myocardial oxygen demand. She improved hemodynamically
with increase of BP from 100/70 on admission to 130s.
Bronchoscopy showed no source of bleeding and presumed bleeding
from aggressive suctioning. Therapeutic thoracentesis was
performed for R sided effusion--proved to be transudate. Pt was
weaned from ventilator and called back to the floor on [**2168-8-8**].
Pt continued her XRT upon transfer to OMED service. On the night
of [**2168-8-12**] patient fell and had a negative head CT (without
contrast) with no events noted on telemetry. On [**2168-8-13**] patient
became more lethargic and nonverbal. Neurological exam was noted
to be non-focal. In the evening she was responding to yes/no
questions by shaking head but not opening eyes. Stat repeat head
CT was negative for hemorrhage. At 5 pm patient with increasing
O2 requirements. O2 sats were 85-90% on 35-40% via trach collar
and increasing respiratory distress was noted throughout the
night; she was using accessory muscles for breathing. 4 pm ABG
7.38/77/54 on 50% trach mask and at 6pm 7.41/67/53 on 60% trach
mask. Patient was transferred to the [**Hospital Unit Name 153**] for impeding
respiratory failure. Of note, pt serum bicarb had been
increasing from 30--->40 at time of second admission to [**Hospital Unit Name 153**].
Past Medical History:
COPD
colon CA (XRT and chemo)
MV replacement
A fib
CAD s/p CABG
HTN
Hyperlipidemia
arthritis
Osteoporosis
Social History:
Mrs.[**Last Name (STitle) **] lives with her husband. She does not drink, but has a 50
pack-yr history of tobacco use.
Family History:
Significant for CAD, ?GI CA, breast CA.
Physical Exam:
On admission
98.7 133/59 86 20 95%RA
Gen: cachectic, NAD
HEENT: + R supraclavicular LAD, PERRL, EOMI
CVS: Irreg, irreg
Chest: CTA B
Abd: soft, NT/ND, +BS
Extr: no c/c/e
Neuro: CNII-XII grossly intact, strength 5/5 throughout
Befor d/c
96.8, 114/72, 84, 18, 96% on 35% trach mask
gen - cachectic female, ill appearing, NAD
cv- irreg, irreg, meachanical click
pul- moves air well bilaterally, diffuse loud ronchi
abd- soft, nt, nabs, GJ in place
extrm- cold, no c/c/e
neuro- cn II-XII intact, motor [**4-18**] in UE and LE
Pertinent Results:
[**2168-7-16**] 05:05AM BLOOD ALT-22 AST-26 LD(LDH)-377* AlkPhos-69
TotBili-1.0
[**2168-7-7**] 08:45PM BLOOD TSH-1.1
[**2168-7-16**] 05:05AM BLOOD CEA-25*
[**2168-8-12**] 07:09AM BLOOD WBC-1.8* RBC-3.08* Hgb-10.0* Hct-27.3*
MCV-94 MCH-32.5* MCHC-34.7 RDW-14.0 Plt Ct-77*
[**2168-8-12**] 07:09AM BLOOD Plt Ct-77*
[**2168-8-12**] 12:20AM BLOOD Glucose-122* UreaN-15 Creat-0.3* Na-138
K-3.7 Cl-99 HCO3-35* AnGap-8
[**2168-8-12**] 07:09AM BLOOD Calcium-7.1* Phos-1.5* Mg-1.6
[**2168-8-1**] 10:29AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2168-8-1**] 10:29AM URINE RBC-9* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
Studies:
CT chest: 1. Right apical spiculated nodule and mediastinal and
right supraclavicular lymphadenopathy. The differential
diagnosis includes nonsmall cell cancer with extensive
mediastinal involvement or small cell lung cancer. The
appearance of the mediastinal nodal mass with confluent features
and encasement of vessels suggests the possibility of lymphoma.
Given that there is biapical scarring, the spiculated lesion in
the right apex could possibly relate to nodular scarring.
Finally, metastatic disease should be considered from unknown
primary.
2. Moderate-to-severe emphysema.
3. Cardiomegaly with notable enlargement of the right and left
atria. Patient is status post mitral valve replacement.
Swallow eval: Aspiration, spontaneous cough does not clear the
airway. For further details, refer to report from Speech
Therapy.
The study and the report were reviewed by the staff radiologist.
Right supraclavicular lymph node: Poorly differentiated
carcinoma (non small cell). Tumor cells stain for CK-7 and
TTF-1, consistent with a lung origin.
Metastatic work-up:
CT abd and pelvis: IMPRESSION: 1. Free intraperitoneal air. This
is most likely related to the recent gastrostomy tube placement
by the GI service. Correlation with physical exam and patient
status is recommended to exclude a pathological bowel
perforation. Of note, no oral contrast material or ascites is
noted in the abdomen.
2. New right pleural effusion and aspiration-like changes at the
left base since the prior chest CT.
3. Splenic infarction.
4. Marked distention of the urinary bladder to a calculated
volume of 770 cc. Does this patient have clinical signs of
urinary retention?
5. Thickened adrenal glands without discrete mass.
6. Marked biatrial enlargement.
MRI head: No convincing evidence for intracranial metastatic
disease.
Bone scan: 1) No evidence of metastases. However, evaluation of
the pelvis
is limited by tracer activity within the bladder. 2) Distended
bladder with
pooling of activity within the left renal collecting system
Brief Hospital Course:
1.) Non-small cell lung cancer--CT chest showed a 0.9cm
spiculated nodule in the R apex as well as extensive mediastinal
LAD. Thoracic surgery was consulted and a biopsy of the R
supraclavicular node was obtained, which showed poorly
differentiated non-small cell lung CA. It was thought that the
extensive hilar and mediastinal LAD was compressing the
recurrent larngeal nerves, with resultant vocal cord paralysis.
Initially, this was limited to the R VC. A swallow study at this
time found Mrs.[**Last Name (STitle) **] to be at great risk for aspiration of liquids,
so she was kept on a soft solid diet with no liquids. While in
the hospital, however, the paralysis worsened and came to
involve both vocal cords. Mrs.[**Last Name (STitle) **] was kept NPO, a PEG was placed
that was advanced to a GJ tube because of poor GI motility and
possible proximal obstruction. Radation therapy was initiated
in the hopes of shrinking the mediastinal masses and relieving
the vc paralysis. Metstatic work-up for staging was done,
including a bone scan, head MRI and abd and pelvic CT-all of
which were neg for mets. While in the hospital, Mrs.[**Last Name (STitle) **] received
multiple treatments of XRT as well as formal mapping. Her
radiation oncologist Dr. [**Last Name (STitle) **] felt that she had completed a
course of palliative XRT and was not a candidate for further
radiotherapy. Given her poor medical state, she was felt to not
be a candidate for chemotherapy. After extensive code status
discussion with her family (please see below), Mrs. [**Known lastname 102718**]
code status was changed to comfort measures; she was scheduled
for discharged in stable condition to rehab for ventilator
training of the family who would then perform home ventilator
care with home hospice; she however passed away on [**2168-9-3**] early
in the morning. Because monitoring had been discontinued as
part of the code status, it was difficult to ascertain the
immediate cause of death secondary to her end-stage lung cancer.
2.) Mental Status Change
Pt with fall on [**8-12**] and head CT at that time was negative for
hemorrhage. Mental status changes thought secondary to
hypercarbia, but patient has continued to be withdrawn after
hypercarbia corrected. Metastasis unlikely given sudden time
course of events. Stroke is unlikely as patient with two
interval head CTs that were negative and an TTE was negative for
bacterej[. Celexa d/c'd. Urine/blood tox screens sent [**2168-8-15**].
Ritalin 5 mg qd started [**2168-8-21**]. Haldol 0.5mg q4-6h prn
agitation. With persistant decreased mental status, ritalin
increased to 10mg qd and celexa d/c'd for concern of mental
status changes from serotonin syndrome. The patient's mental
status improved within a day or two after these changes,
although it was not clear that they were causative.
3.) Bilateral vocal cord paralysis--ENT followed Mrs.[**Last Name (STitle) **] through
the course of her hospitalization to evaluate VC function.
Initially, she was to undergo R VC medialization. However, the
evening prior to the procedure, she was scoped and found to have
bilateral VC involvement. As airway closure would be an even
greater risk with the new development, the plans for R VC
medialization were suspended. XRT was initiated in the hopes
that the mediastinal LAD would be decompressed with resultant
improvement of VC paralysis. ENT continued to follow Mrs.[**Last Name (STitle) **] with
daily scoping. On [**7-20**], it appeared that her VC were
reapproximating, making airway closure almost inevitable. Rather
than waiting for this to occur, it was decided that Mrs.[**Last Name (STitle) **] should
undergo a tracheostomy to ensure a patent airway. She tolerated
the procedure well and was followed by ENT and respiratory care
post-op for trach
management and suctioning. Pt was to get Passy Muir Valve on
[**7-25**] but was contraindicated because pt has B/L vocal cord
paralysis. As of discharge she is on the ventilatory with the
cuff nfate
4.) COPD/Pleural effusion/Respiratory failure--Mrs[**Last Name (STitle) **] COPD
flared during the course of her hospitalization. She recveived
nebulizers, chest CT, mucomyst, and supplemental O2 PRN and a
steroid taper. Her O2 sats on this regimen remained stable in
the 95-99% range. However, over the course of her stay, she
became more dependent on O2. Further exacerbating Mrs[**Last Name (STitle) **]
pulmonary status was a R pleural effusion that developed over
the week of [**7-15**] to [**7-22**]. She had a thoracentesis to remove 1L of
fluid on [**7-23**]. The effusion was most likely the result of the
lung CA and there was no evidence of PNA or empyema. She began
to improve from a respiratory standpoint and ventilatory weaning
by sprint/rest method was initiated. At first, she was able to
tolerate only 3 hours on the tracheostomy mask before becoming
acidotic. Eventually, however, she tolerated up to 24 hours at
a time without ventilatory support. She appeared during these
periods off the vent to be comfortable. However the patient
began to fatigue after continued trials and eventually was
requiring the ventilator for increasing periods of time. The
tracheostomy site was inspected and appeared to be oozing
purulent and serosanginous fluid at times; interventional
pulmonology, following consultation, felt that the site of
tracheostomy was too large, and that it was erythematous,
draining into the trachea. The patient was treated with
vancomycin, levofloxacin, and aztreonam for a 14 day day course.
Because she continued to spike after the vanco and levoflox
were added, they were d/c'd, they were d/c'd and she was
continued on a 14-day course of meropeen alone. After a 48 hour
period of rest, the patient was once again tried for a short
period on the trach mask, but acutely became uncomfortable,
diaphoretic, and hypercapneic. After a number of trials, it was
felt that the likelihood was very low of her being able to be
weaned off the ventilator. In discussion with the patient that
she would be most comfortable remaining on the ventilator
without trying to wean off.
5.) CVS--Because of her h/o MV replacement and Afib, Mrs.[**Last Name (STitle) **] was
kept anticoagulated throughout the course of her
hospitalization. She was on a Heparin drip so that she could be
weaned off for PEG placement and tracheostomy. Her goal PTT was
60-100 sec. Anticoagulation was bridged on [**7-22**] and Mrs.[**Last Name (STitle) **] was to
be sent to Rehab on coumadin with a goal INR of 2.5-3.5.
However, as her platelets began to drop she was considered for
HIT. The HIT Ig came back negative, but given the time course,
lack of other etiologies, and rebound of platelet count once off
heparin, HIT seems likely. Pt was switched to lepirudin, a
direct thrombin inhibitor, and restarted on her warfarin.
6.) FEN--After the swallow study noted that Mrs.[**Last Name (STitle) **] was at great
[**Doctor First Name **] for aspiration, it was determined that she would need a PEG
tube for feeding. She received a PEG on [**7-15**] and received promote
with fiber advanced to a rate of 50cc/hr. Her electrolytes were
monitored and repleted as necessary. All of her meds were given
either IV or through the PEG. She was strictly NPO. The PEG was
advanced to a GJ tube, and she was changed to Nepro at 30 cc/hr
with promod. The patient was also started on metoclopramide for
improved gastric motility but this was d/c'd after she has
liquid c/diff (-) stools.
7.)Hemoptysis -- During course of stay, pt's INR became
supertherapeutic to 3.8. After deep suctioning, pt developed
hemoptysis from her trach tube. Pt was transferred to unit for
this and hypotension, but quickly recovered without further
hemoptysis.
8.)Hypotension -- Concurrent with hemoptysis and ICU transfer,
pt became hypotensive and was found to have gram + cocci on
blood culture, and pt was put on vanco and levofloxacin. The
culture came back coag negative staph, and the vancomycin was
stopped. Pt has since recovered without further episodes of
hypotension. Pt will require levofloxacin until [**8-22**], at which
time she should have additional blood cultures drawn. If
positive or if pt becomes febrile, she may require a TEE for
evaluation of endocarditis, given mitral replacement.
9.)Atrial fibrillation -- Pt's rate was well controlled on
amiodarone and metoprolol. Anticoagulation was achieved with
lepirudin and later argatroban in order to be transitioned to
warfarin.
10.)Myocardial ischemia -- Pt had some ST depression while in
unit, felt to be due to tachycardia causing a demand ischemia.
Continue rate control, follow Hct (keep above 28).
11.)Mitral valve replacement -- Pt is being anticoagulated.
12.)Anemia -- Secondary to chronic disease, without obvious
source of blood loss. Started on epogen for support, goal Hct >
28.
13.)Code -- Code discussion was complicated at first by the
patient's withdrawn mental status and then by the patient's
inability to vocalize due to her bilateral vocal fold paralysis.
Discussions were made with the patient and her family on
multiple occasions utilizing head nodding to determine the
patient's wishes. At one point an American Sign Language
interpreter was recruited to assist with sign language. It was
initially interpreted that the patient desired comfort measures
only except with ventilatory support, nebulizers, antiemetics,
and morphine for pain control. Code status was adjusted to add
the patient's tube feeds, warfarin, and digoxin after the
patient made it clear that she understood these to be part of
comfort-oriented care.
14.) Disposition--Mrs. [**Known lastname 102718**] was scheduled for discharged in
stable condition to rehab for ventilator training of the family
who would then perform home ventilator care with home hospice;
she however passed away on [**2168-9-3**] early in the morning.
Because monitoring had been discontinued as part of the code
status, it was difficult to ascertain the immediate cause of
death secondary to her end-stage lung cancer.
Medications on Admission:
Coumadin 7
Lipitor 10
Folate
Fosamax
Bisoprolol 5
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1) Non-small cell lung CA
2) Bilateral vocal chord paralysis
Discharge Condition:
expired
|
[
"790.7",
"491.21",
"478.34",
"518.84",
"707.0",
"427.31",
"162.9",
"284.8",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"97.02",
"31.42",
"34.91",
"40.11",
"38.91",
"92.27",
"99.04",
"31.1",
"33.24",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
16740, 16819
|
6558, 16640
|
340, 388
|
16925, 16935
|
3824, 6535
|
3221, 3262
|
16840, 16904
|
16666, 16717
|
3277, 3805
|
257, 302
|
416, 2940
|
2962, 3069
|
3085, 3205
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,647
| 185,885
|
7694
|
Discharge summary
|
report
|
Admission Date: [**2122-12-2**] Discharge Date: [**2122-12-11**]
Date of Birth: [**2041-2-23**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
pacemaker placement
L cephalic dual chamber St. [**Male First Name (un) 923**] pacemaker
angioplasty of left iliac and profunda
History of Present Illness:
81F with a history of ESRD on dialysis and paroxysmal atrial
fibrillation not on anticoagulation due to history of GI bleed
and fall risk admitted for angioplasty of her left iliac artery
who developed atrial fibrillation to 140s during angioplasty on
[**12-2**] for symptomatic leg ischemia. She received multiple IV
boluses of lopressor as well as 25mg PO x 2 with eventual
decrease in heart rates to 100s. She was noted to have several
bradycardic episodes to 30s ([**3-17**] second pauses) with blood
pressures remaining in 100s. While speaking to the resident this
morning, she again developed heart rates in the 30s and reported
feeling dizzy and became diaphoretic. She also had a single 10
second pause at dialysis today also associated with some
lightheadedness. She was also noted to have pauses on telemetry.
Per the patient's PCP, [**Name10 (NameIs) **] has been treated in the past with
small doses of betablocker which resulted in bradycardia. Thus,
this was discontinued and by report, she has not been troubled
by rapid heart rates. Cardiology (EP) was consulted for possible
tachy-brady syndrome and the possible need for a pacemaker
On cardiac review of symptoms, she denies chest pain. She does
report occasional dizziness at home and at hemodialysis,
exertional SOB and [**Location (un) **].
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
-ESRD on HD, had renal artery stenosis, s/p stent
-Afib
-Controversial dx of SCLCA
-Hypothyroid
-Hx GI bleed in the past
-Hx old foot drop (presumed left based on exam)
-s/p bilateral cataract surgeries
Social History:
She formerly worked for Gilette in financial controls
department; divorced; smoked 1ppd x 50 yrs, quit in [**2116**] at time
of ca dx. She does not drink or use drugs.
Family History:
The patient's father died secondary to coronary artery disease
at the age 66. The patient's sister died at age 51 secondary to
myocardial infarction. The patient's mother has diabetes
mellitus.
Physical Exam:
PHYSICAL EXAMINATION:
VS: 98.9, 111, 127/64, 98% 2L
GENERAL: in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of *** cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. [**Last Name (un) **],tachy, 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. Slight bibasilar
crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2122-12-5**] 04:15AM BLOOD WBC-6.3 RBC-3.49* Hgb-10.5* Hct-31.8*
MCV-91 MCH-30.1 MCHC-33.1 RDW-13.9 Plt Ct-152
[**2122-12-9**] 05:40AM BLOOD WBC-4.7 RBC-3.15* Hgb-9.2* Hct-28.3*
MCV-90 MCH-29.2 MCHC-32.4 RDW-14.2 Plt Ct-207
[**2122-12-5**] 04:15AM BLOOD PT-14.6* PTT-31.9 INR(PT)-1.3*
[**2122-12-8**] 06:30AM BLOOD PT-12.7 PTT-31.1 INR(PT)-1.1
[**2122-12-3**] 06:20AM BLOOD Glucose-89 UreaN-16 Creat-3.9* Na-138
K-4.5 Cl-95* HCO3-33* AnGap-15
[**2122-12-9**] 05:40AM BLOOD calTIBC-109* Ferritn-1467* TRF-84*
[**2122-12-9**] 05:40AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2 Iron-50
[**2122-12-8**] 05:35PM BLOOD Vanco-14.7
Portable TTE (Complete) Done [**2122-12-3**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
global left ventricular hypokinesis (LVEF = 45 %). There is
considerable beat-tobeat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is moderately dilated. 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. Mild to moderate ([**2-13**] +) mitral regurgitation is seen.
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure.
Compared with the report of the prior study (images unavailable
for review) of [**2116-2-10**], left ventricular systolic function is
mildly depressed and mild to moderate mitral regurgitation is
now present.
Brief Hospital Course:
.
# Tachy-brady syndrome - The patient presented symptoms and
telemetry consistent with tachy brady syndrome. She initially
had several long pauses, up to 7 seconds, likely exacerbated by
nodal agents given to her to control her a.fib with RVR. She is
s/p St. [**Male First Name (un) 1525**] pacer placement [**12-8**]. She tolerated the
procedure well and metoprolol was added to her regimen to rate
control. Per EP her metoprolol was changed to amiodarone to both
rate control her and attempt rhythm control. She will follow up
with EP and device clinic. She was evaluated by PT and initially
felt to be a candidate for inpatient rehabilitation. Both the
patient and her niece were against this. The niece was able to
demonstrate that she could complete single person assist
transfers, similar to the patients prior level of functioning.
The risks of home discharge were explained to the patient and
her niece and they accepted them.
.
# PAD - S/P angioplasty of left iliac and profunda after
initially presenting with symptoms of ischemia to the vascular
service. She was started on plavix and continued on her aspirin.
She will follow up with the vascular surgeon.
.
# ESRD - Continued on MWF dialysis. Had one episode of
hypotension at dialysis after she was dialyzed to below her dry
weight after a change in scale. She will continue her outpatient
dialysis schedule.
.
.
# Hypothyroidism - Continued on home levothyroxine.
Medications on Admission:
MEDICATIONS at HOME:
Levothyroxine 88 mcg QD,
Oxazepam 15 mg Capsule QHS
asa 81mg PO daily
.
Medications on Transfer:
levoxyl 88mcg qd
plavix 75mg qd
ASA 81mg qd
heparin 5000u sc tid
Discharge Medications:
1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 1 days: last dose 10/31.
Disp:*2 Capsule(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days.
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): See previous prescriptions for loading doses.
Disp:*72 Tablet(s)* Refills:*2*
10. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO at bedtime as
needed for insomnia. Capsule(s)
11. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
# Tachy-brady syndrome
# End Stage Renal Disease on Hemodialysis
# Coronary Artery Disease
# Peripheral Arterial disease
# Hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
You have came to us with arrthymia of the heart. We noted that
your heart sometimes goes fast, while other times goes slow. It
is corrected by placement of a pacemaker, which was done without
complications. No lifting more than 5 pounds with your left arm
for 6 weeks. Do not lift your left arm over your head for 6
weeks. You will need to get out of bed without using your left
arm. No showers or baths until after you are seen in the device
clinic. The dressing has to stay dry, do not change it unless it
falls off.
Please follow up with your doctors as noted below
Please note that we made the following changes to your
medications:
1. Amiodarone was started to regulate your heart rhythm
2. Plavix was started to keep the arteries in your legs open
3. Cephalexin, an antibiotic, started to prevent infection at
the pacer site.
If you experience any chest pain, shortness of breath,
dizziness, bleeding or swelling at the pacer site, fever,
nausea, chill, please contact your Dr. [**Last Name (STitle) **].
Followup Instructions:
Cardiology:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2122-12-16**] 10:00
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: He will see
you in the device clinic and schedule another appt.
Vascular:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:
Please make an appt to see him next week.
|
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icd9cm
|
[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,639
| 176,944
|
26679
|
Discharge summary
|
report
|
Admission Date: [**2108-3-19**] Discharge Date: [**2108-3-29**]
Date of Birth: [**2048-10-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Suicide attempt, overdose, NSTEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization
Intubation
PICC line placement
History of Present Illness:
Patient is a 59 yo woman with PMH severe depression, migraine
has, recent weight loss w/ negative work up who presents from
[**Hospital3 **] today after suicide attempt, c/b NSTEMI.
Patient initially presented to [**Hospital3 **] on [**2108-3-18**] after
overdosing on pills. She apparently called her grandson stating
that she had taken "45 pills". On evaluation of her pill
bottles, it appears as though she took Zyprexa and Adderall.
She was found minimally responsive by her husband at 2pm on
[**2108-3-18**] who called EMS.
On arrival at [**Hospital1 **], patient was intubated, given charcoal and
NG lavage, and admitted to ICU for managment. On admission, pt
was noted to be tachycardic, but vital signs otherwise stable.
Labs were essentially WNL. Tox screen was negative for benzos,
cocaine, tricyclics, marijuana, opiates, amphetamines, asa,
small amt + of tylenol at 1.7. Initial EKG demonstrated sinus
tachycardia at [**Street Address(2) 65762**] depressions in V1 and diffuse ST
elevations with PR depressions. In terms of her overdose,
poison control was contact[**Name (NI) **] and patient was monitered for
neuroleptic malignant syndrome and anticholinergic effects which
was of concern with her Zyprexa overdose, but did not exhibit
any of these signs. She was otherwise maintained with
supportive care.
Patient was also noted to have Troponin trend from 0.09 night of
admission to 0.03 to 4.5. EKG on 2nd day of hospitalization
demonstrated ST elevations in lateral leads which were more
pronounced than on admission. Patient was not placed on heparin
gtt as it was believed that this troponin elevation was more
likely [**2-9**] strain, as patient had had recent cardiac w/u as
outpt that was negative.
Hospital course otherwise notable for some hypoxia with
borderline O2 sats on 100% FiO2- CXR at that time demonstrated
some evidence of aspiration pna and ?CHF. Pt's WBC also rose to
16. Patient was therefore started on unasyn for broad spectrum
coverage. Patient also developed hypotension, thought ?[**2-9**] pna,
and pt was placed transiently on neosynephrine for BP control,
although was off pressors on transfer to [**Hospital1 **].
Patient was therefore transferred to [**Hospital1 18**] for managment of her
MI and her pulmonary status.
Currently patient is intubated and sedated.
Past Medical History:
(per OSH records):
1.) Depression
2.) Migraine HA
3.) Chronic pain
4.) 100 lb weight loss over past year - pt has undergone
extensive w/u including colonoscopy, GYN exam, HIV test, cardiac
w/u, stool studies, celiac studies negative. Also had abd CT
negative, Chest CT demonstrated LUL nodule which was monitered.
Had recent scan that demonstrated increase in size of LUL nodule
from 3mm->7mm, PET scan in [**12-11**] negative - scheduled to have
repeat Chest CT this month.
Social History:
Patient is married, lives w/ husband and 14 [**Name2 (NI) **] grandson. +
family stress due to death of her son from heroin overdose about
2 years ago. Also has daughter w/ current substance abuse
problems. Remote tobacco history.
Family History:
Unknown
Physical Exam:
Vitals - T 101.8, HR 120, BP 97/68, RR 25-30, O2 95% on
AC/FiO21.0/TV500/RR20/PEEP5
General - intubated, sedated, initially reponded to calling
name, able to squeeze fingers per nurse
[**Last Name (Titles) 4459**] - small pupils b/l minimally reactive
Neck - flat JVP, no noted carotid bruits
CVS - regular rhythm, tachycardic, no noted M/R/G
Lungs - CTA anteriorly, decreased BS at R base, no noted
crackles/rhonci
Abd - hypoactive BS, soft
Ext - no LE edema b/l, 2+ PT pulses b/l
Pertinent Results:
Labs on admission:
[**2108-3-19**] 06:14PM BLOOD WBC-15.7* RBC-4.52 Hgb-14.7 Hct-44.1
MCV-97 MCH-32.4* MCHC-33.3 RDW-13.6 Plt Ct-378
[**2108-3-19**] 06:14PM BLOOD Neuts-84.7* Lymphs-11.2* Monos-3.7 Eos-0
Baso-0.4
[**2108-3-19**] 06:14PM BLOOD PT-11.4 PTT-29.3 INR(PT)-1.0
[**2108-3-19**] 06:14PM BLOOD Glucose-149* UreaN-20 Creat-0.7 Na-145
K-4.4 Cl-115* HCO3-20* AnGap-14
[**2108-3-19**] 06:14PM BLOOD ALT-19 AST-38 LD(LDH)-284* CK(CPK)-206*
AlkPhos-66 Amylase-92 TotBili-0.4
[**2108-3-19**] 06:14PM BLOOD Lipase-19
[**2108-3-19**] 06:14PM BLOOD Albumin-3.4 Calcium-8.5 Phos-3.9 Mg-2.0
[**2108-3-19**] 06:18PM BLOOD Type-[**Last Name (un) **] pO2-65* pCO2-44 pH-7.31*
calHCO3-23 Base XS--4 Intubat-INTUBATED
[**2108-3-19**] 06:18PM BLOOD Lactate-2.4*
[**2108-3-19**] 06:18PM BLOOD freeCa-1.26
.
Cardiac Labs:
[**2108-3-19**] 06:14PM BLOOD ALT-19 AST-38 LD(LDH)-284* CK(CPK)-206*
AlkPhos-66 Amylase-92 TotBili-0.4
[**2108-3-20**] 01:09AM BLOOD CK(CPK)-153*
[**2108-3-20**] 05:41AM BLOOD CK(CPK)-122
[**2108-3-19**] 06:14PM BLOOD CK-MB-31* MB Indx-15.0* cTropnT-1.06*
[**2108-3-20**] 01:09AM BLOOD CK-MB-22* MB Indx-14.4* cTropnT-0.79*
[**2108-3-20**] 05:41AM BLOOD CK-MB-21* MB Indx-17.2* cTropnT-0.67*
.
Other pertinent labs:
[**2108-3-22**] 05:15AM BLOOD Cortsol-23.7*
.
Labs on discharge:
.
Microbiology data:
[**2108-3-19**] Blood culture - 1/4 bottles with Oxacillin sensitive
Staph
[**2108-3-19**] Urine culture - no growth
[**2108-3-19**] Sputum culture - Oxacillin sensitive Staph Aureus
[**2108-3-20**] Sputum culture -
[**3-20**], [**3-22**]: Blood cultures negative
[**3-22**]: sputum culture: 1+ GPC in pairs
[**3-24**]: Blood culture negative to date
.
Imaging:
[**2108-3-19**] CXR:
IMPRESSION:
1. Left lower lobe pulmonary opacity, likely representing
aspiration.
.
[**2108-3-19**] Cardiac catheterization:
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
patent LMCA, LAD that had mild 30% mid vessel lesion, LCx that
was
without obstructive disease and the RCA had a mid vessel 60%
lesion.
2. Left ventriculography was deferred.
3. Hemodynamic assessment showed low normal RAp, elevated PaP
with
marked respiratory variation and normal PCWP. The CI was 2.4.
There was
systemic hypotension with narrow pulse pressure. This was
consistent
with septic shock.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Normal ventricular function.
.
[**2108-3-20**] ECHO:
Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed
(ejection fraction 20-30 percent) secondary to extensive apical
akinesis, with contractile function improving toward the base of
the heart. A left ventricular mass/thrombus cannot be excluded.
There is no ventricular septal defect. The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated. Right ventricular systolic function is borderline
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**2108-3-21**] CXR: IMPRESSION: Interval improvement of pulmonary
edema. Interval improvement of bibasilar opacities, which may
represent residual changes from aspiration.
.
[**2108-3-22**]: CT Chest with Contrast:
IMPRESSION:
1. Bilateral lower lobe consolidation worrisome for multifocal
pneumonia. Given the distribution, aspiration is also a
consideration. Followup after an appropriate clinical interval
post-treatment is recommended to demonstrate complete
resolution.
2. Bilateral pleural effusions, and interlobular septal
thickening that may suggest fluid overload.
3. 3 mm nodule in the right lower lobe. In the absence of known
primary malignancy, followup in twelve months may be performed,
in the presence of known primary malignancy, followup in three
months is recommended.
.
[**2108-3-26**]: CXR:
There has been interval extubation and removal of the
nasogastric tube. A right PICC line terminates in the lower
superior vena cava. Cardiac and mediastinal contours are within
normal limits. There are bibasilar areas of increased opacity
adjacent to small-to-moderate pleural effusions. The left lower
lobe opacity is slightly improved in the interval. The right
basilar opacity is difficult to compare due to the increasing
effusion and differences in positioning of the patient.
IMPRESSION: Bibasilar consolidation in keeping with history of
aspiration pneumonia with interval improvement in left
retrocardiac area. Small-to-moderate bilateral pleural
effusions.
.
CBC:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2108-3-28**] 08:27AM 8.7 3.69* 12.1 35.8* 97 32.7* 33.7 13.5
393
[**2108-3-28**] 05:15AM 8.2 3.31* 10.7* 32.0* 97 32.3* 33.4 13.6
332
[**2108-3-27**] 08:27AM 6.7 3.06* 10.0* 31.4* 103* 32.6* 31.8
13.7 290
[**2108-3-27**] 06:00AM 8.5 3.46* 11.0* 33.6* 97 31.8 32.7 13.6
352
[**2108-3-26**] 06:10AM 7.6 3.61* 11.5* 35.1* 97 31.9 32.8 13.6
362
[**2108-3-25**] 03:20AM 5.7 3.47* 11.4* 33.5* 97 32.7* 33.9 13.4
308
[**2108-3-24**] 04:15AM 5.6 3.44* 11.1* 33.2* 96 32.3* 33.5 13.8
281
[**2108-3-23**] 05:19AM 7.3 3.38* 11.1* 32.5* 96 32.7* 34.0 13.4
326
[**2108-3-22**] 05:15AM 10.8 3.50* 11.3* 33.6* 96 32.2* 33.5 13.7
284
[**2108-3-21**] 04:53AM 13.5* 3.53*# 11.8*# 34.3* 97#1 33.3* 34.3
13.8 265
.
SMA 7:
RENAL & GLUCOSE Glu BUN Creat Na K Cl HCO3 AnGap
[**2108-3-28**] 08:27AM 92 7 0.5 145 3.3 107 26 15
[**2108-3-28**] 05:15AM 83 7 0.5 143 3.4 108 26 12
[**2108-3-27**] 10:12AM 136 3.9
[**2108-3-27**] 06:00AM 93 7 0.4 144 3.3 110* 26 11
[**2108-3-26**] 06:10AM 86 7 0.5 144 4.1 111* 26 11
[**2108-3-25**] 03:20AM 109 7 0.4 145 3.4 110* 26 12
[**2108-3-24**] 04:15AM 96 7 0.4 142 4.1 108 28 10
[**2108-3-23**] 09:22PM 102 6 0.4 143 3.7 108 27 12
[**2108-3-23**] 05:19AM 131 7 0.3 142 4.2 106 30 10
[**2108-3-22**] 05:15AM 172 7 0.4 140 3.6 106 27 11
.
CPK ISOENZYMES CK-MB MB Indx cTropnT
[**2108-3-20**] 05:41AM 21* 17.2* 0.67*1
[**2108-3-20**] 01:09AM 22* 14.4* 0.79*1
[**2108-3-19**] 06:14PM 31* 15.0* 1.06*1
.
Brief Hospital Course:
Assessment/Plan: Patient is 59 yo woman without known cardiac
history, presented to OSH with suicide attempt o/d on zyprexa
and adderall, now intubated w/ pna and course c/b NSTEMI.
.
# Aspiration PNA/MSSA sepsis: The patient was started on levo
([**3-19**]) at admission and then added vanc the following day. Her
sputum and Bcx (1 out of 4) from admission grew out MSSA. The
patient finished 7 day course of levoquin (750mg/day) on [**3-25**]
and was switched to oxacillin on [**3-25**] as BCX came back as MSSA.
The patient will finish 14 day course oxacillin on [**4-2**]. She
was on levophed for septic shock and has been off for >36hours
with SBP in high 80s-100s prior to call-out to the floor.
.
# Respiratory failure: Pt was initially intubated for airway
protection after found unresponsive and subsequently found to
have bilateral pneumonia thought to be [**2-9**] aspiration. The
patient was extubated on [**3-23**] and has required high O2, so
empirically started short-course prednisone (5days) for presumed
COPD exacerbation on [**3-25**].
.
# Cardiac:
A. Ischemia: Patient with flat troponins on initial
presentation to OSH, then trended up. No history of CAD and per
OSH records, had recent cardiac w/u which was negative. EKG on
initial presentation to OSH demonstrates diffuse ST elevation
and PR depression. EKG on day of transfer demonstrates
anterolateral ST elevation with reciprical inferior changes. Pt
went to cath on night of presentation to [**Hospital1 18**] ([**3-19**]) that
demonstrated no significant CAD (30% LAD, 60% RCA), more septic
physiology. The patient was started on ASA. Due to
hypotension, carvedilol was started but never given. Lipitor
was not started as cholesterol was low.
.
B. Pump: Patient appears clinically euvolemia, no hx of CHF.
ECHO [**3-20**] demonstrated LV systolic dysfxn with EF 20-30% [**2-9**]
extensive apical akinesis, also 3+ MR. This was thought to be
stress-induced cardiomyopathy. Will need a BB and ACEI once BP
stable and as BP tolerates. The patient has been auto-diuresing
without needing lasix for all the fluid she received for sepsis.
.
C. Rhythm: Was in sinus tachy on presentation, now in NSR. No
prolongation of intervals on EKG.
.
# Suicide attempt/OD: Per OSH records, pt OD on zyprexa and
adderall. Seen by poison control at OSH - monitered for
neuroleptic malignant syndrome and anticholinergic effects which
were not noted. Tox screen neg at OSH. After extubation, she
was placed on CIWA scale and 1:1 sitter for possible alcoholism
and SI. The patient was also evaluated by psych who recommended
d/cing 1:1 sitter and CIWA as pt was no longer suicidal and had
no previous ETOH abuse. Pt was also started on Remeron per
psych recs. On discharge from unit, pt was not suicidal and
although admits depression and anxiety.
.
# FEN: Started TFs w/ nutrition recs while intubated. Once
extubated, started po diet as tolerated. Repleted lytes K to 4
and mag to 2.
.
# PPX: SC heparin, lansoprazole, colace
.
# Code status: Full
.
Patient was discharged from the ICU onto the floor and remained
without a sitter. Since she was not exhibiting signs of SI to
the psych service, SW or to us, it was felt that reinstituting a
sitter would be seen as punitive. During her stay, patient
expressed remorse for her suicide attempt and plans for
restarting her life. Psychiatry felt that the patient was safe
to discharge home with her attending a day program at [**Hospital 882**]
hospital and in addition to having regular meetings with her
therapist, which she agreed to and was arranged. In addition,
she was discharged with a crisis plan in place which was
explained to the patient.
.
She was continued on IV oxacillin and was changed to Levofloacin
on discharge - since her bacteremia was also succeptible to this
antibiotics. She was prescribed enough Levoquin until [**4-2**] (end
of 14 day course of total antibiotics). She did not spike any
fevers while on the floor and surveillance blood cultures were
negative from [**3-20**] and [**3-22**]. Follow up urine cultures were also
negative.
.
Patient's BP remained in the 80s-90s for much of her stay on the
floor making it difficult to add on BB and ACE-I. On discharge,
her SBP rose to 108. Hence low dose metoprolol was initiated.
She was on ASA on the floor. 20mg lipitor was started on
discharge. (Lipid panel showed LDL of 54 and HDL of 43)
.
During her stay on the floor, she was walked with PT and her
oxygen requirements were weaned down slowly; on discharge
patient was completely off of oxygen and was comfortable. Repeat
CXR on [**3-26**] showed resolution of her pulmonary edema. She
finished a 5 day course of steroids for putative bronchospasm in
the hospital and was maintained on nebulizers.
------
Outstanding issues:
- Patient would likely benefit from starting an ACE-I as an
outpatient.
- Patient was on adderall and topamax as outpatient; these were
discontinued and will not be restarted; In particular, the
adderall may have played a significant part in the drastic
weight loss that the patient has experienced over the past year.
In addition, patient will need basic oncologic screening - in
particular, her pulmonary nodule will need follow up - per
Radiology here at [**Hospital1 **], it was recommended that this nodule be
followed up in [**3-12**] months with repeat CT.
- For her depressed EF, she will need a follow up ECHO,
particularly in the event that she may have a depressed EF due
to myocardial stress
Medications on Admission:
Outside medications (per OSH records):
Percocet 5/325 q6hr PRN
Zyprexa ?2.5mg qd
Prozac 60mg QD
Inderal - recently d/ced
HCTZ - recently d/ced
Topomax
Nexium 40mg QD
Premarin 0.625mg QD
.
Medications on admission:
Unasyn 1.5grams IV q6hr
Versed gtt
Morphine 2mg IV q1hr PRN agitation
Pepcid 20mg IV BID
Heparin SC
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 MDI* Refills:*0*
4. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*16 Tablet(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for constipation.
Disp:*20 Tablet(s)* Refills:*0*
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 2
doses.
Disp:*2 Tablet(s)* Refills:*0*
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation four times a day.
Disp:*1 QS* Refills:*2*
10. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a
day.
Disp:*30 tablets* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Suicide attempt/Overdose
2. Depression
3. Respiratory failure
4. Aspiration pneumonia
5. Cardiac marker elevation
6. Hypotension
Discharge Condition:
Good, oxygenating well on room air
Discharge Instructions:
You are discharged to home where you should continue all
medications as prescribed. You will not be taking Topamax or
Adderall any longer. You will follow-up with the [**Hospital1 882**] Day
Program, your psychiatrist, and your primary care physician.
We have given you a crisis plan with phone numbers. If you feel
unsafe or have thoughts of hurting yourself, please seek help
immediately by contacting someone at one of those numbers.
Please alert your primary care physician or present to the ER if
you experience chest pain, shortness of breath, increasing
cough, fevers, chills, night sweats, or other concerns.
You should keep all follow-up appointments.
Followup Instructions:
You have an appointment with the [**Hospital1 882**] Day Program on
Wednesday, [**2108-3-21**] at 10:00am.
You should arrange a follow-up appointment with your outpatient
counselor [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 65763**] for Monday, [**2108-4-2**]. Please call his
office at [**Telephone/Fax (1) 65764**].
You have a follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Tuesday, [**2108-4-3**] at 11:45AM.
[**Telephone/Fax (1) 4475**].
Please call [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NPN at [**Telephone/Fax (1) 65765**] to schedule a
follow-up appointment.
Completed by:[**2108-4-12**]
|
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"410.71",
"276.2",
"428.0",
"414.01",
"482.41",
"785.52",
"296.20",
"425.4",
"305.00",
"783.21",
"507.0",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"88.56",
"00.17",
"37.23",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17729, 17735
|
10646, 16148
|
349, 405
|
17911, 17948
|
4051, 4056
|
18660, 19418
|
3524, 3533
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16513, 17706
|
17756, 17890
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16388, 16490
|
6373, 10623
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17972, 18637
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3548, 4032
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276, 311
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5343, 6356
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433, 2756
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5278, 5324
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4070, 5256
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2778, 3256
|
3272, 3508
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,521
| 199,238
|
35408
|
Discharge summary
|
report
|
Admission Date: [**2177-2-1**] Discharge Date: [**2177-2-5**]
Date of Birth: [**2099-1-29**] Sex: F
Service: MEDICINE
Allergies:
Lamictal / Niaspan
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
hypotension and hypoxia
Major Surgical or Invasive Procedure:
Left IJ placed
PICC line placed
History of Present Illness:
78F pt of Dr [**Last Name (STitle) **], coming from [**Hospital **] [**Hospital **] Nursing home where
she c/o cough and was hypoxic, 92% on 2L on arrival, became
hypotensive to 70s shortly after arrival. Got vanc/zosyn. Little
response to IVF (2L NS), got left IJ--when US probe was placed
over R IJ, there was concern for a DVT, so a formal RUE US was
ordered--and needed levophed. Repeat CXR after 2L (for line)
looked wet, BNP 7200.
Got CT torso for poorly explained hypoxia and abd tenderness; no
PE and no intra abd process, but infiltrates c/w pna as well as
increased interstitial markings c/w pulm edema.
VS in ED prior to transfer: 101 rectal, 61, 111/45 on levo, 98%
5L, asleep/comfortable.
Pt unable to communicate history [**2-10**] aphasia.
ROS: Unable to obtain.
Past Medical History:
h/o stroke with expressive aphasia and R hemiparesis
recent prolonged intubation according to call-in sheet, no
further details available
HTN
hyperlipidemia
bladder spasm
CAD s/p CABG (details of anatomy not available)
PVD s/p fem-[**Doctor Last Name **] bypass
Social History:
Lives in nursing home since [**2174**]. Widowed. Eats regular diet,
takes meds in pudding or applesauce.
Family History:
Noncontributory
Physical Exam:
Vitals: T:95.3 BP:115/54 HR:65 RR:14 O2Sat:96%
GEN: obese elderly female
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. Right facial
expression dampened compared to L. Cannot move R arm or leg
against gravity. Strength 4/5 in L upper and lower extremities.
Patellar DTR +1.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2177-1-31**] 11:30PM GLUCOSE-118* UREA N-32* CREAT-1.1 SODIUM-141
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-15
[**2177-1-31**] 11:30PM ALT(SGPT)-11 AST(SGOT)-13 CK(CPK)-99 ALK
PHOS-76 TOT BILI-0.5
[**2177-1-31**] 11:30PM LIPASE-9
[**2177-1-31**] 11:30PM cTropnT-0.05* proBNP-7221*
[**2177-1-31**] 11:30PM CK-MB-NotDone
[**2177-1-31**] 11:30PM ALBUMIN-3.4
[**2177-1-31**] 11:30PM WBC-26.5* RBC-3.35* HGB-10.7* HCT-30.2*
MCV-90 MCH-32.0 MCHC-35.6* RDW-15.3
[**2177-1-31**] 11:30PM NEUTS-92.7* LYMPHS-5.9* MONOS-1.2* EOS-0.2
BASOS-0.1
[**2177-1-31**] 11:30PM PLT COUNT-198
[**2177-1-31**] 11:30PM PT-16.1* PTT-34.8 INR(PT)-1.4*
[**2177-1-31**] 11:42PM LACTATE-1.7
[**2177-2-1**] 03:42PM CK(CPK)-82
[**2177-2-1**] 03:42PM CK-MB-4 cTropnT-0.05*
[**2177-2-1**] 12:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
[**2177-2-1**] 12:00AM URINE RBC-0 WBC-21-50* BACTERIA-MOD YEAST-NONE
EPI-0-2
Laboratories: Labs sent from nursing home were remarkable for
WBC 32.7, Hct 35, Plts 224; BUN 29/Cr 0.9; [**Hospital1 18**] ED labs notable
for WBC 26, electrolytes wnl, BNP 7220. UA 21-50 wbc, mod
bacteria. See below for rest of labs.
ECG: Sinus rhythm 77 with PACs, incomplete LBBB. No prior for
comparison.
Imaging:
CT torso with contrast ([**2-1**]):
1. No central pulmonary embolus.
2. Bilateral lower lobe opacities, with dense consolidation
opacification of the posterior basal segment of the left lower
lobe, concerning for pneumonia.
3. Pulmonary edema with effusions.
4. Severe vascular calcifications.
5. 2.2 cm right groin pseudoaneurysm at the confluence of the
aorto-femoral graft and native artery.
6. Indeterminant 4.4 cm left adrenal mass. This can be further
evaluated
with an adrenal protocol CT on a non-emergent basis.
7. Mediastinal lymphadenopathy.
RUE US ([**2-1**]): no evidence of right upper extremity DVT
Brief Hospital Course:
78F with h/o stroke with R hemiparesis and aphasia presents with
hypoxia, volume overload/CHF, and hypotension.
# Sepsis - On admission she met SIRS criteria with T101, WBC 26,
hypoxia, and hypotension. She was started on pressors in the ED
and quickly weaned off pressor support the next morning. The
suspected source was aspiration PNA given her CT evidence of
bilateral opacities. She was treated with vanc and zosyn (day 1
= [**2-1**]); flagyl was initially started for empiric C diff
coverage however given the lack of diarrhea of findings of
colitis on CT abdomen it was stopped.
She will continue Vanc and Zosyn for nursing home acquired pna
for a 10 day course. Blood and urine cultures have been NGTD.
A speech and swallow evaluation was performed given concern for
aspiration as the source of the patient's sepsis. The bedside
and videoswallow did not reveal any evidence of aspiration or
silent aspiration. The patient may aspirate her gastric
contents when supine but changing her diet will not decrease the
occurrence of this. Strict aspiration precautions when patient
eating.
# CHF systolic , acute: EF 45%. CT chest showed pulmonary edema
with effusion. Patient's ace-I restarted and the patient was
diuresed with resumption of her home lasix dosage on discharge.
# CAD s/p CABG: EKG without signs of active ischemia, two sets
of enzymes negative. She was continued on ASA, Plavix, statin.
Her metoprolol was initally held given her hypotension and was
restarted once her SBPs were stable.
# stroke with aphasia: The patient presented with bilateral
lower lobe pna suspicious for aspiration. Speech and swallow
exam ordered to assess aspiration risk. She was continued on
her outpatient regimen of baclofen, oxybutynin, lidoderm,
neurontin for chronic pain on the hemiparetic R side.
# depression: She was continued on her outpatient regimen of
paroxetine and buspirone.
# ? RIJ/RSC DVT: US showed no evidence of DVT
# Pseudoaneurysm: 2.2 cm right groin pseudoaneurysm was seen on
CT at the confluence of the aorto- femoral graft and native
artery.
-Patient will likely need outpatient vascular surgery evaluation
pending family's goals of care. This finding was discussed with
the patient, her family and their nurse practitioner.
# Incidental adrenal nodule: 4.4 cm left adrenal mass was noted
on CT on admission.
Previously known finding that has been thorughly evaluated
previously. Family, patient and nurse practitioner aware of
findings. No desire for further inpatient evaluation per
family.
# Code: full
# Comm: with patient; Daughter [**Telephone/Fax (1) 80705**]
Medications on Admission:
furosemide 20mg daily
lisinopril 40mg daily
simvastatin 80mg daily
plavix 75mg daily
aspirin 81mg daily
metoprolol 25mg [**Hospital1 **]
buspirone 5mg [**Hospital1 **]
gabapentin 600mg qhs
paroxetine 50mg qhs
prilosec 20mg daily
baclofen 20mg tid
oxybutynin ED 5mg daily
colace, senna
tylenol prn
lidoderm to R shoulder during the day
robitussin prn
levofloxacin 500mg started 1/23pm
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Paroxetine HCl 25 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO HS (at bedtime).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Baclofen 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
12. Oxybutynin Chloride 5 mg Tab,Sust Rel Osmotic Push 24hr Sig:
One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY AT 6AM ().
17. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
18. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 6 days.
19. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 grams Intravenous Q8H (every 8 hours) for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Pneumonia, bacterial likely aspiration
Acute Systolic Heart Failure
Sepsis, hypotension
CAD s/p CABG
CVA old with residula right hemiparesis
PVD s/p fem-[**Doctor Last Name **]
Left adrenal mass (old)
Right groin pseudoaneurysm (2.2cm)
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Patient to retrun to ED if she is having high fevers, worsening
hypoxemia requiring high flow oxygen.
Followup Instructions:
Patient to f/u with her PCP [**Last Name (NamePattern4) **] [**1-10**] weeks.
|
[
"401.9",
"V45.81",
"311",
"438.20",
"428.21",
"442.3",
"438.11",
"255.9",
"038.9",
"507.0",
"995.91",
"272.4",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9000, 9094
|
4239, 6857
|
301, 334
|
9373, 9393
|
2292, 4216
|
9543, 9623
|
1570, 1588
|
7292, 8977
|
9115, 9352
|
6883, 7269
|
9417, 9520
|
1603, 2273
|
238, 263
|
362, 1145
|
1167, 1431
|
1447, 1554
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,973
| 195,451
|
38588
|
Discharge summary
|
report
|
Admission Date: [**2118-4-25**] Discharge Date: [**2118-5-10**]
Date of Birth: [**2070-1-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
OSH transfer for pancreatitis, fevers, respiratory failure
Major Surgical or Invasive Procedure:
Mechanical Ventilation
History of Present Illness:
Mr. [**Known lastname 24214**] is a 48 yo man with history of chronic EtOH abuse,
who was admitted to [**Hospital3 **] on [**2118-4-11**] with alcohol
withdrawal. He was diagnosed with pancreatitis based on labs,
and given degree of withdrawal and concern for delirium tremens
he was admitted to the ICU and treated with Librium and Ativan.
He subsequently developed signs of respiratory distress
(tachypnea 40-50) and was intubated. On [**4-12**] he was 5.5L
positive and sedated on propofol. He has been treated with
empiric antibiotics: Vanco, Imipenem, and Fluconozole (added
[**2118-4-20**]). His hospital course was complicated by acute renal
failure (resolved), ?pseudocyst formation and persistent daily
fevers ([**Date range (1) 85791**] T > 102F). Work-up of his persistent fevers
has included: 1) negative blood, urine cultures, 2) negative LP
3) negative aspiration of pseudocyst (appeared purulent, but
negative gram stain) 4) negative thoracentesis 5) central venous
line change x 2. General Surgery team at [**Hospital3 **]
suggested a laparotomy and the family requested transfer to a
tertiary care center.
The patient remains intubated, mechanically ventilated, with
central access (sedated with Propofol). He is receiving TPN.
Urine output has been good.
Past Medical History:
Hepatitis C infection
- L foot fracture ( 2 days prior to admission )
- Alcohol abuse
- GERD/hiatal hernia
- Hypertension
- Depression/Anxiety
- Hypertriglyceridemia
- L renal tumor (s/p cryoablation [**2116**])
- Renal colic/L nephrolithiasis
- s/p cholecystectomy
Social History:
Heavy alcohol use, h/o cocaine use. Negative tobacco
Family History:
Brother died of complications of pancreatitis. Hx prostate
cancer and diabetes
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
Vent AC Tv 550 RR 14 PEEP 5 FiO2 50%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, obvious bruising of left foot dorsum, slight erythema
around site of power PICC
Pertinent Results:
ADMISSION LABS
[**2118-4-25**] 11:45PM BLOOD WBC-10.5 RBC-3.43* Hgb-9.5* Hct-29.1*
MCV-85 MCH-27.7 MCHC-32.6 RDW-15.6* Plt Ct-526*
[**2118-4-25**] 11:45PM BLOOD PT-14.5* PTT-23.2 INR(PT)-1.3*
[**2118-4-25**] 11:45PM BLOOD Glucose-154* UreaN-10 Creat-0.6 Na-140
K-3.4 Cl-102 HCO3-31 AnGap-10
[**2118-4-25**] 11:45PM BLOOD ALT-53* AST-53* LD(LDH)-278* AlkPhos-116
TotBili-0.7
[**2118-4-25**] 11:45PM BLOOD Albumin-2.8* Calcium-8.7 Phos-3.8 Mg-1.7
[**2118-4-25**] 11:45PM BLOOD Triglyc-355*
[**2118-4-26**] 12:27AM BLOOD Lactate-0.9
CTA TORSO [**4-27**]
1. Filling defect within the right lower lobe and middle lobe
pulmonary
arteries are concerning for pulmonary embolism.
2. Pancreatitis with extensive peripancreatic fluid. Pancreatic
necrosis
within the the head.
3. Large pancreatic pseudocyst anterior to the pancreas which is
stable since outside hospital study.
4. Small ventral hernia containing loops of small bowel with no
evidence of obstruction.
5. Small left pleural effusion with adjacent atelectasis.
CT ABD [**5-4**]
1. Pancreatitis. Slightly decreased pseudocyst. Partial necrosis
of
pancreatic head with some persistent parenchyma. No new
complication.
2. Small bowel-containing ventral hernia without complication.
3. Small left pleural effusion and atelectasis.
Discharge labs:
[**2118-5-10**] 03:45AM BLOOD WBC-7.3 RBC-3.41* Hgb-9.2* Hct-28.9*
MCV-85 MCH-27.1 MCHC-32.0 RDW-16.2* Plt Ct-354
[**2118-5-10**] 03:45AM BLOOD PT-23.6* INR(PT)-2.2*
[**2118-5-8**] 06:50AM BLOOD Glucose-135* UreaN-3* Creat-0.8 Na-141
K-3.4 Cl-104 HCO3-31 AnGap-9
[**2118-5-1**] 03:59AM BLOOD ALT-39 AST-40 LD(LDH)-238 AlkPhos-99
TotBili-0.5
[**2118-5-7**] 04:57AM BLOOD Calcium-9.3 Phos-3.1 Mg-1.7
Brief Hospital Course:
48 M with hx of Etoh abuse, HCV presented to OSH with delirium
tremens, intubated for airway protection and found to have
severe pancreatitis. He had unrelenting fevers despite
appropriate antibiosis and had a workup that included pseudocyst
aspiration, thoracentesis of L pleural effusion, LP and serial
CT's. He was transferred for further management and found to
have a PE. He was slowly weaned from the vent and extubated
successfully
1. Respiratory Failure: Intubated on [**4-11**] at OSH, extubated on
[**5-4**]. Barriers to extubation were body habitus (high peep
requirement), PE (hypoxia), oversedation. Patient did well after
extubation
2. Pancreatitis: patient had stable/decreasing pseudocyst with
pancreatic necrosis that surgeons deferred to medical
management. He had fevers in the ICU thought secondary to his
necrotizing pancreatitis vs PE. He had an extensive work up in
the OSH and here was intermittently on meropenam. This was
discontinued after another negative infectious work up. ON the
floor, he has remained afebrile x 48 hours and has not had
leukocytosis. He was transitioned from TPN at the OSH to TEN by
Nasojejunal tube in the [**Hospital Unit Name 153**] without complication. He was
transitioned to PO intake on the floor. Speech and swallow
evaluated him and did not feel there was evidence of aspiration.
He will need outpatient follow up with [**First Name8 (NamePattern2) **] [**Doctor Last Name 468**] and Dr.
[**Last Name (STitle) 174**] (appointments already made).
3. Pulmonary Embolism - discovered on CT torso. Started on
heparin, bridged to coumadin. Is now therapeutic on Coumadin.
He should have INR checked every 2 days while in rehab with goal
INR [**2-16**] x 3 values. He will be discharged on coumadin 5mg daily
4. Agitation - patient arrived on a regimen of severe
polypharmacy - haldol IV BID, seroquel, trazodone, propofol,
versed and fentanyl. This regimen was slowly rationalized.
Methadone was used to bridge off of fentanyl and a combination
of antipsychotics were used to control agitation
peri-extubation. He was maintained on IV midazolam drip in the
ICU, and then moved to tapering valium dosing per CIWA scale.
On transfer to the floor, he was transitioned off his CIWA and
given valium 5mg [**Hospital1 **] x 2 doses (this had been discontinued on
[**5-9**] and there was no evidence of benzodiazepine withdrawal on
[**5-10**]).
5. Broken Metatarsal - Ortho evaluated and recommended an
aircast with outpatient follow-up in [**7-23**] days. this has been
arranged as per f/u appointments.
6. Hypertension - Variable hypertensive readings. Some likely
due to benzo withdrawal initially, though chronic alcohol may
also cause persistent hypertension. He was moved to daily
Toprol XL 100mg daily and Lisinopril 40mg daily. Amlodipine
10mg daily was added [**2118-5-9**] (he stated he took this as
outpatient). His blood pressure will need to be monitored at
rehab to ensure he is well controlled. If his blood pressure
remains elevated then covering physician can consider increased
metoprolol sl to 150mg daily.
7. Weakness - Very deconditioned when out of ICU to medical
floor, requiring significant Physical Therapy. Felt that would
not do well to go home and so inpatient PT rehab was
recommended.
8. Hyperglycemia - He was started on glargine 20 units at
bedtime in the ICU and this was continued on the floor. His new
insulin requirements are likely secondary to his pancreatitis.
He will need to continue glargine for now and also to continue
the insulin sliding scale. If his fasting blood sugars are <
120 x 2 days, would decrease glargine to 15 untis at bedtime.
He will need outpatient follow up with his primary care
physician for this.
9. H/o Depression - He was continued on trazadone and seroquel,
but lexapro was discontinued on arrival to the ICU. This can be
restarted at 10mg daily at rehab or on follow up with his
primary care provider. [**Name10 (NameIs) 4692**], quetiapine was decreased
to 200mg daily (from 600mg from OSH) records. He is stable on
this regimen was this was not increased prior to discharge.
Trazadone was also decreased to 100mg at bedtime (from 200mg).
10. Alcohol withdrawal - He was initially admitted to an OSH for
DT. He was transferred to the ICU there and subsequently
transferred to the ICU at [**Hospital1 18**]. He was initially managed on a
versed gtt and this was transitioned off. On the floor, he was
transitioned to a CIWA protocol, later discontinued on [**2118-5-9**].
He was kept on Valium 5mg [**Hospital1 **] x 2 doses and this was
transitioned off. No evidence of benzodiazepine withdrawal on
exam on discharge.
11. Klebsiella UTI - This was diagnosed at the OSH and he was
placed on Imipenam (mostly for his necrotizing pancreatitis).
His urine cultures at [**Hospital1 18**] was negative to date here.
12. GERD/Esophagitis - Continued PPI
13. Hepatitis C - Stable. Will need outpatient follow up.
14. H/o renal mass - No mention of renal mass on [**Hospital1 18**] imaging.
Will need follow up with his primary care provider.
Medications on Admission:
Prior to OSH hospitalization
amlodipine 10mg daily
Lexapro 10mg daily
omeprazole 40mg daily
lisinopril 10mg [**Hospital1 **]
niacin 500mg daily
Tramadol 50mg TID
seroquel 600mg at bedtime
trazadone 200mg at bedtime
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Polyethylene Glycol 3350 17 gram/dose Powder [**Last Name (STitle) **]: One (1) PO
DAILY (Daily) as needed for constipation.
3. Quetiapine 100 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO HS (at
bedtime).
4. Trazodone 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
5. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO Q4H (every 4
hours) as needed for pain.
6. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4
PM.
7. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily):
hold for sbp < 120.
8. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily):
hold for sbp < 120.
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
hold for sbp < 100, hr < 55.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q4H (every 4 hours) as
needed for SOB/Wheeze.
11. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
12. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: 20 units
Subcutaneous at bedtime: please continue to monitor blood
glucose qac and qhs. please follow the sliding scale as was
followed in the hospital.
13. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Two (2) PO BID (2
times a day).
14. Acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: One (1) PO Q4H
(every 4 hours) as needed for fever.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Necrotizing pancreatitis, acute
Pancreatic pseudocyst
Respiratory failure w/ mechanical ventilation
Pulmonary Embolism
Hypertension
Weakness
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 with necrotizing pancreatitis with pseudocyst,
and pulmonary embolism. The former was managed conservatively.
You are on a blood thinner called warfarin for the clot in your
lung. The effectiveness of this medication needs ongoing
monitoring with a goal INR of [**2-16**]. You will need careful
follow-up for this.
Your medications have been adjusted. Please make a note of the
medications you are going home on, and take only these
medications unless otherwise instructed by a physician.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2118-5-30**] at 10:15 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2118-5-25**] at 3:45 PM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Name: [**Doctor Last Name **],PRITI A.
Appointment: Tuesday, [**2119-5-31**]:15am
Address: [**State **] STE G, [**Location (un) **],[**Numeric Identifier 22165**]
Phone: [**Telephone/Fax (1) 85792**]
|
[
"518.81",
"415.19",
"300.4",
"249.00",
"577.0",
"070.54",
"E916",
"577.2",
"518.0",
"511.9",
"530.81",
"291.0",
"553.21",
"825.25",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"99.15",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11670, 11768
|
4526, 9618
|
373, 398
|
11953, 11953
|
2804, 4087
|
12671, 13525
|
2079, 2159
|
9883, 11647
|
11789, 11932
|
9644, 9860
|
12136, 12648
|
4104, 4503
|
2174, 2785
|
275, 335
|
426, 1702
|
11968, 12112
|
1725, 1993
|
2009, 2063
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,509
| 194,534
|
11945+56309
|
Discharge summary
|
report+addendum
|
Admission Date: [**2143-12-31**] Discharge Date: [**2144-1-16**]
Date of Birth: [**2069-2-13**] Sex: F
Service: GENERAL SURGERY/BLUE TEAM
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 5715**] is a 74 year-old
female who is transferred from [**Hospital 11694**] [**Hospital 107**] Hospital
about a month ago in [**Month (only) **] after being found to have
hypoxic respiratory failure and hypotension and developed
azotemia. She was found to have coag negative staphylococcus
and [**Female First Name (un) **] albicans in her blood. Her hospitalization was
complicated by a DIC, a GI bleed, oral herpes simplex virus
and C-difficile colitis. She was discharged to the
rehabilitation center on [**2143-12-25**]. The patient was
doing well until [**12-30**] when she developed abdominal
pain, sharp, constant, diffuse. The patient was noted to
have a temperature of 102.8. She denied any pulmonary or
urinary symptoms. She had a Foley in place on arrival. She
had nausea. No vomiting.
PAST MEDICAL HISTORY: As before sepsis, acute renal failure,
C-difficile colitis, fungemia, herpes simplex virus, oral
DIC, GI bleed, hypertension, hypothyroidism, question of
heparin induced thrombocytopenia, hypercholesterolemia.
PAST SURGICAL HISTORY: None.
ALLERGIES: No known drug allergies.
MEDICATIONS: On arrival she was on Acyclovir 400 mg t.i.d.,
Celexa 400 mg q.d., Diflucan 200 mg q.d., Flagyl 500 mg
t.i.d., Nystatin 5 cc q.i.d. swish and swallow, Zantac 150 mg
b.i.d. and Levoxyl 15 micrograms q.d.
PHYSICAL EXAMINATION: Temperature 103. Heart rate 100.
Blood pressure 94/50. Chest was with decreased breath sounds
at the bases. Abdomen was distended, tender to palpation
diffusely, right greater then left. She had guarding in the
right with rebound tenderness. Tenderness to percussion plus
shake tenderness and no hernia. Rectal was nontender. No
mass. Normal tone. Heme positive yellow stool.
LABORATORY: White count 16.5, hematocrit 34.2, platelets
201. Lytes were sodium 142, potassium 3.6, BUN 21,
creatinine 1, glucose 257, ALT 19, AST 20, alkaline
phosphatase 106, total bilirubin 0.4, LDH 290, amylase 108.
PT 14.3, PTT 24.4, INR 1.4. Urinalysis was positive for
nitrites, 3 to 5 red blood cells, 6 to 10 white blood cells.
No bacteria. No yeast. Chest x-ray was small left effusion.
No free air. Abdominal CT showed free air stranding
thickened loops of small bowel. No obstruction.
HOSPITAL COURSE: The patient was taken to the Operating Room
for exploratory laparotomy for a perforated viscus. The
patient had a small bowel resection, drainage of abscess by
Dr. [**Last Name (STitle) **] and by Dr. [**First Name (STitle) 2819**]. Please see operative note for
details. Postoperatively, the patient began Vancomycin,
Ceptaz, Diflucan, Flagyl. Hematology was consulted for
possible heparin induced thrombocytopenia with platelets of
189. The patient given her history hematology suggested that
she did not have heparin induced thrombocytopenia. The
patient on the CT was found to have a right common femoral
deep venous thrombosis and heparin was started on her TPN.
The patient was taken to the Surgical Intensive Care Unit.
Her SICU course was uncomplicated. She was given intravenous
antibiotics, intravenous fluids and carefully monitored. She
was transferred to the floor on [**1-4**] postoperative day
four. She was taking Ampicillin, Gentamycin, Flagyl and
Fluconazole. The Fluconazole was discontinued on [**1-15**]
due to her previous [**Female First Name (un) **] albicans fungemia. The patient
was started on TPN due to prolonged NPO course
postoperatively and also poor po intake. The patient was
transfused a unit of blood on [**1-7**], [**1-10**] and
[**1-14**].
Postoperatively day nine the patient was antibodied with
Vancomycin, Gentamycin and Flagyl for enterococcus and coag
positive staph in the blood. Infectious disease was
reconsulted for CMV colitis via pathology. Ganciclovir
intravenous was started. CT of the chest, abdomen and pelvis
was performed on [**1-15**], which continued to show a
pulmonary nodule. A 14 mm ileal bowel wall thickening patent
SMA, small amount of ascites, fluid surrounding area of ileum
with bowel wall thickening. No peritoneal free air. There
were no abscesses or collections found. The patient is
currently postoperative day fifteen and taking po minimally
due to poor appetite on TPN for 40 kilograms 1000 K calories
1 liter 60% amino acids, 170% dextrose, 20% fat, sodium
chloride 100, potassium chloride 80, potassium phosphate 20,
magnesium sulfate 5, calcium gluconate 15. Her INR this
morning was 3.3. She was on her fourth day of Coumadin on .5
mg po q.h.s. dosed dally depending on INR. Her BUN is 22,
creatinine 0.8. Her sodium is 133. The rest of her
electrolytes are within normal limits. Her calorie count
done on the 26th showed less then 50% total calorie intake,
less then 30% protein requirements and thus TPN continued.
Vancomycin, Levo, Flagyl day seventeen. Cut off day is
[**2144-1-22**]. Ganciclovir is day seven cut off day is
[**2144-1-30**]. The patient is stable, afebrile,
incontinent to urine and stool.
MEDICATIONS ON DISCHARGE: Levofloxacin 500 mg intravenous
q.d., Vancomycin 1 gram intravenous b.i.d., Flagyl 500 mg
intravenous q 8 hours, Ganciclovir 350 mg intravenous q 12
hours, Lopressor 25 mg b.i.d., Coumadin dosed daily, Zoloft
50 mg q.d., Protonix 40 mg po q.d.
The patient is stable pending rehab.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Name8 (MD) 6908**]
MEDQUIST36
D: [**2144-1-16**] 08:57
T: [**2144-1-16**] 10:15
JOB#: [**Job Number 37597**]
Name: [**Known lastname **], [**Known firstname 6758**] Unit No: [**Numeric Identifier 6783**]
Admission Date: [**2144-1-1**] Discharge Date: [**2144-1-16**]
Date of Birth: [**2069-2-13**] Sex: F
Service:
ADDENDUM:
In summary:
1. Neurologically the patient is taking Zoloft 50 mg po q d.
She is taking minimal pain medications, however, she is
written for Dilaudid 2 mg po q 4-6 hours prn as needed.
2. Respiratory, the patient requires pulmonary toilet with
physical therapy and chest PT. The patient will benefit from
Albuterol, Atrovent meter dose inhalers.
3. Cardiovascular, patient is stable. The patient is on
Lopressor 25 mg po bid.
4. GI, patient has CMV colitis on Ganciclovir, the dose as
mentioned above to end on [**2144-1-30**]. The patient is on
prophylaxis. Stress ulcer on Protonix 40 mg po q d.
5. GU, patient is making adequate urine.
6. Infectious Disease, the patient is on Vanco and Flagyl
for cultures, bacteremia from outside hospital and cath line
sepsis. Patient was also found to have enterococcus fecalis
and coag negative staph in the blood 12-11, being treated
with Levo, Vanco and Flagyl, to end on [**2144-1-22**].
7. Heme: Patient has known DVT as mentioned above, being
dosed daily, Coumadin .5 to 2 mg each day for a goal INR of
[**2-23**].
8. Fluids, Electrolytes & Nutrition: Patient's po intake is
poor and is not meeting caloric goal. Patient has met an
average of 14% k cals/43% protein over the last four days
prior to discharge. We would encourage to advance diet as
tolerated to improve caloric intake. TPN as mentioned above
should be used, however, as po intake improves, TPN should be
weaned.
For further information, page Dr. [**Last Name (STitle) 3124**] at the [**Hospital1 960**] [**Telephone/Fax (1) **], pager #[**Numeric Identifier 6786**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-205
Dictated By:[**Name8 (MD) 3713**]
MEDQUIST36
D: [**2144-1-16**] 12:02
T: [**2144-1-16**] 13:12
JOB#: [**Job Number **]
|
[
"558.9",
"401.9",
"569.83",
"453.8",
"244.9",
"790.7",
"078.5",
"272.0",
"567.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"54.19",
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
5216, 7839
|
2471, 5189
|
1276, 1539
|
1562, 2453
|
187, 1018
|
1041, 1252
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,431
| 164,496
|
35628
|
Discharge summary
|
report
|
Admission Date: [**2201-3-17**] Discharge Date: [**2201-3-25**]
Date of Birth: [**2141-1-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Bactrim / Amoxicillin / Sulfur / Codeine / Lasix
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath and fatigue
Major Surgical or Invasive Procedure:
[**2201-3-17**] Mitral Valve Replacement (25mm St. [**Male First Name (un) 923**] Mechanical
Valve)
History of Present Illness:
60 year old female with increasing shortness of breath since
[**10-25**]. Work-up revealed severe mitral regurgitation with clean
coronary arteries. Now presents for surgery.
Past Medical History:
Mitral Regurgitation
Chronic obstructive pulmonary disease
Asthma
Gastroesophageal reflux disease
Chronic fatigue
Fibromyalgia
Pneumonia
Social History:
Cashier. Current smoker at 1/2ppd x 45 years. Denies alcohol
use. Lives with husband.
Family History:
Non-contributory
Physical Exam:
Vitals: 86 14 154/86 65" 153lbs
General: Well-developed, well-nourished female in no acute
distress
Skin: Unremarkable
HEENT: Unremarkable
Neck: Supple, full range of motion, no carotid bruits
Chest: Clear to auscultation bilaterally
Heart: Regular rate and rhythm with 2/6 late systolic murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-pefused, -edema
Neuro: Alert and oriented x 3, non-focal
Pertinent Results:
[**2201-3-25**] 05:30AM BLOOD WBC-10.4 RBC-2.51* Hgb-8.1* Hct-24.2*
MCV-96 MCH-32.1* MCHC-33.4 RDW-14.6 Plt Ct-468*#
[**2201-3-17**] 02:26PM BLOOD WBC-13.4* RBC-2.26*# Hgb-7.5*# Hct-22.1*#
MCV-98 MCH-33.1* MCHC-34.0 RDW-12.7 Plt Ct-192#
[**2201-3-25**] 05:30AM BLOOD Plt Ct-468*#
[**2201-3-25**] 05:30AM BLOOD PT-25.6* PTT-97.5* INR(PT)-2.5*
[**2201-3-17**] 02:26PM BLOOD Plt Ct-192#
[**2201-3-17**] 02:26PM BLOOD PT-14.7* PTT-37.8* INR(PT)-1.3*
[**2201-3-17**] 02:26PM BLOOD Fibrino-197
[**2201-3-25**] 05:30AM BLOOD Glucose-101 UreaN-15 Creat-0.7 Na-143
K-4.0 Cl-103 HCO3-30 AnGap-14
[**2201-3-17**] 03:41PM BLOOD UreaN-18 Creat-1.0 Cl-113* HCO3-27
[**2201-3-20**] 01:20PM BLOOD ALT-20 AST-49* LD(LDH)-349* AlkPhos-144*
TotBili-0.2
[**2201-3-25**] 05:30AM BLOOD Mg-1.9
[**Known lastname 81070**] [**Known lastname **],[**Known firstname **] [**Medical Record Number 81071**] F 60 [**2141-1-14**]
Radiology Report CHEST (PA & LAT) Study Date of [**2201-3-22**] 9:57 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2201-3-22**] 9:57 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 81072**]
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
60 year old woman with MVR
REASON FOR THIS EXAMINATION:
interval change
Final Report
PA AND LATERAL CHEST ON [**2201-3-22**] AT 10 O'CLOCK
INDICATION: Post-operative - check for change.
COMPARISON: [**2201-3-18**].
FINDINGS: Left pleural effusion is again seen. There are linear
atelectatic
changes on the right. There is suggestion of a more patchy
feature in the
right lower lobe and distinction from a developing pneumonia
versus
atelectasis cannot be made. I suspect the former based on lack
conspicuity on
the lateral view. Pulmonary vascular markings are stable and
within normal
limits. Features of surgical change from MVR evident. No PTX.
IMPRESSION:
New airspace opacity in the right lower lung zone not well seen
on lateral
view. Atelectasis versus pneumonia and followup recommended. No
other
interval changes.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: SUN [**2201-3-22**] 5:35 PM
[**Known lastname 81070**] [**Known lastname **],[**Known firstname **] [**Medical Record Number 81071**] F 60 [**2141-1-14**]
Cardiology Report ECG Study Date of [**2201-3-17**] 3:55:40 PM
Junctional rhythm. Prior inferior myocardial infarction. Low
limb lead
voltage. Delayed precordial R wave transition. Compared to the
previous
tracing of [**2201-2-18**] there is now evidence for interim inferior
infarction and
junctional rhythm. The rate has slowed. Followup and clinical
correlation are
suggested.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
51 0 78 458/442 0 -15 42
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 81073**] [**Known lastname **],[**Known firstname **] [**2141-1-14**] 60 Female [**Numeric Identifier 81074**]
[**Numeric Identifier 81075**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 44437**]/mtd
SPECIMEN SUBMITTED: MITRAL VALVE.
Procedure date Tissue received Report Date Diagnosed
by
[**2201-3-17**] [**2201-3-17**] [**2201-3-19**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 14739**]/ttl
DIAGNOSIS:
Mitral valve, excision:
Valvular tissue with subendocardial fibrosis; no significant
inflammation is identified, see note.
Brief Hospital Course:
Admitted same day admit and went to the operating room and
underwent a mitral valve replacement. Please see operative
report for surgical details. She received cefazolin for periop
antibiotics. Following surgery she was transferred to the CVICU
for hemodynamic monitoring. Within 24 hours she was weaned from
sedation, awoke neurologically intact and extubated. She was
started on captopril for blood pressure management to wean off
nitroglycerin and coumadin for mechanical valve. She was
transferred to the floor on post operative day 2 for the
remainder of her stay. Physical therapy worked with her on
strength and mobility. On post-op day three, after two doses of
Coumadin, patients INR jumped to 7.4. she received FFP and
Vitamin K with decrease in INR. Echocardiogram ruled out
pericardial effusion. She was then slowly restarted on lower
doses of coumadin and heparin drip for mechanical valve. On
post operative day 8 she was ready for discharge home with
services.
Sternal incision no erythema no drainage sternum stable
Edema trace bilateral lower extremities
Weight preoperative 69.1 kg discharge 75kg
Medications on Admission:
Protonix 40mg daily, Cymbalta 60mg daily, Serax 30mg qhs,
Amitriptyline 100mg daily, Servent INH, Albuterol INH, Naproxen
500mg [**Hospital1 **], MVI daily, Rixcet 5/325mg QID, Tramadol 50mg PRN,
Bumetonide 0.5mg daily
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Location (un) 5087**]
Discharge Diagnosis:
Mitral Regurgitation status post Mitral Valve Replacement
Secondary: Chronic obstructive pulmonary disease, Asthma,
Gastroesophageal reflux disease, Chronic fatigue, Fibromyalgia,
Pneumonia
Discharge Condition:
Good
Discharge Instructions:
Keep wounds clean and dry. Shower daily, no bathing or swimming.
Take all medications as prescribed.
Call for any fever(Temp>100.5), redness or drainage from sternal
wound
No lifting greater than 10 pounds for 10 weeks
No driving for 1 month until follow up with surgeon
No lotion, powder, cream or ointment on wounds
Call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments:
Dr [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 36012**] in [**6-26**] days office should contact
you tomorrow [**3-26**] with date and time, if not please call
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**] in [**1-20**] weeks [**Telephone/Fax (1) 5315**]
Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
******
Lab: PT/INR for coumadin dosing - indication mechanical mitral
valve, goal INR 3.0-3.5 first draw friday [**3-27**] with results
to [**Hospital3 **] Medical Center [**Hospital3 **] attn: [**Doctor First Name **]
at phone:([**Telephone/Fax (1) 81076**] fax: [**Telephone/Fax (1) 75944**]
Completed by:[**2201-3-25**]
|
[
"305.1",
"530.81",
"724.5",
"790.92",
"E878.1",
"729.1",
"394.1",
"780.79",
"518.0",
"300.4",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.32",
"88.72",
"35.24",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6466, 6543
|
5073, 6197
|
347, 448
|
6777, 6784
|
1404, 2554
|
7214, 7978
|
931, 949
|
2594, 2621
|
6564, 6756
|
6223, 6443
|
6808, 7191
|
964, 1385
|
276, 309
|
2653, 5050
|
476, 652
|
674, 812
|
828, 915
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,778
| 125,312
|
907
|
Discharge summary
|
report
|
Admission Date: [**2101-6-30**] Discharge Date: [**2101-7-7**]
Date of Birth: [**2023-9-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypoglycemia, hypotension
Major Surgical or Invasive Procedure:
Central venous catheter placement.
History of Present Illness:
Ms. [**Known lastname 6129**] is a 77yo female with PMH significant for COPD on 4L
NC, HTN, anemia, and recent pubic ramus fracture who is being
transferred to the MICU for hypotension, hypoxemia, and
hypoglycemia. Per her family, she fractured her pubic ramus 3
weeks ago. She was evaluated at the [**Hospital1 756**] and was found to be
a non-surgical candidate. She was then transferred to [**Hospital 882**]
Hospital and admitted. During her stay she was found to have a
UTI and was treated with Cipro. Her daughter states that after 5
days of treatment she found out that the bug in her urine was
resistent to the Cipro. She was then apparently treated with
Cefpodoxime and the last day was [**6-19**]. She had a foley in place
during these times which was removed yesterday. Two days after
being at the NH, she represented to [**Hospital1 882**] ED with symptoms
suggestive of a bowel obstruction. Of note, she has been on
narcotics during this time. She was then discharged back to
Bostonian where she has been since [**6-18**]. Per daughter, she has
had poor intake over the past few days.
At 8:15am this morning her BS was low according to the
glucometer. She was immediately given Glucagon IM and glucose
gel. Her BS increased to 40 at 8:50am after a second glucagon
shot. Blood sugar remained at 42 per nurse [**First Name (Titles) **] [**Last Name (Titles) **]. EMS was called
and she was immediately brought to [**Hospital1 18**].
In the ED initial vitals were T 98.2 BP 119/70 AR 78 RR 28 O2
sat 80% RA. She was immediately placed on NRB and her O2
saturation increased to 92%. Repeat blood sugar was 135. She
received ASA 325mg, Levaquin 750mg IV, Flagyl 500mg IV, Zofran
4mg IV, and 3L normal saline. She was then transferred to the
MICU for further management.
Past Medical History:
1)Pubic ramus fracture
2)Syncope
3)COPD on 4L at home
4)IDDM
5)Hypertension
6)Anemia (followed by hematologist)
Social History:
Patient lives with husband. [**Name (NI) **] current tobacco, alcohol, or
IVDA.
Family History:
NC
Physical Exam:
vitals T 95.6 BP 161/84 AR 89 RR 20 O2 sat 86% on 6L NC
Gen: Awake, responsive to commands, increased respiratory effort
HEENT: Mucous membranes slightly dry
Heart: RRR, no audible m,r,g
Lungs: CTAB, +crackles at posterior bases
Abdomen: Soft, distended, NT/ND, +BS
Extremities: 1+ bilateral edema
Pertinent Results:
CT abdomen and pelvis:
1. Patchy and nodular depdendent airspace opacities most
consistent with
aspiration pneumonia/neumonitis and tiny bilateral pleural
effusions.
2. Evidence of constipation, with large amount of stool in
rectum.
3. No other evidence of acute abdominal process.
.
.
CT angiogram of the chest:
1. No pulmonary embolism identified.
2. Left lower lobe infiltrate, perhaps representing aspiration
pneumonia.
3. Smaller right lower lobe infiltrate. Small bilateral pleural
effusions.
.
.
Echocardiogram
Severe pulmonary hypertension with dilated right ventricle and
global right ventricular systolic dysfunction. Grossly preserved
left ventricular systolic function. Moderate tricuspid
regurgitation. Dilated thoracic aorta.
.
.
Urine cultures: E. coli resistant to cipro only
.
.
Blood and sputum cultures negative
Brief Hospital Course:
Ms. [**Known lastname 6129**] is a 77yo female with PMH as listed above who presents
with hypotension, hypoxemia, and hypoglycemia, originally
admitted to the MICU.
.
1)Urosepsis: Patient has had multiple UTIs over the past few
weeks. Per daughter, the bacterial strain was resistant to
flouroquinolones (cipro). She was subsquently treated with
Cefpodoxime for unknown time course which she completed on [**6-19**].
On arrival to the ED she was hypotensive and U/A was floridly
positive. She was given Levaquin in the ED. Her blood pressure
improved with IVFs. On transfer to the MICU she was started on
Vancomycin and Cefepime for broad spectrum coverage. Once she
stabilized, she was converted back to cefpodoxime to complete a
seven day course.
.
2)Hypoxemia: Patient is on 4L NC at home for COPD. She presented
with an increasing oxygen requirement from baseline. An
echocardiogram obtained in the MICU showed preserved LVEF but
also revealed a dilated RV without hypertrophy, consistent with
pressure overload and severe pulmonary hypertension. A CTA of
the chest was obtained to rule out PE given her multiple risk
factors. Her CT showed no PE but confirmed bilateral airspace
disease, and she was covered with vancomycin and cefepime for
possible hospital acquired PNA. This was changed to cefpodoxime
to cover both her UTI and likely aspiration PNA. Her oxygen
requirements returned to baseline but her right-sided heart
failure warrants further evaluation.
.
3)Hypoglycemia: Patient was found to be hypoglycemic on the
morning of admission. BS was ~40s despite receiving Glucagon x2.
She was on a very aggressive regimen at home including
metformin, NPH, and lispro; and was only requiring 6-8 units
daily of sliding scale. We held her home regimen and will
continue to titrate up as needed.
.
4)COPD: Baseline is 4L NC at home, she was maintained on this,
and her nebulizers were continued.
.
5) Bladder retention: The patient failed a foley removal trial,
and will need bladder retraining.
.
6) Abdominal pain: The patient is having vague cramping
abdominal pain, with no fevers or diarrhea. Her KUB was
negative, however, there is moderate clinical suspicion for C.
diff in the setting of multiple abx. She will need to be tested
for this while at rehab.
Medications on Admission:
Enoxaparin 30mg SQ daily
Procrit 40,000 units Tuesday, Saturday
NPH insulin 10 units QHS
Lispro 2 units with meals
Vitamin C 500mg PO BID
Zinc sulfate 220mg PO daily
Bisacodyl 10mg PRN
levothyroxine 200 mcg daily
Oxycodone 2.5mg PO Q4H PRN
Lactulose
Enalapril 20mg PO daily
Albuterol nebs
Tiotropium
Fluticasone
Vitamin B12 [**2093**] mcg daily
Metformin 500 mg [**Hospital1 **]
ASA 325mg PO daily
Simvastatin 40mg PO daily
Cyanocobalamin 100 micrograms PO daily
Multivitamin
Docusate 100mg PO BID
Oxycontin 20mg PO BID
Senna
Niferex
Lasix 80 mg [**Hospital1 **]
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Procrit 40,000 unit/mL Solution Sig: 40,000 units Injection
On tuesdays and thursdays.
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every four (4)
hours as needed for pain.
7. Oxycodone 5 mg Capsule Sig: 0.5 Capsule PO every four (4)
hours as needed for pain.
8. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulized solution Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing. nebulized solution
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Hexavitamin Tablet Sig: One (1) Tablet PO once a day.
14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
16. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
17. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
19. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding
scale units Injection ASDIR (AS DIRECTED).
20. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
--Type 2 Diabetes Mellitus, poorly controlled with complications
[**Hospital 6130**] healthcare associated pneumonia
--Urinary tract infection (E. coli)
--Severe COPD on chronic home O2 (3-4 L by NC)
--CKD - stage III
--Anemia NOS
--Hypothyroidism with abnormal TFTs
--Severe constipation, resolved
--Osteoporosis with recent pelvic fracture
--Right heart failure, NOS, presumably secondary to COPD
--Delirium, multifactorial, improving
--Incidentally noted 1.2 cm nonspecific precarinal lymph node
--h/o TAH and Bilateral Salpingoophorectomy with h/o endometrial
CA
--left heel decubitus ulceration
--Urinary retention
Discharge Condition:
Stable on baseline O2 requirement of 4L through a nasal cannula,
satting 90-92%, which is her goal oxygen saturation.
Afebrile
Conversant
Discharge Instructions:
You were admitted with low blood pressure and blood sugar. We
think this is because you had a UTI, pneumonia, and your insulin
regimen was too aggressive.
.
We made the following changes to your medications:
1. We are not continuing your NPH or metformin, you will have an
insulin sliding scale and have this increased as you need it.
2. We decreased your lasix to 40mg twice daily
.
Please follow up as indicated below
.
If you experience any further hypotension, fevers, or
signs/symptoms of hypoglycemia, please return to the emergency
department so you can be evaluated.
Followup Instructions:
.
Please see the pulmonologist Dr. [**Last Name (STitle) **] on [**7-28**] at 1pm on the
[**Location (un) **] of the [**Hospital Ward Name 23**] building.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2101-8-17**]
10:00
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2101-9-28**]
1:00
***You had an incidentally noted enlarged lymph node in your
chest that should be followed with a CT scan in [**4-7**] months to
ensure it is not getting larger.***
***You should have repeat thyroid function tests in 6 weeks***
***You had urinary retention and should see a urologist for
follow up.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"788.20",
"428.32",
"496",
"733.00",
"707.07",
"250.80",
"599.0",
"041.4",
"584.9",
"293.0",
"995.92",
"507.0",
"403.90",
"285.21",
"038.9",
"428.0",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8321, 8387
|
3623, 5897
|
339, 376
|
9051, 9191
|
2768, 3600
|
9815, 10648
|
2431, 2435
|
6510, 8298
|
8408, 9030
|
5923, 6487
|
9215, 9395
|
2450, 2749
|
9424, 9792
|
274, 301
|
404, 2183
|
2205, 2318
|
2334, 2415
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,457
| 186,364
|
44185
|
Discharge summary
|
report
|
Admission Date: [**2142-7-21**] Discharge Date: [**2142-8-6**]
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is an 83-year old
female who presented from a nursing home with two days of
vaginal bleeding, a left thigh abscess, and fever. The
vaginal bleeding consisted of a bloody/foul-smelling fluid.
She was noted to have a leukocytosis of 25. She was
transferred from [**Hospital3 **] to [**Hospital1 346**] with a diagnosis of left thigh
abscess.
PAST MEDICAL HISTORY: Significant for paraesophageal hernia,
Parkinson disease, hypothyroidism, dementia, hypertension,
hypercholesterolemia, osteoporosis, and peptic ulcer disease.
PAST SURGICAL HISTORY: Significant for a left hip repair,
total abdominal hysterectomy, a jejunostomy tube placement,
and open cholecystectomy.
MEDICATIONS ON ADMISSION:
1. Celebrex.
2. Sinemet.
3. Fosamax.
4. Multivitamin.
5. Tylenol.
6. Colace.
ALLERGIES: BACTRIM and SULFA.
SOCIAL HISTORY: The patient lives at the [**Hospital3 1761**] Center. She has two sons who are intimately
involved in her care.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on
admission revealed her temperature was 100.4, her heart rate
was 90, her blood pressure was 120/80, her respirations were
18, and her oxygen saturation was 97 percent on 2 liters. In
general, alert and followed commands. Head, eyes, ears,
nose, and throat examination revealed normocephalic and
atraumatic. The extraocular muscles were intact. The pupils
were equal, round, and reactive to light and accommodation.
Cardiovascular examination revealed a regular rate and
rhythm. No murmurs, rubs, or gallops. Pulmonary examination
revealed the lungs were clear to auscultation bilaterally.
The abdomen was obese, soft, nontender, and nondistended. No
guarding. The patient noted mild discomfort diffusely to
palpation. The extremities revealed purulent left thigh with
induration and malodorous discharge. The distal pulses were
intact.
LABORATORY DATA ON ADMISSION: Sodium was 142, potassium was
5.1, chloride was 106, bicarbonate was 24, blood urea
nitrogen was 50, creatinine was 1.4, and blood glucose was
115. White blood cell count was 27, her hematocrit was 33,,
and her platelets were 481. Prothrombin time was 14.2,
partial thromboplastin time was 28.5, and her INR was 1.3.
RADIOLOGY: Electrocardiogram on admission revealed a normal
sinus rhythm with a rate of 79. Left bundle branch block
present.
A computed tomography of the abdomen and pelvis demonstrated
a large paraesophageal hiatal hernia/a small anterior
abdominal wall hernia - not causing obstruction. No
intraabdominal or pelvic abscess. There was a large area of
inflammation, edema, and stranding involving the soft tissues
of the medial left thigh in conjunction with subcutaneous air
tracking underneath the muscle fascia. Status post
hysterectomy with air and fluid seen in the remaining vaginal
cuff. Findings strongly support necrotizing fasciitis.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
Platinum Surgery Service and taken to the operating room on
[**2142-7-21**]. She underwent a wide debridement of the left
thigh and vulva including skin, soft tissue, and muscle.
There was a tremendous degree of necrotic and foul-smelling
fluid spreading along the fascial planes from roughly the
level of the knee posteriorly to the perineum along the
medial and posterior thigh.
A Urology consultation was called, and during the time of the
operation Urology placed a suprapubic tube. A Gynecology
consultation was also called, and they performed biopsies of
the vaginal mucosa. An Orthopaedic Surgery consultation was
called to evaluate the left hip prosthesis. It was their
recommendation to keep the prosthesis in place, as it was not
involved with the wound at this time.
The patient was admitted to the Intensive Care Unit
postoperatively where she was followed closely. She was
started on vancomycin, Zosyn, and clindamycin. Her wound was
treated with wet-to-dry dressing changes twice per day. The
patient was intubated and kept sedated in the Intensive Care
Unit.
On postoperative day three, a feeding tube was placed and the
patient was started on tube feedings. On postoperative day
five, a Gastroenterology consultation was called to assist
with placement of the Dobbhoff tube post pylorically. This
was unable to be done by Interventional Radiology due to her
paraesophageal hernia. A Plastic Surgery consultation was
also called regarding her left thigh wound as well as right
hand superficial wound.
On postoperative day seven, the patient was extubated, and
she was able to spontaneously breathe on her own. The
vaginal biopsy results came back, which showed no malignancy.
On postoperative day eight, the patient was stable enough to
be transferred to the floor. On postoperative day 10, the
patient removed her feeding tube. Therefore, a swallow
evaluation was done to see if the patient was able to
tolerate oral intake. She failed this swallow evaluation,
and therefore Interventional Radiology was called to replace
the Dobbhoff tube. Therefore, a feeding tube was re-placed
by Radiology. This was replaced on postoperative day 11, and
the patient's tube feeds were restarted. However, the same
day, she removed her feeding tube again. Therefore,
discussions were had with the family regarding potential
placement of a jejunostomy tube. The family did not wish to
proceed with this course of action. Therefore, it was
decided a repeat swallow evaluation would be done when the
patient was more awake to see if she could tolerate oral
intake. In the meantime, the patient received intravenous
fluids.
On postoperative day 13, the patient passed the bedside
swallow evaluation and was started on nectar-thick liquids
and pureed solids. She was restarted on by mouth
medications. On postoperative day 14, the patient's
intravenous antibiotics were discontinued as she had
completed a 2-week course.
On postoperative day 16, the patient was doing well. Her
wound was granulating, and she was tolerating oral intake and
by mouth medications. Her staples were discontinued from her
abdomen, and plans were made for her to be discharged to
[**Hospital3 **] Center. Follow-up plans were discussed
with Plastic Surgery and with Urology.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To an extended care facility.
DISCHARGE DIAGNOSES: Necrotizing fasciitis.
Dementia.
Hypertension.
Hypercholesterolemia.
Hypothyroidism.
Peptic ulcer disease.
Parkinson disease.
Status post incision and debridement from necrotizing
fasciitis.
Placement of a suprapubic tube.
MEDICATIONS ON DISCHARGE:
1. Sarna lotion applied topically four times per day as
needed (for rash).
2. Sinemet 25/100-mg tablets one tablet by mouth four times
per day.
3. Acetaminophen 325-mg tablets one to two tablets by mouth
q.4-6h. as needed.
4. Metoprolol 25-mg tablets one-half tablet by mouth twice
per day.
5. Pantoprazole 40-mg tablets one tablet by mouth q.24h.
6. Miconazole powder one application topically as needed (for
yeast at skin folds).
7. Polyvinyl alcohol 1.4 percent-drops 1 to 2 drops in the
eyes as needed.
8. Percocet 5/325-mg tablets one to two tablets by mouth q.4-
6h. as needed (for pain).
DISCHARGE INSTRUCTIONS AND FOLLOWUP: The patient was
instructed to follow up with Dr. [**First Name (STitle) **] in Plastic Surgery in
one to two weeks. The patient was to call telephone number
[**Telephone/Fax (1) 274**] for an appointment.
The patient was also instructed to follow up with Dr. [**First Name (STitle) **]
[**Name (STitle) 4229**] in Urology in two weeks; please call telephone number
[**Telephone/Fax (1) 10941**] for an appointment.
The patient will need wet-to-dry dressing changes twice per
day for her left thigh wound and a dry dressing on the right
arm wound.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13137**]
Dictated By:[**Last Name (NamePattern1) 11988**]
MEDQUIST36
D: [**2142-8-6**] 10:24:45
T: [**2142-8-6**] 11:31:39
Job#: [**Job Number **]
|
[
"294.10",
"623.8",
"785.4",
"041.85",
"882.0",
"V43.64",
"331.82",
"728.86",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"70.24",
"57.18",
"38.93",
"96.6",
"96.71",
"83.45"
] |
icd9pcs
|
[
[
[]
]
] |
6445, 6677
|
6703, 8172
|
846, 957
|
698, 820
|
3023, 6339
|
135, 490
|
2021, 2994
|
513, 674
|
974, 2006
|
6364, 6423
|
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