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25,708
| 121,769
|
52300
|
Discharge summary
|
report
|
Admission Date: [**2178-9-3**] Discharge Date:
Date of Birth: [**2120-6-4**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 58 year old man with
past medical history significant of autoimmune deficiency
syndrome, diagnosed in [**2159**], last CD4 count 132 in [**7-25**],
viral load 15,000, chronic obstructive pulmonary disease
(three liters oxygen at home), cardiomyopathy, hepatitis B
hemodialysis, now admitted on [**2178-9-3**], with an episode of
bright red blood per rectum. Workup done in [**5-24**], revealed
grade I known bleeding internal hemorrhoids and local erosions
thought to be due to enema use..
In the Emergency Department on admission, he was found to
have positive bleeding hemorrhoids. Also, initial oxygen
liters which improved to 93% on 100% nonrebreather. He was
in extremis. A long discussion of code status was initiated. The
decline was thought to be due to an infection (aspiration
pneumonitis) or a flare of chronic obstructive
pulmonary disease. Because of the respiratory distress, the
patient was initially admitted to Medical Intensive Care Unit
where he was started on Levofloxacin and steroids and placed on
bipap.
PAST MEDICAL HISTORY:
1. Autoimmune deficiency syndrome, diagnosed in [**2159**].
2. Chronic obstructive pulmonary disease.
3. Cardiomyopathy secondary to HIV.
4. History of pulmonary embolism and deep vein thrombosis.
5. Hepatitis C and B.
6. Hemorrhoids.
7. Polysubstance abuse.
8. End stage renal disease on hemodialysis.
9. History of pancreatitis.
10. History of anemia.
11. Benign prostatic hypertrophy.
12. Depression.
13. PPD positive.
MEDICATIONS ON ADMISSION:
1. Amiodarone 200 mg q.d.
2. Protonix 40 mg p.o. q.d.
3. Zoloft 50 mg p.o. q.d.
4. Zestril 20 mg p.o. q.d.
5. Lamivudine 20 mg p.o. q.d.
6. Albuterol nebulizer q.i.d.
7. Lactulose 30 ml t.i.d.
8. Valium 5 mg p.o. t.i.d.
9. Renagel 4 mg p.o. q.i.d.
10. Multivitamins.
11. Methadone 50 mg q.d.
12. Colace 100 mg p.o. b.i.d.
13. Bactrim DS Thursday, Tuesday, Saturday.
14. Levaquin 250 mg q.o.d.
15. Tylenol 650 mg p.r.n.
16. Percocet one to two tablets p.r.n.
17. Fentanyl 100 mcg q72hours.
18. TUMS.
19. Lopressor 12.5 mg b.i.d.
20. Captopril 6.25 mg t.i.d.
21. Prednisone taper.
22. Stavudine 20 mg p.o. q.d.
ALLERGIES: Haldol developing rash. Thorazine producing
anaphylaxis. H2 blockers producing thrombocytopenia.
Clindamycin and Codeine and Stelazine rash.
PHYSICAL EXAMINATION: On admission, temperature was 99.2,
heart rate 110, blood pressure 100/62, low 90s% sat on NRB.
The patient was in acute distress, tachpneic and disoriented.
Head, eyes, ears, nose
and throat - pupils are equal, round, and reactive to light
and accommodation, mild esotropia, no oral thrush. The neck
is supple, no lymphadenopathy. Cardiac - S1 and S2, regular
rate and rhythm, II/VI holosystolic murmur. The lungs
revealed bilateral rhonchi, no dullness. The abdomen is
soft, nontender, mildly distended. Extremities - chronic
venous stasis, no edema.
HOSPITAL COURSE: This is a 58 year old man with history of
autoimmune deficiency syndrome, chronic obstructive pulmonary
disease, cardiomyopathy, hepatitis B and C, polysubstance
abuse, end stage renal disease on hemodialysis, now admitted
with an episode of bright red blood per rectum due to
hemorrhoidal bleeding and flare of chronic obstructive
pulmonary disease.
Gastrointestinal - The patient has a history of bright red
blood per rectum for which had previous workup in [**5-24**],
which reveled grade I nonbleeding hemorrhoids. His
colonoscopy also revealed rectal ulcer and surgery who
followed the patient previously felt that ulcer is cause for
his bleed. This hospitalization the patient did not have
further episodes of bleeding and his hematocrit remained
stable. It was therefore decided not to pursue further
workup.
Pulmonary - The patient was admitted with worsening oxygen
saturation requiring BIPAP and this was believed to be due to
chronic obstructive pulmonary disease flare. Labs showed an
acute on chronic respiratory acidosis, possible chronic
metablic acidosis (renal failure). The patient was
started on Levofloxacin on [**2178-9-5**], and steroid taper with
significant improvement of oxygen saturation. Because there
was also believed to be a component of aspiration, the
patient had also swallowing study, which showed only mild
abnormalities.
Renal - The patient has a history of end stage renal disease
on hemodialysis. He continued to have hemodialysis during
hospitalization. There were no active issues.
Infectious disease - The patient was on Levaquin for flare of
chronic obstructive pulmonary disease, continues on Bactrim
DS q.i.d. as prophylaxis of PCP and is also on antiretroviral
medications.
Cardiovascular - The patient has a history of cardiomyopathy
secondary to HIV. He continues to be on ace inhibitor and
beta blockers. There were no active issues regarding
cardiomyopathy during this hospitalization.
LABORATORY DATA: White blood count 2.7, hemoglobin 10.2,
hematocrit 32.1, platelet count 87,000. Partial
thromboplastin time 33.6, INR 1.3. Granulocyte count 1280.
Glucose 83, blood urea nitrogen 68, creatinine 9.4, sodium
143, potassium 4.7, chloride 107, bicarbonate 26. Liver
function tests within normal limits. CK negative. Albumin
2.6, calcium 8.6, phosphorus 6.6, magnesium 2.3.
Chest x-ray reveals no evidence of congestive heart failure
or pneumonia.
DISCHARGE DIAGNOSES:
1. Respiratory failure
2. Rectal bleeding
3. Autoimmune deficiency syndrome.
MEDICATIONS ON DISCHARGE:
1. Amiodarone 200 mg q.d.
2. Protonix 40 mg p.o. q.d.
3. Zoloft 50 mg p.o. q.d.
4. Lamivudine 20 mg p.o. q.d.
5. Albuterol nebulizer q.i.d.
6. Lactulose 30 ml t.i.d.
7. Valium 5 mg p.o. t.i.d.
8. Renagel 4 mg p.o. q.i.d.
9 . Multivitamins.
10. Methadone 50 mg q.d.
11. Colace 100 mg p.o. b.i.d.
12. Bactrim DS Thursday, Tuesday, Sunday.
13. Tylenol 650 mg p.r.n.
14. Percocet one to two tablets p.r.n.
15. Fentanyl patch 100 mcg q72hours.
16. TUMS.
17. Lopressor 12.5 mg b.i.d.
18. Captopril 6.25 mg t.i.d.
19. Prednisone taper.
20. Stavudine 20 mg p.o. q.d.
CONDITION ON DISCHARGE: The patient was discharged home in
stable condition.
[**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**]
Dictated By:[**Last Name (NamePattern1) 6063**]
MEDQUIST36
D: [**2178-9-7**] 17:20
T: [**2178-9-7**] 19:38
JOB#: [**Job Number 108130**]
|
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13,163
| 130,683
|
7242+7243
|
Discharge summary
|
report+report
|
Admission Date: [**2173-3-1**] Discharge Date: [**2173-3-8**]
Date of Birth: [**2112-6-12**] Sex: M
Service: GU
Principle Diagnosis:Carcinoma of the prostate, organ confined
Secondary diagnoses: Traumatic glotitis & laryngeal edema
Postoperative ileus
Anxiety disorder with panic attacks
Postoperative anemia
Seizure disorder
History of C. diff colitis
Surgery: Bilateral pelvic lymphadenectomy & Radical Retropubic
Prostatectomy [**2173-3-1**] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9125**]
Consultations: ENT & Pain Service
HOSPITAL COURSE: This is a 60-year-old physician admitted after
[**Name Initial (PRE) **] radical prostatectomy for treatment of recently diagnosed CaP.
In the PACU, the patient had an episode of what
seemed to be an anxiety attack with a vasovagal component.
He was noted to be unresponsive and apneic. He was resuscitated
and give assisted ventilation. He was transferred to the ICU
over night for observation. He remained in a monitored bed,
where he ruled-out for an acute MI. He was then transferred to
the floor on postoperative day #1.
On postoperative day 2, his epidural catheter ceased to function
and was removed. His pain was difficult to manage with Toradol
and oral medications. He received anti-seizure medications,
including benzodiazopams, which often seemed to overly sedate
him. No seizure activity was reported, however. He had low-
grade postop fevers and complained of sorethroat and hoarseness.
On postoperative day 5, these complaints were getting worse, so
an ENT consult was requested. ENT noted that his
larynx was rather reddened and inflamed with evidence of partial
paralysis of one vocal cord. The etiology appeared to be related
to intubation for surgery, although no intubation trauma had
been recorded by anesthesia. He was given doses of
dexamethasone and started iv Clindamycin (penicillin allergy).
The glotitis also resulted in difficulty swallowing, so his oral
intake was inadequate during this time and had to be
supplemented ith iv fluids.
Because of Dr.[**Known lastname 26806**] previous history of C- diff colitis, he
received concommittant treatment with Flagyl for prevention.
On on postoperative day 7, his sorethroat and hoarseness were
somewaht improved, a Dilantin level was stable, and his catheter
was draining clear urine. He was afebrile. His hematocrit
declined to 25 posoperatively and stabilized. Consideration of
blood transfusion was discussed with the patient, but declined
since he was asymptomatic from the anemia. INR and creatinine
all remained stable throughout his
His diet was fully advanced, and he
was tolerating p.o. pain medications for several days before
discharge.
He does have a complaint of bladder spasms for which he was
started on both Ditropan and sublingual Levsin for which he
would alternate.
DISCHARGE MEDICATIONS: Ativan 1 mg p.o. q.8 hours p.r.n.
anxiety, pyridium 200 mg p.o. t.i.d. p.r.n. bladder burning,
Levsin sublingually 0.125 mg sublingual q.2-4 hours p.r.n.
bladder spasm, Dilaudid 2 mg p.o. q.4 hours p.r.n. pain,
Protonix 40 mg p.o. b.i.d., clindamycin 300 mg p.o. q.6
hours, Flagyl 250 mg p.o. t.i.d. remain on for 6 days.
FOLLOW UP: He will followup with Dr. [**Last Name (STitle) 9125**] for catheter removal
in 2 days. He will also followup with Dr. [**Last Name (STitle) 1837**] of the
ENT service.
Discharge condition: Satisfactory
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 9125**], [**MD Number(1) 23434**]
MEDQUIST36
D: [**2173-3-8**] 16:21:41
T: [**2173-3-8**] 19:24:50
Job#: [**Job Number 26807**]
Admission Date: [**2173-3-1**] Discharge Date: [**2173-3-8**]
Date of Birth: [**2112-6-12**] Sex: M
Service: UROLOGY
Allergies:
Morphine / Penicillins / Tetracyclines
Attending:[**First Name8 (NamePattern2) 19908**]
Chief Complaint:
Prostate adenocarcinoma
Major Surgical or Invasive Procedure:
Radical Retropubic Prostatectomy with bilateral pelvic lymph
node dissection [**2173-3-1**]
History of Present Illness:
60yo M with h/o hematuria in [**2168**] with cystoscopy and bladder bx
neg for interstitial cystitis that presents for RRP following
[**2173-1-8**] prostate biopsy cores demonstrating prostatic
adenocarcinoma, [**Doctor Last Name **] 7 (3+4) and high grade intraepithelial
neoplasia
Past Medical History:
Bilateral hernias, dyslipidemia, hypertension, BPH, R acoustic
neuromma, eczema, bilateral hearing loss, gynecomastia, anxiety
attacks.
Isolated seizure in [**2171-9-6**].
GERD
LBP
PSHx: bilateral herniorrhapies, sigmoid resection
Social History:
Currently disable gastroenterologist that had a busy practice in
Northern [**State 350**]. He does not smoke, does not drink, and
does not exercise routinely
Family History:
Noncontributory
Physical Exam:
Cardiovascular Preoperative PE
Patient was able to walk into the exam room
without difficulty in gait, breathing, or speaking. He was
accompanied by his wife. His [**Name2 (NI) **] pressure taken in the right
arm seated position was 138/80. The heart rate was 80 and
regular. Neck exam revealed no elevation of the jugular veins.
There were no carotid bruits. There was no lymphadenopathy or
thyromegaly. Lungs were clear to auscultation and percussion.
Cardiovascular exam revealed a nondisplaced PMI with a normal
intensity S1, S2. There were no murmurs appreciated. Abdomen
was soft, without hepatosplenomegaly. Extremities revealed no
edema. Distal pulses were strong and symmetric
Pertinent Results:
[**2173-3-1**] 06:23PM CK-MB-2 cTropnT-<0.01
[**2173-3-1**] 06:23PM WBC-12.2* RBC-3.19* HGB-10.1* HCT-30.1*
MCV-94 MCH-31.7 MCHC-33.6 RDW-14.8
[**2173-3-1**] 06:23PM PLT COUNT-169
[**2173-3-1**] 01:51PM GLUCOSE-93 UREA N-13 CREAT-0.8 SODIUM-145
POTASSIUM-3.9 CHLORIDE-115* TOTAL CO2-23 ANION GAP-11
[**2173-3-1**] 01:51PM CALCIUM-7.4* PHOSPHATE-3.5 MAGNESIUM-1.4*
[**2173-3-1**] 12:37PM TYPE-ART PO2-123* PCO2-45 PH-7.35 TOTAL
CO2-26 BASE XS-0 -ASSIST/CON
Brief Hospital Course:
Patient tolerated radical retropubic prostatectomy well on
[**2173-3-1**]. While in the PACU, patient was noted to be visibly
anxious and was given ativan for his h/o panic attacks. The
episode resolved without complications. At approximately 1700 on
[**3-1**], the PACU contact[**Name (NI) **] the GU team to inform them that on
preparations for moving the patient to the surgical floor, the
patient was noted to be acutely distressed, and panicked,
wishing to get up from his bed. On lifting the head of his bed,
the patient went pale and dropped his SBP into the 50's, with
concomitant loss of consciousness. Though no cardiac rhythm or
oxygen saturation could be obtained as his leads had been
removed for transport, the patient was resuscitated with ambu
bag and returned to consciousness without any focal neurological
deficits within one minute. EKG obtained shortly after this time
showed no acute changes from preop baseline, and the patient
ruled out by cardiac enzymes. Because of the event the patient
was transferred to the MICU overnight. The patient had one
additional panic attack that resolved with ativan
administration. The patient was transferred to the regular
surgical recovery floor on POD1 and placed on telemetry. The
patient retained good pain control via epidural infusion and was
advanced to clear diet on POD1. The patient was also returned
to his home medications. Over the night of POD1, the patient's
epidural was found to have fallen out. Pain service was
contact[**Name (NI) **] and they removed the epidural while recommending
percocet PO for pain control. The patient was found in the
morning of POD2 to be in mild distress from poor pain control
and was administered 1mg of dilaudid IV with good relief. Acute
pain service was consulted and they recommended a change from
percocet to oxycodone PO for pain control, in addition to the
scheduled toradol instituted by GU team. The patient was also
started on ditropan for continued bladder spasms and placed on a
regular diet with good tolerance. Overnight on POD2, the patient
had continued lower abdominal pain, but on interview in the
morning of POD3 was comfortable, and the patient had his JP
drain removed, with additional abdominal pain relief. Due to
poor oral liquid intake, and signs of dehydration, the patient
was placed on IVF hydration overnight. On POD4, the patient had
continued c/o hoarseness for which anesthesia and ENT were
contact[**Name (NI) **]. Anesthesia did not have further recommendations and
recommended an ENT consult. He was maintained medically with
previous management. Patient described panic attack episode in
morning of POD5 that was resolved with PRN ativan and had
concern for low grade fever to 100.1. ENT saw the patient on
POD5 and felt that a dose of dexamethasone and initiation of IV
clindamycin would improve the patient's glottitis, which made
speaking difficult and PO intake poor. He was restarted on IV
fluids and noted improvement in odynophagia and hoarseness on
POD6. The patient's HCt was noted to drop to 25, but the
patient refused [**Name (NI) **] transfusion. The patient was discharged
on POD7 with adequate PO intake, good pain control, and improved
ambulation.
Medications on Admission:
Vit c, cardura 6, ASA 81', dilantin 230qam 200qpm, klonipin
0.5'', nexium
Discharge Medications:
1. Ativan 1 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for anxiety.
Disp:*25 Tablet(s)* Refills:*0*
2. Pyridium 200 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*20 Tablet(s)* Refills:*0*
3. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1)
Sublingual q2-4hours as needed for spasms.
Disp:*20 tabs* Refills:*0*
4. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every four (4)
hours.
Disp:*50 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
7. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Prostate adenocarcinoma
Postoperative ileus
Anxiety disorder with panic attacks
Postoperative anemia
Seizure disorder
History of C. diff colitis
Discharge Condition:
Stable
Discharge Instructions:
Please resume all of your home medications. Please adjust them
for changes made during this hospitalization
You may take a shower, allow the water to run over your
incision, but do not rub the surgical site. The staples will be
removed on your follow up appointment.
Please return to hospital ER for any of the following reasons:
fever to 101.4, worsening abdominal pain, development of
nausea/vomiting, signs of a wound infection: redness, swelling,
increased tenderness, or drainage of purulent material; return
to ER for inability to urinate or symptoms of a UTI: increased
urinary frequency or pain on urination
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 9125**] after discharge from the
hospital. Please call [**Telephone/Fax (1) 6445**] to schedule an appointment
Completed by:[**2173-3-15**]
|
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icd9cm
|
[
[
[]
]
] |
[
"60.5",
"96.71",
"40.3",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10455, 10461
|
6219, 9439
|
4136, 4230
|
10670, 10679
|
5727, 6196
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4989, 5006
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5021, 5708
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3335, 3506
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4073, 4098
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4258, 4542
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4564, 4798
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4814, 4973
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,938
| 190,428
|
49982
|
Discharge summary
|
report
|
Admission Date: [**2169-3-13**] Discharge Date: [**2169-3-19**]
Service:
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female
with a history of multiple medical problems as listed below
including recurrent pancreatitis attributed to
microlithiasis, who was in her usual state of health until
today when she developed abdominal pain radiating to her back
and side, and had some nausea. She was brought to the
emergency department where she was found to have laboratory
values consistent with pancreatitis. In the emergency
department, the patient received Lopressor for initially
elevated SBP of 187, but subsequently became hypotensive.
She received 5 liters of normal saline resuscitation, but
remained hypotensive, and therefore, was started on dopamine
and transferred to the ICU for further management. Upon
initial evaluation, the patient also was describing
substernal chest discomfort as a complaint in association
with her back pain. CT of her torso was performed, which
ruled out dissection, but did show distended gallbladder with
common bile duct, increase in diameter as well. CT scan also
showed some stranding of the colon. It was thought that her
hypertension may have led to her low flow state and bowel
ischemia. Surgery was consulted in the emergency department,
but the patient was not a surgical candidate. She was given
prophylactic antibiotics because of the CT findings.
ALLERGIES: PENICILLIN AS DOCUMENTED PREVIOUSLY.
OUTPATIENT MEDICATIONS:
1. Aricept 10 mg daily.
2. Aspirin 81 mg daily.
3. Glipizide 20 mg twice daily.
4. Lasix 60 mg daily.
5. Levothyroxine 75 mcg daily.
6. Atorvastatin 10 mg daily.
7. Lisinopril 2.5 mg once daily.
8. Nitroglycerin sublingual as needed.
9. Protonix 40 mg daily.
10. Toprol XL 25 mg p.o. once daily.
11. Seroquel 25 mg one-and-a-quarter tablet daily.
12. Ursodiol 300 mg p.o. b.i.d.
13. Colace p.r.n.
14. Senna p.r.n.
PAST MEDICAL HISTORY: Pancreatitis, since [**2168-8-1**].
Coronary artery disease, status post MI in [**2167**].
Angiographic evaluation was declined at that time. Her last
echocardiogram showed systolic congestive heart failure with
an LV ejection fraction of 35 to 40 percent, apical left
ventricular aneurysm and diffuse wall motion abnormalities.
The left ventricle showed 1 plus aortic insufficiency.
Type 2 diabetes controlled with oral sulfonylurea.
Mild Alzheimer's disease for which she receives Aricept and
Seroquel for sleep.
Hyperthyroidism.
Hypertension.
Recurrent UTIs.
Symptomatic bradycardia necessitating DDD cardiac pacemaker
placement.
Colon cancer at the age of 78 status post surgical resection.
No radiation or chemotherapy was performed.
Previous right-sided stroke.
Hysterectomy.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: She lives with her daughter. She does not
smoke or drink or abuse drugs.
PHYSICAL EXAMINATION ON ADMISSION: T-max 97.8, heart rate
70, blood pressure 106/27, respiratory rate 17, saturation 98
percent on room air. Well-appearing female in no apparent
distress, lying flat in bed. HEENT: Oropharynx: Dry mucous
membranes, otherwise clear. Neck: Supple. No
lymphadenopathy. No JVD. Cardiac exam: Regular rate, S1,
S2. No murmurs, rubs or gallops. Pulmonary: Normal with
slight crackles heard at the bases. Abdominal exam: Mild
distention, tympanic to percussion in the epigastric and
right upper quadrant region. No rebound or guarding. No
hepatosplenomegaly or masses appreciated. Extremity exam:
Unremarkable. Neurologic exam: Alert and oriented x3,
moving all extremities. No focal abnormalities.
LABORATORY DATA FROM ADMISSION: White blood cell count 8.4,
65 percent polys, 30 percent lymphocytes, 2.4 percent
monocytes, 2.4 percent eosinophils. Hematocrit 37.1,
platelets 302 and MCV 93. Chemistry profile notable for a
BUN of 39, creatinine of 1.2, ALT 18, AST 37, alkaline
phosphatase 85, total bilirubin 0.4, amylase 652, lipase
2,642, CK 63, troponin 0.06. Urinalysis, positive for
leukocyte esterase and blood, negative nitrites, greater than
50 white blood cells, moderate bacteria noted, 0 to 2
epithelial.
IMPRESSION: A [**Age over 90 **]-year-old female presenting with recurrent
pancreatitis and hypertension, question of bowel ischemia,
most likely secondary to low flow state.
HOSPITAL COURSE: The patient was in the ICU after pressors
were discontinued. She was transferred out to the floor on
[**2169-3-14**]. Upon transfer to the floor, the patient developed
acute congestive heart failure from flash pulmonary edema.
Her saturation dropped to 76 percent on room air with a blood
pressure 205/142 and a heart rate of 105. Lungs exam were
notable for diffuse expiratory wheezes and chest x-ray showed
evidence of pulmonary edema. The patient was given nitrates,
morphine, Ativan. Her pressure dropped to 70/44, but
subsequently responded to BiPAP and Lasix, with a normalized
pressure, and saturations returned to 96 to 97 percent on
room air. The patient was sent to the NICU for respiratory
monitoring and BiPAP. The patient was then called out again
to the floor with standing dose of by mouth Lasix and a net
diuresis of approximately 2 liters. She received a total of
two units of packed red blood cells for anemia. Her
laboratory studies were notable for a rising troponin of 1.08
with normal CK. EKG showed pseudonormalization of T waves in
the lateral precordial leads, otherwise it was stable from
prior studies. It was thought that this patient may have
suffered from a non-ST-elevation myocardial infarction in the
setting of having flash pulmonary edema. Repeat
echocardiogram was performed on the 14th, which showed an EF
of 30 percent, moderate regional LV systolic dysfunction
consistent with CAD, moderate MR, worse from prior study,
most likely in the setting of having decompensated congestive
heart failure. The patient was maintained on Toprol XL and
aspirin after a net diuresis with IV Lasix. She is
clinically stable without any evidence of chest discomfort or
cough. Cardiac enzymes began to trend down upon the time of
discharge. The patient was also initiated on statin therapy
in the setting of having had a non-ST-elevation myocardial
infarction. Plavix was also restarted.
Hypertension: The patient's blood pressure was normalized
upon the time of discharge. She was maintained on
antihypertensive regimen.
Type 2 diabetes: The patient was restarted on her glipizide.
Urinary tract infection: Urine cultures were negative and
the patient was asymptomatic, and therefore, antibiotics were
held.
Anemia: Unclear etiology. The patient had iron studies that
were sent. Guaiac studies were negative. The patient did
have a stable hematocrit post transfusion, may have been
likely hemodilutional. However, the patient does have a
history of cancer as well as coronary artery disease and
diabetes, all of which are chronic conditions, which could be
contributing to her chronic anemia.
Pancreatitis: The patient is status post aggressive IV fluid
hydration, normalization of her LFTs and resolution of her
abdominal pain.
Code status: The patient was DNR/DNI during this
hospitalization course.
DISCHARGE DIAGNOSES: Pancreatitis.
Hypertension.
Non-ST-elevation myocardial infarction.
Congestive heart failure.
Anemia.
DISCHARGE MEDICATIONS:
1. Ursodiol 300 mg p.o. b.i.d.
2. Aricept 10 mg p.o. at bedtime.
3. Seroquel 25 mg p.o. once daily.
4. Levothyroxine 75 mcg daily.
5. Aspirin 81 mg daily.
6. Glipizide 10 mg 2 tablets p.o. daily.
7. Lasix 60 mg daily.
8. Lisinopril 2.5 mg daily.
9. Nitroglycerin sublingual as needed for chest discomfort.
10. Protonix 40 mg daily.
11. Colace as needed.
12. Senna as needed.
13. Toprol XL 25 mg daily.
[**First Name11 (Name Pattern1) 1356**] [**Last Name (NamePattern1) **], [**MD Number(1) 104366**]
Dictated By:[**Last Name (NamePattern1) 12866**]
MEDQUIST36
D: [**2169-10-5**] 16:19:12
T: [**2169-10-6**] 04:46:11
Job#: [**Job Number 104367**]
|
[
"244.9",
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"599.0",
"401.9",
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"V45.01",
"250.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2775, 2793
|
7234, 7337
|
7360, 8059
|
4352, 7212
|
1509, 1950
|
113, 1485
|
2921, 3542
|
3560, 4334
|
1973, 2758
|
2810, 2906
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,779
| 150,851
|
35316
|
Discharge summary
|
report
|
Admission Date: [**2159-10-17**] Discharge Date: [**2159-11-8**]
Date of Birth: [**2114-3-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
Fulminant liver failure - ? Tylenol toxicity, acute renal
failure
Major Surgical or Invasive Procedure:
Intracranial bolt placement and removal
Placement of multipl central lines and removal
Placement of tunneled dialysis line
Debridement of feet wound
Intubation and extubation
History of Present Illness:
45F w/ h/o psychiatric disorder, depression and domestic abuse
transferred from [**Hospital **] hospital where she was admitted yesterday
evening with acute liver failure likely secondary to Tylenol
ingestion (level was initially 11 but repeat was <10, o/w tox
was negative for alcohol and urine tox was negative). Per the
outside records, her case worker ([**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 1968**]) through the
domestic violence shelters was concerned after speaking to her
one day PTA where she was noted to be confused and then went to
see patient and confirmed MS change and went to ED. There, she
was afebrile, hypotensive (70/45), tachycardic (HR 111), with RR
16 on 2L NC (96% O2 sats). She was given normal saline (6L),
zofran, reglan, protonix, and was started on a norepinephrine
drip. She was also started on an octreotide drip (per GI
consult), vit K and NAC. She had progressive respiratory
distress and was intubated in the MICU. Prior to intubation she
only answered minimal questions, c/o of abdominal pain and
denied ingestion of any toxic substances or Tylenol. In MICU,
she had ARF w/ creatinine of 4.1 and anuric, INR 4.9, lactic
acidosis (lactate 5.2 to 6.3), pH 7.23, bicarb 13. Her LFTs
were: AST 6067, ALT 4509; AP 268, TBili 2.1; CK 3087 - peak
9048; WBC 6.6,
HCT 28.6, and Plts 285. In addition, she was placed on broad
spectrum antibiotics (vancomycin & zosyn) for empiric coverage.
She was transferred here for further management.
Past Medical History:
ankylosing spondylitis (on pain medications, prednisone)
psychiatric disorder (on depakote)
ovarian cyst
Iron deficiency anemia
Victim of domestic abuse
Social History:
History of domestic violence, staying at domestic violence
shelter since 6/[**2159**]. Per reports, no history of drug use,
minimal alcohol use, unknown tobacco smoking status. However,
interview with family members (who are more or less estranged
from patient) after arrival to SICU, revealed that she has
history of polysubstance abuse including use of crack cocaine.
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
Drips: Neo 0.2; Propofol 65; NAC 63cc/hr (8.8mg/ml)
O: T: 97.1 HR: 121 ST BP: 102/58 RR: 36 O2Sats: 91% Vent
Vent: PCV 4/100%/505x30/20, PIP 25
Gen: intubated, sedated, NAD, no jaundice
HEENT: Pupils equal, round, reactive 4 to 3mm bilaterally;
+ecchymosis L eye
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: tachycardic
Abd: diminished BS, Soft, NT, mild distension, no HSM
Extrem: Warm and well-perfused, mild edema
Neuro: unable to assess
Physical Exam on discharge:
T: 98.4 HR: 103 BP: 107/65 RR: 20 O2 sat: 98% (2L NC)
HEENT: PEERL, EOMI, MMM
CV: Tachycardic, regular rhythm, no murmurs
Resp: clear to auscultation bilaterally
Abdomen: +bs, soft, non-distended, non-tender
Extremity: Healing necrotic wound in the superficial surfaces of
both feet. Left feet wound with exposed tendon. No signs of
active infection. Left leg slightly larger in size than right
leg. Tenderness on palpation. 1+ edema up to mid-calf
bilaterally.
Neuro: alert and oriented to person, place and time
Pertinent Results:
Labs on discharge:
- CBC: WBC-8.1 RBC-2.54* Hgb-7.6* Hct-22.9* MCV-90 MCH-30.1
MCHC-33.4 RDW-16.1* Plt Ct-213
- COAGS: BLOOD PT-13.2 PTT-33.3 INR(PT)-1.1
- CHEM 10: Glucose-93 UreaN-34* Creat-3.1* Na-134 K-3.8 Cl-101
HCO3-28 Calcium-8.3* Phos-3.4 Mg-1.7
- LFT's: ALT-34 AST-28 AlkPhos-256* TotBili-2.8*
.
Imaging/diagnostics:
- CT head w/o contrast ([**2159-10-17**]):Diffuse effacement of cerebral
sulci increased from one day prior, suggesting increased diffuse
cerebral edema. Opacification of bilateral ethmoid air cells and
also right mastoid air
cells, probably related to OG tube and ET tube, which are in
place. Narrowed cervical spinal canal at C1, as described above,
and seen to
[**Hospital1 2824**] extent on outside institution CT C-spine from one day
prior.
.
- CT head w/o contrast ([**2159-10-22**]): Improvement in cerebral edema
with reexpansion of the sulci, ventricles and some basal
cisterns. New 1 cm lesion with peripheral hyperdensity in the
superficial left occipital lobe, which could indicate a subacute
hematoma. An infectious or embolic lesion cannot be excluded.
Upon clinical correlation, MRI should be
considered for further evaluation. New partial opacification of
the left mastoid air cells.
.
- EEG ([**2159-10-22**]):This is an abnormal continuous EEG due the
presence of a
6-6.5 Hz theta rhythm background with frequent bursts of frontal
delta
slowing occasionally reaching a semi-rhythmic pattern observed
throughout the recording. This is consistent with a mild to
moderate
diffuse encephalopathy, such as most commonly seen with
medication
effect, metabolic derangement, or infection. Compared to the
previous
tracing, the background rhythm has improved and the patient now
demonstrates evidence of Stage I and II sleep architecture, as
well as a
slow posterior dominant rhythm.
.
- Bilateral lower extremity ultrasound ([**2159-11-1**]): No DVT in
bilateral lower extremity.
.
- CXR ([**2159-11-5**]): Significantly improved multifocal pneumonia.
.
- Echocardiogram ([**2159-11-7**]): The left atrium is normal in size.
The estimated right atrial pressure is 0-10mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests
a normal left ventricular filling pressure (PCWP<12mmHg).
Doppler parameters are most consistent with normal left
ventricular diastolic function. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. IMPRESSION: Normal
biventricular systolic function. Normal left ventricular
diastolic function.
Brief Hospital Course:
45yo F with history of depression, anemia, ankylosing
spondylitis, polysubstance abuse, admitted for acetominophen
overdose resulting in hepatic failure, renal failure,
respiratory failure, cerebral edema, who received vasopressors
through veins in feet resulting in ischemic necrosis.
.
Brief SICU course:
On arrival, R IJ HD line, L IJ CVL (triple lumen), R Axillary
[**Last Name (un) **] a-line were placed, outside hospital femoral a-line along
w/ bilateral pedal PIVs removed. Patient was initially on
propofol for sedation on the ventilator. CT head w/o contrast
showed cerebral edema. Neurosurgery placed ICP monitor and
patient treated with hypertonic saline. ICP was removed and
patient's mental status improved.
She was treated with NAC gtt and then stopped after liver
function started to recover. ARF (ATN) and was started on CVVH
and then HD with renal following her closely. She was weaned off
pressors and extubated. Continued on stress steroids given
ankylosing spondylitis. Patient transferred to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**]
service for further management.
.
LIVER SERVICE hospital course:
# Liver failure: LFTs were AST/ALT = 45/108 wit tbili 6.8 on
transfer. They continued to trend down, and her synthetic
function was intact throughout. At the time of discharge, they
were AST/ALT = 28/24. Tbili = 2.8. Alk phos 256.
.
# Acute renal failure: Acute tubular necrosis from acetaminophen
overdose. Cr was 5.4 with oliguria (<20 cc/hr) on transfer.
Renal service followed closely. She was dialysed on average
3x/week until discharge. Her renal function fluctuated between
2.5 - 5. A tunneled hemodialysis line was placed in the right IJ
prior to discharge. She will continue with dialysis at rehab
after discharge.
.
# Pneumonia/Hypoxia: Patient had 2L NC oxygen requirement on
transfer. She developed a fever and CXR showed LUL pneumonia.
Patient was started empirically on vancomyinc and cefepime for
ventilator-associated pneumonia. Repeat CXR showed resolution of
pneumonic after 7-day course. BNP was elevated so echocardiogram
was performed, which showed EF>55% and normal ventricular
function. Fluid removal through dialysis further improved
respiratory function. Patient continued to have 2L oxygen
requirement, but only at night. Patient should be worked up for
obstructive sleep apnea as an outpatient.
.
# Feet necrosis: From having levophed and calcium infusing
through peripheral IV at OSH. This lead to full thickness
necrosis. Plastics performed debridement and followed closely
with daily dressing changes. The wounds continued to heal but
were still deep at the time of discharge. Patient has follow-up
appointment with plastic surgery after discharge.
.
# Anemia/thrombocytopenia: Patient has no standing anemia. Her
Hct in the hosptial ranged from 21 - 25. She was transfused with
pRBC when Hct <21 with appropriate response. No active bleeding
source found. Her platelets recovered with improvement of liver
function. At the time of discharge, platelet count was >200
thousand.
.
# Psychiatric/delirium: Patient had waxing and wanning mental
status at first, but improved quickly. Psychiatry followed the
patient throughout. She required a 1:1 sitter at first but later
was deemed safe to be alone. She was started on Haldol 5 mg at
night to help with sleep. She will have regular psychiatric
follow-up at discharge to rehab. After rehab, psychiatry service
will rearrange for inpatient psychiatric treatment.
.
# Anklylosing Spondylitis: Patient was on 10 mg po prednisone
chronically. She was treated with stress dose therapy while in
the ICU, but was transitioned back to home dose. She did not
have a flare while in the hospital.
Medications on Admission:
-Depakote 1g daily at night
-Klonopin 1mg [**Hospital1 **]
-Nabumatone 500mg [**Hospital1 **]
-Prednisone 10mg daily
-Vicodin 5/500 mg q 4 hrs prn for pain
-Ambien 10mg at night prn
Discharge Medications:
1. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. haloperidol 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital1 8**]
Discharge Diagnosis:
Acetaminophen overdose
Suicide attempt
Fulminant liver failure
Acute renal failure requiring dialysis
Cerebral edema
Respiratory failure
Ischemic necrosis of the feet
Ankylosing spondylitis
Anemia
Thrombocytopenia
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:
Ms. [**Known lastname 40984**], you were admitted to the [**Hospital1 827**] because you overdosed on tylenol. You had
difficulty breathing and had to be placed on the ventiltor. Your
liver was affected and we gave you medication to protect it from
being damaged. Your kidneys also were affected and you had to
start dialysis which you will continue with. You had medicine
through IVs in your feet at the outside hosptial, which led to
severe damage of the flesh on your lower legs. We cleaned and
dressed the wounds. You will follow up with platic surgery after
discharge. Your platelet count was low but improved with time.
You had a pneumonia which we treated with antibiotics. Your
oxygen level is low when you sleep at night. You should see a
doctor to see if you have obstructive sleep apnea once you are
discharged. The psychiatrists followed you while you were here.
They recommend continue psychiatric care at the rehabilitation
center, and then possibly inpatient psychiatric treatment
afterwards.
.
We made the following changes to your medications:
STARTED:
- Haloperidol 5 mg by mouth at night
Followup Instructions:
Department: DIV. OF PLASTIC SURGERY
When: FRIDAY [**2159-11-16**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], MD [**Telephone/Fax (1) 6331**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: LIVER CENTER
When: WEDNESDAY [**2159-11-21**] at 4:20 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2159-11-8**]
|
[
"785.4",
"707.13",
"720.0",
"V58.65",
"518.81",
"788.5",
"785.59",
"570",
"276.2",
"572.2",
"572.4",
"348.5",
"E959",
"486",
"995.80",
"286.7",
"E967.0",
"997.31",
"287.5",
"584.5",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"39.95",
"83.39",
"88.67",
"38.95",
"01.10",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11096, 11161
|
6749, 7866
|
383, 560
|
11419, 11419
|
3738, 3738
|
12726, 13440
|
2665, 2683
|
10681, 11073
|
11182, 11398
|
10474, 10658
|
7883, 10448
|
11595, 12627
|
2698, 2712
|
3204, 3719
|
12656, 12703
|
278, 345
|
3757, 6726
|
588, 2083
|
2726, 3176
|
11434, 11571
|
2105, 2260
|
2276, 2649
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,517
| 160,804
|
45179
|
Discharge summary
|
report
|
Admission Date: [**2107-11-11**] Discharge Date: [**2107-11-14**]
Service: MEDICINE
Allergies:
Lipitor / Lovastatin / Vancomycin
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
hyperkalemia, altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt. is a [**Age over 90 **] yo female with PMH of CHF, CAD, afib and HTN who
presents with elevated potassium by labs taken at her rehab. She
was noted at [**Hospital3 2558**] rehab, where she was recovering from
a very recent pelvic fracture s/p mechanical fall, to have
decreased appetite and poor PO intake. K was 6.6 and creatinine
was 1.9.
.
In the ED she was found to have a K of 5.9 and she was given 10U
of regular insulin in D50 once as well as 30g of kayexalate x1
and Ca gluc 2 g x 1. She was also noted to have pyuria by UA and
was give 400mg of IV cipro and 250 IV NS bolus and 1 liter slow
infusion given her low EF. She was also found to have acute on
chronic renal failure with a Cr of 2.3 and a baseline of
1.0-1.3. She had a negative head CT. CXR showed Large bilateral
pleural effusions, right much greater than left. Underlying
consolidative process in the right lower lung is difficult to
entirely exclude.Patient cannot give much history but does
report that she feels sob. Denies chest or abd pain.
Past Medical History:
Hypertension
Hypercholesterolemia
CAD s/p CABG at [**Hospital1 112**] [**2092**]
CHF (EF 30%)
Carotid stenosis
AFib
Cholecystitis
Left cataract surgery
Vaginal cyst removal
Seasonal allergies
hx of MRSA
Social History:
She works as a volunteer at the [**Hospital1 18**]. Denies tobacco, alcohol,
IVDU. She lives by her self [**Last Name (NamePattern1) 18764**] at baseline but has
been at [**Hospital3 2558**] in [**Location (un) **] since recent d/c. Has a
daughter who lives in [**Name (NI) 4628**].
Family History:
Non Contributory.
Physical Exam:
vitals: T 95.6 BP 120/44 HR 58 RR 19 SpO2 100 on 3 L NC
gen: eyes closed, tacchypneic, frail-appearing woman
heent: NCAT, anicteric, no injections, pt would not keep eyes
open during exam, OP clear with very dry MM
neck: no JVD, supple, no LAD
pulm: very diminished at bases R > L
cv: sinus brady with 3/6 holosytolic murmur at apex
abd:+bs, soft, nt, nd
extr: 2+ pitting edema to buttocks, no pedal pulses appreciated,
legs were warm
neuro: could not assess
Pertinent Results:
Labs:
pH 7.37 pCO2 48 pO2 191 HCO3 29 BaseXS
K:5.9
Color Yellow Appear Clear SpecGr 1.015 pH 5.0 Urobil Neg
Bili Neg Leuk Tr Bld Neg Nitr Neg Prot Tr Glu Neg Ket Neg
RBC 0-2 WBC [**11-29**] Bact Few Yeast None Epi 0-2 Other Urine Counts
CastHy: 0-2
138 102 73
-------------< 97
27 2.3
estGFR: 19/24 (click for details)
CK: 48 MB: Notdone Trop-T: 0.04
Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
[**91**]
wbc 8.5 hgb 8.1 hct 26.2 424
26.2
N:86.6 Band:0 L:10.1 M:2.7 E:0.3 Bas:0.3
Hypochr: 2+ Anisocy: 2+ Poiklo: 1+ Macrocy: 1+ Microcy: 1+
Ovalocy: 1+ Burr: OCCASIONAL
Imaging:
CHEST (PORTABLE AP) Study Date of [**2107-11-10**] 8:27 PM
FINDINGS: The study is compromised secondary to positioning and
the patient is in a marked reverse lordotic orientation. This,
however, is similar to multiple prior examinations. There are
bilateral pleural effusions, right much greater than left,
stable since the prior exam. Pulmonary vascularity is hazy and
there may be underlying mild interstitial edema. No definite
focal consolidation is seen. However, given the opacity from the
large effusions, the basilar process is difficult to entirely
exclude. There is marked senescent calcification of the
tracheobronchial tree, again incidentally noted. Atherosclerotic
disease of the aorta is also present. The cardiac silhouette
remains enlarged with a left ventricular configuration.
IMPRESSION: Large bilateral pleural effusions, right much
greater than left. Underlying consolidative process in the right
lower lung is difficult to entirely exclude. There is a
hypertensive cardiomediastinal configuration.
.
CT HEAD W/O CONTRAST Study Date of [**2107-11-10**] 8:44 PM
NON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage.
Moderate cerebral atrophy is noted. The visualized paranasal
sinuses are clear. There is mild opacification of right ethmoid
air cells. The EACs are clear. There is a calvarial fracture or
soft tissue abnormality.
IMPRESSION: No acute intracranial hemorrhage.
ekg- 2 ekgs, one with rate 58 and LAD with LVH and TWI I, AVL
and V4-6 and later one with rate of 115, lad, LVH, TWI I, AVL,
V5 and V6, lead v4 with pseudonormalization. Also with st
depression v5, v6.
Brief Hospital Course:
This is a [**Age over 90 **] yo female with PMH of CHF, CAD, afib and HTN who
was admitted for hyperkalemia, acute on chronic renal failure,
and altered mental status, in setting of recent pelvic fracture.
She was also found to have pyuria treated with cipro abx, and
large bilateral pleural effusions R>L on CXR. She was initially
admitted to the ICU for monitoring. However unfortunately had
progressive decline over the first 24 hours, according to notes,
with worsening hypoxia, hypotension and altered mental status.
ICU team discussed goals of care with daughter ([**Name (NI) **]) and her
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1728**], and plan made to focus care on comfort and
dignity, without aggressive interventions or escalation of care.
On [**11-13**], lost IV access and replacement was unsuccessful. IV
team recommended that patient would need PICC or central line
for access if felt necessary. However, given goals of care no
further line placed. Started on PO liquid morphine for comfort.
Last note from ICU team from the morning of [**11-13**] reports patient
nonresponsive to questions but does open eyes to voice.
Called out to floor on evening of [**11-13**] at 1045pm. Sitter at
bedside. Patient noted to be unresponsive with agonal breathing
pattern. Subsequently passed away peacefully, time of death
pronounced at 12:48am. Daughter [**Name (NI) 96562**] Notified.
Medications on Admission:
lactobacilli 1 tab [**Hospital1 **]
lovenox 40 mg sc qd
lopressor elixir 2 mg [**Hospital1 **]
tylenol 650 q 4 prn
duoneb q6 prn
debrox qhs
saline nasal spray tid
asa 81 mg qd
pureed diet
celexa 20 mg qd
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"414.00",
"585.9",
"427.31",
"276.7",
"V45.81",
"799.02",
"599.0",
"584.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6326, 6335
|
4629, 6043
|
280, 286
|
6387, 6397
|
2398, 4089
|
6449, 6455
|
1884, 1903
|
6298, 6303
|
6356, 6366
|
6069, 6275
|
6421, 6426
|
1918, 2379
|
205, 242
|
314, 1338
|
4098, 4606
|
1360, 1564
|
1580, 1868
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,267
| 114,162
|
48226
|
Discharge summary
|
report
|
Admission Date: [**2191-4-19**] Discharge Date: [**2191-5-17**]
Date of Birth: [**2138-3-6**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
mental status changes, sepsis
Major Surgical or Invasive Procedure:
Placement of right IJ central venous catheter
Placement of right peripherally inserted central catheter
Hemodialysis
Surgical debridement R thigh.
History of Present Illness:
Ms. [**Known lastname 37559**] is a 53 y/o female with PMH significant for DM, ESRD
on HD s/p R proximal SFA to proximal AT bypass on [**2191-3-31**]
admitted with wound infection. She was discharged then
readmitted [**2195-4-6**] for volume overload. Subsequently, she
returned to rehab but then was readmitted to the Vascular
Surgery service on [**2191-4-19**] with purulent drainage from her
wound. She was initially treated with vanc/levo/flagyl, and
original wound culture grew pansensitive E coli. On [**4-22**], she
was taken back to the OR where subsequent cultures grew MRSA and
Klebsiella. Over her hospital course, the patient was
intermittently confused and disoriented. The patient tolerated
HD on [**4-25**], but could not tolerate HD on [**4-27**] [**12-31**] hypotension
(down to 59 systolic). On [**4-27**], ID was consulted who recommended
vancomycin, meropenem and gentamycin. EKG on admission to the
ICU showed new lateral TWI (no intervention, occurred in setting
of hypotension, peak troponin 0.9 and CK ~ 800). The patient was
bolused with IVF in the MICU (transfer on [**4-27**]) and antibiotics
were broadened per ID recs.
In the ICU, an A line could not be placed but R IJ was placed on
[**4-28**]. She was transfused 1 U PRBCs on [**2191-4-29**]; she received
ativan and haldol for agitation thought [**12-31**] toxic metabolic
state as well as infection. Gentamycin d/c'd on [**4-29**] but patient
continues on vancomycin (d13), meropenem (d5), and flagyl (d3).
She was noted to have scant blood out of rectal tube but
hematocrit has been stable thus far and patient is on multiple
anticoagulants (ASA, plavix, SC heparin). Vascular surgery
continues to follow with next wound vac change is planned for
[**Last Name (LF) 766**], [**5-2**]. At the present time, the patient feels quite
well. She has no shortness of breath or chest pain. She has some
right leg pain which is overall quite improved from prior. She
denies any nausea or vomiting; she is having [**4-3**] diarrheal
stools per day, which is unchanged over the past few days.
Past Medical History:
renal failure secondary to diabetes mellitus on HD
status post R nephrectomy for renal cell cancer
depression
cholecystectomy
gastric ulcer
PVD s/p Left SFA to dorsalis pedis artery bypass for L
gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on
[**2191-3-31**]
OSA
Gastroparesis
Social History:
lives in senior housing, 2 children, former tobacco, quit 7 yrs
ago, 1PPDx20 yrs, no ETOH, no drugs
Family History:
Multiple family members with [**Name (NI) 2320**] and HTN
Physical Exam:
VS: T 99.1 HR 68 BP 95/59 RR 18 94% on 3L NC (home O2
requirement)
GENL: obese, cooperative, speaking clearly and in full
sentences, appropriate
HEENT: OP clear, MMM, no JVD, no icterus
CV: RRR, + II/VI systolic murmur at RSB, no rubs/gallops
Lungs: clear bilaterally
Abd: soft, nd, bs+ no masses. no HSM. obese.
Ext: R thigh wound with wound vac in place. No obvious drainage
from incisions in right lower leg. DP pulses 1+ bilaterally. No
peripheral edema.
Pertinent Results:
Labs on admission:
Imaging:
Microbiology:
Labs on discharge:
Brief Hospital Course:
53 y/o F ESRD on HD, with large Right thigh wound at site of
saphenous vein harvest for CABG, originally admitted to the
hospital for wound infection and a question of sepsis. She was
treated with meropenem and vanco on the floor until she was
found to be bleeding large amounts from rectum.
She was transferred to the MICU on [**2191-5-5**] for LGIB with
hypotension.
MICU course. Pt was readmitted to the ICU with hematochezia. Pt
was irgently brought to the ICU, where SBP dropped to the 60's.
Trauma line was placed, 4 units of PRBC, 2 bags of platelets,
and ddAVP 20 mcg given, and patient was brought to IR, where
angio was performed in hopes of embolization. Pressors were
initiated for a matter of minutes. The [**Female First Name (un) 899**] though located, could
not be cannulated due to its small caliber, calcification and
tortuosity. A generalized run was therefore performed adjacent
to the orifice of the [**Female First Name (un) 899**], and this demonstrated no active
extravasation, as well. Given no active site of bleed. Patient
was returned to the floor, with BP's continung in the 80's
systolic. MAP mantained above 60 by transfusion. Transfused to
crit>28. Surgery and GI consulted. GI performed NG lavage with
bilious material therefore endoscopy not performed. Surgery
consulted and deferred surgery given inability to localize bleed
and desire to avoid total colectomy in patient with numerous
comorbidities. Prep for colonoscopy was not initiated day one
given labile blood pressure and concern for hemodynamic
stability. Day two patient was prepped for colonoscopy. Only
sigmoidoscopy completed as linear ulcerations consistent with
ischemic colitis found. Deemed likely etiology of bleed.
Ischemic colitis in the setting of atheroschlerosis with
hypotension from sepsis leading to poor perfusion. Patient kept
NPO, with bowel rest, maintaining blood pressure, and [**Hospital1 **] PPI.
No hematochezia after day two in the MICU. Day prior to call out
pt developed hemoptysis in the setting of wretching. NG lavage
was negative for gross blood. GI informed. No EGD at that time.
Patient was called out of the MICU with stable hematocrit, and
BP on clear diet. No hematemesis, hematochezia, melena at time
of transfer to floor.
Angiography showed: Assessment of the celiac, SMA and [**Female First Name (un) 899**]
demonstrating no abnormal vasculature, no evidence of active
extravasation
.
On the floor, her right thigh wound was managed with a wound
vac, changed by vascular surgery on [**2191-5-10**]. She was taken to
the OR for debridement on [**5-12**]. She continued on vanco/meropenem
for 21 days.
.
Hemodynamically, she remained stable while on the floor after
transfusion of pRBCs, FFP and ddAVP, with a stable HCT. Her
blood pressure, while difficult to obtain (right forearm only)
remained in the 95-105 range. She did not have further GI
bleeding while on the floor. Her diet was slowly advanced and
she toelrated it well.
.
While in the MICU, she was noted to have EKG Changes: ST
depressions in inferolateral distribution; however, recent Echo
and stress test were normal. Enzymes have peaked and are
trending down.
She was originally started on ASA, plavix, and a statin. The
plavix was held in the setting of her GI Bleed.
A repeat EKG on [**5-10**] showed resolution of ST depressions. At no
time did she experience chest pain.
.
The patient was continued on her home diabetes regimen, and
insulin sliding scale added when needed.
.
ESRD: The renal team folowed the patient. She had dialysis
every mon, wed, Fri while in house. She had one episode of
hypotension during dialysis, requiring blood transfusion.
Electrolytes remained normal. Subsequent dialysis was without
problems.
.
She was found to have a stage II sacral decubitus ulcer. She
was transferred to a [**Doctor First Name **]-air bed, and a wound care nursing
consult was enacted. Physical Therapy was also consulted.
.
During her initial hospital stay, she experienced Mental status
changes/Agitation: Likely result of toxic metabolic causes,
infection, in addition to encephalopathy from Uremia and use of
pain meds. Dilaudid in particular seemed to cause mental status
changes and agitation. Upon transfer to the floor, she was
alert and oriented, without agitation.
.
Access: R IJ placed on [**2191-4-28**], d/ced in ICU. R PICC placed.
She also has a left av fistula for dialysis use.
She was Full code
.
After the surgical debridement of her right thigh wound, the
patient remained stable and tolerated POs. She was then
transferred to rehab for continued treatment.
Medications on Admission:
Meds on transfer from MICU:
ASA 81 mg daily
cinacalcet 60 mg daily
plavix 75 mg daily
gabapentin 300 mg daily
haldol 2 mg IV prn (agitation)
heparin SC TId
SSI, NPH insulin
iron 150 mg daily
ativan 0.5 mg prn agitation
Meropenem 500 mg IV daily
flagyl 500 mg Q12H
nephrocaps 1 daily
oxycodone prn pain
protonix 40 mg daily
sevelamer 2400 TID
simvastatin 20 mg daily
simethicone prn
vancomycin 500 mg at HD
Discharge Medications:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
2. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: 1-20 units
Subcutaneous ASDIR (AS DIRECTED).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
12. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
13. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 3 days: Stop date [**5-19**].
Disp:*3 Recon Soln(s)* Refills:*0*
14. Vancomycin 1,000 mg Recon Soln Sig: One (1) dose Intravenous
QHD per protocol for 2 days: stop day [**5-19**].
Disp:*2 bags* Refills:*0*
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by
2 ml of 100 Units/ml heparin (200 units heparin) each lumen
Daily and PRN. Inspect site every shift.
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Right thigh wound with wound vac
Diabetes Mellitus
Right heel wound
Ischemic colitis
End Stage Renal Disease on Hemodialysis
Discharge Condition:
Fair
Discharge Instructions:
You have been in the hospital because the wound on your right
thigh was infected. YOu are almost finished with a long course
of antibiotics. The wound will heal over time, but will
continue to need a wound vac dressing for many weeks.
Please continue all medicines as prescibed.
Please continue hemodialysis as usual.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 2450**] in [**11-30**] weeks. Call his office at
[**Telephone/Fax (1) 250**] to make an appointment
Please follow up with Dr. [**Last Name (STitle) **] on [**5-27**] at 930 at [**Hospital1 **].
call [**Telephone/Fax (1) 2395**] for directions
|
[
"557.9",
"707.03",
"998.59",
"038.11",
"403.91",
"V09.0",
"285.1",
"585.6",
"250.40",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"83.39",
"39.95",
"38.93",
"48.23",
"88.47",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
10290, 10387
|
3643, 8244
|
300, 448
|
10556, 10563
|
3555, 3560
|
10933, 11231
|
3001, 3060
|
8701, 10267
|
10408, 10535
|
8270, 8678
|
10587, 10910
|
3075, 3536
|
231, 262
|
3620, 3620
|
476, 2544
|
3575, 3600
|
2566, 2868
|
2884, 2985
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,881
| 113,879
|
25414+25415
|
Discharge summary
|
report+report
|
Admission Date: [**2111-2-5**] Discharge Date: [**2111-2-6**]
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
failure to thrive
Major Surgical or Invasive Procedure:
Placement of open gastrojejunal feeding tube.
History of Present Illness:
The patient is an 81-year-old lady, status post
a sigmoid colectomy. Postoperatively the patient developed
respiratory failure requiring an open tracheostomy tube and
the patient also had a history of CVA and not able to
tolerate a regular diet. For the past several months, the
patient had been fed via nasal jejunal feeding tube and the
patient was taken to the operating room on an elective basis
for an open gastrojejunal feeding tube placement.
Past Medical History:
PMH: Hypothyroidism; Temporal arteritis 2 years ago, with
residual left eye blindness; HTN; h/o dizziness/vertigo;
Polymyalgia rheumatica; h/o laryngeal CA [**25**] yrs, s/p XRTx41.
PSH: Hysterectomy at age 25 for fibroids, per pt; Appendectomy
[**2054**]; Breast lump excision, benign per pt; Right knee
arthroscopy
Social History:
Pt is married and has 2 children. 35 pack year smoker, quit 20
years ago.
Family History:
Father died of lung CA, sister and brother died of MI. Other
brother had a stroke in his 80s, now 84.
Physical Exam:
Afebrile VSS
NAD
CTA B/L
RRR
+BS, NT, ND, soft
Pertinent Results:
[**2111-2-5**] 06:27PM BLOOD Glucose-121* K-4.6
[**2111-2-5**] 06:27PM BLOOD Calcium-8.8 Phos-5.5*# Mg-1.6
Brief Hospital Course:
The patient was taken to the operating room on [**2111-2-5**] for
placement of open gastrojejunal feeding tube. There were no
complications and the patient was transfered to the floor from
the PACU. On POD 1 tube feeds were started (promode [**1-19**]
strangth @ 30ml/hr) and tracheostomy was decanulated. The
patient was tolerating TF & breathing well on her own. She was
subsequently discharged back to [**Hospital3 7**].
Medications on Admission:
1. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): via
G tube.
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily): via G tube.
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): via G tube.
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): via
G tube.
5. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): via G tube.
7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) 30 mg PO DAILY (Daily): via G tube.
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO once a
day.
9. Calcium Carbonate 1,250 mg Capsule Sig: One (1) Capsule PO
twice a day: via G tube.
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO four times a day: via G tube.
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day:
via G tube.
12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO twice
a day: via G tube.
13. Loperamide 1 mg/5 mL Liquid Sig: Two (2) mg PO QID PRN: via
G tube.
14. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day:
via G tube.
15. Potassium Chloride 10 % Liquid Sig: Forty (40) meq PO once a
day: via G tube.
16. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg PO once a
day: via G tube.
17. Dalteparin (porcine) 5,000 anti-Xa u/0.2mL Syringe Sig: One
(1) Subcutaneous twice a day.
18. Acetaminophen 500 mg/5 mL Liquid Sig: Five (5) mL PO q4-6 hr
prn: via G tube.
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily): via
G tube.
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily): via G tube.
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): via G tube.
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): via
G tube.
5. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): via G tube.
7. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) 30 mg PO DAILY (Daily): via G tube.
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO once a
day.
9. Calcium Carbonate 1,250 mg Capsule Sig: One (1) Capsule PO
twice a day: via G tube.
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO four times a day: via G tube.
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day:
via G tube.
12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO twice
a day: via G tube.
13. Loperamide 1 mg/5 mL Liquid Sig: Two (2) mg PO QID PRN: via
G tube.
14. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day:
via G tube.
15. Potassium Chloride 10 % Liquid Sig: Forty (40) meq PO once a
day: via G tube.
16. Furosemide 10 mg/mL Solution Sig: Twenty (20) mg PO once a
day: via G tube.
17. Dalteparin (porcine) 5,000 anti-Xa u/0.2mL Syringe Sig: One
(1) Subcutaneous twice a day.
18. Acetaminophen 500 mg/5 mL Liquid Sig: Five (5) mL PO q4-6 hr
prn: via G tube.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
failure to thrive
Discharge Condition:
good
Discharge Instructions:
Restart you home medications as usual. You may resume activity
as tolerated.
You may shower, then pat-dry incision. Do not rub incision. No
tub baths or swimming for 3-4 weeks.
You may leave the incision uncovered or use a light dressing for
comfort. Keep the white strips until they fall off.
* Increasing pain
* Fever (>101.5 F) or Vomiting
* Inability to eat or drink
* Inability to pass gas or stool
* Other symptoms concerning to you
Followup Instructions:
1. Call Dr.[**Name (NI) 6433**] office for a follow-up appointment ([**Telephone/Fax (1) 9946**]
Completed by:[**2111-2-6**] Admission Date: [**2111-2-6**] Discharge Date: [**2111-2-11**]
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Respiratory distress after discharge to extended care facility
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is an 81 year-old female who was recently on the
Blue surgery service and was released to [**Hospital1 **] extended care
facility on [**2111-2-6**]. On post-discharge day #1, the patient
desaturated to 70%. She was brought to the [**Hospital1 18**] ED where her
tracheostomy tube was recannulated. She was also give furosemide
40mg IV, after which time her respiratory distress was in part
mitigated.
Past Medical History:
PMH: Hypothyroidism; Temporal arteritis 2 years ago, with
residual left eye blindness; HTN; h/o dizziness/vertigo;
Polymyalgia rheumatica; h/o laryngeal CA [**25**] yrs, s/p XRTx41.
PSH: Hysterectomy at age 25 for fibroids, per pt; Appendectomy
[**2054**]; Breast lump excision, benign per pt; Right knee
arthroscopy
Social History:
Pt is married and has 2 children. 35 pack year smoker, quit 20
years ago.
Family History:
Father died of lung CA, sister and brother died of MI. Other
brother had a stroke in his 80s, now 84.
Brief Hospital Course:
The patient is an 81 year-old female who was recently released
to [**Hospital1 **] extended care facility on [**2111-2-6**]. She was on the
Blue surgery service for elective placement of open
gastrojejunal feeding tube on [**2111-2-5**]. Prior to discharge, her
tracheostomy was decannulated such that the patient was
breathing on her own.
On post-discharge day #1, the patient desaturated to 70%. She
was brought to the [**Hospital1 18**] ED where her tracheostomy tube was
recannulated. She was also give furosemide 40mg IV, after which
time her respiratory distress was in part mitigated.
She was admitted to the SICU for close observation and
ventilatory support. Blood, urine and sputum cultures were
obtained. On HD#2, the patient received 1 unit of packed red
blood cells for a hematocrit value of 23.7. On HD#4, blood and
urine cultures proved negative, but sputum cultures grew 4+ E.
coli sensitive to meropenem, with which she was treated. The
patient was weaned off the ventilator, was placed on a
tracheostomy mask and was transferred from intensive care to the
surgical [**Hospital1 **]. She did very well, maintaining her saturations
above 96% on an FiO2 of 0.4.
On HD#6, she was discharged back to [**Hospital1 **] extended care
facility in good condition, with instructions to follow up in
clinic with Dr. [**Last Name (STitle) **].
Medications on Admission:
prednisone 5mg po qd
VitD3 400U po qd
atorvastatin 10mg po qd
lisinopril 5mg po qd
levothyroxine 100mcg po qd
lansoprazole 30mg po qd
clotrimazole cream TP [**Hospital1 **]
metoprolol 75mg po qd
CaCo3 1250mg po qd
simethicone 80mg po QID
folate 1 mg po qd
FeSO4 300mg po BID
sertraline 25mgpo qd
loperamide 2mg po QID:PRN
furosemide 20mg po qd
dalteparin 5000u sc BID
Discharge Medications:
meropenem 1g IV q8hours x 7 days.
prednisone 5mg po qd
VitD3 400U po qd
atorvastatin 10mg po qd
lisinopril 5mg po qd
levothyroxine 100mcg po qd
lansoprazole 30mg po qd
clotrimazole cream TP [**Hospital1 **]
metoprolol 75mg po qd
CaCo3 1250mg po qd
simethicone 80mg po QID
folate 1 mg po qd
FeSO4 300mg po BID
sertraline 25mgpo qd
loperamide 2mg po QID:PRN
furosemide 20mg po qd
dalteparin 5000u sc BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Respiratory distress
CHF exacerbation
pneumonia
HTN
hypothyroidism
temporal arteritis
colon cancer
laryngeal cancer
endometrial cancer
Discharge Condition:
Stable
Discharge Instructions:
You may resume your pre-hospital medications, if any.
Call Dr. [**Last Name (STitle) **] or come to the ER if you have:
* fever above 101F
* nausea, vomiting or diarrhea that doesn't stop
* drainage from or separation of the wound
* chest pain or shortness of breath
You may shower, but no soaking in a tub or swimming for 4 weeks
after surgery.
You may resume your normal diet.
Followup Instructions:
See Dr. [**Last Name (STitle) **] in clinic in 2 weeks. Call ([**Telephone/Fax (1) 29931**] for an
appointment.
Completed by:[**2111-2-11**]
|
[
"V10.42",
"518.81",
"401.9",
"285.9",
"482.82",
"V10.21",
"244.9",
"428.0",
"V10.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"97.23",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
9293, 9372
|
7094, 8449
|
6070, 6077
|
9551, 9560
|
1397, 1505
|
9988, 10131
|
6968, 7071
|
8867, 9270
|
9393, 9530
|
8475, 8844
|
9584, 9965
|
1329, 1378
|
5968, 6032
|
6105, 6519
|
6541, 6860
|
6876, 6952
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,234
| 144,313
|
24869+57421
|
Discharge summary
|
report+addendum
|
Admission Date: [**2132-10-31**] Discharge Date: [**2132-11-12**]
Date of Birth: [**2062-3-21**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Unwitnessed fall approximately [**5-15**] ft
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 year old male s/p unwitnessed fall from approximately [**5-15**]
feet; following commands at the scene. Seizure activity and
declining mental status at referring hospital; intubated. CT
scan of head revealed frontal contusions. Patient transferred
here for continued trauma care.
Past Medical History:
No known medical problems
Appendectomy
Hernia repair
Social History:
Retired Marine drill [**Last Name (un) **]
Denies ETOH
Quit pipe smoking [**2130**]
Family History:
Non-contibutory
Physical Exam:
VS upon admission to trauma bay:
198/106 113 100%
Gen: Intubated/sedated
HEENT:PERRL, sluggish 2-1 mm; 2 cm occipital laceration, staples
in place
Chest: CTA bilat
Cor: RRR
Abd: soft, ND FAST negative
Pelvis: Stable
Rectum: guaiac negative
Extr: no deformities
Pertinent Results:
[**2132-10-31**] 10:55PM LACTATE-2.0
[**2132-10-31**] 10:45PM GLUCOSE-150* UREA N-21* CREAT-0.8 SODIUM-140
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-27 ANION GAP-17
[**2132-10-31**] 10:45PM ALBUMIN-4.4 CALCIUM-8.7 PHOSPHATE-3.5
MAGNESIUM-1.8
[**2132-10-31**] 10:45PM WBC-18.2* RBC-5.14 HGB-14.6 HCT-42.6 MCV-83
MCH-28.3 MCHC-34.2 RDW-14.0
[**2132-10-31**] 10:45PM PLT COUNT-219
[**2132-10-31**] 10:45PM PT-12.7 PTT-19.9* INR(PT)-1.1
[**2132-10-31**] 10:45PM FIBRINOGE-385
[**2132-10-31**] 06:30PM AMYLASE-59
CHEST (PA & LAT) [**2132-11-10**] 8:56 AM
CHEST (PA & LAT)
Reason: new or changing consolidation?
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with AMS and new fever
REASON FOR THIS EXAMINATION:
new or changing consolidation?
TWO VIEW CHEST, [**2132-11-10**]
COMPARISON: [**2132-11-3**].
INDICATION: Fever.
The heart size is normal, and there is no evidence of
mediastinal or hilar lymphadenopathy. There are linear band-like
areas of opacity in the right middle and lower lobes, but no
focal confluent areas of consolidation are observed. There are
no pleural effusions.
IMPRESSION: Linear right middle and lower lobe opacities in
keeping with discoid atelectasis. No areas of consolidation to
suggest pneumonia.
Based on [**2124**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a low risk (prophylaxis not recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
PATIENT/TEST INFORMATION:
Indication: Syncope.
BP (mm Hg): 140/75
HR (bpm): 68
Status: Inpatient
Date/Time: [**2132-11-4**] at 09:35
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2005W429-0:05
Test Location: West Echo Lab
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.4 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: 0.29 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 50% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.7 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.13
Mitral Valve - E Wave Deceleration Time: 21 msec
TR Gradient (+ RA = PASP): <= 20 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 0.9 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
Septal e'=0.12
Lateral
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Normal regional LV
systolic function. Low normal LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Mildly dilated ascending
aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Based on [**2124**] AHA endocarditis prophylaxis
recommendations,
the echo findings indicate a low risk (prophylaxis not
recommended). Clinical
decisions regarding the need for prophylaxis should be based on
clinical and
echocardiographic data.
Conclusions:
The left atrium is mildly elongated. Left ventricular wall
thicknesses and
cavity size are normal. Regional left ventricular wall motion is
normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta
is mildly dilated. The aortic valve leaflets (3) appear
structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial
effusion.
IMPRESSION: Low normal left ventricular systolic function
without regional
dysfunction.
Based on [**2124**] AHA endocarditis prophylaxis recommendations, the
echo findings
indicate a low risk (prophylaxis not recommended). Clinical
decisions
regarding the need for prophylaxis should be based on clinical
and
echocardiographic data.
CAROTID SERIES COMPLETE [**2132-11-3**] 10:16 AM
CAROTID SERIES COMPLETE
Reason: syncope w/u
[**Hospital 93**] MEDICAL CONDITION:
70 year old man s/p fall
REASON FOR THIS EXAMINATION:
syncope w/u
INDICATION: 70-year-old man with history of syncope and fall.
COMPARISON: None available.
TECHNIQUE AND FINDINGS: Duplex ultrasonography was performed at
the level of the cervical portions of the bilateral carotid and
vertebral arteries.
No plaque was found on either side. The waveforms and velocities
in the bilateral internal, common, and external carotid arteries
and bilateral vertebral arteries were strictly normal, with
antegrade flow.
CONCLUSION:
Examination within normal limits.
CT HEAD W/O CONTRAST [**2132-11-3**] 4:48 PM
CT HEAD W/O CONTRAST
Reason: MENTAL STATUS CHANGES R/O NEW BLEED HX OF SAH
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with AMS
REASON FOR THIS EXAMINATION:
new bleed?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 70-year-old man with mental status changes. Evaluate
for new bleed.
COMPARISON: [**2132-11-1**].
TECHNIQUE: Head CT without contrast.
There is stable appearance of multiple contusion in the frontal
lobes bilaterally and the left temporal lobe. The surrounding
areas of low attenuation in the frontal and left temporal lobes
appears more prominent indicative of increased edema. Small
amount of subarachnoid blood is again noted around the frontal
lobes and temporal lobes. The left parafalcine subdural hematoma
is reduced in size. There is no shift of normally midline
structures, hydrocephalus or major vascular territorial
infarction. Brain herniations are noted.
Midline fracture of the occipital bone is again noted.
IMPRESSION: Interval increase in the area of low attenuation
around the frontal and temporal lobes around the brain
contusions indicative of increased edema.
Reduction in size of left parafalcine subdural hematoma.
Otherwise, this study is unchanged with multiple bilateral
frontal and left temporal contusions with associated small
amount of subarachnoid hemorrhage.
CHEST (PORTABLE AP) [**2132-11-11**] 5:18 AM
CHEST (PORTABLE AP)
Reason: eval pneumonia, effusions
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with ICH sp fall, ETT was in R main stem, RLL
atelectasis with fevers
REASON FOR THIS EXAMINATION:
eval pneumonia, effusions
PORTABLE CHEST [**2132-11-11**].
COMPARISON: [**2132-11-10**].
INDICATION: Fevers.
The heart is upper limits of normal in size and stable. The lung
volumes are relatively low. Linear opacities in the right mid
and lower lung zones are not significantly changed accounting
for this factor. No definite areas of consolidation are
observed, but PA and lateral chest radiograph may be helpful for
more complete assessment if clinical suspicion for pneumonia
persists.
Brief Hospital Course:
Patient admitted to the trauma service. Neurosurgery, and
Behavioral Neurology were consulted. Neurosurgery has
recommended non-surgical intervention with follow up head CT
scan in 6 weeks and continue Dilantin for at least one week if
no seizure activity; maintain SBP less than 160. Behavioral
Neurology consulted because of patient's head injuries and his
impulsiveness; they have recommended to continue with the
Dilantin and monitor levels closely; regulate sleep-wake cycle
with Trazodone, adjust Zyprexa dose by decreasing daytime dose
for optimal alertness. His day time dose of Zyprexa was
discontinued because of increased day drowsiness; nighttime dose
has been decreased from mg to 2.5 mg. As his behavior improves
would consider discontinuing Zyprexa altogether. He was
re-loaded with Dilantin and put on base dose of 200 mg po BID;
his levels will need to be rechecked in 3 days. He has not had
any seizure activity during his stay here. He developed fever
101.4 on HD#11, he was cultured; chest xray obtained (see
pertinent results). His Urinalysis was negative; urine culture
result pending at time of dictation; LENIS negative for deep
vein thrombus; CXR with no consolidation; his WBC was 10.4 on
[**11-12**]. Physical therapy and Social work were consulted as well.
Physical therapy has recommended rehabilitation in a Traumatic
Brain Injury facility.
Medications on Admission:
"Occassional" Albuterol
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
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. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QD PRN () as
needed for increased agitation.
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
10. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): Hold for SBP less than 110 mmHg.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
12. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO Q 12H (Every 12 Hours).
13. Olanzapine 5 mg Tablet Sig: [**2-10**] tab Tablet PO HS (at
bedtime).
14. Trazodone 50 mg Tablet Sig: [**2-10**] Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
s/p Fall
Bilateral Frontal COntusions
Left Temporal Contusion
Subarachnoid Hemorrhage
Discharge Condition:
Stable
Discharge Instructions:
Follow up with Neurosurgery in 6 weeks.
Follow up with your Primary Care Doctor after your discharge
from rehabilitation.
Followup Instructions:
Call [**Telephone/Fax (1) 1669**] for an appointment in 6 weeks with
Neurosurgery; inform the office that you will need a repeat head
CT scan prior to your appointment.
If you choose to you may follow up in Behavioral [**Hospital 878**]
CLinic as an outpatient after your discharge from
rehabilitation, call [**Telephone/Fax (1) 1690**] for an appointment.
Completed by:[**2132-11-12**] Name: [**Known lastname 5786**],[**Known firstname **] Unit No: [**Numeric Identifier 11222**]
Admission Date: [**2132-10-31**] Discharge Date: [**2132-11-12**]
Date of Birth: [**2062-3-21**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 844**]
Addendum:
Patient's Dilantin level subtherapeutic today; 4.7, he is being
reloaded with a total of 1 GM in 3 divided doses. He will
receive at least the first 2 doses here and the 3rd dose will
need to be given at the rehab facility. Please page the Trauma
Intern if you have further questions.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**] MD [**MD Number(1) 846**]
Completed by:[**2132-11-12**]
|
[
"780.39",
"801.20",
"E884.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13014, 13240
|
8829, 10201
|
321, 328
|
11790, 11799
|
1150, 1772
|
11969, 12991
|
833, 850
|
10277, 11567
|
8196, 8282
|
11681, 11769
|
10227, 10252
|
11823, 11946
|
2675, 6078
|
865, 1131
|
233, 283
|
8311, 8806
|
356, 640
|
662, 716
|
732, 817
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,157
| 126,232
|
33488
|
Discharge summary
|
report
|
Admission Date: [**2201-4-22**] Discharge Date: [**2201-4-30**]
Date of Birth: [**2167-10-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Gunshot wound to abdomen
Major Surgical or Invasive Procedure:
[**2201-4-22**] Exploratory laparotomy, partial left colectomy, proximal
jejunal resection and anastomosis, [**Doctor Last Name **] procedure, end
sigmoid colostomy, take down splenic flexure
History of Present Illness:
33 yo male who sustained 32 caliber gunshot wound from ~10ft
away to his abdomen. GCS 15 at scene. He was taken to an area
hospital and becasue of his injuries was medflighted to [**Hospital1 18**]
for further management.
Past Medical History:
Chronic low back pain
Panic attacks
Social History:
Married, lives with wife
h/o cocaine use
Family History:
Noncontributory
Pertinent Results:
[**2201-4-22**] 08:46PM GLUCOSE-152* LACTATE-2.2* NA+-134* K+-4.3
CL--100 TCO2-26
[**2201-4-22**] 08:16PM GLUCOSE-142* LACTATE-1.8 NA+-139 K+-4.2
CL--100 TCO2-26
[**2201-4-22**] 08:05PM AMYLASE-51
[**2201-4-22**] 08:05PM ASA-9 ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2201-4-22**] 08:05PM WBC-23.2* RBC-4.19* HGB-12.7* HCT-36.2*
MCV-87 MCH-30.4 MCHC-35.1* RDW-12.9
[**2201-4-22**] 08:05PM PLT COUNT-337
[**2201-4-22**] 08:05PM PT-10.9 PTT-20.0* INR(PT)-0.9
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Age (years): 33 M Hgt (in): 71
BP (mm Hg): 138/87 Wgt (lb): 256
HR (bpm): 129 BSA (m2): 2.34 m2
Indication: tachycardia
ICD-9 Codes: 427.89
Test Information
Date/Time: [**2201-4-24**] at 14:06 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7474**], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2008W00-: Machine: Vivid [**7-27**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.6 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 70% to 80% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.80
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Hyperdynamic LVEF >75%. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. No 2D or Doppler evidence of distal
arch coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal mitral valve supporting structures. No MS. LV inflow
uninterpretable due to tachycardia and/or fusion of spectral
Doppler E and A waves
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor parasternal views. Suboptimal
image quality - poor apical views.
Conclusions
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Left ventricular systolic function is hyperdynamic
(EF 70-80%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
Pathology Examination
SPECIMEN SUBMITTED: LEFT COLON, SMALL BOWEL-PROXIMAL JEJUNUM.
DIAGNOSIS:
I) Proximal jejunum segment (A-C):
Transmural defect with adjacent hemorrhage.
II) Left colon, segment (D-H):
Transmural defects with adjacent hemorrhage.
Clinical: Gunshot to abdomen.
Gross: The specimen is received fresh, in two parts, each
labeled with the patient's name '[**Known lastname 77651**], [**Known firstname 2398**]" with the
medical record number.
Part 1 is additionally labeled "small bowel, proximal jejunum".
It consists of a segment of bowel measuring 6.5 x 4 x 2.5 cm. It
has two staple ends, measuring 4 cm and 3.5 cm, respectively.
The specimen is previously opened to reveal erythematous mucosa.
It is serially sections to reveal hemorrhagic submucosa. The
specimen is represented as follows: A=staple margins,
B-C=random sections.
Part 2 is additionally labeled "left colon". It consists of a
segment of colon with attached mesocolonic fat measuring 18 x
7.5 x 2.5 cm overall. The colon measures 17 cm in length and 3
cm in diameter. It has two stapled ends, measuring 7.5 cm and
5.8 cm, respectively. The mesocolon is focally hemorrhagic. The
colon is opened along the antimesocolic surface to reveal two
areas of submucosal hemorrhage. The first area measures 3.5 x
3.5 cm abutting one of the staple margins, within which a
transmural defect is identified measuring 1.9 x 1.5 cm. The
second hemorrhagic area measures 7.5 x 6 cm, located 3 cm from
the other stapled margin. Within this area, two transmural
defects are identified, measuring 2.1 x 0.8 cm and 1.5 x 0.8 cm,
respectively. The specimen is represented as follows: D=staple
margin with abutting hemorrhagic area, E=the other staple
margin, F=defect at first hemorrhagic area, G=defect at second
hemorrhagic area, H=unremarkable colon.
Brief Hospital Course:
He was admitted to the Trauma service and taken to the operating
room for exploratory laparotomy, proximal jejunal resection and
primary anastomosis, partial left colectomy, end sigmoid
colostomy, [**Doctor Last Name **] procedure and take down of splenic flexure.
There were no intraoperative complications; postoperatively he
was extubated and taken to the Trauma ICU where he remained for
several days. He was later transferred to the regular nursing
unit. He developed an ileus and was kept NPO for a couple of
days; this did resolve and he is now tolerating a regular diet.
His colostomy is producing adequate amounts of stool. There were
also some issues with urinary retention postoperatively; he
failed an initial voiding trial and had his Foley replaced. The
catheter was left in for another 2 days and with bladder
training was removed successfully. He is voiding on his own
without any difficulties. He will require follow up with Dr.
[**Last Name (STitle) 519**], Surgery, the week following discharge for removal of his
staples.
Acute Pain Service was also consulted given his history of
chronic pain and now with his recent traumatic injury. He was
initially on a Ketamine drip; later Methadone was added and
Dilaudid IV for breakthrough pain. The Ketamine drip was
stopped; his Methadone was increased to 30 mg tid and he was
switched to oral Dilaudid prior to discharge. He will be
discharged on Methadone and Dilaudid.
At this time Social Work had been closely involved with patient;
they recommended a Psychiatry consult because of issues
surrounding anxiety; patient self reports history of panic
attacks. He was started on Klonopin 1 mg tid which helped with
his anxiety. It was also recommended that he be started on
Duloxetine 20 mg daily for depression. He has been instructed to
follow up with his PCP early next week for a referral to a
Psychiatrist in his area. He is agreeable to the plan discussed.
The Wound Ostomy Nurse was also consulted to assist with
teaching regarding ostomy care. He is being discharged with home
services to assist with ongoing teaching with his ostomy.
He was also evaluated by Physical therapy and cleared for
ambulation.
Medications on Admission:
Oxycontin 120mg tid
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
Disp:*5 Patch Weekly(s)* Refills:*2*
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*1*
3. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day): For pain control scondary to acute pain syndrome.
Disp:*270 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for headache.
5. Topiramate 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*1*
6. Duloxetine 20 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:*1*
7. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for breakthrough pain.
Disp:*90 Tablet(s)* Refills:*0*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*1*
9. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
10. Magnesium Citrate 1.745 g/30mL Solution Sig: [**1-21**] - 1 Bottle
PO once a day as needed for constipation.
11. Ostomy supplies
[**First Name9 (NamePattern2) **] [**Last Name (un) **] fit wafer
2 [**1-23**] in flange
#[**Numeric Identifier 77652**]
2 boxes 11 refills
12. Ostomy supplies
[**Numeric Identifier **] Pouch Invisiclose
2 [**1-23**] in
#[**Numeric Identifier 77653**]
2 boxes 11 refills
13. Ostomy supplies
Safe & simple wipes
25 per pkg
#SNS00525
2 boxes 11 refills
14. Ostomy supplies
Stomadhesive powder
#[**Numeric Identifier 29197**]
1 bottle 11 refills
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
s/p Gunshot wound to abdomen
Small bowel injury
Postoeprative ileus
Urinary retention
Acute pain syndrome
Discharge Condition:
Good
Discharge Instructions:
Return to the emergency room if you develop any fevers, chills,
headache, dizziness, shortness of breath, chest pain, increased
abdominal pain, nause, vomiting, diarrhea, abscence of stool
from your colostomy, increased redness/drainage from your
incision site and/or any other symptoms that are concerning to
you.
It is importnat that you take your medications as prescribed.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 519**] in clinic nex week for removal of your
staples, call [**Telephone/Fax (1) 6554**] for an appointment.
It is important that you follow up with your primary care
doctor, Dr. [**First Name (STitle) **] within the next week, you will need to ask
him for a referral to see a Psychiatrist for ongoing counseling
surrounding your mental health.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2201-4-30**]
|
[
"788.20",
"E878.6",
"863.39",
"997.5",
"E965.0",
"863.53",
"997.4",
"560.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.10",
"45.75",
"45.62",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
10422, 10478
|
6440, 8622
|
344, 537
|
10627, 10633
|
957, 6417
|
11060, 11605
|
921, 938
|
8694, 10399
|
10499, 10606
|
8648, 8669
|
10657, 11037
|
276, 306
|
565, 788
|
810, 847
|
863, 905
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,700
| 154,513
|
30190
|
Discharge summary
|
report
|
Admission Date: [**2199-5-22**] Discharge Date: [**2199-6-7**]
Date of Birth: [**2147-6-13**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Cephalosporins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
shortness of breath and edema
Major Surgical or Invasive Procedure:
plasmapheresis/hemodialysis catheter placement
History of Present Illness:
Pt is a 51 y/o F call-out from MICU after admission for likely
TTP. Please see excellent MSIII note for full details, but
briefly, pt had been in USOH being treated for foot cellulitis X
2weeks with Keflex. After 10 days Keflex, she began to note full
body non-raised rash, petechiae over arms, and larger
confluences on her legs. Keflex d/c'd, given Benadryl, and
started on doxycycline, which she said made her feel sick. Pt
noted increased fatigued, [**Location (un) **] over her baseline, increasing SOB
with exertion.
.
In the ED, initial laboratories remarkable for anemia with a hct
of 25.7 and thrombocytopenia 85,000. BUN/Cr 83/10. She was
afebrile but hypertensive. Heme/onc and renal consulted. RBCs
and RBC casts in urine. Smear positive for schistocytes.
Plasmapheresis initiated for presumed TTP. She was given nitro
paste, tylenol, solumedrol 500mg IV x1, and labetalol 400mg po
x1. A R IJ pheresis catheter was placed.
.
In MICU, improvement in thrombocytopenia and elevated LDH s/p
pheresis and HD X3. She was hemodynamically stable and called
out to floor. Pt still oliguric.
.
On floor, she has no complaints exceot some mild fatigue on
exertion; however, she reports feeling better with improved
breathing and able to lie flat without SOB/orthopnea. She denies
any pain. ROS negative for recent diarrhea, no viral URIs, no
icterus or changes in the color of her skin or urine. Denies
dysuria, chest pain, confusion, fevers, or ataxia.
Past Medical History:
None
Social History:
Lives with husband and 2 of her 3 children. Denies tobacco,
drinks occasional social EtOH, and denies IVDU. Is [**Name8 (MD) **] RN in day
surgery.
Family History:
no known clotting d/o, no PE or DVT; M with + miscarriage
Physical Exam:
VS: 99.3 185/110 86 20 93 % RA
Gen: well appearing, NAD
HEENT: faint scleral icterus, PERRL, EOMI, OP clear
NECK: RIJ in place, nl LAD
CV: RRR, nl S1/S2, 2/6 SEM (flow murmur)
Pulm: bibasilar crackles at bases bilaterally
Abd: soft, NT/ND, +BS, no masses
Ext: trace pitting edema, warm, good pulses
Neuro: alert and oriented, appropriate
Skin: Irregular 1cm left upper back lesion nontender, raised,
pink (known to pt). Numerous small papules over entire back;
non-pruritic
Pertinent Results:
.
.
.
.
.
.
.
.
DIC labs negative
DAT negative
LDH high, haptoglobin low
.
[**Doctor First Name **] positive
ANCa negative.
Hepatitis screen: negative, Hep Sab postive.
.
.
IMAGING:
.
Peripheral Blood Smear (per Dr. [**Last Name (STitle) 20764**]: Prominent neutrophils
(mature); low platelets with some large forms and no platelet
clumps; occasional hypochromic red cells; on average 5 schistos
per HPF ([**4-10**] schistos noted in every field examined in the thin
area of the slide).
.
[**5-27**] CXR: mild CHF
.
Renal U/S: no hydro; small to moderate bilateral pleural
effusions
.
ECHO: The left atrium is mildly dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional 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 aortic valve leaflets
(3) appear structurally normal with good leaflet excursion.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: No left ventricular outflow tract obstruction or
significant
valvular disease seen. Symmetric left ventricular hypertrophy
with preserved systolic function.
Brief Hospital Course:
51 y/o female patient with microangiopathic hemolytic anemia,
thrombocytopenia, and acute renal failure thought to be the
result of scleroderma renal crisis.
.
# Microangiopathic hemolytic anemia/Thrombocytopenia:
The final cause for [**Doctor First Name **] and Thrombocytopenia is still not
completely clear, though it was likely somehow associated with
her scleroderma renal crisis. Initially, pt was tought to have
TTP/HUS (she met 3 out of diagnostic 5 criteria) and was treated
by plasmapheresis. ADAMST13-actvity was low but at a level
significant enough to induce TTP; no ADAMST13-inhibitor was
found. Inciting factors were not fully clear, keflex was
considered initially. Patient was screened for Cryoglobulin,
Anticardiolipin-Antibodies, Lupus-Anticoagulans, Hep A,B and C
serology, C3, and C4, which were all within normal limits.
Improvement in thrombocytopenia and elevated LDH s/p 1st cycle
of pheresis. However, pheresis was discontinued as she did not
seem to be improving significantly with it.
Pt was found to have elevated [**Doctor First Name **] (1:1280--pre-plasmapheresis).
This along with notable skin findings and hx of Raynauds raised
suspicion for scleroderma with associated renal crisis.
.
# Scleroderma: This diagnosis was made primarily on clinical
finding: the pt's sclerodactaly, h/o Raynauds as wel as her (+)
[**Doctor First Name **]. Pt did not have (+) Anti-Scleroderma antibody
titers--however, this test is not specific. Pt underwent skin
bx which, with given her clinical picture, was consistent with
scleroderma. The pt was followed by both dermatology and
rheumatology, who are scheduled to see her as an outpatient.
She will need further evaluation as an outpatient to assess the
extent of organ involvement. For instance, she will need a
repeat echo to assess PA pressure (her first echo could not
assess this) as well as chest CT.
.
# Renal failure:
Pt presented with acute renal failure that was likely due to
scleroderma renal crisis. Per rheumatology, this scleroderma
renal crisis is typically characterized by acute onset of renal
failure with relatively [**Name2 (NI) 29734**] urine sediment, marked
hypertension, and can be complicated by microangiopathy. It also
is typically seen earlier on in the natural history of Diffuse
Systemic Sclerosis, consistent with her otherwise limited past
history.
Pt was also evaluated for idiopathic TTP, [**Last Name (un) **],B,C serologies,
C3, C4, SPEP, UPEP, ASO and ANti GBM, which were all within the
normal limits. She did receive steroids on admission for
initial concern of GN--her admission UA showed RBC casts.
However, subsequent UA's did not show RBC casts, and, thus, the
steroids were discontinued.
Given the severity and persistence of her renal failure, the pt
was initiated on hemodialysis. A peritoneal dialysis catheter
was also placed as the pt was expected to need long-term
dialysis.
The pt was started on captopril for treatment of presumed
scleroderma renal crisis. ACE inhibitors are the cornerstone of
treatment of scleroderma induced renal disease. This was
evidenced by the positive effect it had on her BP. The pt was
kept on captopril (and not converted to lisinopril) as she
seemed respond better to the captopril than the lisinopril.
.
# HTN:
This was first time the patient was noticed to have hypertension
(as high as 170/110). She was initially treated with metoprolol
but later switched to Captopril (as above), along with
Amlodipine and Valsartan.
.
# PVC:
Pt was found to have irregular rhythm and monomorphic PVCs.
Echocardiography revelaed left ventricular hypertrophy but the
reason for PVCs was not fully clear. While in hospital she was
monitored on Tele.
.
# Contact Dermatitis:
Pt developed ichty rash over her back. Symptoms got better upon
Savar cream and anti-allergic bedclothes.
.
# Basal Cell Carcinoma: pt to have f/u with derm for basal cell
lesions on back and chest.
Medications on Admission:
occasional Motrin or Tylenol
recently on Keflex and doxy
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Captopril 50 mg Tablet Sig: Three (3) Tablet PO three times a
day.
Disp:*270 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Microangiopathic anemia and thrombocytopenia
Probable scleroderma renal crisis
Probabl basal cell carcinoma
Discharge Condition:
Good s/p Hemodialysis
Discharge Instructions:
Please call Dr. [**Last Name (STitle) 2450**] or Dr. [**Last Name (STitle) 7473**] or go to the ED if you
experience shortness of breath, chest pain, fever, chills,
redness around your catheter sites or any other concerning
change in your condition.
.
You are to receive hemo-dialysis support at [**Location (un) **] dialysis
unit starting on Tuesday.
.
Please limit your intake of fluids (as instructed by the renal
doctors).
.
Please do not shower or get your PD catheter wet until you are
seen by Dr. [**First Name (STitle) **] on [**2198-6-28**].
.
Please call your HMO and switch your primary care doctor to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**] (as soon as possible)--this is necessary to do
before your appointment with him.
.
If you decide that you would like to attend the M&M conference
on Tuesday [**6-18**] from 8-9am in the [**Hospital1 **] 312/315 conference
room, please page Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] #[**Numeric Identifier 71939**]. You may call the
main # for the hospital to page: [**Telephone/Fax (1) 22727**].
Followup Instructions:
Date/Time: [**2199-6-13**] at 8:20 with your new PCP, [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8145**],
M.D., Phone:[**Telephone/Fax (1) 673**] (in [**Hospital Ward Name 23**] Building [**Hospital Ward Name 71940**])
.
Date/Time: [**2199-6-20**] at 12:15 with Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**] (RHEUM
LMOB) in the [**Hospital Unit Name **] Phone:[**Telephone/Fax (1) 2226**]
.
Date/Time: [**2199-6-21**] at 11:45 with Provider: [**First Name11 (Name Pattern1) 2747**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], NP
(dermatology) Phone:[**Telephone/Fax (1) 1971**]
.
Date/Time: [**2199-6-28**] at 1:40 with Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD
(transplant surgery)
.
|
[
"428.0",
"403.91",
"584.5",
"701.0",
"E930.4",
"553.1",
"283.9",
"287.5",
"427.89",
"692.9",
"585.6",
"443.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.71",
"39.95",
"38.93",
"54.93",
"86.11",
"38.95",
"53.49"
] |
icd9pcs
|
[
[
[]
]
] |
8722, 8728
|
4163, 8087
|
313, 361
|
8889, 8913
|
2634, 4140
|
10062, 10874
|
2061, 2120
|
8194, 8699
|
8749, 8868
|
8113, 8171
|
8937, 10039
|
2135, 2615
|
244, 275
|
389, 1850
|
1872, 1878
|
1894, 2045
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,480
| 194,275
|
54144
|
Discharge summary
|
report
|
Admission Date: [**2177-6-17**] Discharge Date: [**2177-6-22**]
Date of Birth: [**2109-7-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / scallops only
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion/AF
Major Surgical or Invasive Procedure:
[**2177-6-18**]
Mitral Valve Repair (28mm St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **])
Maze, Left Atrial Appendage Ligation
History of Present Illness:
67 year old male hospitalized for
rapid A Fib earlier this year with dyspnea on exertion. He was
cardioverted to SR and echo showed severe mitral regurgitation.
Of note, he has history of mitral valve prolpase x 15 years.
Presents today for pre-op cath, which reveals normal coronaries.
Past Medical History:
Mitral Regurgitation
Atrial Fibrillation
PMH:
Hyperlipidemia
Hypertension
Diabetes mellitus type II
Osteoarthritis
Abdominal aortic aneurysm (2.4-3.2cm)
Prostate Cancer (watchful waiting)
Bilateral knee patellofemoral syndrome
Past Surgical History:
Lap cholecystectomy
Bilateral hernia repair
Social History:
Lives with: Wife in [**Name2 (NI) 745**], MA
Occupation: Retired CPA
Tobacco: Denies
ETOH: several/wk
Family History:
Non-contributory
Physical Exam:
Pulse: 52 Resp: 18 O2 sat: 98%
B/P Right: 133/69 Left:
Height: 5'8" Weight: 170 lbs
General: Well-developed male in no acute distress
Skin: Warm[X] Dry [X] intact [X]
HEENT: NCAT[X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur 3/6 systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X]
Edema none
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
No bruits
Pertinent Results:
[**2177-6-18**], Intra-op TEE
Conclusions
PRE-BYPASS: The left atrium is markedly dilated. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. No spontaneous echo contrast or thrombus is
seen in the body of the left atrium or left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is mildly depressed (LVEF=
40-50 %). Right ventricular chamber size is normal. with
borderline normal free wall function. There are simple atheroma
in the ascending aorta. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. The mitral valve leaflets are
myxomatous. There is partial posterior mitral leaflet flail of
the P2 scallop. The mitral valve leaflets do not fully coapt.
There is moderate thickening of the mitral valve chordae. An
eccentric,anteriorly directed directed jet of Severe (4+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is no pericardial
effusion.
POST CPB:
1. Unchanged left and right ventricular systolci function ((With
patient on epinephrine infusion)
2. An annuloplasty ring (Saddle Shaped) is present in the
mitralposition. Well seated and stable. Normal anterior and
posterior mitral leaflet motion.
3. MVA by PHT method = 1.45 cm2. PG =11 mm Hg. MG= 4 mm Hg
4. Trace AI and intact aorta
5. No other change.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2177-6-18**] 13:50
Brief Hospital Course:
The patient was admitted following cath for IV heparin. He was
brought to the Operating Room on [**2177-6-18**] where the patient
underwent Mitral Valve Repair (28mm St. [**First Name4 (NamePattern1) 923**] [**Last Name (NamePattern1) **]), Maze and
Left Atrial Appendage Ligation with Dr. [**Last Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Heart rate was in the 50s initially, and
beta blocker was held. The patient was gently diuresed toward
the preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Heart rate would increase
to the 70s-80s and Sotalol was resumed. Chest tubes and pacing
wires were discontinued without complication. Lopressor was
started after he demonstrated stable vital signs on Sotalol for
24 hours. Metformin was resumed and blood glucose remained well
controlled. Coumadin was resumed, and Dr. [**Last Name (STitle) **] will continue
to follow this after discharge. The patient was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 4 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged home with VNA
in good condition with appropriate follow up instructions.
Medications on Admission:
Coumadin 3mg daily
Lipitor 40mg daily
Avodart 0.5mg daily
Losartan 50mg daily
Metformin 500mg twice daily
Metoprolol succinate 50mg daily
Sotalol 80mg daily
Flomax 0.4mg daily
Aspirin 81mg daily
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR
Coumadin for Atrial Fibrillation
Goal INR 2-2.5
First draw day after discharge [**2177-6-23**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) **]
Results to phone [**Telephone/Fax (1) 62**]
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO daily ().
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. sotalol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
10. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
11. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
14. 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*
15. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Mitral Regurgitation
Atrial Fibrillation
PMH:
Hyperlipidemia
Hypertension
Diabetes mellitus type II
Osteoarthritis
Abdominal aortic aneurysm (2.4-3.2cm)
Prostate Cancer (watchful waiting)
Bilateral knee patellofemoral syndrome
Past Surgical History:
Lap cholecystectomy
Bilateral hernia repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Trace LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Please call to schedule the following:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], 1 week
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**], 3-4 weeks
Cardiologist Dr. [**Last Name (STitle) **], 2-3 weeks
Primary Care Dr. [**First Name (STitle) 1313**] [**Telephone/Fax (1) 355**] in [**3-18**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for Atrial Fibrillation
Goal INR 2-2.5
First draw day after discharge [**2177-6-23**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) **]
Results to phone [**Telephone/Fax (1) 62**]
Completed by:[**2177-6-22**]
|
[
"V58.61",
"429.5",
"427.31",
"250.00",
"441.4",
"424.0",
"416.8",
"401.9",
"272.4",
"285.1",
"185",
"715.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"39.61",
"37.21",
"37.36",
"37.33",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7427, 7476
|
3918, 5532
|
338, 493
|
7814, 7985
|
2011, 3353
|
8773, 9587
|
1263, 1281
|
5778, 7404
|
7497, 7724
|
5558, 5755
|
8009, 8750
|
7747, 7793
|
1296, 1992
|
275, 300
|
521, 809
|
831, 1058
|
1143, 1247
|
3363, 3895
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,161
| 146,543
|
28420
|
Discharge summary
|
report
|
Admission Date: [**2145-3-27**] Discharge Date: [**2145-4-12**]
Date of Birth: [**2106-12-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex / Ciprofloxacin / Sulfa (Sulfonamides) /
Clarithromycin / Demerol / Red Dye
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 1968**] is a 38 year old male with history of cerebral palsy
who lives at home with his parents. Yesterday the patient
developed a constellation of symptoms including increased
agitation, cough, nausea/vomiting and headache. He has not been
experiencing diarrhea. The patient is at baseline
non-communicative but is reportedly able to communicate through
translation with his mother with gesturing of his eyes. He will
look upward to answer yes.
Given the patient's symptoms his temperature was taken with
reported Tmax of 102. The patient's mother reports that a number
of family members have recently had a viral syndrome including
fever and cough. The patient has not been noted during this time
to have any seizures. Given concern, the patient was brought to
the ED for further evaluation.
ED COURSE: Vitals: T- 99.5 (102.7 highest documented). 128/100,
114, 22, 96% on 2L (room air not documented) In the ED the
patient had a UA which was negative for UTI and a CXR which did
not reveal pneumonia. The patient received 1gm Vancomycin, 2g
Aztreonam, 500mg Flagyl with plan for potential intubation and
LP if ID eval negative. A CT Abd/Pelvis was obtained which
revealed no intraabdominal infection but evidence of bibasilar
infiltrates concerning for organizing pneumonia. Diazepam,
Phenobarb, Tylenol and Ondansetron. He received 3L NS prior to
transfer.
Past Medical History:
#. Cerebral Palsy
- wheelchair bound at baseline
#. Seizure Disorder
#. Ulcerative Colitis
#. History of Aspiration Pneumonia
#. GERD
#. s/p feeding tube placement
Social History:
The patient currently lives at home with his parents who provide
his care. He is at baseline wheelchair bound, dependent on
family for all ADL. He received his care previously at
[**Hospital3 1810**] but currently transitioning to adult
medicine. Receives nutrition predominantly through G-tube but is
allowed minimal solid PO intake, no liquids. Personal care
assistant at home 100 hours a week, patient's mother with him
24-7, very involved in his care.
Tobacco: None
ETOH: None
Illicits: None
Family History:
NC
Physical Exam:
Vitals: T- 100.8 BP- 104/60 HR- 116 RR-24 O2- 86% RA
95% 4L
.
General: Patient is a young male, non-communicative, moderately
agitated with many gutteral upper airway sounds.
HEENT: NCAT, PEERL. Sclera anicteric, conjunctiva WNL. Per
interviewed with mother, patient reports headache but denies
neck pain with forced flexion
Skin: No petechiae, no rashes
OP: Limited exam secondary to participation. + Dental work,
mucous membranes relatively moist appearing
Chest: Course transmitted upper airway sounds on expiration, few
crackles appreciated at left base as well
Cor: Limited by loud pulmonary sounds, regular, no obvious
murmurs, rubs, gallops
Abd: + G-tube, surrounding skin appears intact without erythema
or induration. Mildly distended, no guarding with exam. No pain
on exam per mother's report
Back: Small scar over sacrum s/p mole removal, no sacral
decubitus ulcers
Ext: Hands and legs contracted. No cyanosis, no edema
Neuro: Limited secondary to cooperation
CNII-XII: Appears symmetric, tracks in all directions
Motor: Moves all limbs relativley equally
Pertinent Results:
WBC 8.7(N:88 Band:4 L:5 M:2 E:0 Bas:0 Atyps: 1)
Hct: 40.2
Phenobarb: 16.3
[**Doctor First Name **]: 63
Lip: 17
Alk Phos: 176 (181 [**2143-11-3**])
LDH: 261
Tb: 0.5
Alb: 4.9
Cr: 1.0
.
Microbiology:
UA: Leuk Neg, Nitr Neg, Trace Ket
Ucx: Pending
.
Blood Cultures x 2: Pending
.
.
Imaging:
.
[**2145-3-27**]: Portable CXR
IMPRESSION: No acute cardiopulmonary abnormality
.
[**2145-3-27**]: Portable Abdomen
IMPRESSION: No evidence of obstruction
.
[**2145-3-27**]: CT Abd/Pelvis: Wet read - Bibasilar aveolar infiltrates
likely indicate pneumonia, possibly aspiration pneumonia.
Brief Hospital Course:
38 year old male with history of cerebral palsy, ulcerative
colitis, previous aspiration pneumonias, here with influenza,
aspiration pneumonia, and antibiotic-associated diarrhea.
***FOLLOWUP:
1. Cdiff toxin B pending. Cdiff x2 negative on stool culture.
Was treated with 10 day course of Flagyl IV during admission,
and diarrhea did not change in frequency or quantity.
# Influenza/aspiration pneumonia:
The patient presented with nausea and vomiting from influenza,
and likely aspirated during this admission in this setting. On
[**3-28**], he had an aspiration event and hypoxemia, and CXR showed
LLL infiltrate from aspiration pneumonia. He was treated with
Clindamycin and Levofloxacin, but he developed diarrhea. The
patient has a history of colitis with Ciprofloxacin in the past
per his mother, and Levofloxacin was stopped on [**4-1**], and
Azithromycin was started. On [**4-1**], the patient developed stridor
and worsening O2 saturation to the low 80s with minimal
improvement on NRB. Although ENT found no airway edema,
obstruction or tracheomalacia, the patient's respiratory status
continued to worsen and he was transferred to the MICU and
intubated.
He remained intubated for two days, on aztreonam and vancomycin
(both started [**4-1**]). His weaning was complicated by agitation
and tachycardia, which improved as lines/tubes were minimized.
He was extubated successfully 2 days prior to transfer to the
floor.
# Diarrhea:
On [**3-31**], the patient spiked a new fever and developed
antibiotic-associated diarrhea. His diarrhea continued, despite
being maintained on flagyl x 6 days and cdiff negative x 2.
Cdiff toxin B was still pending on the day of discharge.
# Dystonic reaction to Haldol:
When he arrived to the floor after being in the MICU, he
developed dystonia and partially fixing of his head turned to
the left side, tongue thrusting movements, toe curling, arm and
wrist bending. He had been given haldol 2.5 IV daily because he
had been very agitated in the MICU. When he clinically improved,
his signs did not change. He responded well to Benadryl 50 IV
and Ativan 1 IV TID prn, with relief of dystonia within minutes.
Benztropine was never given because of concern of exacerbating
sinus tachycardia with HR 100-105 due to infection.
# Sinus tachycardia:
His baseline HR is 80s per his mother, who is very involved in
his care. His HR was consistently 100-105 during admission,
despite fluid repletion and running of tube feeds and water
flushes at home rate for 3 days before discharge. His HR should
be rechecked as an outpatient, discussed with his mother. His
mother stated that she was cancelling the patient's appointment
with GI tomorrow because the patient greatly wanted to be home
and away from hospitals, but she lives near a pediatrician
friend who agreed to check the patient's vitals at his house
this week. VNA was offered to the patient's mother and family,
but they agreed to have the pediatrician see the patient in 3
days after discharge.
# Seizure Disorder:
The patient was continued on Phenobarbital, level was
therapeutic during admission.
# Cerebral Palsy:
The patient was continued on Valium QHS for spasms.
# Ulcerative Colitis:
He was continued on Asacol per outpatient regimen.
# GERD:
He was continued on home regimen of PPI and H2-Blocker.
Medications on Admission:
Famotidine 20mg [**Hospital1 **]
Glycolax 1 cap daily
Asacol 1200mg [**Hospital1 **]
Celexa 20mg daily
Prevacid 30mg daily
Phenobarbital 96.12mg (3 x 32.4) qhs
Diazepam 6mg qhs
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Phenobarbital 30 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
4. Prevacid 30 mg Susp,Delayed Release for Recon Sig: One (1)
tablet PO once a day.
5. Diazepam 2 mg Tablet Sig: Three (3) Tablet PO QHS (once a day
(at bedtime)).
6. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*180 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. GlycoLax 17 gram (100 %) Powder in Packet Sig: One (1) caplet
PO once a day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Pneumonia, antibiotic-associated diarrhea
Secondary diagnosis: Cerebral palsy
Discharge Condition:
HR 95-105, tube feeds at home rate, smiling, communicating that
he feels better.
Discharge Instructions:
Please return to the emergency room if you experience increased
shortness of breath, cough, diarrhea, fever, other concerning
symptoms.
Please keep all appointments with your physicians.
Followup Instructions:
1. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6925**] Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2145-4-13**]
1:00
2. Dr. [**First Name8 (NamePattern2) 333**] [**Known lastname 1968**], [**Telephone/Fax (1) 3329**], primary care. Since Dr.
[**Known lastname 1968**] is out for the next few months, please followup with the
primary care physician covering for Dr. [**Known lastname 1968**] per our
conversation.
Completed by:[**2145-4-12**]
|
[
"333.72",
"530.81",
"345.90",
"E930.8",
"487.0",
"507.0",
"E939.2",
"556.9",
"518.81",
"787.91",
"V44.1",
"334.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8440, 8446
|
4213, 7526
|
363, 369
|
8588, 8671
|
3612, 4190
|
8907, 9383
|
2500, 2504
|
7754, 8417
|
8467, 8467
|
7552, 7731
|
8695, 8884
|
2519, 3593
|
317, 325
|
397, 1782
|
8550, 8567
|
8486, 8529
|
1804, 1970
|
1986, 2484
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,404
| 129,129
|
24900
|
Discharge summary
|
report
|
Admission Date: [**2157-12-28**] Discharge Date: [**2158-1-3**]
Date of Birth: [**2088-12-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ampicillin / Demerol
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath and fatigue
Major Surgical or Invasive Procedure:
[**2157-12-28**] - Redo sternotomy/Aortic Valve Replacement (21mm
[**Last Name (un) 3843**] [**Doctor Last Name **] pericardial valve)
History of Present Illness:
This 69-year-old patient with previous coronary artery bypass
grafts in [**2150**] with vein graft to the diagonal and obtuse
marginal artery, presented
with a recent increase in shortness of breath and was
investigated and was found to have critical aortic stenosis with
an aortic valve area of 0.6. The vein grafts to the diagonal and
OM were patent. There was no significant disease
on the right coronary artery. There was moderate disease on the
left anterior descending artery. She was electively admitted for
re-do aortic valve replacement and possible coronary artery
bypass grafting.
Past Medical History:
Aortic stenosis
Hypertension
Hypercholesterolemia
Diabetes Mellitus
Left Bundle Branch Block
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
[**2150**]
h/o Atrial tachycardia
Breast cancer s/p Left mastectomy/XRT
Varicose Veins
Basal Cell CA s/p removal
s/p Left thyroid lobectomy
s/p hysterectomy
s/p appendectomy
s/p tonsillectomy
Social History:
Married and a retired nurse. [**First Name (Titles) 4084**] [**Last Name (Titles) 18038**]. Drinks 1 wine per
day.
Family History:
Brother with CABG at age 65
Physical Exam:
GEN: NAD
SKIN: Well healed sternotomy
HEENT: Oropharynx benign
LUNGS: Clear
HEART: RRR, IV?VI systolic murmur
ABD: Benign
EXT: Warm
NEURO: Alert and orientated
Pertinent Results:
[**2158-1-2**] 09:10AM BLOOD WBC-8.2 RBC-3.13* Hgb-9.8* Hct-27.3*
MCV-87 MCH-31.2 MCHC-35.7* RDW-15.0 Plt Ct-207
[**2158-1-3**] 07:10AM BLOOD Hct-26.8*
[**2157-12-29**] 04:13AM BLOOD PT-12.7 PTT-32.7 INR(PT)-1.1
[**2158-1-2**] 07:45AM BLOOD Glucose-104 UreaN-27* Creat-0.9 Na-138
K-4.2 Cl-100 HCO3-28 AnGap-14
[**2158-1-3**] 07:10AM BLOOD UreaN-21* Creat-0.8 K-4.5
[**2158-1-3**] 07:10AM BLOOD Mg-2.5
Brief Hospital Course:
Mrs. [**Known lastname 62622**] was admitted to the [**Hospital1 18**] on [**2157-12-28**] for elective
surgical management of her aortic stenosis. She was taken
directly to the operating where she underwent a redo sternotomy
with an aortic valve replacement utilizing a 21mm [**Last Name (un) 3843**]
[**Doctor Last Name **] pericardial valve. Please see op note for surgical
details. Postoperatively she was taken to the cardiac surgical
intensive care unit on titrated propofol and phenylephrine
drips. On postoperative day one, she awoke neurologically intact
and was extubated. Aspirin and beta blockade was resumed. Swann
was also removed on POD #1. She was then transferred to the
cardiac surgical step down unit for further recovery. She was
gently diuresed towards her preoperative weight (d/c wt. approx
10 kg above pre-op, will be d/c-d on Lasix). The physical
therapy service was consulted for assistance with her
postoperative strength and mobility. Chest Tubes were removed on
POD #2, as well as her Foley. Pacing wires were removed without
incident on POD #3. Beta blockade was titrated and she was
transfused one unit of PRBCs on post op day 3. During the
remainder of her hospital stay she continued to make a steady
recovery. [**Last Name (un) **] was consulted on post op day six d/t poor
glucose control and ongoing diabetes management. She was
discharged home with VNA services and the appropriate follow-up
appointments on post op day six.
Medications on Admission:
Altace 10mg [**Hospital1 **]
Lopressor 25mg [**Hospital1 **]
HCTZ 25mg QD
Lipitor 80mg QD
Zoloft 50mg QD
Aspirin 81mg QD
Actonel
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:*2*
3. Atorvastatin 80 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:*40 Tablet(s)* Refills:*0*
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8117**] VNA
Discharge Diagnosis:
Aortic stenosis s/p Aortic Valve Replacement
Hypertension
Hypercholesterolemia
Diabetes Mellitus
Left Bundle Branch Block
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
[**2150**]
h/o Atrial tachycardia
Breast cancer s/p Left mastectomy/XRT
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Do not bath. Gently pat incisions dry.
Do no apply lotions, creams, ointments, or powders to incisions.
Monitor wounds for signs of infection. These include redness,
drainage or increased pain. Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
No lifting greater then 10 pounds for 10 weeks.
No driving for 1 month.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in 1 month.
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) 62623**] in 2 weeks.
Call all providers for appointments.
Completed by:[**2158-1-3**]
|
[
"V10.3",
"V15.3",
"998.11",
"V58.67",
"401.9",
"414.01",
"424.1",
"250.00",
"519.3",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.31",
"99.04",
"88.72",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
5193, 5252
|
2242, 3705
|
319, 455
|
5550, 5556
|
1817, 2219
|
1593, 1622
|
3884, 5170
|
5273, 5529
|
3731, 3861
|
5580, 5973
|
6024, 6268
|
1637, 1798
|
248, 281
|
483, 1076
|
1098, 1445
|
1461, 1577
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,113
| 173,172
|
4891
|
Discharge summary
|
report
|
Admission Date: [**2140-11-16**] Discharge Date: [**2140-11-23**]
Date of Birth: [**2103-5-24**] Sex: F
Service: Transplant
HISTORY OF PRESENT ILLNESS: This is a 37-year-old female who
presents on an elective basis for a living-related kidney
transplant.
The patient has a history of end-stage renal failure
secondary to type 1 diabetes with a baseline creatinine of
around 5. She is receiving a kidney from her sister. The
patient has a history of hypertension, coronary artery
disease, and insulin-dependent diabetes for 32 years. She is
status post myocardial infarction in [**Month (only) 547**] of this year and
subsequently underwent coronary artery bypass surgery. She
present electively on the morning of her surgery with no
recent changes in her medical problems.
PAST MEDICAL HISTORY:
1. Sarcoidosis since [**2129**].
2. She is status post cholecystectomy.
3. Status post tubal ligation.
4. Status post left arteriovenous graft placement for
hemodialysis.
5. Insulin-dependent diabetes mellitus times 32 years.
6. Hypertension.
7. Coronary artery disease, status post myocardial
infarction in [**2140-5-1**].
8. End-stage renal disease, on hemodialysis for 1.5 years.
ALLERGIES: Allergies include AMOXICILLIN and CODEINE.
MEDICATIONS ON ADMISSION:
1. Insulin by sliding-scale, NPH insulin 16 units in the
morning and 6 units in the evening.
2. Lipitor 20 mg p.o. q.d.
3. Zoloft 50 mg p.o. t.i.d.
4. Reglan 10 mg p.o. t.i.d.
5. Lopressor 50 mg p.o. b.i.d.
6. Aspirin 81 mg p.o. q.d.
7. Multivitamin 1 p.o. q.d.
8. Remeron p.o. q.d.
SOCIAL HISTORY: She is a half to one pack per day smoker for
10 years who quit approximately one week prior to her
admission. She denies alcohol use.
PHYSICAL EXAMINATION ON ADMISSION: Physical examination at
the time of admission revealed she was in no acute distress.
Blood pressure was 150/79, a pulse of 81. She is legally
blind. She was without any adenopathy. Her chest was clear
to auscultation. Heart had a normal S1 and S2, with no
murmurs, gallops or rubs. Her abdomen was soft with
well-healed incisions. There was no organomegaly.
Extremities were without edema. She had a functioning
arteriovenous fistula with a thrill and a bruit in her left
arm.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area and taken electively to the
operating room. She underwent a living-related renal
transplant in the right iliac fossa. The operation was
somewhat technically difficult secondary to a short segment
of ureter which was anastomosed over a stent to the bladder.
Otherwise, there were difficulties, and estimated blood loss
was minimal.
She was taken postoperatively to the recovery room already
making a large amount of urine. Intraoperatively, for
immunosuppression she received thymoglobulin and Solu-Medrol.
She was started on Prograf and CellCept in the postoperative
period. She was also maintained on Bactrim postoperatively
and did not require ganciclovir, as she and her sister were
cytomegalovirus negative.
The patient's initial postoperative course was relatively
uneventful. Her creatinine, which was 5 initially
postoperatively, slowly dropped over the next few days until
eventually reaching a low of 1. She did receive pamidronate
on postoperative day one and received a total of four doses
thymoglobulin. Her steroid doses were slowly tapered over
her hospital course, and her Prograf level was adjusted to
maintain therapeutic values between 10 and 15. She continued
to make good urine over the first few days and had her urine
losses replaced with intravenous fluids.
On postoperative day three, the patient had an episode of
shortness of breath that was evaluated by both the Renal and
surgical residents. It was found that she was in acute
pulmonary edema and required transfer to the Surgical
Intensive Care Unit. Her blood pressure at the time of this
incident was in the range of 200/120. Her electrocardiogram
showed no specific ST changes, but there was some loss of her
R wave progression laterally. Serial enzymes were drawn, and
Cardiology was consulted. With blood pressure control via a
nitroglycerin drip and fluid restriction, the patient quickly
improved and a had a relatively short stay in the Intensive
Care Unit. Throughout this time, her creatinine continued to
drop, and there was no apparent deleterious effect on her
transplant from this episode. Her beta blocker was
progressively increased, and her nitroglycerin drip was
weaned down.
Two days after this event, she underwent an echocardiogram
which was significant for slightly depressed left ventricular
systolic function with severe posterior wall hypokinesis.
This was a change from her prior echocardiogram and
demonstrated evidence of a small myocardial infarction.
Clinically, she did much better and her blood pressure was
optimized prior to discharge.
She was transferred out of the Intensive Care Unit on
postoperative day five and was stable on the floor for the
next two days.
DISCHARGE DISPOSITION: She was set to be discharged to home
on [**11-23**], on postoperative day seven.
MEDICATIONS ON DISCHARGE:
1. Prograf 4 mg p.o. b.i.d. (this may change depending on
her most recent Prograf level which will be drawn on the
morning of [**11-23**]).
2. Prednisone 20 mg p.o. q.d.
3. CellCept 1 mg p.o. b.i.d.
4. Bactrim 1 single-strength tablet p.o. q.d.
5. Zantac 150 mg p.o. b.i.d.
6. NPH insulin 16 units q.a.m. and 6 units q.p.m.
7. Zoloft 175 mg p.o. q.d.
8. Colace 100 mg p.o. b.i.d.
9. Reglan 10 mg p.o. t.i.d.
10. Percocet one to two tablets p.o. q.4-6h. p.r.n.
11. Lopressor 125 mg p.o. b.i.d.
12. Aspirin 81 mg p.o. q.d.
13. Cardizem-CD 180 mg p.o. q.d.
DISCHARGE FOLLOWUP: Follow-up appointments should be with
Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] in the [**Hospital 1326**] Clinic.
Furthermore, she needs a follow-up appointment with
Dr. [**Last Name (STitle) **] of Cardiology within the next two weeks.
DISCHARGE STATUS: The patient was discharged to home.
CONDITION AT DISCHARGE: Condition was good.
DISCHARGE DIAGNOSES: Status post living-related renal
transplant with perioperative small myocardial infarction.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern1) 20409**]
MEDQUIST36
D: [**2140-11-22**] 18:32
T: [**2140-11-23**] 12:49
JOB#: [**Job Number 20410**]
(cclist)
|
[
"250.51",
"997.1",
"250.41",
"V45.81",
"135",
"362.01",
"428.0",
"410.71",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
5057, 5139
|
6149, 6530
|
5166, 5742
|
1292, 1584
|
2277, 5033
|
6106, 6127
|
5763, 6091
|
170, 796
|
1774, 2259
|
818, 1266
|
1601, 1759
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,386
| 158,089
|
28977
|
Discharge summary
|
report
|
Admission Date: [**2145-12-13**] Discharge Date: [**2145-12-17**]
Date of Birth: [**2085-12-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**2145-12-13**]
-Coronary artery bypass grafting x4 with left internal
mammary artery to left anterior descending coronary
artery; reverse saphenous vein single graft from aorta
to diagonal coronary artery; reverse saphenous vein
single graft from aorta to the second obtuse marginal
coronary artery; reverse saphenous vein single graft
from aorta to distal right coronary artery.
-Epiaortic duplex scanning.
-Left carotid endarterectomy with right greater saphenous vein
patch angioplasty
History of Present Illness:
59 year old male well known to service
that presented for PAT in preparation to CABG. He has had
ongoing DOE that occurs after walking 15 minutes on flat
surface,
and chest pain after exercise that resolves with rest, occuring
everyday but only with activity.
Past Medical History:
Coronary Artery Disease, Peripheral Vascular Disease, s/p CABG,
Carotid Endarterectomy [**2145-12-13**]
PMH: VFib arrest followed by cardiac cath, L ICA stenosis, HTN,
hyperlipidemia,LAD stent placement [**2144**], coronary artery disease
Social History:
Lives with: Wife
Contact:[**Name (NI) 3443**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **](niece) Phone: [**Telephone/Fax (1) 69845**]
[**First Name4 (NamePattern1) 3443**] [**First Name8 (NamePattern2) **] [**Doctor Last Name **](niece) Phone [**Telephone/Fax (1) 69846**]
Occupation:retired
Cigarettes: Smoked no [] yes [x] Hx: 40 pyh, quit [**2144-5-30**]
ETOH: none in last year previously 1 a month
Illicit drug use:denies
Family History:
Father CAD s/p CABG deceased 83
Siblings x 2 hypertension alive
Brother [**Name (NI) **] [**Name (NI) 3730**] deceased 40
Physical Exam:
General: In no acute distress
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 - none
Abdomen:Soft[x] non-distended[x] non-tender[x] bowel sounds +
[x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: LE
Neuro: Alert and oriented x3 nonfocal steady gait
Pulses:
Femoral Right: +2 Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Pertinent Results:
Intra-op TEE [**2145-12-13**]
Conclusions
PRE-CPB: 1. The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the left atrial appendage. No thrombus
is seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild to moderate ([**1-31**]+) aortic regurgitation is seen.
The AI is mostly central with 2 smaller jets seen between the
NCC and LCC and the RCC and LCC.
7. The mitral valve appears structurally normal with trivial
mitral regurgitation.
Drs. [**Last Name (STitle) 914**] and [**Name5 (PTitle) **] were notified in person of the results.
POST-CPB
1. On infusion of phenylphrine briefly then A pacing, now SR
2. Preserved biventricular systolic function.
3. AI unchanged ([**1-31**]+), MR remains trace.
4. No air.
5. Aortic contour normal post decannulation.
[**2145-12-16**] 04:23AM BLOOD WBC-9.5 RBC-2.86* Hgb-9.0* Hct-26.2*
MCV-92 MCH-31.6 MCHC-34.5 RDW-14.0 Plt Ct-142*
[**2145-12-17**] 05:06AM BLOOD Glucose-112* UreaN-15 Creat-0.9 Na-138
K-3.6 Cl-102 HCO3-27 AnGap-13
[**2145-12-17**] 05:06AM BLOOD Mg-2.3
Brief Hospital Course:
The patient was brought to the Operating Room on [**2145-12-13**] where
the patient underwent Coronary Artery Bypass x 4 with Dr.
[**Last Name (STitle) 914**] and Left Carotid Endarterectomy with Dr. [**Last Name (STitle) **].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 4 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home with VNA in good condition with
appropriate follow up instructions.
Medications on Admission:
Plavix 75 mg daily - last took [**12-5**] instructed not to take
Lisinopril/HCTZ 20/25mg daily
Toprol XL 50 mg daily
Prilosec 20 mg daily
Simvastatin 80 mg daily
Aspirin 325 mg daily
Calcium 600 mg twice a day
Nabumetone 500 mg prn pain - usually once a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. 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*
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 7 days.
Disp:*7 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary Artery Disease, Peripheral Vascular Disease, s/p CABG,
Carotid Endarterectomy [**2145-12-13**]
PMH: VFib arrest followed by cardiac cath, L ICA stenosis, HTN,
hyperlipidemia,LAD stent placement [**2144**], coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage.
Edema -trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on [**1-17**]:30, in the [**Hospital **] Medical office
building, [**Doctor First Name **], [**Hospital Unit Name **]
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2145-12-28**] 10:30
Cardiologist:[**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2145-12-17**] 1:20
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8236**] in [**5-4**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2145-12-17**]
|
[
"401.9",
"424.1",
"411.1",
"285.1",
"V45.82",
"433.10",
"272.4",
"443.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"38.12",
"39.61",
"00.40",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
6569, 6626
|
4099, 5258
|
316, 833
|
6911, 7134
|
2563, 4076
|
7975, 8782
|
1872, 1996
|
5567, 6546
|
6647, 6890
|
5284, 5544
|
7158, 7952
|
2011, 2544
|
273, 278
|
861, 1123
|
1145, 1388
|
1404, 1856
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,486
| 112,328
|
16091
|
Discharge summary
|
report
|
Admission Date: [**2128-4-3**] Discharge Date: [**2128-4-7**]
Date of Birth: [**2071-6-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
NGT tube placed - removed [**4-5**]
History of Present Illness:
HPI: 56 year old male with Hep C cirrhosis transferred from
[**Hospital3 3583**] with change in mental status. He was recently
admitted to [**Hospital1 18**] [**Date range (1) 46019**] with encephalopathy, which
improved with lactulose. 5 BM yesterday. No BRBPR, no melena, no
vomiting, no hemetemesis, no abdominal pain, no F/C/R. At 5 a.m.
on DAT, wife unable to arouse him from sleep and called 911. He
was transported to [**Hospital3 **], where HCT 21.7 (from 32.5
[**2128-3-29**]). NG lavage (-), gauiac (-). He received 1uPRBC, 100 g
lactulose down NGT, and levofloxacin 500 mg IV X 1 and
transferred to [**Hospital1 18**]. In [**Hospital1 18**] ED, gauiac (-), NG lavage
pink-tinged w/o clots or evidence of active bleeding.
*
Past Medical History:
PMHx
1) Cirrhosis [**2-18**] HCV: awaiting liver transplant
- [**2127-11-20**] EGD petechiae and erythema in antrup and pyloris c/w
hemorrhagic gastritis; portal gastropathy
- [**2126-8-20**] cls: wnl
- currently enrolled in clinical trial Tolvaptan for chronic
hyponatremia
2) Chronic HCV: likely [**2-18**] IVDU
- s/p INF/ribavarin [**2126**]; d/c'd [**2-18**] low plt/alb
3) Depression
4) PVD
5) h/o CHF: [**11-19**] TTE: mod LA/RA dilation, mild sym LVH, minimal
AS, trivial MR, trivial TR
6) Type II DM
7) HTN
8) s/p cervical spine fusion
9) s/p appendetomy
10) s/p laryngeal polyp removal
11) Arthritis
12) Barrett's esophagus
*
Social History:
The patient actively smokes a pipe/day x 30 yrs, no ETOH, no
IVDU for past 30 yrs, lives w/ wife, has 2 grown children (21yo
and 25yo), retired rec center worker.Wife: [**Name (NI) **] (?[**Telephone/Fax (1) 46017**]
Family History:
brother - MI age 45
father - MI age 67
no h/o liver dz or cancers
Physical Exam:
PE: Temp: 98.3 BP: 100/58 HR: 68 RR; 20 99% on RA
gen: awake, able to answer questions, AEO x 2
HEENT: +icteric scleric, NGT tube in place
CV: RRR, nl s1, s2, no m/r/g
Resp: cta-blt
Abd: slightly distended, soft, nt, nabs
Ext: no c/c, 1+ edema blt
Pertinent Results:
Abd CT: bibasilar atelectasis, small amt ascites, gynecomasty,
cirrhotic liver, spleen enlarged, splenorenal shung, SC edema.
No RP bleed.
CXR: no infiltrate effusion, pulmonary edema
*
[**2128-4-3**] 02:15PM URINE RBC-21-50* WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2128-4-3**] 02:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-TR
[**2128-4-3**] 02:15PM URINE COLOR-LtAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.020
[**2128-4-3**] 02:15PM FIBRINOGE-96.0*
[**2128-4-3**] 02:15PM PT-15.6* PTT-45.2* INR(PT)-1.5
[**2128-4-3**] 02:15PM PLT COUNT-54*
[**2128-4-3**] 02:15PM ANISOCYT-2+ POIKILOCY-1+ MACROCYT-3+
[**2128-4-3**] 02:15PM NEUTS-78.0* BANDS-0 LYMPHS-14.1* MONOS-7.1
EOS-0.4 BASOS-0.3
[**2128-4-3**] 02:15PM WBC-6.8 RBC-3.22* HGB-11.1* HCT-32.9*
MCV-102* MCH-34.5* MCHC-33.7 RDW-19.1*
[**2128-4-3**] 02:15PM AMMONIA-170*
[**2128-4-3**] 02:15PM calTIBC-174* HAPTOGLOB-<20* FERRITIN-1167*
TRF-134*
[**2128-4-3**] 02:15PM TOT PROT-5.3* CALCIUM-8.0* PHOSPHATE-3.0
MAGNESIUM-1.9 IRON-170*
[**2128-4-3**] 02:15PM LIPASE-33
[**2128-4-3**] 02:15PM ALT(SGPT)-61* AST(SGOT)-72* LD(LDH)-312* ALK
PHOS-110 AMYLASE-31 TOT BILI-10.7*
[**2128-4-3**] 02:15PM GLUCOSE-181* UREA N-28* CREAT-1.0 SODIUM-138
POTASSIUM-4.7 CHLORIDE-108 TOTAL CO2-24 ANION GAP-11
[**2128-4-3**] 03:20PM LACTATE-3.5*
[**2128-4-3**] 05:30PM HCT-34.6*
[**2128-4-3**] 05:49PM HGB-9.2* calcHCT-28
[**2128-4-3**] 05:49PM LACTATE-2.2*
[**2128-4-3**] 05:49PM TYPE-ART PO2-97 PCO2-31* PH-7.48* TOTAL
CO2-24 BASE XS-0
[**2128-4-3**] 06:07PM URINE RBC-21-50* WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2128-4-3**] 06:07PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-1 PH-6.5 LEUK-SM
[**2128-4-3**] 06:07PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2128-4-3**] 10:45PM HCT-32.4*
Brief Hospital Course:
1) Change in MS:likely hepatic encephalopathy, originally it was
thought that this may have been precipitated by UTI. Patient had
a dirty UA and was originally treated with levofloxacin, however
cultures grew out coag neg staph (likely staph epi), thus levo
was stopped after 5 days. CXR (-). Head CT (-) at OSH. Blood
cx, ucx, sputum cx showed no growth. Patient had an NGT placed
with lactulose q 2hours, with good result. Patient quickly
became more oriented and therefore NGT was pulled and patient
was allowed to eat. Patient was dc'ed on lactulose QID.
*
2) Anemia: HCT stable 32-34 while in ICU, following 1 u PRBC at
OSH, HCT 21.7 -> 34.6; it was thought that thet HCt of 21.7
likely represents lab error at OSH
While in the hospital, patient was both gauic (-) and w/ (-) NG
lavage; benign abd exam (-) abd CT. After being transferred to
floor, patient hct was 28, but no signs of bleed. It was
attributed to fluid shifts (as patient had received fluids
secondary to being dry) and closely monitored.
*
3) Cirrhosis: Patient was continued on rifaximin, propranolol,
ursodiol (initially held). He was also continued on
spironolactone, furosemide. Patient was also continued on the
experimental drug, tolvartan.
*
4) Type II DM: RISS and with glargine.
Medications on Admission:
1. Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day). Disp:*60 Tablet(s)* Refills:*2*
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day). Disp:*60 Capsule(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO qd. Disp:*30
Tablet(s)* Refills:*2*
5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day). Disp:*120 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0*
7. TOLVAPTAN Sig: Sixty (60) QD ().
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO four times
a day. Disp:*3600 ML(s)* Refills:*1*
9. medications continue all diabetes meds as previously
prescribed
10. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO twice a
day. Disp:*60 Tablet(s)* Refills:*2*
Discharge Medications:
1. Propranolol HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO qd.
Disp:*30 Tablet(s)* Refills:*2*
5. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
7. TOLVAPTAN Sig: Sixty (60) QD ().
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO four times
a day.
Disp:*3600 ML(s)* Refills:*1*
9. medications
continue all diabetes meds as previously prescribed
10. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic encephalopathy
1) Cirrhosis [**2-18**] HCV: awaiting liver transplant
- [**2127-11-20**] EGD petechiae and erythema in antrup and pyloris c/w
hemorrhagic gastritis; portal gastropathy
- [**2126-8-20**] cls: wnl
- currently enrolled in clinical trial Tolvaptan for chronic
hyponatremia
2) Chronic HCV: likely [**2-18**] IVDU
- s/p INF/ribavarin [**2126**]; d/c'd [**2-18**] low plt/alb
3) Depression
4) PVD
5) h/o CHF: [**11-19**] TTE: mod LA/RA dilation, mild sym LVH, minimal
AS, trivial MR, trivial TR
6) Type II DM
7) HTN
8) s/p cervical spine fusion
9) s/p appendetomy
10) s/p laryngeal polyp removal
11) Arthritis
12) Barrett's esophagus
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or come to ED if you develop chest pain,
shortness of breath, confusion, nausea, vomiting, fevers,
abdominal pain
Please call your doctor or come to ED if you develop chest pain,
shortness of breath, confusion, nausea, vomiting, fevers,
abdominal pain
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2128-4-22**] 11:00
Follow up with [**First Name8 (NamePattern2) 19313**] [**Last Name (NamePattern1) 11805**] for tolvapatan study in early
[**Month (only) 547**]
Your labs should be drawn an [**Hospital3 3583**] next Monday, 28th
Completed by:[**2128-4-7**]
|
[
"285.9",
"789.5",
"070.54",
"276.3",
"V49.83",
"250.00",
"428.0",
"571.5",
"599.0",
"572.2",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7687, 7693
|
4319, 5584
|
321, 358
|
8389, 8397
|
2383, 4296
|
8721, 9126
|
2031, 2099
|
6647, 7664
|
7714, 8368
|
5610, 6624
|
8421, 8698
|
2114, 2364
|
272, 283
|
386, 1122
|
1144, 1781
|
1797, 2015
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,188
| 152,045
|
46190
|
Discharge summary
|
report
|
Admission Date: [**2177-7-18**] Discharge Date: [**2177-7-24**]
Service: MEDICINE
Allergies:
Nsaids
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo F with h/o diverticular and internal hemorrhoidal bleeds,
LE DVT in [**1-12**] for which IVC filter placed, b/l PE diagnosed
[**5-/2177**] though of undetermined chronicity, on coumadin since
[**5-/2177**] presents with GIB. Pt reports diarrhea x 1 week PTA, then
blood in stools 3 days PTA; blood worsened from just being on
the stool to filling toilet. She was sent here from [**Hospital 4382**] via ambulance due to worsening bleeding. She denies
dizziness, diaphoresis, SOB, CP, n/v/abd pain or rectal pain.
.
ED COURSE: Initial VS T 99.1, HR 100, 122/70, 98% RA, remained
HD stable, GI called but did not see pt in ED. Recieved 2U FFP,
5mg Vit K IV x1, NS IVF x1L, 1UPRBC transfused; 2nd unit PRBC
infusing en route to [**Hospital Unit Name 153**]. Did have CP, CE pending. EKG w/o
changes per ED resident. NG lavage was not done as INR was 2.6.
Admitted to [**Hospital Unit Name 153**] for closer monitoring.
Past Medical History:
1. GI Bleeding with Diverticulitis in [**2165**]. Recurrent GIB [**11-11**]
w/o clear source - suspect hemorrhoids vs diverticular
2. b/l segmental pulmonary emboli [**5-/2177**]-initiated coumadin
3. right popliteal DVT dx [**1-12**] s/p IVC filter
4. Sliding Hiatal hernia: Seen on UGI swallow in [**2164**]
5. metaplasia consistent with Barrett's esophagus [**2174**]
6. Negative PMIBI [**7-11**] with EF 66% (multiple negative stress
tests)
7. Status post appendectomy.
8. Cataract surgery [**2167**]
9. Status post tubal ligation.
10. History of pneumonia.
11. Pap smear [**5-/2170**] with atrial thick pathology.
12. Retinacular cyst of right ring finger removed in [**2173**]
13. Mild centrilobular emphysema on CT Scan [**2171**]
14. Incidental left renal cysts on CT Scan [**2170**]
15. Microcytic anemia with a (baseline Hct 28-34) with normal
iron studies in [**5-10**]
16. Transfusion History: 14 prior red blood cell transfusions -
last transfusion on [**2175-5-12**] complicated by febrile, non-hemolytic
transfusion reaction. known Anti-K antibody, now with a new
diagnosis of Anti-Fya antibody. Difficult cross-match.
Social History:
Lives in [**Hospital3 **], [**Hospital1 789**] House [**Telephone/Fax (1) 98220**]. No
Etoh, tob, illicit drugs. Granddaughter [**Name (NI) 21892**] [**Name (NI) 1968**] is HCP.
Family History:
Brother: gastric, colonic cancer
CAD in multiple relatives
Physical Exam:
On admission:
VS: T 97.5F HR 77 BP 147/76 RR 17 O2sats 98% RA
GEN: Resting quietly, NAD
HEENT: dry mucous membranes
RESP: CTA bilaterally
CV: RRR, no m/g/r
ABD: soft, +bs, nttp
EXT: Warm to touch, +dp pulses
NEURO: AAO x 3
RECTAL per ED: Gross blood, ? internal hemorrhoids, no rectal
lesions or masses
Pertinent Results:
Admission labs:
[**2177-7-18**] 07:30PM GLUCOSE-105 UREA N-28* CREAT-1.3* SODIUM-143
POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-23 ANION GAP-12
[**2177-7-18**] 07:30PM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-2.3
[**2177-7-18**] 07:30PM WBC-5.3 RBC-3.42* HGB-9.1* HCT-25.5* MCV-75*
MCH-26.6* MCHC-35.6* RDW-17.0*
[**2177-7-18**] 07:30PM PT-25.4* PTT-35.4* INR(PT)-2.6*
[**2177-7-18**] 07:30PM CK-MB-4 cTropnT-<0.01
[**2177-7-18**] 07:30PM CK(CPK)-169*
.
EKG [**2177-7-18**]- NSR, rate 70, nml axis, no ST changes
.
CHEST (PORTABLE AP) [**2177-7-18**] 8:46 PM
Tortuosity of the aorta with wall calcifications are essentially
unchanged. Pulmonary vasculature is within normal limits without
evidence of CHF. No definite pleural effusions are identified.
IVC filter is seen within the abdomen.
.
EGD [**11/2176**]
Patulous esopgagus. GE junction was in the right place. The
lumen of the stomach was tortuous. The duodenum was straight as
if there was a malposition of the pylorus. Normal mucosa in the
duodenum
Smal polypoid lesion, most likely a suction polyp in the fundus.
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
[**Age over 90 **] yo F with h/o GIB on coumadin for PE s/p IVC filter presents
with hematochezia.
.
1. GI bleed: Resolved once INR normalized with vitamin K and
FFP. Pt remained hemodynamically stable, did receive 2 units
packed red blood cells. She was evluated by GI team and it was
felt that blled was likely from known diverticulosis or internal
hemmorrhoids with bleeding exacerbated by coumadin. Decsion was
made with patient not to pursue colonoscopy given known history
and spontaneous resolution. After prolonged discussion of the
risks of bleeding on coumadin and of the risks of pulmonary
embolism on coumadin, pt stated she would not restart coumadin.
2. Pulmonary Embolism: Pt was diagnosed with b/l segmental PE's
in [**5-12**], although it is unkown at what point these occurred, i.e
these could have been present prior to the placement of the IVC
filter in [**1-12**]. At admission, pt had been on coumadin,
therapuetic levels, for approximately 10 weeks. the IVC filter
was placed in [**1-/2177**] because she was found to have a LE
popliteal DVT and there was concern for risk of GI bleeding on
coumadin given multiple episodes of GI bleeding in past. At
present hospitalization, pt refuses to restart coumadin. This
was discussed with HCP, grandaughter [**Name (NI) 21892**] [**Name (NI) 1968**], as well as
her PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 3510**]. Hopefully, IVC filter can prevent large
PE's. Pt aware of risk.
.
3. ARF: On admission pt had ARF which resolved with IVFs and
blood products.
.
4 Thrombocytopenia, mild: At baseline pt is usually normal,
with episodes of low platelets. This is likely not a major
contributing factor to her GIB. Heparin antibody test was
negative on 12/[**2176**]. She is currently not on any heparin.
.
5. PPX: PPI, heparin sc - please have MD at rehab decide when pt
is ambulating enough to stop heparin prophylaxis
.
6. CODE: DNR/DNI
.
7. Communication: Grandaughter [**Location (un) 21892**] [**Telephone/Fax (1) 98221**]
Medications on Admission:
Pantoprazole 40 PO daily
Warfarin with goal INR 2.0-2.5
Docusate 100 mg PO bid
Senna 8.6 mg [**Hospital1 **]
Bimatoprost 1 drop daily
Sucralfate 1 g qid
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for PAIN, FEVER.
3. Bimatoprost 0.03 % Drops Sig: One (1) drop Ophthalmic 1 DROP
DAILY ().
4. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for Chest pain.
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day): discontinue once ambulating
Discharge Disposition:
Extended Care
Facility:
Provident Skilled Nursing Center - [**Location (un) 583**]
Discharge Diagnosis:
GI bleed
Pulmonary embolism
Discharge Condition:
stable, eating well, not confused, oriented x3
Discharge Instructions:
Please follow up with Dr. [**First Name (STitle) 3510**]. Call Dr. [**First Name (STitle) 3510**] or return
to the emergency room with chest pain, bleeding, or other
concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 3510**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2177-7-24**]
|
[
"276.51",
"562.12",
"V12.51",
"584.9",
"V58.61",
"287.5",
"455.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7373, 7458
|
4127, 6156
|
220, 227
|
7530, 7579
|
2974, 2974
|
7815, 8026
|
2565, 2625
|
6359, 7350
|
7479, 7509
|
6182, 6336
|
7603, 7792
|
2640, 2640
|
175, 182
|
255, 1193
|
2990, 4104
|
2654, 2955
|
1215, 2352
|
2368, 2549
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,241
| 112,575
|
8139
|
Discharge summary
|
report
|
Admission Date: [**2150-5-23**] Discharge Date: [**2150-5-24**]
Date of Birth: [**2084-7-29**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 28994**]
Chief Complaint:
Fevers, tachycardia, tachypnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 28983**] is a 65 year old man with a history of CLL and
pulmonary embolus. He has been off of treatment for his CLL
secondary to complications from the chemotherapy. He has
required frequent transfusions for his anemia (last transfusion
of 2 units of pRBC's on [**5-21**]). He is neutropenic and has been on
valacyclovir, pentamidine, and voriconazole.
.
He reports a dry cough starting about one month ago. Two weeks
ago he began having a cough slightly productive of whitish
sputum. The cough was at night and would occasionally wake him
up. He did not take any medication for the cough and it was not
made better or worse by anything that he noticed. At his
oncology appointment on [**5-21**] he reported worsening of this
cough. A chest xray showed a right sided infiltrate with concern
for a fungal process. He was started on Augmentin and
azithromycin. He felt febrile last evening, but did not have a
thermometer. He took Motrin and drove back from [**Location (un) **] to his
regular home. His temperature this AM was 98.7. By noon his
temperature was 102.5. He called his oncologist and was sent to
the ED for further evaluation and workup of his fevers.
.
In the ED, initial vs were: 102.5 130 113/58 26 100 on 4L. He
was given a total of 2 L of normal saline and 1000 mg of
acetaminophen. His blood pressures were in the low 90's during
most of his stay in the ED. His respiratory rate increased to
the 30's, but improved after treatment with a nebulizer. His
heart rate improved to the 110's after fluids. He also received
100 mg of hydrocortisone. After discussion with the onc fellow,
the patient was started on vancomycin and cefepime. His
antifungal coverage was not increased.
.
Vital signs on transfer were: 102.8 98/43 112 22 99 on 4L.
Initially on presentation to the [**Hospital Unit Name 153**], he reported being
relatively comfortable, but tachypneic. Afterwards he developed
on ongoing cough that was improved with guafenesin and a
nebulizer. He stated that his breathing felt more comfortable
than yesterday.
.
Review of sytems:
Reports recent constipation, but now having regular bowel
movements. He reports having a few episodes at home where he
will not be able to get to the bathroom quick enough. He had
some incontinence of urine last night, but denied dysuria or
hematuria. He reports last night using the urinal and having a
bowel movement at the same time on the floor. He reports being
able to sense the bowel movement, but not being able to get to
the toilet quick enough. Reports little appetite over the last
day. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
Oncology History:
SUMMARY OF CLL HISTORY:
1) He developed herpes zoster of the right cheek in [**2143**],
treated with Valtrex. In [**2143**], he had recurrence of a
cutaneous eruption involving the right cheek, but evaluation was
felt inconsistent with recurrent herpes zoster and biopsies
supported a clonal low-grade B-cell lymphoproliferation, perhaps
"marginal zone B-cell lymphoma," reviewed by dermatologist Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 28984**] at [**Hospital1 112**].
(2) This right face cutaneous eruption waxed and waned in early
[**2144**], extending to involve the right nostril and skin to the
left of midline underneath the nose. In follow-up evaluation a
CBC showed leukocytosis (WBC = 22.7K), but differential was not
obtained. He saw Dr. [**Last Name (STitle) 28984**] in follow-up who performed skin
lesional punch biopsy of the superior nasolabial crease on
[**2145-4-7**]. This showed skin involvement by CLL, without evidence of
transformation.
(3) Subsequently, he saw Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Company 2860**], and flow
cytometry of peripheral blood on [**2145-4-28**] confirmed a lymphocyte
predominance by CLL; 3% of cells were positive for CD38. On
[**2145-4-28**], torso CT scan at [**Hospital1 112**] showed extensive lymphadenopathy
at multiple sites throughout the upper neck, chest, abdomen and
pelvis, as summarized in my [**2146-2-25**] note.
(4) Repeat CBCs in [**5-11**] again showed leukocytosis with
lymphocyte
predominance on differential. He saw hematologist Dr. [**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 410**]
for a second opinion. At [**Hospital1 18**], WBCs = 13.6 and 17.9K with 76%
and 66% lymphocytes on [**2145-5-26**] and [**2145-5-31**], respectively. Flow
cytometry at [**Hospital1 18**] again confirmed CLL; however, 50% of B cells
were CD38 positive.
(5) In [**5-11**], he developed fevers and constitutional symptoms
with
marked fatigue and weight loss. On evaluation by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]
at [**Company 2860**], concern was raised regarding transformation of his CLL,
and repeat torso CT scan was obtained on [**2145-6-3**], showing
interval increase in some but not all areas of lymphadenopathy,
as summarized in my [**2146-2-25**] note. However, subsequent evaluation
by infectious disease specialist Dr. [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) 1057**] at [**Hospital1 18**]
disclosed erlichiosis, and therapy with doxycycline was begun.
By
[**2146**], he had noted marked improvement in his constitutional
symptoms with resolution of fevers and stabilization of his
weight, having had a 15-pound weight loss during his summer
illness.
(6) In [**12-12**], he developed bilateral otitis media, worse on the
right, complicated by tympanic membrane perforation. Throughtout
[**Month (only) 404**] and [**2146-1-6**] he noted progressive DOE. He saw Dr.
[**Last Name (STitle) **] at [**Company 2860**] on [**2146-1-13**] who noted 2 cm submandibular and
inguinal lymph nodes, in addition to small anterior and
posterior
cervical and bilateral axillary lymph nodes. Chest exam was
clear. WBC was now 60K, representing a tripling in WBC over 4
months. Peripheral blood FISH analysis on CLL cells was obtained
showing abnormalities for the D13S319 13q14.3 and P53 17p13.1
probes in 4/100 and 70/100 nuclei, respectively.
(7) In [**2-9**], he met pulmonologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2168**] and
cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], who diagnosed and managed CHF. On
lasix, he felt improved shortness of breath. However, on [**2146-3-28**]
and [**2146-4-11**] he experienced "crashing" fevers and sweats. With
progressive dyspnea, he was found to have markedly increased
left
pleural effusion and posterior pericardial effusion with RV
collapse. Admitted to hospital on [**2146-4-27**], he ultimately
underwent placement of a pericardial window, with drainage of
left pleural and pericardial fluid, both showing CLL cells.
However, evaluation of pericardial tissue showed organizing
fibrinous material with entrapped mixed inflammatory cells,
including numerous small lymphocytes consistent with CLL cells.
However, there was no evidence of [**Doctor Last Name 6261**] transformation or
otherwise, and CLL cells were regarded as "bystanders." The
overall findings were those of an "organizing pericarditis, the
cause of which is unclear." Of note, multiple specimens for
various infectious diseases (see OMR) were negative except for
[**Location (un) **] B4 and B5 antibodies which were "8" rather than "less
than 8."
(8) On [**2146-5-12**], he was admitted to hospital from [**6-2**] to [**2146-6-9**]
with progressive dyspnea related to worsening bilateral pleural
effusions. Left thorascopic pleural biospy and talc pleurodesis
were performed on [**2146-6-6**]. Pleural biopsy showed: "Extensive
granulation tissue along with mesothelial proliferation and
hemosiderin-laden macrophages are seen, consistent with the
chronicity of the effusive process is present. No morphological
evidence of large cell transformation or infection is seen. The
morphology, supported by the concurrent flow cytometry
immunophenotyping ([**-6/2615**]: CD20 dim, CD5-positive,
CD23-positive, lambda light chain expression) is consistent with
a diagnosis of chronic lymphocytic leukemia/small lymphocytic
lymphoma." Again, CLL was felt to be a "bystander" and not the
cause of the pleural effusion. Of note, convalescent serum
samples subsequently returned showing a rise in [**Location (un) **] B5
antibody to a level of 32. Molecular analyses for Erlichia were
negative on pleural tissue. He felt improved after talc
pleurodesis.
(9) With progressive symptomatic anemia and thrombocytopenia, he
began his first chemotherapy for CLL on [**2146-9-21**], receiving
cycle
#1 of fludarabine/Cytoxan (without rituximab). On [**2146-10-24**], when
peripheral blood lymphocytes declined below 50K, he received his
first dose of Rituxin, given over 2 days. Further therapy with
Fludara/Cytoxan was held due to persistent thrombocytopenia. On
[**2146-11-1**], with persistent thrombocytopenia, he began weekly
Rituxin X 4 with vincristine and prednisone 100 mg daily x5
added
to Rituxin on [**2146-11-8**], followed by prednisone taper for presumed
ITP. With subsequent improvement in platelet counts, he received
R-CVP from [**2146-11-23**] to [**2146-11-25**]. On [**2146-12-20**], with substantial
recovery in all blood counts, he received FCR, with FC
administered on days 1 and 2, not day 3. Full-dose cycle 3 FCR
was administered on days 1 through 3 beginning [**2147-1-17**].
(10)Due to worsening anemia and thrombocytopenia thought to be
secondary to ITP as well as bone marrow involvement with CLL, he
received a pulse of high-dose dexamethasone at the beginning of
[**9-12**] with 4 doses of weekly rituximab and weekly vincristine
on weeks 2 through 4 ([**2147-9-14**] through [**2147-10-5**]). On [**2147-9-21**], he
began daily prednisone instead of dexamethasone pulsing.
Thrombocytopenia improved but anemia persisted.
(11) On [**2147-10-16**], he began Campath subcutaneously in an attempt
to further unload CLL from bone marrow. On [**2147-10-27**], after five
Campath doses, Campath was held secondary to WBC 0.4 with ANC
297
and increased anemia and thrombocytopenia. He received one week
of weekly rituximab on [**2147-10-23**].
(12) Hospitalized [**2147-12-27**] to [**2148-1-2**] with febrile neutropenia
attributed to viral infection. Blood cultures, urine culture,
CMV
viral load, adenovirus PCR, EBV PCR, Parvo 19 DNA negative and
HHV-8 PCR and respiratory viral screen and cultures were all
negative. Received Cefime and Neupogen with resolution of
fever.
(13) On [**2148-10-10**], with worsened severe thrombocytopenia
attributed
to ITP complicating progressive CLL, he resumed prednisone 1
mg/kg = 80 mg daily.
14) From [**10-18**] to [**2148-10-20**], he recieved cycle 1 cyclophosphamide
plus 7 days dexamethasone (in lieu of prednisone). Cycle 1 was
complicated by H1N1 infection with presumed superimposed
aspergillosis, and he was in hospital with prolonged
neutropenia.
With persistent neutropenia, he received 4 weekly doses of
rituximab in [**11/2148**] and again in [**12/2148**], ending on [**2149-1-1**].
Prednisone was resumed for ITP following hi-dose pulsed
dexamethasone, and prednisone dosing has been tapered slowly. On
[**2149-2-18**], we administered IVIg for hypogammaglobulinemia in the
setting of his infection. On [**2149-3-3**], repeat chest CT showed
marked improvement with near complete resolution of ground glass
lung opacities, prompting infectious disease specialist Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] to discontinue voriconazole therapy for
aspergillosis.
(15) Began RCD chemotherapy on [**2149-4-29**] for progressive
thrombocytopenia, anemia, lymphadenopathy and neutropenia.
(16) After four cycles of RCD chemotherapy, anemia and
thrombocytopenia improved, and lymphadenopathy resolved.
Decision
made to hold off on further cycles due to prolonged leukopenia
and increasing fatigue.
.
OTHER PMH:
(1) History of basal cell carcinoma of skin.
(2) Osteoarthritis of hands.
(3) Urinary frequency with BPH.
(4) Hyperplastic colonic polyp resected in [**2-4**] colonoscopy.
(5) Ankle fracture in early [**2128**] complicated by DVT requiring
coumadin anticoagulationx
Social History:
Retired banking lawyer. Lives on the [**Hospital3 **], but spends the
summers on [**Hospital3 **]. Rare alcohol. Denies tobacco/illicits.
Family History:
Father had bladder cancer
Physical Exam:
Admission Exam:
General: Alert, oriented
HEENT: sclera anicteric, MMM
Neck: supple, JVP not elevated
Lungs: crackles at bases, rhonchorous breath sounds over right
middle and upper lobes
CV: Tachycardic
Abdomen: soft, non-tender, slightly-distended, bowel sounds
present, no rebound tenderness or guarding
Ext: warm, well perfused, 2+ DP/PT pulses, 2+ LE edema.
Neuro: sensation intact around perirectal area, appears to have
good tone
Discharge Exam: Deceased
Pertinent Results:
Admission Labs:
[**2150-5-23**] 09:34PM TYPE-ART PO2-50* PCO2-22* PH-7.56* TOTAL
CO2-20* BASE XS-0
[**2150-5-23**] 09:34PM LACTATE-1.5
[**2150-5-23**] 09:34PM O2 SAT-86
[**2150-5-23**] 05:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2150-5-23**] 05:35PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
[**2150-5-23**] 05:35PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2150-5-23**] 05:35PM URINE MUCOUS-RARE
[**2150-5-23**] 02:30PM LACTATE-1.7
[**2150-5-23**] 02:30PM HGB-8.5* calcHCT-26
[**2150-5-23**] 02:20PM GLUCOSE-127* UREA N-21* CREAT-0.8 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-22 ANION GAP-15
[**2150-5-23**] 02:20PM estGFR-Using this
[**2150-5-23**] 02:20PM ALT(SGPT)-52* AST(SGOT)-40 ALK PHOS-146* TOT
BILI-0.7
[**2150-5-23**] 02:20PM LIPASE-13
[**2150-5-23**] 02:20PM cTropnT-0.03*
[**2150-5-23**] 02:20PM ALBUMIN-3.3* CALCIUM-8.2* PHOSPHATE-3.0
MAGNESIUM-1.8
[**2150-5-23**] 02:20PM WBC-5.4 RBC-2.51* HGB-8.2* HCT-25.3* MCV-101*
MCH-32.8* MCHC-32.6 RDW-21.3*
[**2150-5-23**] 02:20PM NEUTS-2* BANDS-0 LYMPHS-96* MONOS-0 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0 OTHER-1*
[**2150-5-23**] 02:20PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-2+
TEARDROP-OCCASIONAL BITE-1+
[**2150-5-23**] 02:20PM PLT SMR-RARE PLT COUNT-20*
[**2150-5-23**] 02:20PM PT-12.8 PTT-31.0 INR(PT)-1.1
Blood cultures [**2150-5-23**]
[**2150-5-23**] 2:20 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2150-5-24**]):
GRAM NEGATIVE ROD(S).
Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 28089**] AT 14:40PM
ON [**2150-5-24**].
Urine Culture [**2150-5-23**]: pending
Imaging:
CXR [**2150-5-24**]:Large opacity is identified within the right upper
to mid lung zone, corresponding to the region of abnormality on
prior chest radiograph, though significantly increased in
size/severity compared to prior. The left lung is clear. There
is no pneumothorax. No significant vascular congestion or
pulmonary edema is identified. Mild blunting of the right
costophrenic angle is unchanged from prior and likely represents
a stable small effusion. A trace left effusion may also be
present. Cardiomediastinal and hilar contours are within normal
limits.
IMPRESSION:
1. Large consolidation within the right upper lung zone,
significantly
increased in size since prior, probable pneumonia given the
clinical history and increase in severity compared to prior.
2. Stable small right pleural effusion. Possible trace left
pleural
effusion.
Brief Hospital Course:
Mr. [**Known lastname 28983**] is a 65 year old man with advanced CLL which left
him neutropenic for an extended period of time. He met SIRS
criteria on admission with tachycardia, fevers and leukopenia.
His CXR revealed a RUL consolidation concerning for pneumonia.
He was broadly covered for bacterial pathogens with vancomycin
and cefepime. He had been on voriconazole prophylaxis prior to
admission which was expanded to ambisome for fungal coverage.
He had a history of erlichia and was started empirically on
doxycycline as he had spent time on [**Hospital3 **] this season. His
blood and urine was cultured, and beta glucan and galactomanan
were assayed. Blood cultures would later show GNR.
Despite treatment, he had persistent respiratory distress with
increased work of breathing and hypoxia. He was clear that he
did not want to be intubated and maintained a DNR/DNI order. He
briefly tried non-invasive BiPAP mask ventilation for comfort
the morning after his arrival, though this measure was poorly
tolerated. After discussing with his family, he elected to
focus his goals of care on comfort only. His antibiotics were
discontinued. He was placed on a morphine drip and his
respiratory distress was alleviated. He died several hours later
at 14:30 on [**2150-5-24**] in the company of his family. An autopsy
was declined.
Medications on Admission:
ENOXAPARIN 80 mg [**Hospital1 **]
LORAZEPAM - 0.5-1 mg Tablet QHS prn sleepiness
METOPROLOL SUCCINATE - 25 mg
PANTOPRAZOLE - 40 mg
PENTAMIDINE [NEBUPENT] 300 mg(s) inhaled via nebulizer every 4
weeks
PREDNISONE - 5 mg Tablet qAM, 2.5 mg qPM
TAMSULOSIN - 0.4 mg Capsule
VALACYCLOVIR - 500 mg Tablet [**Hospital1 **]
VORICONAZOLE [VFEND] - 200 mg Tablet [**Hospital1 **]
DIPHENHYDRAMINE HCL [BENADRYL] 25 mg QHS prn
MULTIVITAMIN
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
|
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[
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|
16174, 17521
|
300, 306
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18091, 18100
|
13415, 13415
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230, 262
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2411, 3129
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3151, 12720
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12736, 12875
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,585
| 121,873
|
7636
|
Discharge summary
|
report
|
Admission Date: [**2121-5-27**] Discharge Date: [**2121-6-7**]
Date of Birth: [**2076-10-6**] Sex: M
Service: Transplant Surgery
CHIEF COMPLAINT: End stage renal disease.
HISTORY OF PRESENT ILLNESS: The patient is a 44 year old
male with end stage renal disease, status post living related
renal transplant which had failed in the past, presenting for
cadaveric renal transplantation. The patient reports
excellent health until the age of 17 when he developed
appendicitis with rupture and incidental finding of nephrotic
syndrome, treated medically with Prednisone and managed
chronic renal insufficiency until end stage renal disease
requiring hemodialysis at age 32. He was on hemodialysis
times twelve months until receiving renal transplant from
brother, 100 percent match. Graft lasted four years and
resumed hemodialysis for the past five years until the
patient was now able to have a cadaveric renal transplant.
PAST MEDICAL HISTORY:
1. End stage renal disease secondary to glomerulonephritis.
2. Hypertension.
3. Motor vehicle accident [**2095**].
4. Ruptured appendix [**2093**].
5. AV graft shunt times three.
6. Knee surgery [**2117**].
7. Depression.
8. Lumbago.
MEDICATIONS ON ADMISSION: The patient was not on any
significant medications on admission.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives alone. He is single and
occupation is custodian. Smoker twenty pack years of
cigarettes, positive marijuana.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient on admission had a blood
pressure of 167/74, heart rate 77, temperature 98.4,
respiratory rate 16, and oxygen saturation 97 percent in room
air. His lungs were clear to auscultation bilaterally .
Heart was regular rate and rhythm. Head, eyes, ears, nose
and throat examination was normocephalic and atraumatic.
Anicteric. The pupils are equal, round and reactive to light
and accommodation. Extraocular movements intact. The
abdomen was soft, nontender, nondistended. Extremities were
warm and well performed with two plus pedal pulses.
HOSPITAL COURSE: In summary, the patient was a 44 year old
male with end stage renal disease secondary to
glomerulonephritis with a past history of failed living
related renal transplant, presenting for cadaveric renal
transplant. The patient was taken to the operating room for
cadaveric renal transplantation on [**2121-5-27**]. For operative
details, please see operative note. Postoperative course was
complicated by delayed graft function. The patient was not
making much urine throughout postoperative day one through
six. On postoperative day six, the patient was transferred
to the Intensive Care Unit for increasing pCO2 and decreasing
saturation rates. While in the Intensive Care Unit, the
patient responded to Narcan times two and all narcotics were
stopped. Renal continued to follow the patient. The patient
through his hospital course was dialyzed three times. The
patient was transferred out of the Intensive Care Unit after
saturation rate began to improve on postoperative day seven
and the patient continued to have decreasing saturations
while on the floor. Pulmonary medicine was called for
consultation and the patient was bronchoscoped for CT scan
findings of ground glass appearance of bilateral upper lobes,
right middle lobe and also persistent consolidation in the
right lower lobe. Bronchoscopy was clean and the patient
began to auto diurese postoperative day eight and saturation
rates increased in room air. The patient's postoperative
course was also complicated by left leg numbness and pain
starting postoperative day one for which neurology saw the
patient and attributed it to femoral cutaneous nerve damage
which was reversible and would take time to reverse. This
pain got better as hospital course moved on and physical
therapy was continuing to see the patient throughout hospital
course. The patient was discharged on [**2121-6-7**], with home
physical therapy.
DISCHARGE DIAGNOSES: End stage renal disease, status post
cadaveric renal transplantation.
MEDICATIONS ON DISCHARGE:
1. Bactrim 400-80 mg tablet, one tablet p.o. once daily.
2. Valcyte 450 mg tablet, one tablet p.o. four times a day.
3. Protonix 40 mg tablet, one tablet p.o. once daily.
4. Nystatin 100,000 units/ml Suspension 5 ml p.o. four times
a day.
5. Colace 100 mg capsule one p.o. twice a day.
6. Labetalol 100 mg tablet, three tablets p.o. twice a day.
7. Sertraline 100 mg tablet, one tablet p.o. once daily.
8. Klonopin 1 mg tablet, 1.5 mg p.o. q.h.s.
9. Calcium Carbonate 500 mg tablet, one p.o. four times a
day.
10. Prednisone 20 mg tablet, one p.o. once daily.
11. Nifedipine 30 mg tablet one tablet p.o. once daily.
12. CellCept [**Pager number **] mg tablet, two tablets p.o. twice a
day.
13. Tacrolimus 1 mg tablet, eight capsules p.o. twice a
day.
[**Name6 (MD) **] [**Name8 (MD) **], MD 2922
Dictated By:[**Doctor Last Name 9174**]
MEDQUIST36
D: [**2121-6-9**] 13:22:14
T: [**2121-6-10**] 19:03:21
Job#: [**Job Number 27828**]
|
[
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icd9cm
|
[
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icd9pcs
|
[
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1317, 1335
|
4040, 4111
|
4137, 5132
|
1234, 1300
|
2117, 4018
|
1543, 2099
|
168, 194
|
223, 949
|
971, 1207
|
1352, 1520
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,822
| 165,404
|
9281+56025
|
Discharge summary
|
report+addendum
|
Admission Date: [**2197-2-23**] Discharge Date: [**2197-3-10**]
Date of Birth: [**2128-1-30**] Sex: F
Service: [**Hospital Unit Name 196**]
AGE: 69.
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname 31811**] is a 68-year-old
female with the past medical history significant for coronary
artery disease status post four-vessel coronary artery bypass
graft in [**2180**], with re-catheterization and PTCA in [**2187**],
history of atrial fibrillation status post cardioversion in
[**12/2196**], who presented with dyspnea. The patient also has a
history of renal artery stenosis. Increasing fatigue and
dyspnea occurred in the setting of attempts to decrease her
Lasix dose over the prior two weeks of admission. She had
worsening abilities to do her activities of daily living over
the last two weeks being able to partially dress herself and
make it part way down the [**Doctor Last Name **] to being bedridden. During
this time, she was undergone workup for renal artery
stenosis, which was seen on MRA and shown to have severe
stenosis of her right renal artery. Renal scan, with flow
study, on [**2197-2-21**] demonstrated diminished function of the
right kidney and 30% smaller size.
HOSPITAL COURSE: The patient was admitted for workup of her
progressive dyspnea. Initially, she presented on the day of
admission to [**Hospital6 **]. She was found to be
bradycardiac to the 30s with blood pressure of 100/palpation.
She was started on a dopamine drip and then stopped.
Atropine was also given, but this did not help her heart
rate. She was given 120 mg total IV Lasix and diuresed
....................cc. She also got Aluterol nebulizers
times four with some improvement in her respiratory symtpoms.
She was sent to [**Hospital1 69**]. In the
ED, she was started on nitroglycerin drip and two more nebs.
Temperature was 96.4, pulse 50, blood pressure 178/88,
respiratory rate 20, 100% oxygen saturation on 4 liters nasal
cannula. GENERAL: In general, she was in mild distress.
Oropharynx was dry. I was unable to assess JVD. The heart
was bradycardiac, soft murmur at the apex. Lungs
demonstrated poor air movement, scattered expiratory wheezes,
bibasilar crackles. GASTROINTESTINAL: The patient was
obese. There was ecchymosis from EPO injection; unable to
assess for hepatomegaly, normoactive bowel sounds.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery
bypass graft [**2180**], PTCA in [**2187**].
2. Refractory congestive heart failure, question of
diastolic failure.
3. Type 2 diabetes mellitus.
4. Chronic renal insufficiency.
5. Renal arterial stenosis.
6. Paroxysmal atrial fibrillation status post cardioversion,
1/[**2196**].
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Hydralazine 100 b.i.d.
2. Levoxyl 100/1.
3. Aldactone 25 b.i.d.
4. Zaroxolyn 2.5 b.i.d.
5. Amiodarone 200 per day.
6. Plavix 75 per day.
7. Zoloft 50 per day.
8. Prevacid 30 per day.
9. Aspirin 81 per day.
10. Lopressor.
11. Xanax.
12. Lipitor 40 per day.
13. Lasix 120 per day.
14. Vicodine p.r.n.
15. Serevent 2 b.i.d.
16. NPH 20 in the morning; 10 in the p.m..
17. Epogen 3000 units per week.
LABORATORY DATA: Laboratory data on admission revealed the
following: Negative troponin I. Chest x-ray was consistent
with mild CHF. The EKG showed Q and 3, T-wave inversions in
1, AVL, first degree AV block, incomplete right bundle branch
block.
HOSPITAL COURSE: The patient was admitted and the course, by
systems, is as follows:
1. CARDIOVASCULAR: Echocardiogram was obtained on
[**2197-2-24**], which showed pulmonary hypertension, right heart
failure, but relatively LV function.
On [**3-2**], the patient was taken to the cardiac catheterization
laboratory for right heart catheterization and a renal artery
stent. The patient tolerated the procedure well initially.
Cardiac catheterization confirmed pulmonary hypertension with
secondary right heart failure with pulmonary artery pressures
of 64/24 and a pulmonary capillary wedge pressure of 28.
After the procedure, the patient developed ATN secondary to
dye contrast.
After placement of the renal artery stent the patient was
sent to the Coronary Care Unit for diuresis and monitoring
with pulmonary artery catheter. She was then discontinued
from ACE inhibitors and continued on the negative fluid
balance and attempt to maintain her a renal dose of Dopa to
help perfuse her kidneys because of the dye toxicity. Swan
Ganz numbers improved. She was taken off dopamine on [**3-5**] and continued on diuretic to maintain her urine output.
She was also maintained on nitroglycerin drip for blood
pressure for greater than 120.
By [**3-6**], she was diuresing well. She did not require
any diuretics after that. On [**3-7**], she was more than
three liters negative in twenty-four hours. Zaroxolyn was
discontinued, and the ATN was resolving.
She was transferred out of the Coronary Care Unit to the
floor. Over the next twenty-four hours she had a total of
eight liters negative total body balance without any
diuretic.
She continued this course of diuresis for the next day.
During the hospital course, she was continued on Amiodarone
for atrial fibrillation. She continued on Plavix, aspirin,
and Lipitor.
The source of her right heart failure is likely due to
pulmonary hypertension, which will be followed up on an
outpatient.
#2. RENAL: The patient has baseline chronic renal
insufficiency. During this admission the patient had acute
renal insufficiency thought to be secondary to acute tubular
necrosis caused by contrast dye. This has resolved and by
the day before discharge the creatinine was down to 2.7. The
baseline creatinine was 1.8 to 2. At the time of discharge,
the patient is probably still 5 to 10 liters positive and
will need to have continued diuresis until she is euvolemic.
#3. PULMONARY: The patient was seen by the Pulmonary
consultation during this visit. CT scan showed ground-glass
opacities. She was ruled out by VQ scan for chronic PEs. It
is not clear what the etiology of her pulmonary hypertension
is, but this is likely related to obstructive sleep apnea
secondary to her obese body habitus. It is recommended that
she followup in the Pulmonary Clinic for a sleep study in one
to two months after she is clinically stable.
#4. HEMATOLOGY: The patient has chronic anemia, likely
secondary to renal failure and diabetes mellitus. She
remains on iron and Epogen.
#5. ENDOCRINE: The patient remains on a stable dose of NPH
and regular insulin sliding scale.
The patient was afebrile during her hospital stay and did not
require any antibiotics.
She was seen by physical therapy consultation and it was
determined that she was going to need acute rehabilitation
following this hospital stay.
MEDICATIONS ON DISCHARGE:
1. Amiodarone 200 per day.
2. Lipitor 40 per day.
3. Aspirin 81 per day.
4. Plavix 75 per day.
5. Hydralazine 100 q.i.d.
6. Atrovent MD
7. Serevent MDI.
8. Levothyroxine 100 per day.
9. Iron sulfate 325 t.i.d.
10. Renagel t.i.d.
11. NPH 26 units a.m.; 13 units p.m..
12. Regular insulin sliding scale.
13. Epogen 5000 units every week.
14. Neurontin 300 per day.
15. Ambien p.r.n.
The patient was discharged to rehabilitation hospital in good
condition.
Addendum is to follow to identify the actual site of her
discharge.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Name8 (MD) 4430**]
MEDQUIST36
D: [**2197-3-9**] 14:18
T: [**2197-3-9**] 14:30
JOB#: [**Job Number 31812**]
Name: [**Known lastname 5549**], [**Known firstname 5550**] Unit No: [**Numeric Identifier 5551**]
Admission Date: [**2197-2-23**] Discharge Date: [**2197-3-11**]
Date of Birth: [**2128-1-30**] Sex: F
Service:
ADDENDUM: Due to delay in bed availability Ms [**Known lastname **] was
discharged on [**2197-3-11**] to [**Hospital6 5552**],
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 5553**]. In addition her complete medicine list on
discharge is as follows.
DISCHARGE MEDICATIONS:
Atrovent 2 puffs q.i.d.
Heparin 5000 units subcutaneously b.i.d.
Iron Sulfate 325 mg p.o. t.i.d.
Levothyroxine 100 mcg p.o. q.d.
Amiodarone 200 mg p.o. q.d.
Epogen 5000 units subcutaneously q. week
Lipitor 40 mg p.o. q.d.
Aspirin 81 mg p.o. q.d.
Serevent 2 puffs t.i.d.
Protonix 40 mg p.o. q.d.
Plavix 75 mg p.o. q.d.
NPH Insulin 26 units q. AM, 13 units q. PM
Hydralazine 100 mg p.o. q.i.d.
Neurontin 300 mg p.o. q.d.
RenaGel 800 mg p.o. t.i.d. with meals
Vicodin 1 to 2 tablets p.o. b.i.d. prn
Dulcolax 10 mg p.o. prn
Ambien 5 mg p.o. q.h.s. prn
Senna one to two tablets p.o. q.h.s. prn
Albuterol/Atrovent nebulizers q. 4 to 6 hours prn
Oxygen by nasal cannula - keep oxygen saturations greater
than 92%
Digoxin 0.125 mg q.d. - Digoxin had been 0.125 mg b.i.d.
times two days and was held afternoon dose on [**2197-3-10**]
for Digoxin level 2.3, level will be checked again the
morning of [**3-11**] and Digoxin should be followed by level
while at [**Hospital1 **] [**Hospital1 5553**] and .125 mg q.d. started when her level
is less than 2.
FOLLOW UP: The patient has an appointment with Dr. [**Last Name (STitle) 5554**]
on Tuesday [**3-14**] at 3:30 PM. This appointment can be
cancelled now that the patient will be followed at the
[**Hospital1 **] [**Hospital1 5553**] by Dr. [**Last Name (STitle) 274**].
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 285**]
Dictated By:[**Name8 (MD) 502**]
MEDQUIST36
D: [**2197-3-10**] 15:26
T: [**2197-3-10**] 15:49
JOB#: [**Job Number 5555**] & [**Numeric Identifier **]
|
[
"427.31",
"583.81",
"997.5",
"416.8",
"428.0",
"250.40",
"V45.81",
"584.5",
"440.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.23",
"39.90",
"88.55",
"88.45",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
8173, 9220
|
6872, 8150
|
2808, 3469
|
3487, 6846
|
9232, 9743
|
2386, 2782
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,185
| 180,219
|
10230
|
Discharge summary
|
report
|
Admission Date: [**2145-3-25**] Discharge Date: [**2145-4-9**]
Date of Birth: [**2096-6-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
renal transplant [**2145-3-25**]
History of Present Illness:
48 y.o. male with ESRD, HIV, HepC last dialyzed yesterday [**3-24**]
via left chest permcath. Recent infection of the line with staph
aureus treated with antibiotics. Currently no fever or sx. Makes
minimal urine. HBsAb +
Past Medical History:
ESRD on HD (MWF), HCV, HIV, malignant HTN
PSH:AV graft, left shoulder operation, umbilical hernia repair
Social History:
History of IV drug abuse
Physical Exam:
AVSS
Cor RRR
Lungs clear
Abd soft, NT/ND
Ext no edema
Pertinent Results:
[**2145-3-25**] 01:28PM WBC-6.3 LYMPH-30 ABS LYMPH-1890 CD3-67 ABS
CD3-1263 CD4-30 ABS CD4-571 CD8-36 ABS CD8-685 CD4/CD8-0.8*
[**2145-3-25**] 01:28PM PT-15.3* PTT-43.9* INR(PT)-1.4*
[**2145-3-25**] 01:28PM PLT COUNT-306
[**2145-3-25**] 01:28PM TRIGLYCER-101 HDL CHOL-49 CHOL/HDL-3.8
LDL(CALC)-115
[**2145-3-25**] 01:28PM ALBUMIN-4.1 CALCIUM-8.1* PHOSPHATE-6.0*
MAGNESIUM-2.3 CHOLEST-184
[**2145-3-25**] 01:28PM LIPASE-66*
[**2145-3-25**] 01:28PM ALT(SGPT)-12 AST(SGOT)-38 LD(LDH)-288* ALK
PHOS-123* TOT BILI-0.3
[**2145-3-25**] 01:28PM estGFR-Using this
[**2145-3-25**] 01:28PM UREA N-40* CREAT-9.7* SODIUM-139
POTASSIUM-5.2* CHLORIDE-95* TOTAL CO2-29 ANION GAP-20
[**2145-3-25**] 05:59PM PLT COUNT-326
Brief Hospital Course:
He was taken to the OR on [**2145-3-25**] for DCD renal transplant by
Dr. [**First Name (STitle) **] [**Name (STitle) **]. The donor was a 22-year-old, brain-dead male
donor who was Hep C and Hep B core antibody positive with a
prior history of drug use. IV Vanco was given for recent blood
culture. Induction immunosuppression consisted of solumedrol,
cellcept and simulect. Urine output was 9-17cc/hour. He was then
taken back to the OR for emergent ex-lap for postop hemorrhage
from the drain site. Please see operative dictations for the
above procedures.
Postop he was tachycardic with Hct drop to 31.4 and K+ 8.4. He
was emergently dialyzed without ultrafiltration after
insulin/dextrose and calcium were given. He was transferred to
the SICU. Post K+ was 5.2. Serial Hcts dropped to 22 with inr
1.8. He was given 5 u PRBC,3 FFP, vit K and DDAVP for plt
dysfunction. An ultrasound done of the transplanted kidney was
normal with no perinephric collection. On pod 1 he was dialyzed
again for K 5.6. Labetolol was given for sbp ranging b/w
160-180. He remained on Levo for previous bacteremia. Lamivudine
was continue for HAART and HBV prophylaxis. ID followed closely.
On pod 2 ([**3-27**])he spiked at temp 102. Blood cultures were done
and negative. CXR showed plate-like atelectasis in the right
lower lung. The previously visualized question of a nodular
opacity in the right mid lung was not visualized. There were no
new infiltrates. Lasix iv was given x1 with minimal response.
On pod 1&2 he experienced loss of consciousness. He was
transferred back to the SICU for an unresponsive episode.
Neurology was consulted and recommended MRI/EEG. MRI showed no
acute ischemia. Chronic small vessel ischemic changes. No
findings indicative of posterior reversible leukoencephalopathy.
1.8 cm cyst within the posterior nasopharynx indicating a
Tornwaldt's cyst. Slight heterogeneity of the signal intensity
of the clivus which may represent sequela of chronic anemia or
possibly a marrow infiltrative disorder. EEG was negative for
seizure activity. No anti-seizure medication was recommended
given that it was unclear whether he had had a seizure.
LFTs increased. Hepatology followed and recommended u/s with
doppler to assess PV. U/S was unremarkable. LFTs trended back
down. Hemodialysis was done intermittently for delayed graft
function. Diet was advanced.
He received several doses of prograf then became
supratherapeutic with a level of 47. Prograf was held. He
continued to receive dilaudid for c/o back pain and RLQ pain
near drain site. [**Doctor Last Name 406**] drain was removed on pod 7. He continued
to be anuric requiring intermittent hemodialysis.
On POD 9 he continued to complain of pain. A KUB was done for
abdominal distension and tympanitic exam which showed possible
bowel obstruction. An abdominal CT revealed a large heterogenous
perinephric collection measuring 16 cm in maximum diameter and
which most likely represents hemorrhage. He was taken to the OR
by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] for exploration and evacuation of a
large hematoma evacuation and a biopsy of the renal transplant.
On [**4-4**] Prograf 1mg was given for a level of 9.7.
On POD 10 the renal biopsy returned positive for rejection.
Solumedrol 500mg IV QD was ordered for 3 days then 250mg once
then 20mg qd. Prior to d/c prograf level was 5.6. He was given a
one time dose of 2mg. Outpatient labs will be drawn every Monday
and Thursday. The transplant clinic will call him with next dose
of prograf based on levels.
Abd pain decreased following evacuation. He tolerated a renal
diet and he was ambulating with a cane and rolling walker.
Hemodialysis continued intermittently based on labs and physical
exam. Labs will be drawn on Tuesday. Nephrology will order HD.
Lasix 100mg qd was ordered. He was dialyzed on [**4-8**] prior to
discharge home.
Medications on Admission:
Labetolol 600mg, Diovan 160mg, nifedipine 90mg, ASA 81mg,
Protonix 40mg [**Hospital1 **], Viracept 1500mg [**Hospital1 **], Epivir 150mg 3xweek,
retrovir 100 tid, catapres #2 patch, renacap vit, renagel 800mg
w/ meals.
.
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
5. Zidovudine 100 mg Capsule Sig: One (1) Capsule PO Q 8H (Every
8 Hours).
6. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
7. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,FR).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
11. Labetalol 200 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
12. Tacrolimus 1 mg Capsule Sig: Zero (0) Capsule PO per
transplant office: you will receive a call from transplant
office when you will take based on drug level.
13. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
14. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
15. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
17. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QFRI (every Friday).
18. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED): please follow sliding
scale.
Disp:*2 2 bottles* Refills:*2*
19. Nelfinavir 625 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
20. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
22. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
23. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day.
24. syringes
low dose
1 box
refill:1
25. Lancets
1 box
refill:1
26. One Touch Ultra
1 box
refill:1
27. Lasix 40 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ESRD
HIV
Discharge Condition:
good
Discharge Instructions:
Call Transplant office [**Telephone/Fax (1) 673**] if fevers, chills, nausea,
vomiting, inability to take pain medication, incision
redness/bleeding/drainage, weight gain of 3 pounds in a day,
shortness of breath, or any questions.
No heavy lifting, no driving/drinking alcohol while taking pain
medication,
[**Month (only) 116**] shower
Hemodialysis at [**Location (un) **] in [**Location (un) **] as indicated
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2145-4-15**] 3:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2145-4-13**] 11:00
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] [**Doctor Last Name 22344**], OD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2145-4-20**] 9:00
Completed by:[**2145-4-9**]
|
[
"570",
"998.12",
"070.30",
"996.81",
"780.09",
"585.6",
"790.7",
"V08",
"403.01",
"560.1",
"E878.0",
"287.5",
"428.0",
"785.59",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"00.93",
"99.07",
"55.23",
"99.04",
"39.95",
"54.12"
] |
icd9pcs
|
[
[
[]
]
] |
8156, 8214
|
1613, 5547
|
317, 352
|
8267, 8274
|
863, 1590
|
8734, 9213
|
5819, 8133
|
8235, 8246
|
5573, 5796
|
8298, 8711
|
789, 844
|
273, 279
|
380, 603
|
625, 731
|
747, 774
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,553
| 152,313
|
19023
|
Discharge summary
|
report
|
Admission Date: [**2108-2-6**] Discharge Date: [**2108-2-15**]
Date of Birth: [**2063-1-28**] Sex: M
Service: BONE [**Doctor First Name **]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 44-year-old
gentlemen who was diagnosed with [**Location (un) 5622**] chromosome
positive acute lymphocytic leukemia in [**2107-4-7**] and who
was admitted on [**2108-2-6**] with RSV infection/pneumonia.
The patient has been treated by Dr. [**First Name (STitle) 1557**] since his
diagnosis. Initially he was treated with hyper CVAD and went
into initial remission. The patient was then placed on
Gleevec from [**2107-6-7**] through [**2107-8-8**].
However, the patient subsequently relapsed and was put back
on a cycle of hyper CVAD. In [**2107-11-7**], the patient's
counts rose dramatically and he was treated with ifosfamide
on VP16 protocol. The patient was scheduled to be admitted
for an allogenic bone marrow transplant on [**2107-12-16**],
but he developed RSV infection. Nasal washing tken at that time
were positive for RSV- DA. On [**2107-12-22**], the patient received his tetanus, pneumovax
and flu shot in the left deltoid in the Infectious Disease
Clinic. On [**2108-1-1**], the patient was admitted for a
matched unrelated donor allogenic bone marrow transplant.
Day zero was [**2108-1-5**]. The patient's course was
complicated by febrile neutropenia with no positive blood
cultures and by a rash thought to be GVHD. The patient was
therefore started on prednisone at 40 mg po q.d. The patient
was discharged from the Bone marrow transplant Unit on
[**2108-2-4**].
The patient presented to clinic on [**2108-2-5**] with
rhinorrhea. Nasal aspirates were sent for RSV-DA. The patient
returned to clinic on [**2-6**] for a hematocrit check and at
that time was still complaining of rhinorrhea. RSV antigens
came back positive and the patient was admitted to the
Intensive Care Unit for ribavirin and monoclonal
immunoglobulin treatments. Prior to his transfer to the
Intensive Care Unit, the patient received polyclonal
immunoglobulins in the outpatient setting.
While in the Intensive Care Unit, the patient received five
days of ribavirin 2 grams inhaled three times a day. His
last dose was received on [**2108-2-11**]. The patient also
received monoclonal IVIG. Chest CT showed no residual
pneumonia. His course was complicated by a fever of 101.8 on
[**2-10**]. The patient was started on cefepime for fever and
functional neutropenia. The patient was continued on
cyclosporin and prednisone, and was transfused to maintain a
hematocrit of 25. The patient continued on total peripheral
nutrition and tolerated a diet.
The patient was transferred to the Bone Marrow Transplant
floor on [**2108-2-12**].
PAST MEDICAL HISTORY:
1. [**Location (un) 5622**] Chromosome positive ALL.
2. Partially occluded deep vein thrombosis in the distal
left subclavian vein, diagnosed [**2107-11-19**].
ALLERGIES: Penicillin causes rash and hives.
MEDICATIONS ON TRANSFER:
1. Acyclovir 400 mg po q. 8.
2. Fluconazole 200 mg po q.d.
3. Ursodiol 300 mg po q.d.
4. Prednisone 40 mg po q.d.
5. Cefepime 2 grams intravenous q. 8.
6. Regular insulin sliding scale.
7. Cyclosporin 192 mg intravenous continuous infusion.
8. Zofran 4 mg intravenous q. 6.
9. Ativan prn.
10. Acetaminophen prn.
11. Diphenhydramine prn.
SOCIAL HISTORY: The patient is married with two children.
He lives in [**Hospital1 1806**], [**State 531**]. He is employed in the family
construction business. He has no history of tobacco or drug
use. The patient was previously a social drinker, but has
not had any alcohol since [**2107-4-7**].
FAMILY HISTORY: [**Name (NI) **] father died in [**2092**] following a
Cerebral vascular accident. The patient's mother had a
pacemaker placed last year. The patient has six sibling who
are not matches.
The patient denies any current fever or chills. He has a
cough, which is improved, and which is productive of clear
sputum. He has continued clear rhinorrhea. He denies any
shortness of breath.
PHYSICAL EXAM ON ADMISSION: Temperature 98.6. Heart rate
74-82. Blood pressure 132/70. Respiratory rate 20. Oxygen
saturation 94-95% on room air. In general, the patient is an
ill-appearing fatigued male in no acute distress, breathing
comfortably on room air. Head, eyes, ears, nose and throat:
There is mucositis, thrush or erythema. There is clear
rhinorrhea. Lungs: Slight crackles at the left base,
otherwise, clear to auscultation bilaterally.
Cardiovascular: Regular without murmurs, rubs or gallops.
Abdomen: Soft, nontender and nondistended. Extremities:
There is no edema present.
LABORATORIES: White blood cell count 2.9, hematocrit 26.5,
platelet count 34,000. Sodium 137, potassium 4.8, chloride
108, bicarbonate 26, BUN 31, creatinine 0.7, glucose 209,
calcium 8.4, magnesium 2.0, phosphorus 2.5, ALT 131, AST 48,
alkaline phosphatase 50, total bilirubin 0.9. Microbiology
blood cultures drawn [**2-10**] showed no growth to date.
Sputum shows no growth to date.
HOSPITAL COURSE:
1. ALL: The patient is day plus 40, status post an
allogeneic matched unrelated donor bone marrow transplant.
He has engrafted well. He is currently on prednisone 40 mg
q.d. for graft versus host disease treatment for his grade 1
skin GVH. He is also on cyclosporin continuous infusion for
his GVH prophylaxis. During the [**Hospital 228**] hospital stay, his
cyclosporin levels were titrated. Initially they was thought
to decrease his prednisone, however, the patient developed
diarrhea, though very small volume. There was concern that
the diarrhea represented graft versus host disease and the
patient was started on enterocort. However, the volumes were
extremely small representing about 30-100 cc per day.
Therefore, it was not thought that this represented graft
versus host disease, however, the prednisone was not tapered.
2. RSV: The patient completed five days of ribavirin and
IVIG. His oxygenation on room air was normal and his
breathing was comfortable. Repeat CT scan showed no evidence
of pneumonia. The patient had been cefepime for neutropenic
fever. He received a total of four days of cefepime and it
was then discontinued as blood cultures were negative. The
patient did not have any recurrent fevers, off of the
cefepime. He remained on prophylactic dose acyclovir and
fluconazole.
3. Elevated LFTs: The patient's elevated LFTs are thought
to be due to liver graft versus host disease. They did
continue to improve during his hospital stay. It is possible
that the elevation in liver function tests was due to
fluconazole, therefore, the patient's dose was decreased to
200 q.d. with improvement in his liver function tests. His
total bilirubin on discharge from this hospital was 1.3.
4. Nutrition: The patient was unable to tolerate a normal
diet. He had only small amounts of oral intake. He was
therefore continued on total peripheral nutrition.
DISCHARGE STATUS: To the BMT apartments with VNA.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Prednisone 40 mg po q.d.
2. Acyclovir 400 mg po t.i.d.
3. Ursodial 300 mg po q.d.
4. Cyclosporin 168 mg continuous infusion q.d. (the
patient's dose was decreased due to elevated cyclosporin
levels drawn the day of discharge).
5. Enterocort 3 mg, 1 po q.d.
6. TPN.
7. Protonix 40 mg, 1 po q.d.
8. Hickman line care.
FINAL DIAGNOSES:
1. Acute lymphocytic leukemia after matched unrelated donor
allogenic bone marrow transplant.
2. RSV respiratory infection, status post ribavirin,
synergist and palivuzinad.
FOLLOW-UP: The patient is to follow-up in the [**Hospital **]
Clinic on [**2108-2-16**] with [**Doctor First Name **] and Dr. [**First Name (STitle) 1557**].
DR.[**First Name (STitle) **],[**First Name3 (LF) 1730**] 12-AHK
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2108-2-18**] 11:54
T: [**2108-2-19**] 08:39
JOB#: [**Job Number 51953**]
|
[
"729.82",
"204.00",
"519.8",
"V12.51",
"288.0",
"V42.81",
"287.5",
"079.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.05",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
7066, 7075
|
3688, 4090
|
7098, 7426
|
5089, 7044
|
7443, 7999
|
186, 2764
|
4105, 5071
|
3021, 3368
|
2786, 2996
|
3385, 3671
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,795
| 138,132
|
868+869
|
Discharge summary
|
report+report
|
Admission Date: [**2145-7-7**] Discharge Date: [**2145-7-20**]
Date of Birth: [**2096-7-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
R IJ -
intubation -
History of Present Illness:
48M with h/o severe COPD (on 2-5L home O2), presenting to OSH
with 2-3wk of increased SOB, with cough productive of
yellow/white sputum, though per his wife, no clear fevers, chest
pain, n/v, abd pain, diarrhea, rash, joint pains. His wife notes
poor compliance with his fluid and dietary restriction, and
increasing weight from ~270 lbs "dry" to ~300 lbs currently. He
has been taking lasix daily. Per wife, he presented to [**Name (NI) 5979**] the day prior to admission, but signed out AMA.
.
Upon arrival to OSH, his VS= 96.9 154/77 81 226 100%6L. He was
speaking in 1 word sentences, with audibly wheezing, and did not
tolerate lying flat. He was placed on BiPaP. ABG 7.26/80/103.
His labs were notable for NA 114. CXR c/w CHF, ECG showed sinus,
no ste/std. He was treated for CHF, and COPD flare with 120mg iv
lasix x1 @ 17:35, duonebs, solumedrol 125mg iv x 1. He made 600
cc UOP at 19:15. He was transferred to [**Hospital1 18**] for further
management.
.
Upon arrival to [**Hospital1 18**] VS= 97.8 121/63 82 38 93% on 6L NC. He was
able to count to 10 in one breath. Labs notable for NA 117, K
5.2, Lactate 1.6, HCT 32.6. ABG here on BiPaP 8/5 with ABG
7.34/79/169 on 50% FiO2 and RR down to 26. CXR with poor
inspiratory effort, bilateral effusion, and interstitial
markings c/w pulmonary edema, cardiomegaly. ECG reveals nsr,
non-specific t-wave changes. He received 1L IVF. Foley was
placed with total return of 1350 UOP. He received CTX
empirically for ?cellulitis/pna (levaquin avoided [**2-15**] coumadin
dosing), and was admitted for management of hypercarbic
respiratory failure. Of note, he continues to smoke.
.
Per medication profile, he was started on cefuroxime 500mg po
bid x 7d on [**2145-6-17**] for unknown indication.
Past Medical History:
- DM2 - on insulin
- CHF
- AVR in [**2134**] (metal valve, st. [**Male First Name (un) **], @ [**Hospital1 112**] x2) - cardiologist
is [**Hospital3 **] Dr. [**Last Name (STitle) 5980**].
- COPD prescribed 2L NC at home, but for past 2 weeks on 5L NC.
- chronic venous stasis changes B LE.
- h/o schizophrenia, psychotic disorder.
- per wife, denies h/o PE/DVT/CRI/CVA.
Social History:
He continues to smoke 3ppd, for past week 1ppd. He denies ETOH,
IVDU. He lives at home with his wife, and 2 sons, in [**Name (NI) 1468**].
Family History:
NC
Physical Exam:
Vitals: 96.7 130 107/45 33 93%NRB -> AC 100% 550x24 5
General: intubated, sedated.
HEENT: s/p left ear trauma, oozing from trauma site.
Neck: supple, unable to assess JVP 2/2 habitus, no LAD
Lungs: bilateral coarse ronchi and crackles, minimal wheezing.
CV: regular rate, normal S1 + S2, no appreciable murmurs, rubs,
gallops.
Abdomen: obese, markedly distended, firm ~5cm diameter region in
epigastrium, +tympany. new echymotic region expanding over
epigastrium. bowel sounds present, no rebound tenderness or
guarding
Ext: Warm, ?1+ pulses, 1+ edema to knees, chronic venous stasis
changes, with multiple <1cm areas of drainage, non-purulent,
oozing blood.
Pertinent Results:
<b> LABS ON ADMISSION ([**7-6**])</b>
WBC-5.8 RBC-4.48* Hgb-10.4* Hct-32.6* MCV-73* MCH-23.1*
MCHC-31.8 RDW-18.9* Plt Ct-122*
Neuts-94.8* Lymphs-3.3* Monos-1.1* Eos-0.2 Baso-0.6
PT-36.3* PTT-36.7* INR(PT)-3.7*
Glucose-104 UreaN-9 Creat-0.7 Na-117* K-5.2* Cl-76* HCO3-36*
AnGap-10
[**2145-7-7**] 03:56AM BLOOD Albumin-3.9 Calcium-8.2* Phos-2.8 Mg-1.9
<b> LABS ON TRANSFER FROM ICU ([**7-17**])</b>
PT-17.4* PTT-56.1* INR(PT)-1.6*
Cardiac Enzymes
[**2145-7-6**] 11:20PM BLOOD cTropnT-<0.01 CK(CPK)-82
[**2145-7-7**] 03:56AM BLOOD cTropnT-<0.01 CK(CPK)-66
[**2145-7-10**] 07:15AM BLOOD cTropnT-0.02* CK(CPK)-50
[**2145-7-10**] 12:22PM BLOOD cTropnT-<0.01 CK(CPK)-48
[**2145-7-10**] 06:39PM BLOOD cTropnT-<0.01 CK(CPK)-38
Pre Intubation ABG: Type-ART pO2-64* pCO2-131* pH-7.16*
calTCO2-49* Base XS-12
ABG at ICU Discharge: Type-ART Temp-37.2 pO2-91 pCO2-70* pH-7.42
calTCO2-47* Base XS-16
Echo ([**7-7**]) - The left and right atra are moderately dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. There
is abnormal septal motion/position suggestive of right
ventricular volume overload. The diameters of aorta at the
sinus, ascending and arch levels are normal. A bileaflet aortic
valve prosthesis is present. The aortic valve prosthesis appears
well seated, with normal leaflet/disc motion and transvalvular
gradients. No aortic regurgitation is seen. ?Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Technically suboptimal study. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Right ventricular cavity enlargement with
free wall hyopokinesis. Normal functioning aortic valve
prosthesis. ?Moderate mitral regurgitation.
If clinically indicated, a TEE would be better able to define
the severity of mitral regurgitation.
<b> LABS ON DISCHARGE ([**7-20**]) <b>
Chem 7
137 91 11 113 AGap=8
3.1 41 0.8
Ca: 8.6 Mg: 2.1 P: 2.6
CBC: 3.7 > 7.9 / 26.4 < 98
PT: 20.7 PTT: 65.5 INR: 1.9
ABG: 7.48 / 58 / 49 / 44 / 16
Iron: 20
calTIBC: 371
Ferritn: 97
TRF: 285
Brief Hospital Course:
# Dyspnea - The patient's chief complaint on admission was
dyspnea. It was felt that this dyspnea was consistent with a
CHF exacerbation. Although, based on his lung exam with
wheezing and rhonchi, it was felt that there was also a COPD
component to the patient's dyspnea. DFA for flu was negative;
urinary legionella antigen was also negative. Over the course
of his initial ICU stay, he was treated with IV solumedrol,
nebs, and cepodoxime/azithromycin for COPD flare. He was also
diuresed with lasix 120mg iv prn, though he autodiuresed
aggressively on his own. He was transfered to the medical floor
on the evening of [**2145-7-10**].
.
Around midnight of that day, he was noted to have increased
agitation. He was then noted to become hypoxic and tachypneic.
He was evaluated by the floor team and noted to have diffuse
crackles without significant wheezing. He was given lasix but
remained tachypneic low oxygen sats. A CXR revealed bilateral
opacification consistent pulmonary edema or new LUL infiltrate.
Additionally, he was visibly oozing from his left face wound,
his nose, and his lower extremity chronic venous stasis ulcers.
.
At this point, he was transferred back to the MICU. Upon arrival
to the MICU, he appeared uncomfortable and tachypneic. Upon
placement of BiPaP, he became acutely more uncomfortable,
sitting forward, pursed lip breathing. The decision was made to
intubate him. He was treated as a flash pulmonary edema case;
he also completed a 7 day course of vanco/zosyn for possible
hospital acquired pneumonia.
.
The patient remained intubated for 4 days, during which time he
was diuresed with lasix. Eventually, on [**2145-7-14**], he was able to
be extubated. In the days following his extubation, he still
appeared to be fluid overloaded. Therefore, he continued to be
diuresed aggressively. Over this time, he reported that his
dyspnea was improving. On [**2145-7-17**], the patient was transferred
from the unit to the medical floor. On the floor he was
continued to be diuresed and his respiratory status continued to
improve. By the time of admission his oxygen requirement had
decreased to his baseline regimen of 2L NC. We increased his
home dose of lasix for discharge to the rehabilitation facility
and recommended strict daily weights.
.
Finally, based on his anatomy and observing him at sleep in the
morning, he also may have a component of obstructive sleep apnea
which may contribute to his pulmonary problems. [**Name (NI) 6**] outpatient
workup for OSA might be reasonable for this patient.
.
# CHF - As stated above, when the patient was admitted, it was
determined that some of his dyspnea was secondary to a CHF
exacerbation. It was felt that he was fluid overloaded. He was
kept on his home lisinopril on admission, and he was diuresed.
Echo done on [**2145-7-7**] showed mild symmetric left ventricular
hypertrophy, right ventricular cavity enlargement with free wall
hyopokinesis, and moderate mitral regurgitation. Diuresis
continued through most of the patient's ICU stay. However,
after his readmission to the ICU and intubation, he did have
some episodes of hypotension. At this point, his lisinopril was
also held. After the hypotension resolved, he continued to be
diuresed. By the time the patient was discharged from the MICU,
he had diurese a total of 14.9 L during his admission. On the
medical [**Hospital1 **] he was further diuresed down to a discharge weight
of 250lb. Given the diastolic nature of his failure and no
recent history of atrial fibrilation we decided to stop the
patient's digoxin. His diltiazem had also been discontinued at
admission as he remained normotensive. Diltiazem and lisinopril
may need to be restarted if he returns to hypertensive state,
particularly his lisinopril from which he would likely derive
benefit both for CHF and renal protection.
.
# COPD - As stated above, on admission, it was also believed
that some of the patient's dyspnea was associated with a COPD
exacerbation component. He was ronchorous and tight with
wheezing on his initial MICU exam. On admit, he was placed on
albuterol/atrovent nebs, steroids, and antibiotics. He was
continued on the albuterol and atrovent throughout his course in
the MICU. His steroids were tapered down and stopped prior to
his transfer out of the MICU. On the floor he was continued on
his albuterol/atrovent nebs. He was discharged to the
rehabilitation facility with albuterol/atrovent inhalers. The
patient notes, however, that he does not feel that these
treatments work, and does not plan to take them.
.
# Hyponatremia - The patient also presented with hyponatremia.
His initial chemistry panel revealed a sodium of 119. It was
believed that this hyponatremia was secondary to fluid overload.
The patient's sodium levels began to normalize with diuresis.
His hyponatremia had resolved by the third day of admission and
remained stable across the remainder of his admission.
.
# Hypotension - After his readmission to the MICU and
intubation, the patient had some problems with hypotension. It
was felt that this was most likely secondary to repeated
sedation boluses. He did require transient pressors for a short
period of time to maintain his blood pressure. Furthermore, the
patient had some problems with bleeding from his oropharyngeal
cavity after intubation. In the setting of this bleeding, the
patient received blood on [**2145-7-10**]. By the time the patient was
discharged from the MICU, he was normotensive, off pressors, and
with a low but stable hematocrit. His antihypertensives other
than lasix continued to be held in the setting of aggressive
diuresis and low normal blood pressure, but lisinopril in
particular should likely be restarted once his blood pressure
returns to higher levels.
.
# Oropharyngeal bleeding - As mentioned above, the patient had
profuse bleeding during intubation. This was felt to likely be
oropharyngeal trauma in the setting a supratherapeutic PTT. He
also had dark maroon aspirated from his OG tube. As stated
above, the patient received blood on [**2145-7-10**]. By the time of
his discharge from the MICU, the patient had a low but stable
hematocrit between 25 and 27 and without further signs of
esophageal or oropharyngeal bleeding.
.
# Bleeding from wounds - Mr. [**Known lastname 5981**] had a scab on his right
face that he sometimes compulsively picked at despite expressing
a wish not to, and for some time needed constant bandage changes
in the setting of heparin and coumadin. This was resolving at
time of discharge. Additionally, he had a central line pulled
and the scab at this site was stable, he did not pick at it, and
there was no further bleeding. He also has chronic bleeding from
his lower extremity wound, described below.
# Cytopenia - The patient remained thrombocytopenic across his
entire admission, with platelet counts averaging approximately
90-100. The cause of this was unclear at the time of discharge,
but it was noted that the patient had had a normal platelet
count as recently as [**2145-5-14**]. He also had a low white count,
and was anemic. The most likely explanation for this is that he
was nutritionally and metabolically challenged by his acute
illness episode and that it will take some time to rebuild his
cell lines. This should be followed as an outpatient and if it
does not resolve as he continues to recover from his acute
illness episode, he may warrant workup for hematologic problems.
.
# Anticoagulation - Because of his mechanical aortic valve, the
patient has a goal INR of 2.5 to 3.5. On admission, he had a
supratherapeutic INR and his coumadin was held. He was put on a
heparin drip for anticoagulation, and his coumadin was soon
restarted. However, these were stopped around the time of his
intubation. After the patient was more stable, the heparin drip
was restarted. After some adjustments, it was decided to keep
the patient on the heparin drip until he reached his goal PTT of
60-80. At that point, he would begin to be transitioned to
coumadin. The patient remained on a heparin drip across his
admission. Coumadin was restarted at 5mg and then raised to
7.5mg, and the patient's INR rose to 1.9 at the time of
discharge. He was discharged on a Lovenox bridge with daily INR
checks.
.
# DM - The patient was put on sliding scale insulin while he was
in the hospital. He was also put on 70/30 with a split dose [**Hospital1 **]
and placed on a diabetic diet. His blood sugars varied during
his hospitalization but generally were <200. His home regimen of
insulin was continued at the time of discharge.
.
# Lower Extremity Skin Changes - The patient had skin changes in
his lower extremities that were consisent with chronic venous
changes. He was treated with lidex to his lower extremities and
wound care by his nurses. Additionally, he has a wound on his
left cheek that bled frequently. Wound care was consulted for
this wound. Dressing changes and wound care were provided by
his nurses. He was discharged with instructions for his wound
care during rehabilitation.
.
# H/o Schizophrenia and Psychotic Disorder - Throughout his ICU
course, the patient had several incidents of wanted to leave
AMA. Apparently, this is consistent with his actions on
previous admissions. While hospitalized, the patient was kept
on his home regimen of geodon 80mg [**Hospital1 **]. Initially, he was kept
on his home regimen of trazodone 600mg po qHS. However, the
trazodone was discontinued while he was intubated. After
extubation, he was started back on a lower dose of trazodone
with the plan to wean him back up to his normal dose. However,
the patient's trazodone dose was held at half its original
amount secondary to sedation. The patient continued to be
somnolent and was therefore discharged on this lower dose
(300mg) of trazadone, which might be increased if he continues
to have sleep problems.
Medications on Admission:
<b>PER WIFE'S MEDICATION LIST</b>
Key medications reconciled with patient's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5982**]
Trazadone 600mg PO QHS
Geodon 80mg [**Hospital1 **]
KCl 80meq CR qAM
Diltiazem ER 240mg PO qAM
Doc-Q-Lace, 100mg, [**Hospital1 **]
Lasix 80mg PO BID
Lisinopril 7.5mg qAM
Digoxin 0.375mg qAM
Coumadin 7.5mg 5/week (M-F)
Coumadin 10mg 2/week (Sa-[**Doctor First Name **])
Novolin Insulin injection 90 Units SQ qAM
Novolog 5 Units TID (morning, noon, night)
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-15**] Inhalation Q4H (every 4 hours) as needed
for dyspnea.
2. Ipratropium Bromide 0.02 % Solution Sig: [**1-15**] Inhalation Q4H
(every 4 hours) as needed for dyspnea.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 tabs* Refills:*4*
4. Ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
6. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Daily, Monday
through Friday: Please take 3 tablets in the morning on Monday,
Tuesday, Wednesday, Thursday and Friday. Please take 4 tablets
by mouth on Saturday and Sunday.
Disp:*100 Tablet(s)* Refills:*2*
8. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen
Sig: Ninety (90) Units Subcutaneous once a day: Inject 90 Units
under the skin every morning only.
9. Insulin Aspart 100 unit/mL Insulin Pen Sig: Five (5) Units
Subcutaneous three times a day: Inject 5 units in the morning, 5
units at noon, and 5 units at night.
10. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous [**Hospital1 **] (2 times a day).
11. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day:
consult patient's physician about changing this dose if patient
gains more than 5 pounds in one day.
12. Weights
of greater than 3 pounds per day.
13. Outpatient Lab Work
Please obtain INR daily until therapeutic (2.5-3.5), then q2
days until stably within range for >5 days; then coordinate labs
and coumadin dosing with outpatient coumadin clinic
14. Miconazole Nitrate 2 % Powder Sig: One (1) Topical twice a
day as needed for erythematous skin on thighs and buttocks.
15. Blood pressure medication
Patient's blood pressure should be taken regularly. If patient's
blood pressure is >140/90 more than once, or is ever >165/90,
contact MD, and consideration should be given to restarting
patient's home Diltiazem and/or lisinopril.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - Colonial Heights - [**Hospital1 487**]
Discharge Diagnosis:
PRIMARY:
1. Acute-on-chronic diastolic heart failure
2. COPD exacerbation
3. Hospital-acquired pneumonia
SECONDARY:
1. DM-II
2. Schizophrenia
Discharge Condition:
stable, on 2L oxygen, tolerating regular diet, no pain, not
actively bleeding
Discharge Instructions:
You were admitted to the hospital with shortness of breath,
which was probably caused by a combination of heart failure and
lung disease. While you were here you were treated with several
different medications including antibiotics for a pneumonia. For
a time, you were also intubated and placed on a ventilator in
order to assist your breathing.
While you were in the hospital we stopped some of your
medications. You should stop taking your digoxin, lisinopril,
and diltiazem until you next see your doctor. In addition, you
should now take only 300mg of trazadone at bedtime. You can
discuss adjusting your dose of this medication when you next see
your doctor. Finally, we have suggested increasing your dose of
Lasix, to 120 mg [**Hospital1 **]. You should discuss this with your
physician [**Name Initial (PRE) 5983**]. You should continue taking all of your other
medications as prescribed before you were hospitalized.
Please call your doctor or return to the emergency department if
you experience any of the following: increased shortness of
breath, chest pain, coughing up blood, vomiting blood, bloody
stool, bloody urine, severe headache, loss of consciousness, or
any other concerning symptoms.
Please also return to the emergency department if you experience
bleeding from any part of your body that lasts more than 5
minutes or involves the loss of significant amounts (more than a
few teaspoons) or blood.
Followup Instructions:
Please schedule a follow up appointment with your primary care
doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5982**], at [**Telephone/Fax (1) 5984**], to see her within
1 week of being discharged from your rehabilitation facility.
Please schedule an appointment with your cardiologist, Dr.
[**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 5980**], at [**Hospital3 **] Cardiology Associates,
[**Telephone/Fax (1) 5985**], for 1-3 weeks after your discharge from the
rehabilitation facility.
Please follow up with your psychiatrist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1852**],
[**Telephone/Fax (1) 5986**], within 1-3 weeks after your discharge from
the rehabilitation facility.
Admission Date: [**2145-7-7**] Discharge Date: [**2145-7-20**]
Date of Birth: [**2096-7-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Right IJ catheter
Intubation for mechanical ventilation
Right PICC line
History of Present Illness:
48 year-old gentleman with severe COPD (2-5L home O2), CHF and
multiple lengthy prior admissions. Initially presented to OSH
with 2-3 weeks increased SOB and cough productive of
yellow/whote sputem but signed out AMA. Admitted to [**Hospital1 18**] MICU
on [**7-7**] with COPD flare and treated with solumedrol, nebs,
cefodoxine/azithromycin, and diuretics. Called out from MICU but
then taken back to MICU due to increased dyspnea and tachypnea.
Intubated and extubated on [**7-14**]. Was net negative 15L across
MICU stays. Also received 7-day course of vanc/zosyn for HAP.
At time of transfer patient was stable. Per ICU patient is still
volume overloaded and needs further diuresis. Patient would be
appropriate for transfer to LTAC bed after the weekend.
On the floor pt was not in any acute distress, lying in a
reclining position, and requesting to go home tomorrow. When
asked why he said "to smoke". Vitals were stable. Patient was
tolerating regular diet without N/V.
.
Review of sytems: as noted in HPI
Past Medical History:
- DM2 - on insulin
- CHF
- AVR in [**2134**] (metal valve, st. [**Male First Name (un) **], @ [**Hospital1 112**] x2) - cardiologist
is [**Hospital3 **] Dr. [**Last Name (STitle) 5980**].
- COPD prescribed 2L NC at home, but for past 2 weeks on 5L NC.
- chronic venous stasis changes B LE.
- h/o schizophrenia, psychotic disorder.
- per wife, denies h/o PE/DVT/CRI/CVA.
Social History:
Social History: Lives with his wife and two sons. On disability
since [**2134**] when had mechanical valve. Smokes 2 PPD since 18yo.
Denies EtOH and illicit drugs.
Family History:
non-contributory
Physical Exam:
Vitals: T-97.6 BP-102/50 P-68 R-22 O2-96% on 4L
General: Alert, oriented, no acute distress, eager to go home
HEENT: MMM, EOMI
Neck: supple, unable to assess JVP, no LAD
Lungs: clear but decreased breath sounds, patient not moving
much air, scattered wheezes and coarse breath sounds
CV: RRR, nl S1, sharp mechanical S2, III/VI SEM, no rubs, no
gallops
Abdomen: obese, soft, NT, distended, NABS, no rebound/guarding;
cannot assess organomegally
Ext: Appear WWP, unable to feel pulses, lower extremities full
of ecchymoses, chronic venous stasis changes, 1+ edema
bilaterally
Neuro: AOx3, unable to assess DTR due to patient positioning
Pertinent Results:
<b>LABS </b>
ON ADMISSION ([**2145-7-7**]):
121 / 80 / 16
===========< 170
5.0 / 37 / 0.9
CBC: 5.8 < 10.4 / 32.6 > 122
PT: 36.3 PTT: 36.7 INR: 3.7
Dig: 1.0
Mg: 2.1
Pre Intubation ABG: Type-ART pO2-64* pCO2-131* pH-7.16*
calTCO2-49* Base XS-12
ABG at ICU Discharge: Type-ART Temp-37.2 pO2-91 pCO2-70* pH-7.42
calTCO2-47* Base XS-16
LABS ON TRANSFER FROM ICU ([**2145-7-17**]):
139 / 92 / 16
==========< 87
3.8 / 43 / 0.6
4.3 > 8.4 / 27.0 < 126 MCV 82
PT-17.4* PTT-56.1* INR(PT)-1.6*
[**2145-7-17**] 04:35AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.3
[**2145-7-17**] 04:58AM BLOOD Type-ART Temp-37.2 pO2-91 pCO2-70*
pH-7.42 calTCO2-47* Base XS-16 Intubat-NOT INTUBA
LABS AT DISCHARGE: [**2145-7-20**]
137 / 91 / 11
==========< 113
3.1 / 41 / 0.8
CBC: 3.7 > 7.9 / 26.4 < 98
PTT-54.9*
ALT-44* AST-22 LD(LDH)-233 AlkPhos-78 TotBili-1.1
Calcium-8.6 Phos-2.6* Mg-2.1 Cholest-123
calTIBC-371 Ferritn-97 TRF-285
Triglyc-71 HDL-45 CHOL/HD-2.7 LDLcalc-64
Type-ART pO2-49* pCO2-58* pH-7.48* calTCO2-44* Base XS-16
BLOOD Lactate-1.1 K-3.1*
<B>MICROBIOLOGY</B>
MRSA SCREEN: POSITIVE FOR MRSA
<B> IMAGING: </B>
CXR [**2145-7-17**]: Comparison is made to the prior study from [**2145-7-16**].
Patient is rotated. The endotracheal tube has been removed.
Right IJ catheter terminates in the superior vena cava. Heart is
enlarged. Patient is status post CABG. There is patchy
consolidation of both lower lobes. There is also underlying
congestive failure, unchanged from prior study. There is a small
right pleural effusion, unchanged since the prior study.
.
EGD [**2145-7-10**]: Old blood in stomach, small amounts diffusely, no
active bleeding. Likely blood from trauma from intubation.
Otherwise normal EGD to second part of the duodenum.
Echo ([**7-7**]) - The left and right atra are moderately dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. There
is abnormal septal motion/position suggestive of right
ventricular volume overload. The diameters of aorta at the
sinus, ascending and arch levels are normal. A bileaflet aortic
valve prosthesis is present. The aortic valve prosthesis appears
well seated, with normal leaflet/disc motion and transvalvular
gradients. No aortic regurgitation is seen. ?Moderate (2+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Technically suboptimal study. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Right ventricular cavity enlargement with
free wall hyopokinesis. Normal functioning aortic valve
prosthesis. ?Moderate mitral regurgitation.
If clinically indicated, a TEE would be better able to define
the severity of mitral regurgitation.
Brief Hospital Course:
## Dyspnea - The patient's chief complaint on admission was
dyspnea. It was felt that this dyspnea was consistent with a
CHF exacerbation. Although, based on his lung exam with
wheezing and rhonchi, it was felt that there was also a COPD
component to the patient's dyspnea. DFA for flu was negative;
urinary legionella antigen was also negative. Over the course
of his initial ICU stay, he was treated with IV solumedrol,
nebs, and cepodoxime/azithromycin for COPD flare. He was also
diuresed with lasix 120mg iv prn, though he autodiuresed
aggressively on his own. He was transfered to the medical floor
on the evening of [**2145-7-10**].
Around midnight of that day, he was noted to have increased
agitation. He was then noted to become hypoxic and tachypneic.
He was evaluated by the floor team and noted to have diffuse
crackles without significant wheezing. He was given lasix but
remained tachypneic low oxygen sats. A CXR revealed bilateral
opacification consistent pulmonary edema or new LUL infiltrate.
Additionally, he was visibly oozing from his left face wound,
his nose, and his lower extremity chronic venous stasis ulcers.
.
At this point, he was transferred back to the MICU. Upon arrival
to the MICU, he appeared uncomfortable and tachypneic. Upon
placement of BiPaP, he became acutely more uncomfortable,
sitting forward, pursed lip breathing. The decision was made to
intubate him. He was treated as a flash pulmonary edema case;
he also completed a 7 day course of vanco/zosyn for possible
hospital acquired pneumonia.
.
The patient remained intubated for 4 days, during which time he
was diuresed with lasix. Eventually, on [**2145-7-14**], he was able to
be extubated. In the days following his extubation, he still
appeared to be fluid overloaded. Therefore, he continued to be
diuresed aggressively. Over this time, he reported that his
dyspnea was improving. On [**2145-7-17**], the patient was transferred
from the unit to the medical floor. On the floor he was
continued to be diuresed and his respiratory status continued to
improve. By the time of admission his oxygen requirement had
decreased to his baseline regimen of 2L NC. We increased his
home dose of lasix for discharge to the rehabilitation facility
and recommended strict daily weights.
.
Finally, based on his anatomy and observing him at sleep in the
morning, he also may have a component of obstructive sleep apnea
which may contribute to his pulmonary problems. [**Name (NI) 6**] outpatient
workup for OSA might be reasonable for this patient.
.
# CHF - As stated above, when the patient was admitted, it was
determined that some of his dyspnea was secondary to a CHF
exacerbation. It was felt that he was fluid overloaded. He was
kept on his home lisinopril on admission, and he was diuresed.
Echo done on [**2145-7-7**] showed mild symmetric left ventricular
hypertrophy, right ventricular cavity enlargement with free wall
hyopokinesis, and moderate mitral regurgitation. Diuresis
continued through most of the patient's ICU stay. However,
after his readmission to the ICU and intubation, he did have
some episodes of hypotension. At this point, his lisinopril was
also held. After the hypotension resolved, he continued to be
diuresed. By the time the patient was discharged from the MICU,
he had diurese a total of 14.9 L during his admission. On the
medical [**Hospital1 **] he was further diuresed down to a discharge weight
of 250lb. Given the diastolic nature of his failure and no
recent history of atrial fibrilation we decided to stop the
patient's digoxin. His diltiazem had also been discontinued at
admission as he remained normotensive. Diltiazem and lisinopril
may need to be restarted if he returns to hypertensive state,
particularly his lisinopril from which he would likely derive
benefit both for CHF and renal protection.
.
# COPD - As stated above, on admission, it was also believed
that some of the patient's dyspnea was associated with a COPD
exacerbation component. He was ronchorous and tight with
wheezing on his initial MICU exam. On admit, he was placed on
albuterol/atrovent nebs, steroids, and antibiotics. He was
continued on the albuterol and atrovent throughout his course in
the MICU. His steroids were tapered down and stopped prior to
his transfer out of the MICU. On the floor he was continued on
his albuterol/atrovent nebs. He was discharged to the
rehabilitation facility with albuterol/atrovent inhalers. The
patient notes, however, that he does not feel that these
treatments work, and does not plan to take them.
.
# Hyponatremia - The patient also presented with hyponatremia.
His initial chemistry panel revealed a sodium of 119. It was
believed that this hyponatremia was secondary to fluid overload.
The patient's sodium levels began to normalize with diuresis.
His hyponatremia had resolved by the third day of admission and
remained stable across the remainder of his admission.
.
# Hypotension - After his readmission to the MICU and
intubation, the patient had some problems with hypotension. It
was felt that this was most likely secondary to repeated
sedation boluses. He did require transient pressors for a short
period of time to maintain his blood pressure. Furthermore, the
patient had some problems with bleeding from his oropharyngeal
cavity after intubation. In the setting of this bleeding, the
patient received blood on [**2145-7-10**]. By the time the patient was
discharged from the MICU, he was normotensive, off pressors, and
with a low but stable hematocrit. His antihypertensives other
than lasix continued to be held in the setting of aggressive
diuresis and low normal blood pressure, but lisinopril in
particular should likely be restarted once his blood pressure
returns to higher levels.
.
# Oropharyngeal bleeding - As mentioned above, the patient had
profuse bleeding during intubation. This was felt to likely be
oropharyngeal trauma in the setting a supratherapeutic PTT. He
also had dark maroon aspirated from his OG tube. As stated
above, the patient received blood on [**2145-7-10**]. By the time of
his discharge from the MICU, the patient had a low but stable
hematocrit between 25 and 27 and without further signs of
esophageal or oropharyngeal bleeding.
.
# Bleeding from wounds - Mr. [**Known lastname 5981**] had a scab on his right
face that he sometimes compulsively picked at despite expressing
a wish not to, and for some time needed constant bandage changes
in the setting of heparin and coumadin. This was resolving at
time of discharge. Additionally, he had a central line pulled
and the scab at this site was stable, he did not pick at it, and
there was no further bleeding. He also has chronic bleeding from
his lower extremity wound, described below.
# Cytopenia - The patient remained thrombocytopenic across his
entire admission, with platelet counts averaging approximately
90-100. The cause of this was unclear at the time of discharge,
but it was noted that the patient had had a normal platelet
count as recently as [**2145-5-14**]. He also had a low white count,
and was anemic. The most likely explanation for this is that he
was nutritionally and metabolically challenged by his acute
illness episode and that it will take some time to rebuild his
cell lines. This should be followed as an outpatient and if it
does not resolve as he continues to recover from his acute
illness episode, he may warrant workup for hematologic problems.
.
# Anticoagulation - Because of his mechanical aortic valve, the
patient has a goal INR of 2.5 to 3.5. On admission, he had a
supratherapeutic INR and his coumadin was held. He was put on a
heparin drip for anticoagulation, and his coumadin was soon
restarted. However, these were stopped around the time of his
intubation. After the patient was more stable, the heparin drip
was restarted. After some adjustments, it was decided to keep
the patient on the heparin drip until he reached his goal PTT of
60-80. At that point, he would begin to be transitioned to
coumadin. The patient remained on a heparin drip across his
admission. Coumadin was restarted at 5mg and then raised to
7.5mg, and the patient's INR rose to 1.9 at the time of
discharge. He was discharged on a Lovenox bridge with daily INR
checks.
.
# DM - The patient was put on sliding scale insulin while he was
in the hospital. He was also put on 70/30 with a split dose [**Hospital1 **]
and placed on a diabetic diet. His blood sugars varied during
his hospitalization but generally were <200. His home regimen of
insulin was continued at the time of discharge.
.
# Lower Extremity Skin Changes - The patient had skin changes in
his lower extremities that were consisent with chronic venous
changes. He was treated with lidex to his lower extremities and
wound care by his nurses. Additionally, he has a wound on his
left cheek that bled frequently. Wound care was consulted for
this wound. Dressing changes and wound care were provided by
his nurses. He was discharged with instructions for his wound
care during rehabilitation.
.
# H/o Schizophrenia and Psychotic Disorder - Throughout his ICU
course, the patient had several incidents of wanted to leave
AMA. Apparently, this is consistent with his actions on
previous admissions. While hospitalized, the patient was kept
on his home regimen of geodon 80mg [**Hospital1 **]. Initially, he was kept
on his home regimen of trazodone 600mg po qHS. However, the
trazodone was discontinued while he was intubated. After
extubation, he was started back on a lower dose of trazodone
with the plan to wean him back up to his normal dose. However,
the patient's trazodone dose was held at half its original
amount secondary to sedation. The patient continued to be
somnolent and was therefore discharged on this lower dose
(300mg) of trazadone, which might be increased if he continues
to have sleep problems.
Medications on Admission:
MEDICATIONS ON TRANSFER:
Heart Failure:
1. Furosemide 40 mg IV TID
2. Digoxin 0.375 mg PO DAILY
Nebulizers/COPD:
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
4. Ipratropium Bromide Neb 1 NEB IH Q4H:PRN dyspnea
Psych:
5. Ziprasidone 80 mg PO BID
6. TraZODONE 300 mg PO HS
Bowel Regimen:
7. Docusate Sodium (Liquid) 100 mg PO BID
8. Lactulose 30 mL PO PRN constipation titrate to 1 BM/day
Sliding Scales & Prophylaxis:
9. Heparin IV Sliding Scale
10. Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed
Dose
11. Pantoprazole 40 mg PO Q24H
PRN:
12. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN rash
13. Ondansetron 8 mg IV Q8H:PRN nausea
14. Senna 1 TAB PO BID:PRN constipation
15. Potassium Chloride 40 mEq PO DAILY Duration 24 Hours
Allergies: NKDA
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-15**] Inhalation Q4H (every 4 hours) as needed
for dyspnea.
2. Ipratropium Bromide 0.02 % Solution Sig: [**1-15**] Inhalation Q4H
(every 4 hours) as needed for dyspnea.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 tabs* Refills:*4*
4. Ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
6. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Daily, Monday
through Friday: Please take 3 tablets in the morning on Monday,
Tuesday, Wednesday, Thursday and Friday. Please take 4 tablets
by mouth on Saturday and Sunday.
Disp:*100 Tablet(s)* Refills:*2*
8. Insulin NPH & Regular Human 100 unit/mL (70-30) Insulin Pen
Sig: Ninety (90) Units Subcutaneous once a day: Inject 90 Units
under the skin every morning only.
9. Insulin Aspart 100 unit/mL Insulin Pen Sig: Five (5) Units
Subcutaneous three times a day: Inject 5 units in the morning, 5
units at noon, and 5 units at night.
10. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) injection
Subcutaneous [**Hospital1 **] (2 times a day).
11. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day:
consult patient's physician about changing this dose if patient
gains more than 5 pounds in one day.
12. Weights
of greater than 3 pounds per day.
13. Outpatient Lab Work
Please obtain INR daily until therapeutic (2.5-3.5), then q2
days until stably within range for >5 days; then coordinate labs
and coumadin dosing with outpatient coumadin clinic
14. Miconazole Nitrate 2 % Powder Sig: One (1) Topical twice a
day as needed for erythematous skin on thighs and buttocks.
15. Blood pressure medication
Patient's blood pressure should be taken regularly. If patient's
blood pressure is >140/90 more than once, or is ever >165/90,
contact MD, and consideration should be given to restarting
patient's home Diltiazem and/or lisinopril.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - Colonial Heights - [**Hospital1 487**]
Discharge Diagnosis:
PRIMARY:
1. Acute-on-chronic diastolic heart failure
2. COPD exacerbation
3. Hospital-acquired pneumonia
SECONDARY:
1. DM-II
2. Schizophrenia
Discharge Condition:
stable, on 2L oxygen, tolerating regular diet, no pain, not
actively bleeding
Discharge Instructions:
You were admitted to the hospital with shortness of breath,
which was probably caused by a combination of heart failure and
lung disease. While you were here you were treated with several
different medications including antibiotics for a pneumonia. For
a time, you were also intubated and placed on a ventilator in
order to assist your breathing.
While you were in the hospital we stopped some of your
medications. You should stop taking your digoxin, lisinopril,
and diltiazem until you next see your doctor. In addition, you
should now take only 300mg of trazadone at bedtime. You can
discuss adjusting your dose of this medication when you next see
your doctor. Finally, we have suggested increasing your dose of
Lasix, to 120 mg [**Hospital1 **]. You should discuss this with your
physician [**Name Initial (PRE) 5983**]. You should continue taking all of your other
medications as prescribed before you were hospitalized.
Please call your doctor or return to the emergency department if
you experience any of the following: increased shortness of
breath, chest pain, coughing up blood, vomiting blood, bloody
stool, bloody urine, severe headache, loss of consciousness, or
any other concerning symptoms.
Please also return to the emergency department if you experience
bleeding from any part of your body that lasts more than 5
minutes or involves the loss of significant amounts (more than a
few teaspoons) or blood.
Followup Instructions:
Please schedule a follow up appointment with your primary care
doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5982**], at [**Telephone/Fax (1) 5984**], to see her within
1 week of being discharged from your rehabilitation facility.
Please schedule an appointment with your cardiologist, Dr.
[**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 5980**], at [**Hospital3 **] Cardiology Associates,
[**Telephone/Fax (1) 5985**], for 1-3 weeks after your discharge from the
rehabilitation facility.
Please follow up with your psychiatrist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1852**],
[**Telephone/Fax (1) 5986**], within 1-3 weeks after your discharge from
the rehabilitation facility.
|
[
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"96.04",
"96.6",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
40064, 40152
|
27050, 36993
|
21521, 21594
|
40339, 40419
|
23916, 24601
|
41893, 42651
|
23227, 23245
|
37812, 40041
|
40173, 40318
|
37019, 37019
|
40443, 41870
|
23260, 23897
|
21474, 21483
|
22620, 22637
|
24620, 27027
|
21622, 22602
|
37044, 37789
|
22659, 23030
|
23062, 23211
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,977
| 146,686
|
32143
|
Discharge summary
|
report
|
Admission Date: [**2164-10-16**] Discharge Date: [**2164-10-26**]
Date of Birth: [**2110-8-9**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
s/p [**2110**]5 feet through scaffold
Major Surgical or Invasive Procedure:
1. Open reduction internal fixation of right elbow fracture
dislocation with radial head replacement.
2. Closed reduction of left wrist with manipulation.
3. Application uniplanar external fixator on left forearm.
4. Open reduction internal fixation of left nasal ethmoidal
orbital fracture.
5. Open reduction internal fixation of palate fracture.
History of Present Illness:
54M s/p [**2110**]5 feet through scaffold, hit face on the way down.
Pt presented to the [**Hospital1 18**] emergency room with a lower lip
avulsion, forehead laceration, epistaxis, right forearm
deformity, and bilateral wrist deformities.
Past Medical History:
PMH: none
PSH: hernia repair
Social History:
lives with wife, works in construction
Family History:
noncontributory
Physical Exam:
On day of discharge:
97.8 138/92 101 20 93%RA
Gen-pleasant NAD
heent-splint in place over nose; forehead incision c/d/i
ctab
rapid rate, reg rhythm
abd mildly distended, no ttp
L forearm w/ ex fix
Pertinent Results:
Imaging:
[**10-16**] CT head: neg for bleed. numerous facial fx incl
pneumocephalus from fx of inner and outer table of frontal sinus
[**10-16**] CT maxillofacial: 2 lg parallel fractures from max. bones
bilaterally extending post to the petrous ridge, fx of left
frontoethmoidal recess
[**10-16**] CT C-spine: 1. No evidence of acute cervical spine fracture
or alignment abnormality. 2. Degenerative changes, especially at
the level of C3-4 and [**6-3**].
[**10-16**] CT torso: 1. No evidence of acute injury in the chest,
abdomen or pelvis. 2. Degenerative changes of the thoracolumbar
spine.
[**10-16**] RUE: Extensive fracture-dislocation around the right elbow
joint, with comminuted olecranon fracture, with telescoping, and
a large displaced bone shard directed ventrally, and fracture of
the radial head/neck junction.
[**10-16**] LUE: Impacted, comminuted fracture at the distal left
radius with dorsal displacement and angulation of the distal
fragment, and dislocation
of the distal ulna at the DRUJ.
[**10-17**] head CT: improved pneumoceph, no hemorrhage, shift, or
hydroceph
Micro:
[**10-18**] MRSA screen-negative
[**2164-10-18**] 1:27 am CSF;SPINAL FLUID Site: LUMBAR PUNCTURE
GRAM STAIN (Final [**2164-10-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2164-10-21**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take 3-8 weeks to grow..
VIRAL CULTURE (Preliminary): No Virus isolated so far.
[**10-18**] Sputum Cx: 1+ GPC (pair/clusters), 1+ GNR, 1+ GN Diplococci
[**10-17**] BCx: no growth
Brief Hospital Course:
Pt was evaluated in the [**Hospital1 18**] emergency department. His complex
lip laceration was repaired by plastic and reconstructive
surgery. Neurosurgery was consulted for pneumocephalus and
cribriform plate fracture. They recommended treating with vanco,
gentamicin, and flagyl and monitoring for CSF leak. He was taken
to the OR with orthopaedic surgery on HD2 for ORIF of right
elbow fracture-dislocation and closed reduction w/external
fixator placement for his left distal radius fracture.
Postoperatively, the patient was febrile to 105. Lumbar puncture
was performed by trauma team (final results were negative). He
was started on cefazolin, flagyl, and zosyn. He remained
intubated in the PACU overnight. He was transferred to the
trauma SICU and was extubated on HD4. He was transferred to the
floor on HD5, and his diet was advanced. The patient worked with
physical and occupational therapy who cleared him to go home. He
was taken to the operating room with plastic and reconstructive
surgery on [**10-24**] for open reduction and internal fixation of his
[**Male First Name (un) **] and palate fractures. He was stable posoperatively.
Medications on Admission:
none
Discharge Medications:
1. Neomycin-BacitracnZn-Polymyxin 3.5-400-5,000 mg-unit-unit/g
Ointment Sig: One (1) Appl Topical TID (3 times a day).
Disp:*1 1 week supply* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day): swish and spit for 30
seconds for five days.
Disp:*1350 ML(s)* Refills:*2*
4. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*10 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p fall
1. Complex lip laceration
2. Mulitiple facial fractures, including bilateral
[**Last Name (un) **]-ethmoidal, left orbital and zygomatic complex, maxillary
and hard palate fractures
3. Left intraarticular distal radius fracture
4. Right complex elbow fracture dislocation
Discharge Condition:
good, tolerating regular diet, ambulating
Discharge Instructions:
Please return to the hospital if you experience fevers greater
then 101.4, chills, or other signs of infection. Also return to
the hospital if you experience chest pain, shortness of breath,
redness, swelling, or purulent discharge from the incision site.
Return if you experience worsening pain or any other concerning
symptoms.
.
You should follow sinus precautions: make sure you open your
mouth when you sneeze, elevate your head while laying in bed, NO
nose blowing.
.
You should wear your right arm splint at all times. You should
not place any weight on your right arm.
.
You should not place any weight on your left arm. You should
clean around your the pin sites in your left arm two times
daily. Wash hands and use gloves. Use sterile swabs with a
solution of [**1-31**]-hydrogen peroxide and [**1-31**]-normal saline
(approximately 1 teaspoonful (5cc) of normal saline and hydrogen
peroxide). Pull back the skin around the pins and clean
vigorously. Wrap normal saline moistened gauze sponges around
the base of the pin. Please call your doctor if there is
excessive redness, swelling, or increased drainage from your pin
sites, or fever above 101.4.
.
Certain pain medications may have side effects such as
drowsiness. Do not operate heavy machinery while on these
medications.
.
Certain pain medications such as percocet or codeine can cause
constipation. If needed you can take a stool softner such as
Colace (one capsule) or gentle laxative (such as Milk of
Magnesia) once per day.
.
You make shower. Pat your incisions dry after showering.
.
Please take your entire course of antibiotics.
.
Please resume previous medications as prior to your surgery.
Please take pain medications and stool softener as prescribed.
.
Please follow-up as directed.
Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 1 week. Call his office at
([**Telephone/Fax (1) 10820**] to set up an appointment.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1005**] in 2 weeks. Call his
office at ([**Telephone/Fax (1) 2007**] to set up an appointment.
|
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icd9cm
|
[
[
[]
]
] |
[
"84.71",
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icd9pcs
|
[
[
[]
]
] |
4998, 5004
|
3112, 4264
|
353, 703
|
5329, 5373
|
1356, 1377
|
7184, 7550
|
1097, 1114
|
4319, 4975
|
5025, 5308
|
4290, 4296
|
5397, 7161
|
1129, 1337
|
2824, 3089
|
2762, 2785
|
276, 315
|
731, 972
|
1386, 2381
|
2390, 2729
|
994, 1025
|
1041, 1081
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,876
| 122,555
|
35769
|
Discharge summary
|
report
|
Admission Date: [**2184-2-16**] Discharge Date: [**2184-3-9**]
Date of Birth: [**2123-9-5**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Abdominal wound drainage, erythema
Major Surgical or Invasive Procedure:
[**2-17**]: Abdominal wound revision.
[**2184-2-19**]: IR guided Lumbar puncture
Right PICC line placement
History of Present Illness:
Transfer request by neurosurgery Dr. [**Last Name (STitle) **] to Medicine Team.
This is a 60 yo F with PMH of HIV (CD4 count 163 on [**12-29**] with VL
24,900 not on HAART), who was recently hospitalized with
cryptococcal meningitis requiring a VP shunt to decrease ICP.
She now presented on [**2184-2-16**] with "buldge" at her abdominal
insertion site and fevers. She went to the OR for revision of
the VP shunt insertion site which now appears to be functioning
well. She developed fevers though to a Tm on [**2184-2-17**] of 101.9
and now has GPC growing in [**12-22**] bottles from [**2184-2-16**]. Speciation
is still pending. The patient has been on vancomycin,
metronidazole and gentamycin in addition to the fluconazole and
dapsone she came in on. Infectious disease team was consulted
and now neurosurgery is requesting transfer to the medicine
team.
Currently, she has no complaints. She says she felt feverish
yesterday with shaking chills. No nausea or vomiting. No
headache. No chest pain, shortness of breath. No diarrhea
currently (but had some recently). No dysuria. She endorses a
cough (non productive) for one month.
Past Medical History:
1. HIV Dx'd 8 yrs ago - sexually transmitted. Followed by Dr.
[**Last Name (STitle) **] in [**Location (un) 8973**]. Not consistently on anti-retroviarals due
to intolerance and non-response. Last known CD4+ count 168 from
this admission with VL of [**Numeric Identifier **].
2. Hypothyroidism
3. Fibromyalgia
4. Rheumatoid arthritis
5. Vertigo
6. TIA x3 - initially reported as most recently 2mos ago with
dysarthria and facial droop and worked up at [**Hospital3 **] per
daughter. PCP unaware of TIAs. Daughter reported last was 6 yr
prior on requestioning.
7. DM- diet controlled
8. s/p appendectomy
9. s/p hysterectomy for cervical cancer
10. h/o HTN and hyperlipidemia treated w/ tricor per ID records
11. OSA does not use her CPAP at home
12. Per pt childhood polio - no record of this per PCP
13. T&A
14. Cataract surgery per PCP [**Name Initial (PRE) 3726**]
15. B12 deficiency receiving monthly B12 injections
PCP is [**Name9 (PRE) **] [**Name9 (PRE) 47242**] ([**Doctor Last Name **] =NP) [**Telephone/Fax (1) 81345**];
[**Telephone/Fax (1) **] is her ID Dr. [**Last Name (STitle) **] [**Location (un) 8973**] [**Telephone/Fax (1) 58547**]
Social History:
Lives alone, her boyfriend recently broke up with her, does not
work due to RA/fibromyalgia. No smoking, EtOH or illicit drug
hx. She has several children who are very involved.
Family History:
Mother died of throat cancer in her 70's
Father had [**Name2 (NI) 11964**]
Physical Exam:
On Admission:
O: T: 98.1 BP: 136/63 HR: 79 R 16 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
Pupils:3.0mm to 2.5mm EOMs No lateral gaze abnormality
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-20**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3.0mm to 2.5mm
bilaterally. Visual fields are full without lateral gaze
deviation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation unequal with left facial
palsy
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-23**] throughout. No pronator drift
Sensation: Intact to light touch, facial sensation is improving
per pt on the left side.
Toes downgoing bilaterally
Pertinent Results:
Labs on Admission:
[**2184-2-16**] 06:02PM BLOOD WBC-3.5* RBC-2.99* Hgb-9.8* Hct-27.4*
MCV-92 MCH-32.7* MCHC-35.6* RDW-17.5* Plt Ct-303#
[**2184-2-16**] 06:02PM BLOOD Neuts-58.4 Lymphs-26.6 Monos-9.7 Eos-4.8*
Baso-0.4
[**2184-2-16**] 06:02PM BLOOD PT-14.5* PTT-43.7* INR(PT)-1.3*
[**2184-2-16**] 06:02PM BLOOD Glucose-97 UreaN-9 Creat-1.0 Na-141
K-3.0* Cl-104 HCO3-25 AnGap-15
[**2184-2-17**] 10:15AM BLOOD ALT-9 AST-16 LD(LDH)-225 AlkPhos-94
TotBili-0.7
[**2184-2-17**] 10:15AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.6 Mg-1.4*
[**2184-2-16**] 06:02PM BLOOD CRP-39.0*
Labs on Discharge:
[**2184-2-27**] 05:38AM BLOOD WBC-6.1 RBC-2.58* Hgb-8.4* Hct-23.5*
MCV-91 MCH-32.6* MCHC-35.8* RDW-17.9* Plt Ct-347
[**2184-2-21**] 08:05AM BLOOD WBC-4.2 Lymph-24 Abs [**Last Name (un) **]-1008 CD3%-67
Abs CD3-678 CD4%-14 Abs CD4-139* CD8%-53 Abs CD8-538
CD4/CD8-0.3*
[**2184-2-27**] 05:38AM BLOOD Glucose-80 UreaN-19 Creat-1.2* Na-139
K-3.4 Cl-111* HCO3-18* AnGap-13
[**2184-2-27**] 05:38AM BLOOD Calcium-8.4 Phos-4.5 Mg-1.8 Iron-46
[**2184-2-27**] 05:38AM BLOOD calTIBC-194* Ferritn-1565* TRF-149*
Imaging:
CT of Chest/Abdomen [**2-16**]:
Liver lesion is hemangioma Vs mets recommend MR [**First Name (Titles) **] [**Last Name (Titles) 81352**]
Bilat infrahilar soft tissue prominence incompletely
characterized - Lymphadenopathy Vs neoplasm Recommend non-urgent
chest CT Wet Read Audit # 1 GWp MON [**2184-2-16**] 10:19 PM
VP shunt not in peritoneal cavity with low density collection
about distal tip Liver lesion is hemangioma Vs mets recommend MR
to [**Year (4 digits) 81352**]
Final Report
COMPARISON: None available.
TECHNIQUE: Multiple MDCT axial images were obtained from the
lung bases to
the proximal thighs after the uneventful administration of 130
cc of Optiray intravenously. Enteric contrast was not
administered. Sagittal and coronal reformations were derived.
FINDINGS:
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST:
In the visualized thorax, there is bibasilar atelectasis. There
is soft
tissue prominence within the infrahilar regions (series 2, image
1) which may represent lymphadenopathy associated with HIV.
There is no pleural effusion or pneumothorax. The visualized
heart is of normal size. There is no pericardial effusion. In
the abdomen, there is a 4.9 x 7.1 cm rounded hypdensity in
segments VI and VII of the liver demonstrating peripheral
nodular enhancement compatible with a hemangioma. The
gallbladder, spleen, adrenals, pancreas, and abdominal loops of
small and large bowel are unremarkable. The kidneys
symmetrically take up and excrete contrast without
hydrnephrosis. There are multiple oval hypodensities in each
kidney measuring to 1.6 x 2.2 cm on the left and 1.3 x 1.7 cm on
the right, likely benign cysts. There is no free air, free
fluid, or pathologic lymphadenopathy. The abdominal aorta is
normal in caliber and
course, but atherosclerotic calcifications are seen. The takeoff
of the
celiac axis and SMA appear patent. There is a small umbilical
hernia
containing fat. Additionally, multiple subcutaneous nodules are
present within the anterior abdominal wall, and correlation with
history of subcutaneous injections is recommended.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST:
Pelvic loops of bowel are unremarkable. The bladder and distal
ureters are
unremarkable. The adnexa are unremarkable. There is no pelvic
free air or
free fluid. Bilateral inguinal lymph nodes are prominent,
measuring up to 13 mm wide.
MUSCULOSKELETAL: In the right anterior abdominal wall external
to the
abdominal musculature, the ventriculoperitoneal shunt catheter
terminates
outside of the intraperitoneal cavity. Where it terminates,
there is a large 6.5 x 10.0 x 7.8- cm fluid attenuating
collection. There is associated skin thickening. There is no
suspicious osteolytic or osteoblastic lesion. Degenerative
changes are seen at numerous levels in the spine.
IMPRESSION:
1. VP shunt terminates outside of the intraperitoneal cavity,
within the
right anterior abdominal subcutaneous tissues. Where it
terminates, there is a large fluid collection with overlying
skin thickening consistent with a CSFoma. Infection of this
collection cannot be determined on the basis of this
examination, and clinical correlation is recommended.
2. Large segment VI and VII hypodensity with peripheral
enhancing nodularity compatible with a hemangioma.
3. Prominent soft tissue density within both infrahilar regions,
incompletely characterized on this study. Findings may represent
lymphadenopathy associated with HIV.
4. Multiple subcutaneous nodules within the anterior abdominal
wall.
Correlation with history of subcutaneous injections is
recommended.
[**2184-2-20**] CT head:
NON-CONTRAST HEAD CT: There is no hemorrhage, hydrocephalus,
shift of
normally midline structure, or evidence of major vascular
territorial infarct. The [**Doctor Last Name 352**]-white matter differentiation is
preserved. Right frontal
ventriculostomy catheter terminates in the frontal [**Doctor Last Name 534**] of the
left lateral. Hypodensities in the left cerebellar hemisphere,
right temporal lobe, and left caudate head are unchanged,
representing prior sites of cryptococcal involvement. There is
continued opacification of the right sphenoid sinuse and
increased secretions in the nasopharynx.
IMPRESSION: No hemorrhage or change in size or configuration of
ventricles.
Brief Hospital Course:
60 yo F with PMH of HIV (last CD4 in [**12-29**] was 163 and VL 24,900
not on HAART) and recent cryptococcal meningitis s/p VP shunt
for persistently elevated ICP who presents now with CSFoma from
abdominal insertion site and fevers. Neurosurgery said that
initial exam showed some clear fluid from abdominal site which
might have been CSF so there might have been exposure to
abdominal skin, but intra-operatively there was no pus or sign
of infection. They took her to the OR for re-alignment of the
abdominal portion of the VP shunt. Intra-operative swab was sent
and was negative but she had [**12-24**] blood cultures turn positive
for coag negative staph. She was then transferred to the medical
service for further work up of her fevers.
1. Fevers: Pt had coagulase negative staph growing from [**12-24**]
blood cultures from the [**2-16**], she was febrile and had a
leukocytosis relative to her baseline of [**1-21**]. DDx was broad in
this HIV patient with low CD4 count. Main concern was for
bacteria into the VP shunt and to the CSF. Clinically she
appeared well. She was placed on vancomycin when GPCs grew in
the blood cultures. ID consult was obtained and they recommended
ceftazadine until cultures returned from the CSF. She had an IR
guided LP done to evaluate the CSF which showed [**12-23**] WBC and low
glucose of 17 with normal protein. She also had evidence of
cryptococcal yeast on gram stain but no bacteria. Given this the
ceftazadime was discontinued. The cultures showed cryptococcal
yeast on gram stain but the cultures remained negative. She also
developed severe diarrhea and was C diff positive; and she was
treated with metronidazole which started on [**2184-2-19**]. Her course
should have ended on [**2184-3-4**] but patient refused further dosing
on [**2184-2-27**].
2. Cryptococcal meningitis: While CSF cultures were growing, she
was switched from fluconazole to ambisome with flucytosine for
synergy. She refused flucytosine given the large pill burden and
bitter taste. She continued on ambisome until cultures were
negative for 5 days when she was switched back to being treated
with fluconazole 400mg daily to end on [**2184-4-8**], but this was
later stopped once patient was made CMO.
3. Cerebral fluid collection: On [**3-2**], patient was noted to
have left-sided weakness. Pt had a stat CT head that showed
"interval development of vasogenic edema in the right frontal
lobe with associated midline shift and effacement of the
perimesencephalic cistern on the right." Patient was
transferred to the MICU for observation in the event of
herniation. Patient was started on mannitol to decrease
cerebral edema as well as
vanc/ceftaz/flagyl/flucytosine/ambisome to cover infectious
etiology. After discussion with the family including input from
Neurosurgery, the family decided to transition goals of care to
comfort. All antibiotics and antifungals were discontinued.
The patient was discharged to hospice with oral pain medication
for continued comfort care.
Medications on Admission:
Synthroid, Mecllizine, Fluconazole 200mg po QDay, Reg. Human
insulin sliding scale,Bisacodyl 5mg po BID,Colace 100mg po Qday,
Tylenol,Senna,Polyvinyl
alcohol-Povidone 1.4-0.6 Dropperette. 1-2gtts opthalmic
Q2hrs,Heparin 5,000 TID, Levothyroxine 25mcg 1 po Qday, Dapsone
100mg,Fluconazole 200mg po qday
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic HS (at bedtime).
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-21**]
Drops Ophthalmic PRN (as needed).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-21**]
Drops Ophthalmic TID (3 times a day).
4. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for respiratory distress.
5. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever.
6. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: [**11-21**]
Tablet, Sublinguals Sublingual QID (4 times a day) as needed for
secretions.
7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q4H (every 4 hours) as needed for agitation.
8. Morphine Concentrate 20 mg/mL Solution Sig: Twenty (20) mg PO
Q2H (every 2 hours).
9. Morphine Concentrate 20 mg/mL Solution Sig: 10-20 mg PO Q1H
(every hour) as needed for pain, distress.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 81353**]
Discharge Diagnosis:
Abdominal Wound Dehissence
C diff infection
Bacteremia
Cryptococcal meningitis
Hypokalemia
Adjustment disorder
HIV
Hypothyroidism
Anemia of chronic disease
Discharge Condition:
Verbally unresponsive, comfortable. Respirations unlabored.
Discharge Instructions:
You were seen and evaluated for a malpositioned shunt that was
placed to help relieve the pressure building up in your head.
This was fixed surgically. However, you were noted to have a
collection of fluid in your head, possibly an extension of your
infection, that led to swelling and increased pressure in your
head and ultimately impacting your brain. It was felt that your
overall clincal picture was worsening and after conversations
with your family, it was decided to focus our care on your
comfort rather than further treatment. You are now being
discharged to a facility where you can continue to live out the
remaining days of your life as comfortably as possible.
Followup Instructions:
N/A
Completed by:[**2184-3-10**]
|
[
"327.23",
"729.1",
"998.31",
"309.9",
"V45.89",
"321.0",
"276.8",
"E878.1",
"401.9",
"042",
"117.5",
"276.2",
"790.7",
"348.5",
"244.9",
"V45.2",
"272.4",
"V66.7",
"008.45",
"342.90",
"266.2",
"041.19",
"250.00",
"V12.54",
"714.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"54.99"
] |
icd9pcs
|
[
[
[]
]
] |
14167, 14214
|
9792, 12806
|
325, 434
|
14414, 14476
|
4400, 4405
|
15199, 15234
|
2991, 3067
|
13159, 14144
|
14235, 14393
|
12832, 13136
|
14500, 15176
|
3082, 3082
|
251, 287
|
4988, 9077
|
462, 1603
|
3643, 4381
|
9086, 9099
|
9108, 9769
|
4419, 4968
|
3365, 3627
|
1625, 2779
|
2795, 2975
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,857
| 126,601
|
47883
|
Discharge summary
|
report
|
Admission Date: [**2133-5-14**] Discharge Date: [**2133-5-19**]
Date of Birth: [**2084-5-24**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: End-stage renal disease, on hemodialysis.
HISTORY OF PRESENT ILLNESS: This 49-year-old male with end-
stage renal disease secondary to DM type 2, on hemodialysis
since [**2126**], presented for cadaveric renal transplant. On last
hemodialysis via left AV fistula on the previous day, his dry
weight is 148 kg. He is dialyzed every Monday, Wednesday and
Friday and has felt well. Approximately a month prior to
admission, he had a left 3rd finger amputation for an
unresolved infection treated with vancomycin. He denies
fevers, chills, nausea, vomiting, indigestion, shortness of
breath, chest pain, paroxysmal nocturnal dyspnea,
constipation or diarrhea. He does not void.
ALLERGIES: KEFLEX (HAS HIVES FROM THAT) AND MORPHINE (UNSURE
OF REACTION).
PAST MEDICAL HISTORY: Diabetes type 2, hypertension, end-
stage renal disease, left AV fistula, obesity, CAD status
post cabbage in [**2132-4-13**], status post cholesterol and knee
surgery, obstructive sleep apnea, wears a CPAP machine at
night, legally blind in left eye.
MEDICATIONS ON ADMISSION: Folic acid 1 mg daily, Nexium 20
mg daily, Lipitor 20 mg p.o. at bedtime, midodrine 10 mg p.o.
daily, Sensipar 90 mg p.o. daily, Coumadin 4 mg alternating
with 3 mg every other day (took 4 mg on the previous
evening), aspirin 325 mg daily. These were for AFib around
the time of his CABG.
SOCIAL HISTORY: No alcohol. No tobacco. He quit smoking
approximately 20 years prior. No recreational drugs. Married
with 3 children.
PHYSICAL EXAMINATION: Alert and oriented, very pleasant, no
acute distress, obese. HEENT: PERRLA, EOMs intact, anicteric
sclerae. Neck: 2+ right carotid and left 1+. No bruits. No
lymphadenopathy. Short neck. Lungs: Clear bilaterally. Cor:
Very distant heart sounds. Regular. Abdomen: Obese, nontender
and nondistended. Active bowel sounds. Extremities: No
clubbing, cyanosis or edema. Skin: Left dorsum hand pustule 4
mm. No erythema. Bilateral feet red with scaling rash between
toes and on the right ankle. Neurologic: Alert and oriented.
Cranial nerves grossly intact. Toes downgoing bilaterally.
Strength equal. Vascular: Left forearm AV fistula. Positive
bruit and thrill with 2+ DP and PT bilaterally. Vital signs:
Temperature 97.1, heart rate 90 beats, BP 107/60, respiratory
rate 20, oxygen saturation 99% on room air, glucose 114,
weight 148 kg, height 6 feet 3 inches.
HOSPITAL COURSE: The patient was admitted to the transplant
service. He was assessed preoperatively and consented to
participate in the Belatacept study as a participant. The
patient was taken to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient
underwent cadaveric renal transplant from a deceased donor
kidney transplant under general anesthesia. No complications.
The patient was intubated and transferred to the recovery
room in satisfactory condition. Please see operative report
for further details. EBL was approximately 400 cc, urine
output was 250 cc, and the patient was replaced with IV fluid
3500 cc. He had 2 JP drains placed in his right lower
quadrant. One was subcutaneous and a second drain was placed
in the retroperitoneum.
The patient was recovered in the PACU. The patient was
difficult to intubate and he was extubated. He continued on
CPAP postoperatively and weaned off the vent. A renal duplex
was done that demonstrated somewhat limited study due to
patient body habitus. No evidence of perinephric fluid
collection or hematoma. The upper pole of the kidney was not
well visualized. There was no evidence of a fluid collection.
The arterial and venous flow was seen within the transplanted
kidney.
He experienced ATN postoperatively with delayed graft
function requiring hemodialysis as his creatinine rose to 9
with a baseline of 8.8 on admission. Hematocrit decreased to
30.2 postoperatively. He received 1 unit of packed red blood
cells and 3 units of FFP postop. He had received 2 units of
FFP and 1 unit of platelets preoperatively. He had been on
Coumadin and aspirin as previously stated. Preop coags were
PT 18.1, PTT 25.4 and INR 1.7. He received induction
immunosuppression which included Solu-Medrol 500 mg, CellCept
and Belatacept. He followed the study protocol with a
tapering Solu-Medrol dose. On postop day #4, he received
Belatacept as well as Simulect.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtained for hyperglycemia. His Lantus
insulin was resumed and his sliding scale was titrated to
improve glycemic control. The patient was restarted on
midodrine. Physical therapy assessed the patient and felt
that it was safe to discharge the patient home to resume
previously ordered PT for balance and strength.
The JP drains were removed. His incision was clean and dry.
Vital signs remained stable. Heparin antibody was sent off as
his platelet count had decreased. This was negative.
Platelets had dropped to 75 and then started to trend back up
to 100, and a second platelet count was drawn. This was 96.
He was scheduled to receive Epogen at hemodialysis as an
outpatient for a hematocrit of 26.5 on postop days #5.
Nephrology followed the patient closely throughout this
hospital stay, making recommendations and monitoring of the
Belatacept study. His diet was advanced. He tolerated this
well. His pain was controlled with p.o. pain medication.
On postop day #5, he was discharged home in stable condition.
He is alert and oriented. His lungs are distant sounding.
Abdomen was nontender and nondistended. He was passing flatus
and tolerating a regular diet. He is ambulatory.
DISCHARGE MEDICATIONS:
1. Bactrim single strength 1 tablet every Monday, Wednesday
and Friday.
2. Nystatin 5 mL p.o. q.i.d.
3. Colace 100 mg p.o. b.i.d.
4. CellCept [**Pager number **]-mg tabs 2 tabs p.o. b.i.d.
5. Valcyte 450 mg p.o. q.48h.
6. Prednisone 20 mg p.o. daily per Belatacept taper.
7. Midodrine 10 mg p.o. t.i.d.
8. Vicodin 1-2 tablets p.o. p.r.n. q.4-6h.
9. Sevelamer 800 mg p.o. t.i.d.
10. Folic acid 1 mg p.o. daily.
11. Glargine insulin 22 units subcutaneous at bedtime.
12. Humalog insulin per sliding scale.
13. Nexium 20 mg p.o. daily.
DISCHARGE PLAN: Outpatient physical therapy 2-3 times per
week for strengthening and balance with left AFO. He was
scheduled to follow up in the outpatient clinic with Dr.
[**Last Name (STitle) **] on [**2133-5-27**]. He was to resume his previously
scheduled hemodialysis. Labs on discharge included white
count 8.6, hematocrit 26.5, sodium 141, potassium 4.5,
chloride 97, CO2 30, BUN 73, creatinine 8.3 and glucose
ranged 147-202. His Coumadin was on hold pending renal biopsy
that was scheduled for [**2133-5-21**], at 8:00 a.m. in day
care.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2133-5-20**] 08:54:03
T: [**2133-5-21**] 08:33:43
Job#: [**Job Number 101041**]
|
[
"403.91",
"250.40",
"996.81",
"V58.67",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"55.69",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
5770, 6317
|
1229, 1519
|
2556, 5747
|
1678, 2538
|
172, 215
|
244, 926
|
6334, 7119
|
949, 1202
|
1536, 1655
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,571
| 113,102
|
47808
|
Discharge summary
|
report
|
Admission Date: [**2198-4-13**] Discharge Date: [**2198-4-21**]
Date of Birth: [**2124-9-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Gallstone Pancreatitis
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
73M cad, s/p CABG [**01**] yrs ago, HTN, hyperlipd, afib on amiodarone
presented to ED on [**4-13**] with sudden onset generalized abd
pain/nausea/vomiting. S/P CCY 4yrs ago (was necrotic per
report). Denied fevers, chills, dysuria, lighheadedness, chest
pain, SOB. In ED, CT abd showed extensive intra- and
extra-hepatic biliary ductal dilatation with a 2.6 cm oblong
stone likely impacted in the ampulla. There was associated edema
in the pancreas head with surrounding inflammatory change
consistent with biliary stone pancreatitis. ERCP was preformed
on [**2198-4-13**], found impacted stone in the major papilla--was
started on levo and amp. However, the endoscopists were unable
to remove the stone. Instead, they peformed a sphincterotomy and
placed a pigtail biliary stent. Upon admission to the floor,
the patient's LFTs had trended down and his elevated
amylase/lipase have resolved. The patient was maintained on
zosyn and remained afebrile.
.
His floor course was complicated by afib + RVR and newly
discovered pericardial rub. The patient was able to maintain his
pressures. Bedside echo was done to rule out cardiac tamponade
and was negative for pericardial effusion. The patient had
continued to have abdominal pain with a significant
leucocytosis, so the surgical team was consulted to evaluate his
abdomen with the concern that there was may have been a
perforation during the procedure. Repeat abdominal CT, however,
did not demonstrate an acute surgical issue.
Past Medical History:
CAD s/p Cabg [**01**] yrs ago
CHF with EF 40% ([**2-11**])
CCY in [**2193**]
HTN
Afib on amiodarone--not anti-coagulated, pt refused coumadin,
didn't like the frequent f/u, cardioverted in [**2-11**]
Rectal CA s/p local excision
BPH
Hypercholesterolemia
Social History:
h/o tobacco use: 30pack years. now occasional etoh, used to
drink heavily. denies IVDU
.
Family History:
died at [**Age over 90 **]yo CHF--mother; Father: Liver disease
Physical Exam:
96.3 136/78 96 18 99%3L (micu exam)
GENL: elderly male, in bed
HEENT: elev JVP to jaw, OP clear, EOMI
CV: Irregularly irregular, +systolic murmur
Lungs: crackles 1/2 up
Abd: soft, NT, ND, +BS
Ext: no edema, 2+ pedal pulses
Pertinent Results:
[**2198-4-13**] 08:11AM BLOOD Lactate-4.2*
[**2198-4-16**] 10:35PM BLOOD Lactate-1.3
[**2198-4-16**] 06:30AM BLOOD TSH-0.34
[**2198-4-13**] 06:15AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2198-4-13**] 07:40PM BLOOD CK-MB-4 cTropnT-0.02*
[**2198-4-18**] 04:00AM BLOOD CK-MB-3 cTropnT-0.02*
[**2198-4-13**] 06:15AM BLOOD Lipase-8835*
[**2198-4-14**] 06:10AM BLOOD Lipase-688*
[**2198-4-18**] 04:00AM BLOOD Lipase-28
[**2198-4-13**] 06:15AM BLOOD ALT-406* AST-582* CK(CPK)-77 AlkPhos-242*
Amylase-[**2111**]* TotBili-2.7*
[**2198-4-16**] 06:30AM BLOOD ALT-177* AST-55* LD(LDH)-509* CK(CPK)-63
AlkPhos-139* Amylase-70 TotBili-1.6*
[**2198-4-21**] 06:10AM BLOOD ALT-46* AST-19 AlkPhos-94 TotBili-1.0
[**2198-4-13**] 06:15AM BLOOD Glucose-204* UreaN-20 Creat-1.4* Na-144
K-3.6 Cl-102 HCO3-28 AnGap-18
[**2198-4-21**] 06:10AM BLOOD Glucose-86 UreaN-19 Creat-1.3* Na-144
K-3.1* Cl-100 HCO3-34* AnGap-13
[**2198-4-13**] 06:15AM BLOOD Neuts-84* Bands-2 Lymphs-11* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2198-4-13**] 06:15AM BLOOD WBC-19.2*# RBC-4.52* Hgb-14.8 Hct-43.3
MCV-96 MCH-32.7* MCHC-34.1 RDW-14.3 Plt Ct-269
[**2198-4-16**] 06:30AM BLOOD WBC-25.9* RBC-4.55* Hgb-14.7 Hct-44.1
MCV-97 MCH-32.2* MCHC-33.2 RDW-13.9 Plt Ct-170
[**2198-4-21**] 06:10AM BLOOD WBC-15.7* RBC-4.19* Hgb-13.5* Hct-40.6
MCV-97 MCH-32.2* MCHC-33.2 RDW-14.0 Plt Ct-272
.
CT Torso:
CT CHEST WITHOUT AND WITH IV CONTRAST: The aortic root is mildly
dilated measuring 4.2 x 4.1 cm in transverse and AP dimensions
respectively. There is no evidence of aortic dissection. The
heart size is enlarged. There are extensive coronary artery
calcifications. There is moderate mediastinal lipomatosis. The
patient is status post CABG and median sternotomy. No filling
defects are identified within the pulmonary vasculature to
suggest pulmonary embolus. The lungs demonstrate dependent
atelectatic changes. There is no parenchymal consolidation to
suggest underlying pneumonia. There is a moderate hiatal hernia.
Airways are patent to the subsegmental bronchi bilaterally.
There is no pericardial or pleural effusion. No pathologically
enlarged mediastinal or hilar lymph nodes are identified. A
filling defect in the right common carotid artery may reflect
mixing artifact, although underlying thrombosis is not entirely
excluded. The thyroid is enlarged and contains numerous
low-density nodules.
.
CT ABDOMEN WITH IV CONTRAST: There is severe intrahepatic
biliary ductal dilatation with the right common hepatic duct
measuring up to 2 cm. The patient is status post
cholecystectomy. The liver parenchyma is uniformly dense,
possibly secondary to amiodarone therapy. Subcentimeter rounded
hypodensities are seen throughout the liver, too small to
characterize, likely cysts. The common bile duct is dilated to
1.6 cm. There is thickening of the distal common bile duct
adjacent to an oblong 2.6-cm hyperdensity consistent with a
stone that appears to protrude into the lumen of the duodenum.
There is extensive inflammatory change in the adjacent
mesenteric fat with edema and architectural distortion in the
head of the pancreas consistent with acute pancreatitis. There
are multiple periportal, aortocaval and peripancreatic enlarged
lymph nodes measuring up to 1.4 cm in short axis.
.
The stomach and unopacified loops of large and small bowel are
grossly unremarkable. There is no free intraperitoneal air. The
spleen and adrenal glands appear normal. The kidneys demonstrate
cortical thinning but enhance symmetrically and excrete contrast
normally. Several subcentimeter rounded hypodensities within
both kidneys are too small to characterize, likely cysts. There
are extensive calcifications throughout the abdominal aorta and
its branches. A normal air- filled appendix is seen in the right
lower quadrant.
.
CT PELVIS WITH IV CONTRAST: The ureters, urinary bladder, rectum
and sigmoid colon are normal. The prostate is mildly enlarged
measuring 5.6 x 4.1 cm. Small bilateral fat-containing inguinal
hernias. There is no free pelvic fluid and no inguinal or pelvic
lymphadenopathy.
.
IMPRESSION:
1. No evidence of aortic dissection or pulmonary embolus. Mild
dilatation of the ascending aortic root measuring 4.2 x 4.1 cm.
2. Extensive intra- and extra-hepatic biliary ductal dilatation
with a 2.6 cm oblong stone likely impacted in the ampulla. There
is associated edema in the pancreas head with surrounding
inflammatory change consistent with biliary stone pancreatitis.
Further characterization with ERCP is recommended.
3. Multiple low-attenuation nodules in an enlarged thyroid
gland. Correlate clinically and with thyroid ultrasound if
warranted.
4. Subcentimeter rounded hypodensities throughout the liver
which are too small to characterize, likely cysts. Diffuse
attenuation of the liver parenchyma may reflect response to
amiodarone treatment.
5. Atrophic kidneys containing tiny cysts which are too small to
fully characterize. No hydronephrosis or calculi are identified.
6. Moderate degenerative change in the lumbar spine with grade 2
anterolisthesis of L5 on S1.
7. Low attenuation within the right internal jugular vein likely
secondary to mixing, although underlying thrombus is not
excluded. Correlate clinically and with vascular ultrasound if
warranted.
.
Echo:
EF 20%
The left atrium is moderately dilated. The estimated right
atrial pressure is 11-15mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated with severe global left ventricular
hypokinesis and inferior and apical akinesis. No focal aneurysm
or masses/thrombi are seen. Right ventricular chamber size is
normal. There is moderate global right ventricular free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**2-6**]+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
cavity dilation and global/regional left ventricular systolic
dysfunction c/w diffuse process (multivessel CAD, toxin,
metabolic, etc.). Right ventricular free wall hypokinesis.
Mild-moderate mitral regurgitation. Pulmonary artery systolic
hypertension. Dilated ascending aorta.
.
CXR [**4-20**]
PA AND LATERAL CHEST: Cardiomediastinal silhouette is unchanged
from a few days prior with cardiomegaly and calcification of the
aortic arch again noted. Left-sided pleural effusion has
decreased in size and retrocardiac density representing
atelectasis versus consolidation persists. Right lung appears
clear and there is no overt evidence of edema. A minor amount of
fluid is seen within the left major fissure. Midline sternotomy
wires are unchanged.
.
IMPRESSION: Some decrease in size of left-sided pleural
effusion. No new acute cardiopulmonary process.
.
Brief Hospital Course:
#Gallstone Pancreatitis s/p ERCP: as noted the patient underwent
ERCP with unsuccessful removal of a large gallstone. However, a
stent was placed with relief of biliary obstruction and
normalization of LFTs/[**Doctor First Name **]/lipase. Repeat RUQ U/S with resolved
CBD dilation and no definite stone seen, ?had passed.
Nevertheless, will f/u for repeat ERCP in 4 weeks for repeat
ERCP, stent removal and repeat cholangiogram. ASA held for 10
days post-ERCP. Coumadin not started as pt with recent
sphincterotomy. As mentioned, despite a significant
leucocytosis, repeat Abd CT after procedure without perforation
or complication from ERCP. Was kept on 7 days of Zosyn in
house. No evidence of cholangitis.
.
#Cardiovascular Issues
*Ischemia: serial CE negative; ECG without acute changes.
*Pump: given concern for ?rub, an Echo was obtained. It showed
[**Last Name (LF) **], [**First Name3 (LF) **] EF of 20%, and [**2-6**]+MR. ?if Rub heard was MR with an S3.
Nevertheless, pt should have very close f/u with his
PCP/Cardiology, given the fact he had an Echo at the VA in [**2-11**]
with an EF of 40%. Continued on ACE-I. Hospital course
complicated by mild CHF that resolved with IV lasix. D/C'd on
home dose. ?if decreased EF was d/t contributing
tachycardia-induced CM.
*Rhythm: the patient had rapid A fib during his hospitalization,
with rates initially in the 120s. Lopressor increased to 150XL
[**Hospital1 **], and Diltiazem 240 daily added. On this regimine, HR was
~90s. [**Month (only) 116**] need to start Dig as an outpatient. Of note, the
patient asked to be cardioverted numerous times during his stay.
This would be impractical as the patient could not be
coumadinized because of his recent sphincterotomy and need for
repeat ERCP. In addition, given the fact that he is already on
Amio, and has failed to maintain NSR in the past, repeat
cardioversion highly unlikely to restore NSR. Pt would likely
benefit for EP referral for both A fib ablation and ICD given
ischemic CM.
*Prevention: statin held given transaminits. Can be restarted
as an outpatient. ASA held as above.
.
#Thyroid Nodules: needs outpatient f/u.
.
#?RIJ clot: as noted on CT. U/S normal. Likely mixing
artifact.
Medications on Admission:
Fosinopril 20, Toprol XL 75, Simvastatin 80, ASA 325, Coumadin
(had been stopped recently), Lasix 40, Amio 400 daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO twice a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Fosinopril 20 mg Tablet Sig: One (1) Tablet PO qd ().
6. DILT-CD 240 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day: DO
NOT START until [**4-23**].
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Gallstone Pancreatitis s/p ERCP
2. Congestive Heart Failure
3. Atrial Fibrillation
4. Hyperlipidemia
5. Thyroid Nodules
Secondary Diagnoses:
h/o Rectal CA s/p local excision
BPH
s/p CCY
CAD s/p CABG
Discharge Condition:
stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) 48975**] should you develop any fevers, chills,
sweats, abdominal pain, nausea, vomiting, chest pain, shortness
of breath, or any other complaints.
It is very important to call the Visiting Nurses when you get
home.
Followup Instructions:
It is EXTREMELY IMPORTANT to call Dr.[**Name (NI) 100920**] office Monday
morning
for followup.
|
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icd9cm
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[
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[
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icd9pcs
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12878, 12936
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338, 345
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76,697
| 152,593
|
47156
|
Discharge summary
|
report
|
Admission Date: [**2174-6-5**] Discharge Date: [**2174-6-9**]
Date of Birth: [**2098-4-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
worsening abdominal distension, decreased PO intake, fatigue
Major Surgical or Invasive Procedure:
Paracentesis in ED
History of Present Illness:
Mr. [**Known lastname 99928**] is a 76 year old male with metastatic rectal cancer
and a history of biliary obstruction, recent admission for
biliary stent internalization, who presents from home with
worsening abdominal distension, decreased PO intake, fatigue.
On the last admission, the patient had been notified that the
stent was incompletely draining the liver and that he likely
would need another drain; he there was question about whether
this was within goals of care and he wanted to return home, so
he was discharged. At home he had a constellation of symptoms
including confusion, fatigue, decreased PO intake, worsening abd
distention, dark urine, worsening jaundice.
.
In the ED, initial VS were 97.3 93 135/60 18 100 he received a
paracentesis and his lab abnormalities were numerous including
worse renal function, liver tests, leukocytosis to 18, anion gap
metabolic acidosis. He was admitted to [**Hospital Unit Name 153**] and his PCP visited
him, apparently during a more lucid interval, when he was able
to express comfort measures only. He is called out of the [**Hospital Unit Name 99930**]. He appears very sedate currently and is able to open his
eyes to sternal rub, focuses his eyes on you for a second and
can express that he is not in pain, but goes directly back to
sleep. Per the family, he was awake and alert and conversant
last night in the ED, but today he has been sleeping all day. ED
signout to [**Hospital Unit Name 153**] showing he was following commands, oriented x1,
somewhat somnolent.
.
Vitals on transfer from [**Hospital Unit Name 153**]: 90 125/67 14 93%. Only made 200
cc UOP/8 hrs. On exam, he is breathing 6 times a minute.
Past Medical History:
Past Oncologic History:
1. Transanal local excision on [**2164-7-18**]. Pt did not have
adjuvant treatment.
2. Subsequent colonoscopes revealed no malignant lesions until
[**2172-4-13**], when an infiltrative bleeding 2.5 cm mass was found at
the distal rectum. The lesion was removed, path + for
adenocarcinoma.
3. Imaging revealed widely metastatic disease and DVT in the
right common and internal iliac veins.
4. Anticoagulation was discontinued after pt developed
significant rectal bleeding. IVC filter was placed on [**2172-4-28**].
Lovenox was started for a DVT in the tibial vein, popliteal vein
and femoral vein of the left lower extremity on [**2172-8-11**].
5. Palliative radiation to prevent recurrent rectal bleeding
started on [**2172-4-30**].
6. Started chemotherapy with FOLIRI on [**2172-5-26**]. Treatment held
and/or dose-reduced several times because of myelosuppression
and
fatigue. Chemotherapy was also held for about 4 weeks after
cycle
5 in anticipation of resection of the primary tumor. However, pt
then decided against surgery and chemotherapy was restarted on
[**2172-11-23**].
7. Disease progression, FOLFOX started on [**2173-1-19**].
8. Disease progression, started irinotecan + Cetuximab on
[**2173-3-27**].
9. PET/CT [**2173-6-2**] showed marked interval improvement.
10. POD found in [**11-24**] and then he went on a treatment break.
His LFTs rose in [**1-26**] and CT scan revealed additional
progression.
11. Started Xelox on [**2174-2-2**] complicated by vomiting, diarrhea,
loss of appetite and weight loss and chemotherapy discontinued
after 1 cycle.
12. Started Panitumumab 6mg/kg every 2 weeks started on [**2174-4-26**].
Had allergic reaction after 2nd dose on [**2174-5-10**], treatment
stopped.
13. CT scans on [**2174-5-19**] show widespread progression of disease.
.
Other Past Medical History:
- h/o DVT x2 (has IVC filter in place)
- hyperthyroidism, on no meds (? patient denies)
- hypertension
- CAD s/p RCA stent [**2165**] after + stress test, no h/o MI or CHF
- CKD, baseline Cr 1.2-1.4 since [**2-/2174**]
- carotid stenosis, 40-59% R ICA stenosis and 60-69% L ICA
stenosis
Social History:
Married, lives with his wife in [**Name (NI) 3146**]. Has 2 daughters, one
lives locally and one lives in [**Location 19061**]. He quit smoking 25-30
yrs ago, but previously smoked 1ppd. No recent EtOH use.
Previously independent with mobility and self-care. He continues
to work in marketing for [**Company 99929**] Club.
Family History:
Mother died of pancreatic cancer.
Physical Exam:
96.7 101/57 80 6 97%RA
Critically ill pt, extremely sedate but arouses to sternal rub,
focuses/makes eye contact briefly but then drowses back off. He
appears to be passing away and is breathing extremely slowly.
Grossly jaundiced with scleral icterus with all the sequelae of
liver failure.
CTAB anteriorly, port in L chest
RRR, no murmurs, not tachycardic
Distended, hypertympanic abdomen. Not grimacing to palpation of
his abdomen
Gross anasarca from feet to abdomen.
Unable to test mental status exam.
Pertinent Results:
Admssion Labs:
[**2174-6-5**] 09:07PM TYPE-ART PO2-108* PCO2-19* PH-7.32* TOTAL
CO2-10* BASE XS--13
[**2174-6-5**] 09:07PM LACTATE-1.9
[**2174-6-5**] 09:07PM O2 SAT-97
[**2174-6-5**] 09:07PM freeCa-1.12
[**2174-6-5**] 06:03PM URINE HOURS-RANDOM CREAT-60 SODIUM-35
POTASSIUM-37 CHLORIDE-17
[**2174-6-5**] 06:03PM URINE OSMOLAL-368
[**2174-6-5**] 05:00PM ASCITES WBC-280* RBC-1300* POLYS-29*
LYMPHS-17* MONOS-0 MESOTHELI-1* MACROPHAG-53*
[**2174-6-5**] 05:00PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.011
[**2174-6-5**] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2174-6-5**] 05:00PM URINE RBC-0 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2174-6-5**] 05:00PM URINE GRANULAR-0-2
[**2174-6-5**] 02:58PM GLUCOSE-70 UREA N-108* CREAT-4.5*# SODIUM-134
POTASSIUM-5.7* CHLORIDE-104 TOTAL CO2-10* ANION GAP-26*
[**2174-6-5**] 02:58PM estGFR-Using this
[**2174-6-5**] 02:58PM ALT(SGPT)-71* AST(SGOT)-205* ALK PHOS-1830*
TOT BILI-19.7*
[**2174-6-5**] 02:58PM LIPASE-80*
[**2174-6-5**] 02:58PM ALBUMIN-2.4* PHOSPHATE-7.5*# MAGNESIUM-2.5
[**2174-6-5**] 02:58PM AMMONIA-66*
[**2174-6-5**] 02:58PM OSMOLAL-330*
[**2174-6-5**] 02:58PM WBC-18.8*# RBC-3.94* HGB-12.1* HCT-37.4*
MCV-95 MCH-30.7 MCHC-32.4 RDW-17.1*
[**2174-6-5**] 02:58PM NEUTS-92.9* LYMPHS-5.0* MONOS-1.7* EOS-0.1
BASOS-0.2
[**2174-6-5**] 02:58PM [**2174-6-5**] 02:55PM LACTATE-1.9
Discharge Labs PLT COUNT-353
[**2174-6-5**] 02:58PM PT-30.5* PTT-51.9* INR(PT)-3.0*
Brief Hospital Course:
76yo M w/ metastatic, progressive rectal cancer h/o biliary
obstruction, recent admission for stent internalization, who is
called out of [**Hospital Unit Name 153**] where he was admitted for fatigue, decreased
PO intake, poor UOP, increasing abdominal distention; also with
leukocytosis, renal failure, metabolic anion gap acidosis, liver
failure, elevated lipase.
.
1. Multiorgan failure: In discussion with the pt (apparently
during more lucid period during this admission) and the PCP, [**Name10 (NameIs) **]
pt expressed his desire to be comfortable. Family expresses
feeling that they may not be able to care for pt at home, and
may want hospice in a facility. He was made comfort measures
only and admitted to inpatient hospice. He passed away
peacefully on [**2174-6-9**] with his family at his bedside.
Medications on Admission:
Lomotil 1-2 tabs PO QID prn (usually takes it once in the AM)
Lovenox 120mg SC daily
Vitamin D2 50,000 PO q week (last on Monday)
Metoprolol XL 100mg PO daily
Pepcid 20mg PO BID prn
Sildenafil 100mg PO prn
Loperamide prn (takes this rarely)
Magnesium oxide 400mg PO BID
.
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic progressive rectal cancer
Multiorgan failure
Discharge Condition:
Patient passed away.
Discharge Instructions:
N/a
Followup Instructions:
N/a
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
Completed by:[**2174-6-13**]
|
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icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
7937, 7946
|
6769, 7586
|
373, 393
|
8046, 8068
|
5198, 6746
|
8120, 8248
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4613, 4648
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273, 335
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421, 2102
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3969, 4257
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4273, 4597
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,424
| 171,695
|
52166
|
Discharge summary
|
report
|
Admission Date: [**2175-8-15**] Discharge Date: [**2175-9-1**]
Date of Birth: [**2116-3-13**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Aspirin / Ciprofloxacin / Urelle /
Levaquin / Ampicillin / Haldol
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
50 yo F with a fairly long history of acid reflux disease with
heartburn and regurgitation presenting for laparoscopic Nissen
fundoplication.
Major Surgical or Invasive Procedure:
- Laparoscopic Nissen fundoplication;
- Esophagoscopy;
- Right thoracotomy and repair of cervical perforation;
- Intercostal muscle flap buttress and diagnostic endoscopy;
History of Present Illness:
patient has had a long history of acid reflux disease with
heartburn and regurgitation. Some of her symptoms of heartburn
are fairly well controlled, but are not well controlled that her
regurgitative symptoms are getting worse. She has also had
episodes of aspiration and had a CT scan, which showed
aspiration pneumonia. She describes a significant regurgitation
when lying down flat.
Past Medical History:
Her past medical history is notable for history of asthma and
bronchitis as well as ulcerative colitis. She denies heart
disease, diabetes, or renal disease. She is allergic to sulfa
and ampicillin, which gives her abdominal discomfort.
Social History:
Ms. [**Known lastname 107929**] grew up in [**Location (un) **], MA, and is one of 5
children. She attended school through college and worked as a
receptionist at the [**Hospital3 28354**] and
also for her father in sales. Currently, she works as an aide,
taking elderly people shopping; she has not worked since [**2175-2-26**]. She has been married two times and has no children. She
resides in [**Location 1268**] with her significant other, [**Name (NI) **], who
is
a psychologist. He has been a good support for her, as well as
her siblings. Her brother is her health care proxy. [**Name (NI) **] mother
passed away on [**2175-3-19**] from liver cancer.
Family History:
Brother with schizophrenia ("one episode")
Physical Exam:
PE:
Vitals: 98.2 97.7 120/68 88 16 97%RA
Pertinent Results:
[**2175-8-15**] 04:18PM freeCa-1.12
[**2175-8-15**] 04:18PM HGB-12.7 calcHCT-38
[**2175-8-15**] 04:18PM GLUCOSE-137* LACTATE-3.4* NA+-139 K+-3.8
CL--104
[**2175-8-15**] 04:18PM TYPE-ART PO2-316* PCO2-54* PH-7.29* TOTAL
CO2-27 BASE XS--1
[**2175-8-15**] 07:49PM PLT COUNT-197
[**2175-8-15**] 07:49PM WBC-14.9*# RBC-4.12* HGB-12.6 HCT-39.1 MCV-95
MCH-30.5 MCHC-32.2 RDW-12.7
[**2175-8-15**] 07:49PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-1.5*
[**2175-8-15**] 07:49PM estGFR-Using this
[**2175-8-15**] 07:49PM GLUCOSE-185* UREA N-12 CREAT-0.7 SODIUM-140
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
[**2175-8-15**] 08:04PM freeCa-1.10*
[**2175-8-15**] 08:04PM LACTATE-3.8*
[**2175-8-15**] 08:04PM TYPE-ART PO2-117* PCO2-48* PH-7.34* TOTAL
CO2-27 BASE XS-0
----------
Brief Hospital Course:
59 y/o F who was admitted on the day of operation on [**2175-8-15**].
OR [**2175-8-15**]:
Diffucult intubation
Failed laryngoscopic intubation
Failed GlideScope intubation
??????Anesthesia stat??????
Failed attempt with bougie
Intubated successfully with GlideScope with 7mm endotracheal
tube
Laparoscopic Nissen fundoplication complicated by esophageal
perforation from Bougie, repaired and drained via right
thoracotomy.
Taken to T/SICU intubated
POD #1 ([**2175-8-16**]):
significant subcutaneous emphysema of chest, face and neck
minimal cuff leak around endotracheal tube -> remained intubated
POD #2-#3 ([**Date range (1) 107930**]):
crepitus resolved
febrile to 102.1F
Negative cultures
Bronchoscopy: significant airway edema
Otolaryngology service evaluation
TPN started
POD #4 ([**2175-8-19**]):
extubated with full anesthesia presence and back-up
minor ventilation issues
POD#5-#7 ([**Date range (1) 107931**]):
Agitated, anxious, pulled out nasogastric tube
Delirious intermittently
psychiatry consultation
Pain service involvement
One of two thoracostomy tubes removed
WBC to 15K
Intermittantly hypotensive to SBP of 85, MAP ~55
Fluid-responsive
Urine output adequate
Cardiac evaluation negative
POD #8 ([**2175-8-23**]):
Transferred to floor
24-hour private duty nurse
POD #[**9-7**] ([**Date range (1) 107932**]):
Continued debilitating anxiety
Paranoia
Intermittently agitated/delirious
IV and sublingual anxiolytics
POD #10 ([**2175-8-25**]):
Tremulous, delirious, mild cyanosis
Exam: 101.0F HR 112 118/58 26 84%RA (bedside sat monitor),
100%RA (continuous O2 sat monitor)
Dyspneic
Slightly mottled extremities
All incisions and tube sites c/d/i
Non-rebreather O2 mask
ABG 7.46/34/343/25/+1
Reassuring CXR
Pan-cultured
Blood cultures from PICC grew S. aureus
CTA chest: showed very narrow airway
POD #10 ([**2175-8-25**]):
Otolaryngology service
Bedside laryngoscopy -> significant narrowing of larynx
Nebulizers as needed
Humidified air
Emergency tracheostomy kit at bedside
POD #12 ([**2175-8-27**]):
Blood culture results returned S. aureus
PICC removed
TPN held
POD #13 ([**2175-8-28**]):
Barium swallow study: negative for leak, Gross aspiration
Bedside swallow evaluation by speech pathologist:
Gross aspiration of thin and thickened liquids
POD #14 ([**2175-8-29**]):
PICC replaced, TPN resumed
Video oropharyngeal swallow evaluation:
Gross aspiration
Improvement with chin-tuck maneuvers
Significant retention of barium in esophagus with pharyngeal
pooling/aspiration
Delayed esophageal emptying
Physical therapy clearance
POD #17 ([**2175-9-1**]):
Discharged home
NPO/TPN
Cefazolin for MSSA line infection
Medications on Admission:
Medications:
Rowasa enemas prn
Clomipramine
Clonazepam rabeprazole 20mg [**Hospital1 **]
Trazodone 150mg qd
Simvastatin 80mg qd
Discharge Medications:
**PRESCRIPTION FOR OLANZAPINE NOT GIVEN**
1. Outpatient Lab Work
Please obtain CBC, Chem 10, triglycerides on [**2175-9-4**],
[**2175-9-11**], [**2175-9-18**], [**2175-9-25**]. Please call [**Telephone/Fax (1) 2981**] for
fax number to send results to Dr.[**Name (NI) 1482**] office.
2. TPN
Volume(ml/d): 1400, Amino Acid(g/d): 80, Branched-chain AA(g/d):
0, Dextrose(g/d): 240, Fat(g/d): 30, Trace Elements will be
added daily, Standard Adult Multivitamins, NaCL: 30
NaAc: 0, NaPO4: 30, KCl: 15, KAc: 25, KPO4: 10, MgS04: 10,
CaGluc: 5, Total volume of solution per 24 hours = 1400 ml's;
cycle over 15 hours with one hour taper up, one hour taper down.
3. Budesonide 180 mcg/Inhalation Aerosol Powdr Breath Activated
Sig: Two (2) puffs Inhalation twice a day.
4. Clomipramine 50 mg Capsule Sig: One (1) Capsule PO once a
day.
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation for 1 months.
Disp:*20 Suppository(s)* Refills:*0*
7.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
9. Colace 50 mg/5 mL Liquid Sig: Ten (10) mL PO twice a day for
1 months.
Disp:*500 mL* Refills:*0*
10. Roxicet 5-325 mg/5 mL Solution Sig: Five (5) mL PO every [**6-5**]
hours as needed for pain for 2 weeks.
Disp:*250 mL* Refills:*0*
11. Milk of Magnesia 800 mg/5 mL Suspension Sig: Five (5) mL PO
once a day as needed for constipation for 2 weeks.
Disp:*100 mL* Refills:*0*
12. Cefazolin 1 gram Recon Soln Sig: One (1) gram Intravenous
every eight (8) hours for 7 days.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Gastroesophageal reflux disease
Esophageal perforation
Staph aureus bacteremia secodary to line infection.
Swallowing disorder
Anxiety
Discharge Condition:
Ambulatory, afebrile, vital signs stable; in good condition;
Discharge Instructions:
You were treated in the hospital after your laparoscopic Nissen
fundoplication for GERD/heartburn/reflux/aspiration.
You should continue to take your home medications as prescribed.
You should continue to take any new medications as prescribed.
Please return to the hospital or emergency department for any
signs or symptoms of chest pain, abdominal pain,
nausea/vomiting, fever greater than 101, headache, changes to
your stool or blood in your stool, headache, dizziness or any
other symptoms that you may find concerning.
Followup Instructions:
You need to follow-up with Dr. [**Last Name (STitle) **] regarding your
post-operative care. You should call him at [**Telephone/Fax (1) 2981**] to
schedule an appointment in 2 weeks from your discharge.
Completed by:[**2175-11-13**]
|
[
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"E870.0",
"555.9",
"530.81",
"276.3",
"733.00",
"300.00",
"507.0",
"998.2",
"787.29",
"790.7",
"041.89",
"338.12",
"293.0",
"E878.8",
"530.4",
"997.39",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.23",
"38.93",
"96.72",
"99.15",
"34.09",
"33.23",
"44.67",
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] |
icd9pcs
|
[
[
[]
]
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7534, 7586
|
2979, 5624
|
489, 663
|
7765, 7828
|
2160, 2956
|
8404, 8641
|
2038, 2083
|
5802, 7511
|
7607, 7744
|
5650, 5779
|
7852, 8381
|
2098, 2141
|
308, 451
|
691, 1082
|
1104, 1344
|
1360, 2022
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,776
| 129,519
|
1776
|
Discharge summary
|
report
|
Admission Date: [**2139-11-14**] Discharge Date: [**2139-11-25**]
Date of Birth: [**2061-6-14**] Sex: M
Service: MEDICINE
Allergies:
Lasix
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Bleeding from trach site on IV heparin
Major Surgical or Invasive Procedure:
no surgical procedure
pleural tap of right effusion
History of Present Illness:
78 M w/CP on [**10-13**] found to have leak at site of previous
anastamosis s/p CABG X3, re-do sternotomy, repair ascending
aorta graft (Nemtal SJ valve, Cobral) [**10-14**] and takeback for
closure [**10-15**]. s/p Bentall w/[**Doctor Last Name 10010**] modification/mech St. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 1291**]/CABGx2 ('[**28**])
Failure to wean. Trached. Anticoagulated for mech [**Year (2 digits) 1291**]. Sent to
rehab([**Hospital1 **]). Returned to [**Hospital1 18**] on [**2139-11-14**] for eval of trach
site bleeding.
Past Medical History:
Bentall, mechanical VR, CABG X 3 10 years ago
repair ascending aorta graft (Nemtal SJ valve, Cobral) [**10-14**] and
takeback for closure [**10-15**]. s/p Bentall w/[**Doctor Last Name 10010**]
modification/mech St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**]/CABGx2 ('[**28**])
trach
AFib
CAD
hyperlipidemia
HTN
Social History:
married, lives with wife
Family History:
non-contributory
Physical Exam:
[**11-17**] - PHYSICAL EXAMINATION:
T 97.1 P80-90 BP 110/54 R 21 96% FiO2 0.4 TM I/O 2.2L/1.8L
Gen- awake, disoriented
HEENT- anicteric, PERRLA, EOMI, moist mucus membrane, neck
supple, no JVD
CV- regular, no r/m/g
resp- decreased breath sound bilateral bases, mild crackles
anteriorly
ABDOMEN- soft, nontender, nondistended
EXT- no edema, surgical scars noted
Neuro- follow commands, speech hard to comprehend, tremors/jerky
movements noted, PERRLA, EOMI, CNII-XII intact, nml muscle tone,
move all 4 symmetrically, gait not tested
Pertinent Results:
[**2139-11-14**] 09:24PM GLUCOSE-105 UREA N-41* CREAT-1.7* SODIUM-142
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-33* ANION GAP-9
[**2139-11-14**] 09:24PM WBC-7.2 RBC-3.24* HGB-10.2* HCT-30.8* MCV-95
MCH-31.6 MCHC-33.2 RDW-18.7*
[**2139-11-14**] 11:44PM TYPE-ART TIDAL VOL-500 PEEP-5 PO2-105
PCO2-50* PH-7.44 TOTAL CO2-35* BASE XS-7 INTUBATED-INTUBATED
.
[**11-17**] Head CT - CONCLUSION: Sphenoid and mastoid air cell
partial opacification. Images of the brain demonstrate atrophy
but no evidence of hemorrhage or infarction.
.
[**11-24**] - CXR - IMPRESSION: Improving pulmonary edema. Bilateral
pleural effusions, right greater than left.
Brief Hospital Course:
Pt was initially admitted to the CSRU for eval of trach site
bleeding. Heparin was stopped at [**Hospital1 **] prior to admission to
[**Hospital1 18**], INR on admission was 1.3, PTT 29.4. The patient received
2 Unnits PRBCs, trach site was packed w/ surgicell. Pt was
placed on ventilatory support initially then weaned to trach
mask continuous w/ stable resp status. He continued to have
large amount of secretions requiring suctioning. Large right
pleural effusion was noted on CXR and tapped for 2100cc. Heparin
was resumed on [**2139-11-16**] after pleural tap. CXR's were
concerning for reaccumulation of effusion, although oxygenation
was stable. The patient was initially started on ethacrynic
acid for diuresis, however this was held after bicarbonate was
noted to rise to 40. VBG revealed nl CO2 of 49. He will need
on going trach collar care and weaning as tolerated. For the
mechanical valve and a. fib he was continued on heparin drip
until INR was therapeutic. Initially started on 4mg and then
increased to 6 mg on [**2139-11-24**]. Heparin should be continued and
Coumadin dose adjusted appropriately for goal INR 2.5-3.0.
.
In hospital course was complicated by delerium. Neurology was
consulted and work-up including B12, RPR, folate, ammonia were
unrevealing, no evidence of hypoxia, head ct negative for bleed,
and mental status cleared slowly. Post pyloric dob-hoff was
placed on [**11-25**] prior to transfer to rehab.
Medications on Admission:
coumadin, asa 81, clonazepam 0.5', coenzyme q10 100', HCTZ
12.5', Lanoxin 0.125', lopressor 200', mevacor 10mg', MVI,
norvasc 10', heparin drip
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. Tramadol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
3. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
4. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR [**Last Name (STitle) **]: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: [**12-22**] Inhalation Q6H
(every 6 hours).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (2) **]: Six (6)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
8. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (2) **]: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
9. Docusate Sodium 150 mg/15 mL Liquid [**Month/Day (2) **]: One (1) PO BID (2
times a day).
10. Hexavitamin Tablet [**Month/Day (2) **]: One (1) Cap PO DAILY (Daily).
11. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Day (2) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
12. Insulin Regular Human 100 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection ASDIR (AS DIRECTED): Insulin sliding scale.
13. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical QID
(4 times a day) as needed.
14. Amiodarone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
15. Lactulose 10 g/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO BID (2
times a day) as needed for constilpation.
16. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
[**Month/Day (2) **]: One (1) Intravenous ASDIR (AS DIRECTED): Goal PTT 50-70.
17. Warfarin 2 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO DAILY (Daily).
18. Isosorbide Dinitrate 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID
(3 times a day).
19. 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.
20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Respiratory failure
Atrial fibrillation
Mechanical valve
re-do sternotomy, CABG X 3
repair ascending aortic graft on [**2139-10-14**]
s/p mediastinal exploration for bleeding & delayed chest
closure,
s/p trach complicated by bleeding.
Discharge Condition:
deconditioned
Discharge Instructions:
Please continue to administer all medications as below and
follow up with appointments as below.
If you have any difficulty breathing, fevers, shortness of
breath or bleeding episodes please return to the emergency room.
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] regarding any issues
with his tracheostomy.
[**Last Name (NamePattern4) 2138**]p Instructions:
Call Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office [**Telephone/Fax (1) 170**] for a follow up
appointment.
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] regarding any issues
with his tracheostomy.
Completed by:[**2139-11-25**]
|
[
"518.81",
"V45.81",
"E947.9",
"511.9",
"V43.3",
"428.30",
"519.09",
"292.81",
"276.3",
"401.9",
"333.1",
"427.31",
"414.00",
"272.4",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"34.91",
"96.6",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6598, 6698
|
2630, 4083
|
306, 360
|
6977, 6993
|
1964, 2607
|
1378, 1396
|
4277, 6575
|
6719, 6956
|
4109, 4254
|
7017, 7349
|
7400, 7672
|
1411, 1425
|
1447, 1945
|
228, 268
|
388, 953
|
975, 1319
|
1335, 1362
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,870
| 180,502
|
12767+56402
|
Discharge summary
|
report+addendum
|
Admission Date: [**2100-11-20**] Discharge Date: [**2100-11-23**]
Date of Birth: [**2037-12-8**] Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Stress MIBI [**2100-11-23**]:
1. Predominantly fixed perfusion defect in the LAD territory.
2. Global hypokinesis, apical akinesis. LVEF 32%.
History of Present Illness:
62 y/o woman with known coronary disease s/p PCI in [**2088**] @ [**Hospital1 2025**],
chronic renal failure [**3-6**] congenital ureteral implantation
problem, also with antipphospholipid antibody syndrome, on
coumadin, transfered to the CCU after presenting to [**Hospital3 **] with chest pain.
.
She reports waking up from sleep with a "hot cramp" in her upper
back and neck, which radiated to her chest. This pain was
similar to pain she had with a previous heart attack. She went
downstairs and took a nitroglycerine tablet, which did not
relieve her pain. The pain radiated down her arm and jaw and she
came to the ED @ [**Hospital3 **].
.
Her vital signs on presentation were 133/67 HR:96 rr:20 and
sating 99% on 2LNC. Her EKG showed sinus @ 70BPM, nl axis, nl
intervals, ST elevation in V3 and inverted T-waves throughout
the precordium. She was chest pain free soon after arriving to
the [**Hospital3 **] ED with what appears to be administration of IV
ativan only. Initial labs showed troponin I of 0.04 to 0.94, CK
903 to 103, CK-MB 4.5 to 12.2. This is what prompted her
transfer to [**Hospital1 18**].
.
Of note, she has been under extreme stress. Her house burned
down 3 months ago, and she has been living in a trailer on her
charred property. She contines to work @ Ratheon, and recently
purchasing a new home. Also, she witnessed her good friends
husband dying an uncomfortable death of emphysema at home while
on hospice the evening prior to her presentation to [**Hospital3 **].
.
Cardiac review of systems is notable for rare angina with
exertion, especially in the cold weather which is relieved by
cessation of activity. She denies dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
On other review of systems, she denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain.
Past Medical History:
# CAD: 2 previous MI in early 90s. Cardiac cath at that time
repordedly without intervenable disease. She did have a third
"episode" in [**2088**] and had placement of 2 stents @ [**Hospital1 2025**] to a long
proximal LAD lesion repordely extending from the takoff of
vessel fromt he left main to the branching of the first
diagonal. She also thinks she underwent a subsequent which
showed patent stents.
# Chronic Renal Failure secondary to congenital ureteral
anaomaly. Assuming this has caused chronic reflux destructive
nephropathy. Followed by urology and nephrology, gets yearly
stent exchanges (?to prevent reflux vs. obstruction) and has
considered transitioning to peritoneal dialysis. Creatinine has
chornically been in mid 2s, but has risin thoughout [**2100**] to her
current level 4 to 4.5.
# Dyslipidemia
# Hypertension
# Recent social stressors
Social History:
-Tobacco history: quit smoking after first MI, had 35 years of
[**2-2**].5ppd
-ETOH: rarely
-Illicit drugs: none
Previously married x 2, has three kids from first marriage.
Currently in long term relationship x 20 years with male
partner.
Continues to work assembling radar for ratheon.
Family History:
Mother with history of "clotting disorder"
Physical Exam:
VS: 116/48 71 99%RA
GENERAL: NAD, well appearing
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without appreciable JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Physical exam unchanged at time of discharge.
Pertinent Results:
[**2100-11-20**] 06:00PM BLOOD WBC-7.7 RBC-3.56* Hgb-11.1* Hct-33.1*
MCV-93 MCH-31.3 MCHC-33.7 RDW-15.5 Plt Ct-360
[**2100-11-23**] 06:00AM BLOOD WBC-6.2 RBC-3.52* Hgb-10.8* Hct-32.5*
MCV-92 MCH-30.6 MCHC-33.2 RDW-15.4 Plt Ct-367
[**2100-11-20**] 06:00PM BLOOD Neuts-84.0* Lymphs-10.6* Monos-2.6
Eos-2.5 Baso-0.3
[**2100-11-20**] 06:00PM BLOOD PT-30.6* PTT-35.9* INR(PT)-3.1*
[**2100-11-23**] 06:00AM BLOOD PT-28.8* INR(PT)-2.9*
[**2100-11-20**] 06:00PM BLOOD Glucose-112* UreaN-70* Creat-4.2* Na-140
K-5.3* Cl-107 HCO3-21* AnGap-17
[**2100-11-21**] 06:20AM BLOOD Glucose-139* UreaN-69* Creat-4.2* Na-138
K-4.6 Cl-109* HCO3-16* AnGap-18
[**2100-11-22**] 06:00AM BLOOD Glucose-86 UreaN-72* Creat-4.1* Na-134
K-4.9 Cl-102 HCO3-21* AnGap-16
[**2100-11-23**] 06:00AM BLOOD Glucose-83 UreaN-73* Creat-4.0* Na-132*
K-4.6 Cl-102 HCO3-20* AnGap-15
[**2100-11-20**] 06:00PM BLOOD ALT-9 AST-19 LD(LDH)-225 CK(CPK)-92
AlkPhos-100 TotBili-0.1
[**2100-11-20**] 06:00PM BLOOD CK-MB-NotDone cTropnT-0.26*
[**2100-11-21**] 12:08AM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2100-11-21**] 06:20AM BLOOD CK-MB-NotDone cTropnT-0.16*
=============================
Exercise Stress
RESTING DATA
EKG: SINUS, ANTEROLATERAL ST-T ABNLS
HEART RATE: 64 BLOOD PRESSURE: 124/76
PROTOCOL [**Doctor Last Name **] - TREADMILL /
STAGE TIME SPEED ELEVATION HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
1 0-3 1.0 5 89 138/74 [**Numeric Identifier **]
2 [**4-8**] 1.6 6 104 154/70 [**Numeric Identifier 39382**]
3 6-8.25 2.2 7 115 130/60 [**Numeric Identifier 39383**]
TOTAL EXERCISE TIME: 8.25 % MAX HRT RATE ACHIEVED: 73
INTERPRETATION: 62 yo woman (h/o CAD and s/p PCI;
antiphosphlipid
syndrome and severe CRF) was referred post-NSTEMI to evaluate
for
myocardium at risk that may lead to cardiac catheterization. The
patient
completed 8.25 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol; ~ 4.5 METS.
Although the
procedure was going to be stopped due to submaximal endpoints
attained,
exercise was terminated secondary to a hypotensive blood
pressure
response during exercise. The patient reported shortness of
breath and
mild lightheadedness with the drop in blood pressure, however
denied any
chest, back, neck or arm discomforts. Early post-exercise, the
symptoms
resolved with an increase in blood pressure noted. In the
presence of
the anterolateral ST-T wave changes at baseline, the ECG is
difficult to
interpret during exercise. The rhythm was sinus with occasional
aea
noted during exercise; occasional isolated APDs, rare atrial
couplets.
In addition, isolated multiformed VPDs were noted in exercise.
As noted,
a symptomatic hypotensive blood pressure response to exercise
was noted.
IMPRESSION: Test terminated secondary to symptomatic hypotensive
blood
pressure response to exercise. No typical anginal symptoms with
an
uninterpretable ECG. Occasional multiformed VPDs noted during
the
procedure. Nuclear report sent separately.
Resting perfusion images were obtained with Tc-[**Age over 90 **]m tetrofosmin.
Tracer was injected approximately 30 minutes prior to obtaining
the resting images.
At peak exercise, approximately three times the resting dose of
Tc-99m
tetrofosmin was administered IV. Stress images were obtained
approximately 15 minutes following tracer injection.
Imaging Protocol: Gated SPECT
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
The image quality is adequate.
Left ventricular cavity size is increassed.
Resting and stress perfusion images reveal moderate to severe
predominantly
fixed distal anterior wall and apical decreased tracer uptake.
Gated images reveal apical akinesis and global hypokinesis.
The calculated left ventricular ejection fraction is 32%.
IMPRESSION: 1. Predominantly fixed perfusion defect in the LAD
territory.
2. Global hypokinesis, apical akinesis. LVEF 32%.
============================
ECHO
The left atrium is mildly dilated. 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 anterior septum and
anterior walls and distal inferior wall. The apex is mildly
aneurysmal and akinetic. The remaining segments contract
normally (LVEF = 35 %). No masses or thrombi are seen in the
left ventricle. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate ([**2-3**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is an anterior space which most likely represents a fat pad.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD (mid-LAD distribution). Increased
PCWP. Pulmonary artery systolic hypertension. Mild-moderate
mitral regurgitation.
CLINICAL IMPLICATIONS:
Based on [**2099**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
62 y/o woman with CAD, chronic renal failure, and
antiphospholipid antibody syndrome transfered from OSH with
chest pain and troponin elevation.
.
# Chest Pain: EKG changes on presentation: TWIs in V3-V6.
Troponin-I increased from .04 to peak of .94 at OSH. Here,
troponin-T peaked at 0.20 and CK peaked at 71. Findings felt to
be consistent with acute coronary syndrome / NSTEMI despite
marginal enzymes. Troponins also [**First Name8 (NamePattern2) **] [**Last Name (un) 11178**] elevated from renal
failure or due to stress-induced demand ischemia versus acute
plaque rupture. Emoblic phenomenon also possible given
Antiphospholipid antibody syndrome despite INR of 2.1. A time of
discarge, EKG changes and chest pain have resolved. Cardiac cath
was not pursued b/c of worsening CKD. Echo and stress MIBI were
c/w pervious finding one year ago--no apparent impact of
ischemic event on pump function.
- start plavix given benefit in NSTEMI for 1 year, continue ASA
81mg
- Continue Zocor at higher dose (80mg) in setting of ACS.
- switched metoprolol T to Toprol XL given benefit in Heart
Failure, decision to start ACEi deferred to outpt physicians
- follow-up with outpt cardiologist
.
# Chronic Renal Failure: Etiology of renal injury appears to be
longstanding ureteral reflux for which she is followed by
urology. Pt wishes to pursue transplant at [**Hospital1 18**]. She had part
of the work-up done at [**Hospital1 756**] a few years ago showing that her
children are compatible. She will get a referral to the
transplant service from her outpt nephrologist. She has already
been scheduled for an appt with Dr. [**Last Name (STitle) **] of the transplant
service.
- UA pending at time of discharge.
- Pt instructed to complete the course of renally dosed
cefpodoxime which she had started taking prior to admission and
which was continued while inpt.
.
# Antiphospholipid Antibody Syndrome: Has been on coumadin x 12
years without cardiac or other thrombotic events, thus appears
current management effective. Seems unlikely cause of ACS, but
on differential.
- Continue coumadin for anti-phospholipid antibody syndrome with
INR goal [**3-7**] indefinitely.
Medications on Admission:
ASA 81mg po qday
Calcitriol 1mcg po 3x/week
Imdur 60mg sustained release
Iron 65mg 2 tablets qday
metoprolol 100mg po BID
nexium 40mg tablet
nitro SL
Norvasc 5mg po BID
Patanol drops
Procrit 10,000 Q2-3 weeks
Singulair 10mg po Qday
Diazepam 2.5-5mg po QHS prn
Vitamin C
Zocor 20mg po Qday
Coumadin 3mg except on Weds/Sun (takes 5x wk)
Discharge Medications:
1. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO Three
times a week.
2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: Two (2)
Tablet PO once a day.
4. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID PRN ().
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation twice a day as needed
for shortness of breath or wheezing.
12. Procrit Injection
13. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
14. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
15. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes x3 as needed for chest pain.
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. Warfarin 3 mg Tablet Sig: One (1) Tablet PO daily except for
sunday and wednesday.
18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
19. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours): Please finish prescription.
20. Outpatient Lab Work
Please check INR on [**11-26**] and call results to: [**Last Name (LF) 5423**],[**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5424**]
Discharge Disposition:
Home
Discharge Diagnosis:
Compensated Chronic Systolic Heart Failure: EF 32%
Chronic Kidney Disease
Antiphospholipid Antibody Syndrome
Hypertension
Non-ST elevation Myocardial Infarction
Discharge Condition:
stable
hct: 32.5
BUN: 73
Creat: 4.0
INR: 2.9
Discharge Instructions:
You had chest pain and a small heart attack. A stress test was
done that showed no significant change from the previous stress
test. We have recommended not to perform a cardiac
catheterization after speaking with your outpatient
cardiologist. A nephrologist was following you during your
hospital stay and felt that your kidney function was stable.
Your INR was high so we have been holding your Warfarin, you
should now restart on your home regimen.
Medication changes:
We increased your Simvastatin to 80mg
We started Plavix to prevent blood clots and another heart
attack
We changed your Metoprolol to a long acting formulation at the
same dose
.
We have scheduled an appointment with a transplant nephologist
here at [**Hospital1 18**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. You will need a referral from
Dr. [**Last Name (STitle) **]. Please bring any outpatient records you have.
.
Please call your cardiologist if your chest pain returns, if you
have nausea or sweating or trouble breathing. Please also call
your cardiologist if you notice any bleeding, bruising or dark
stools. Pleae check your INR on Friday [**11-26**] and call
results to Dr. [**Last Name (STitle) **].
Followup Instructions:
Primary Care and Cardiology:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 39384**] Phone: [**Telephone/Fax (1) 5424**] Date/time: [**12-6**] at
11:15am.
.
Nephrology:
Transplant:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: Tuesday [**12-21**] at 3pm. [**Last Name (NamePattern1) 12939**],[**Location (un) 436**].
Outpatient:
[**First Name4 (NamePattern1) 7019**] [**Last Name (NamePattern1) **], MD Phone: ([**Telephone/Fax (1) 39385**] Date/time: please call
office for appt.
Completed by:[**2100-11-23**] Name: [**Known lastname 4583**],[**Known firstname 2770**] Unit No: [**Numeric Identifier 7118**]
Admission Date: [**2100-11-20**] Discharge Date: [**2100-11-23**]
Date of Birth: [**2037-12-8**] Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 6568**]
Addendum:
# UTI: Pt instructed to complete course of Cefpodoxime
prescribed by her outpt nephrologist. She should have a
follow-up UA when she follows-up with Dr. [**Last Name (STitle) 7119**] within 1-2 weeks.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3518**] MD [**MD Number(1) 3519**]
Completed by:[**2100-11-23**]
|
[
"V58.61",
"403.91",
"585.5",
"410.71",
"593.73",
"428.22",
"428.0",
"289.81",
"285.21",
"599.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
17109, 17273
|
9942, 12111
|
290, 434
|
14662, 14709
|
4561, 9659
|
15968, 17086
|
3749, 3793
|
12496, 14428
|
14478, 14641
|
12137, 12473
|
14733, 15185
|
3808, 4542
|
9682, 9919
|
15205, 15945
|
240, 252
|
462, 2542
|
2564, 3428
|
3444, 3733
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,919
| 181,946
|
36413+58078
|
Discharge summary
|
report+addendum
|
Admission Date: [**2144-4-29**] Discharge Date: [**2144-5-9**]
Date of Birth: [**2083-3-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
transfer for OSH for cardiac catheterization to
evaluate chest pain and abnl. ETT.
EVENTS / HISTORY OF PRESENTING ILLNESS: 61 year old man with a
history of chronic abdominal pain followed by local pain clinic
and SVT treated with Cartia for the last 10 years was admitted
to
OSH for complaints of palpitations and chest pain radiating to
bilateral arms @ 2:30AM on [**2144-4-26**]. He called 911 and EMS found
pt. to be in SVT with a rate of 170's and possible inferior ST
elevations on EKG. He responded to Adenosine and converted to
normal sinus rhythm. Ck-MB peak was 11.1 on [**2144-4-26**] at 7:46PM
and
peak troponin was 0.38 at 11:15AM on [**2144-4-26**]. Adenosine stress
was positive for fatigue and ST elevations inferiorly. EF was
64%. He has been chest pain free since admit and no further SVT.
He was transferred for cardiac catheterization.
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x 4 (LIMA to LAD, SVG to OM1, SVG
to OM2, SVG to PDA) [**2144-5-4**]
History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS: 61 year old man with a
history of chronic abdominal pain followed by local pain clinic
and SVT treated with Cartia for the last 10 years was admitted
to
OSH for complaints of palpitations and chest pain radiating to
bilateral arms @ 2:30AM on [**2144-4-26**]. He called 911 and EMS found
pt. to be in SVT with a rate of 170's and possible inferior ST
elevations on EKG. He responded to Adenosine and converted to
normal sinus rhythm. Ck-MB peak was 11.1 on [**2144-4-26**] at 7:46PM
and
peak troponin was 0.38 at 11:15AM on [**2144-4-26**]. Adenosine stress
was positive for fatigue and ST elevations inferiorly. EF was
64%. He has been chest pain free since admit and no further SVT.
He was transferred for cardiac catheterization.
Past Medical History:
chronic abdominal pain
hepatic renal/liver cyst with 2 prior surgeries
anxiety
hernia repair
hypertension
supra ventricular tachycardia
Social History:
married, self employed in restaurant
business, children
Social history is significant for the absence of current tobacco
use. Negative alcohol.
Family History:
non-contributory
Physical Exam:
General: Thin pale appearing male in NAD
Skin: nasal fold eczema
HEENT; unremarkable
neck: supple
Chest: lungs CTA
Heart: RRR S1, S2
Abd; soft, NT, ND, +BS. Tenderness in RUQ to palp/fullness in
RUQ
Extrem: well profused- no edema. pulses +2 in all 4 extremities
varicosities: none
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2144-5-9**] 09:10AM 4.8 3.38* 8.6* 26.9* 80* 25.3* 31.8 14.1
211
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2144-4-30**] 05:15AM 58.0 26.9 9.0 5.8* 0.4
DIFF ADDED 12;12PMN
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2144-5-9**] 09:10AM 211
Chemistry
[**2144-5-9**] bun 11 creat 0.7 K 4.2
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2144-4-29**] 11:45AM 16 23 69 65 0.4
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2144-5-6**] 08:55AM 2.2
HEMATOLOGIC VitB12
[**2144-4-29**] 11:45AM 504
DIABETES MONITORING %HbA1c
[**2144-5-1**] 04:55PM 6.0*1
Brief Hospital Course:
Pt was admitted from OSH after presenting w/ new onset chest
pain-radiating to both arms. Admitted for cardiac cath. Cardiac
cath was done revealing 80% left main. Patient was taken to the
OR on [**2144-5-4**] after pre-op work up was completed.
Pt underwent CABg x4 on [**2144-5-4**]. Post operatively he was admitted
to the ICU in stable condition intubated and sedated. He was
awakened from sedation and extubated on POD#1. His chest tubes
and wires were removed per protocol. He was transferred from the
ICU to the floor on POD#1. Pain control was a major issue given
his hisitory of chronic pain- pain service was consulted. He
progressed well with his recovery- was started on betablockers,
aspirin, statin and diuresis. Mr. [**Known lastname 82496**] was cleared for home by
physical therapy and was discharged to home on POD#5. No VNA
services were provided as patient was self pay and declined VNA
services.
Medications on Admission:
Methadone 30', Oxycodone 60 Q4-prn, Cartia XT 360' Valium 10 q8h
prn, ASA 81', Celebrex 200'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
3. Methadone 10 mg Tablet Sig: Three (3) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone 30 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*2*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for headache.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p coronary artery bypass grafts x 4 (LIMA to LAD, SVG to OM1,
SVG to OM2, SVG to PDA) [**2144-5-4**]
coronary artery disease
hypertension
h/o hepatic cysts and resections
s/p herniorrhaphy
anxiety disorder
Discharge Condition:
good
Discharge Instructions:
Shower daily, no baths or swimming.
No lotions, creams or powders to incisions
No driving for 6 weeks and off all narcotics.
No lifting more than 10 pounds for 10 weeks.
Report any fever greater than 100.5.
Report any redness of, or drainage from incisions.
Report weight gain gretaer than 2 pounds a day or 5 pounds a
week.
Take all medications as directed.
call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr.[**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 4783**] (cardiology) in [**2-4**] weeks
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6104**] (PCP)([**Telephone/Fax (1) 82497**]) in [**1-3**] weeks
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Please call for appointments
Completed by:[**2144-5-9**] Name: [**Known lastname 13187**],[**Known firstname **] Unit No: [**Numeric Identifier 13188**]
Admission Date: [**2144-4-29**] Discharge Date: [**2144-5-9**]
Date of Birth: [**2083-3-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Pt was transferred from outside hospital after NSTEMI. Admitted
for cath and eval for cardiac surgery.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2144-6-1**]
|
[
"300.00",
"410.71",
"305.1",
"338.12",
"414.2",
"401.9",
"V58.69",
"414.01",
"593.2",
"427.31",
"122.8",
"338.29",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.13",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
7406, 7534
|
3522, 4440
|
1179, 1280
|
5994, 6001
|
2759, 3499
|
6472, 7383
|
2423, 2441
|
4583, 5713
|
5763, 5973
|
4466, 4560
|
6025, 6449
|
2456, 2740
|
281, 1141
|
1308, 2084
|
2106, 2244
|
2260, 2407
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,911
| 162,546
|
35875
|
Discharge summary
|
report
|
Admission Date: [**2154-12-3**] Discharge Date: [**2154-12-10**]
Date of Birth: [**2087-12-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Naproxen
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2154-12-6**] Four Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending,
with saphenous vein grafts to diagonal, obtuse marginal and PDA
History of Present Illness:
This is a 67 year old female with known history of coronary
disease and multiple medical issues. She presented to [**Hospital1 5979**] with acute pulmonary edema requiring intubation. Her
pulmonary status gradually improved with diuresis and she was
eventually extubated without further complication. She underwent
cardiac catheterization which revealed 60% distal left main
lesion, 80% stenosis of the left anterior descending, totally
occluded circumflex and 80% stenosis of the right coronary
artery. LV gram was notable for an LVEF of 40%. Given the above
findings, she was transferred to the [**Hospital1 18**] for cardiac surgical
intervention. On admission, she was pain free without
respiratory distress.
Past Medical History:
Coronary Artery Disease
History of MI in [**2149**], [**2151**]
Chronic Systolic Congestive Heart Failure
Dyslipidemia
Hypertension
Cerebrovascular Disease, Stroke in [**2138**]
Atrial Fibrillation
Chronic Obstructive Pulmonary Disease
Diabetes Mellitus Type II(diet controlled)
History of GI Bleed
Chronic Renal Insufficiency
Obesity
Gout
Gastritis
Bilateral Total Knee Replacements
History of LLE Cellulitis, Leg Ulcers
Social History:
10 pack year history of tobacco, quit about 15 years ago. Denies
ETOH. Cuurently lives with her son. Requires [**Name2 (NI) **] for
ambulation(since knee replacement surgery).
Family History:
Denies premature family history of coronary disease.
Physical Exam:
Discharge Exam:
T 97.9 , BP 99/62, HR 64, O2 SAT 94% R/A
General:A&Ox3,NAD
CVS:RRR
Lungs: CTA
Abdomen: + BS, soft, NT/ND
Ext: LUE forearm erythematous,indurated. LLE=healing
ulcers/small amount of serosanguinous drainage->cellulitis
resolved
Neuro:grossly intact
Wound incision: sternum stable. No [**Doctor Last Name **]/click. C/D/I
Pertinent Results:
[**2154-12-3**] 07:00PM BLOOD WBC-6.7 RBC-3.57* Hgb-11.0* Hct-32.8*
MCV-92 MCH-30.8 MCHC-33.6 RDW-14.7 Plt Ct-167
[**2154-12-3**] 07:00PM BLOOD PT-14.3* PTT-28.8 INR(PT)-1.2*
[**2154-12-3**] 07:00PM BLOOD Glucose-101 UreaN-20 Creat-1.1 Na-139
K-4.0 Cl-102 HCO3-29 AnGap-12
[**2154-12-3**] 07:00PM BLOOD ALT-14 AST-17 LD(LDH)-187 AlkPhos-74
Amylase-52 TotBili-0.7
[**2154-12-3**] 07:00PM BLOOD Albumin-3.8 Calcium-9.3 Mg-1.6
[**2154-12-5**] 05:40AM BLOOD %HbA1c-5.0
[**2154-12-4**] ECHO:
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. There is mild regional left ventricular systolic
dysfunction with infero-lateral hypokinesis. No masses or
thrombi are seen in the left ventricle. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
[**2154-12-6**] Intraop TEE:
PREBYPASS
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is moderate symmetric left ventricular hypertrophy.
There is mild regional left ventricular systolic dysfunction
with hypokinesia of the apex as well as the apical and mid
portions of the inferior wall.. Overall left ventricular
systolic function is mildly depressed (LVEF= 45 %).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are complex (>4mm) atheroma in the aortic arch. There
are complex (>4mm) atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation.
POST BYPASS
1. Patient is being AV paced and receving an infusion of
phenylephrine and epinephrine.
2. Biventricular systolic function is unchanged.
3. Aorta intact post decannulation.
[**2154-12-10**] 08:55AM BLOOD WBC-10.0 RBC-3.47* Hgb-10.7* Hct-31.1*
MCV-90 MCH-30.8 MCHC-34.3 RDW-15.1 Plt Ct-172#
[**2154-12-10**] 08:55AM BLOOD Glucose-111* UreaN-24* Creat-1.4* Na-137
K-4.8 Cl-101 HCO3-25 AnGap-16 [**Known lastname **],[**Known firstname 81527**] E [**Medical Record Number 81528**] F
67 [**2087-12-2**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2154-12-8**] 3:25
PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2154-12-8**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 81529**]
Reason: CTs removed. ? ptx
[**Hospital 93**] MEDICAL CONDITION:
67 year old woman with
REASON FOR THIS EXAMINATION:
CTs removed. ? ptx
Final Report
STUDY: AP chest, [**2154-12-8**].
HISTORY: Status post removal of chest tube. Evaluate for
pneumothorax.
FINDINGS: Comparison is made to prior study from [**2154-12-6**].
The endotracheal tube, Swan-Ganz catheter, feeding tube, and
chest tubes have
been removed. Study is somewhat suboptimal due to technique,
however, no
pneumothoraces are seen. There is some atelectasis at the left
base.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: MON [**2154-12-9**] 12:12 AM
Imaging Lab
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation. She was started on
Bactrim for a positive urinalysis which eventually grew out
Klebseilla pneumoniae and Citrobacter. She was also seen by the
wound service given her left lower extremity ulcers. There was
no evidence of cellulitis, and she required only local wound
care measures. Preoperative workup was otherwise uneventful and
she was cleared for surgery. She remained symptom-free on
medical therapy.
On [**12-6**], Dr. [**First Name (STitle) **] performed coronary artery bypass
grafting surgery. For surgical details, please see separate
dictated operative note. Following the operation, she was
brought to the CVICU for invasive monitoring. Within 24 hours,
she awoke neurologically intact and was extubated without
incident. She experienced rapid atrial fibrillation which was
initially treated with Amiodarone and beta blockade, along with
electrolyte replacement. IV Amiodarone was changed to po dosing
and her rhythm converted to sinus. She otherwise maintained
stable hemodynamics and transferred to the SDU on postoperative
day three. Physical therapy was consulted for evaluation and
treatment resumed. Wound [**Name8 (MD) **] RN continued to follow
Ms.[**Known lastname 68085**] left lower extremity ulcer. She continued to
progress and she was ready for discharge to rehab on POD# 4. All
follow up appointments were advised.
Medications on Admission:
Fentanyl Patch, Synthroid 150 qd, Aspirin 81 qd, Iron 325 qd,
Metoprolol 25 qd, Prilosec 20 qd, Spiriva 1 qd, Procrit,
Albuterol MDI, Zocor 40 qd, MVI
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed for a-fib: x 7 days, then decrease to 200 mg po
bid x 7 days, then decrease to 200 mg po daily .
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) 7658**]
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Preoperative Urinary Tract Infection
Postoperative Atrial Fibrillation
History of MI in [**2149**], [**2151**]
Chronic Systolic Congestive Heart Failure
Dyslipidemia
Hypertension
Cerebrovascular Disease, Stroke in [**2138**]
Atrial Fibrillation
Chronic Obstructive Pulmonary Disease
Diabetes Mellitus Type II(diet controlled)
History of GI Bleed
Chronic Renal Insufficiency
Obesity
Gout
Gastritis
Bilateral Total Knee Replacements
History of LLE Cellulitis, Leg Ulcers
Discharge Condition:
Good
Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any temperature greater than 100.5
report any drainage from, or redness of incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**First Name (STitle) **] in [**3-30**] weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 4783**] in [**1-27**] weeks, call for appt
Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 10733**] [**Last Name (NamePattern1) 33575**] in [**1-27**] weeks ([**Telephone/Fax (1) 9587**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2154-12-10**]
|
[
"414.01",
"276.7",
"041.3",
"428.23",
"496",
"041.85",
"599.0",
"V43.65",
"585.9",
"274.9",
"401.9",
"250.80",
"278.00",
"427.31",
"707.19",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8935, 9012
|
5928, 7393
|
295, 492
|
9562, 9569
|
2312, 5221
|
9979, 10417
|
1888, 1942
|
7594, 8912
|
5261, 5284
|
9033, 9541
|
7419, 7571
|
9593, 9956
|
1957, 1957
|
1973, 2293
|
236, 257
|
5316, 5905
|
520, 1234
|
1256, 1679
|
1695, 1872
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,428
| 114,010
|
30991
|
Discharge summary
|
report
|
Admission Date: [**2141-7-10**] Discharge Date: [**2141-7-22**]
Date of Birth: [**2087-11-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
s/p CABGx2(SVG->OM, PDA)/MV repair (36mm CE band) [**2141-7-17**]
History of Present Illness:
53 y/o male transferred from OSH for surgical evaluation. He has
no known significant PMH who began experiencing shortness of
breath 4 days after undergoing dental work. At OSH an
echocardiogram revealed mitral valve prolapse with severe MR and
possible superimposed vegetations.
Past Medical History:
Left wrist fracture (2 weeks ago)
Social History:
Denies tobacco use. Admits to 5 alcoholic beverages a week.
Lives alone
Family History:
Non-contributory
Physical Exam:
Gen: NAD
Neuro: A&O x 3, non-focal
Pulm: CTAB -w/r/r
CV: RRR 5/6 SEM
Abd: Soft NT/ND, NABS
Ext: Warm, well-perfused, palpable pulses, left wrist with cast
Pertinent Results:
[**2141-7-11**] Cardiac Cath: 1. Coronary angiography in this right
dominant system demonstrated tortuous vessels suggestive of
hypertensive heart disease. The LMCA was long and free of
angiographically significant disease. The LAD was tortuous and
likely had an intramyocardial segment proximal to S1; there was
a 90% proximal, tubular lesion in a modest D1. The LCX had a
proximal 50% retroflexed stenosis leading to a large branch
OM/vertical LPL. The RCA had diffuse disease throughout,
particularly in its proximal portion; the mid RCA had a 60-70%
stenosis; there was a complex 60% lesions at the origin of the
RPDA involving the distal AV-groove RCA and a lateral branch of
the RPDA; there were multiple tortuous distal RPLs. 2. Limited
resting hemodynamics revealed a mildly elevated pulmonary
capillary wedge pressure. There was no systolic systemic or
pulmonary arterial hypertension. 3. Left ventriculography was
not performed due to risk of entrapping the pigtail catheter on
the torn mitral valve apparatus observed on recent TEE.
[**2141-7-17**] Echo: Prebypass: 1. No atrial septal defect is seen by
2D or color Doppler. 2.Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). [Intrinsic
left ventricular systolic function is likely more depressed
given the severity of valvular regurgitation.] 3.Right
ventricular chamber size and free wall motion are normal.
4.There are 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. There is partial mitral
leaflet flail (P2 segment). There is prolapse of P3 portion of
the posterior leaflet of the mitral valve. Severe (4+) mitral
regurgitation is seen. The mitral regurgitation jet is
eccentric. Post bypass: 1. Patient is in sinus rhythm and
receiving an infusion of phenylephrine. 2. Biventricular
systolic function is unchanged. 3. Annuloplasty ring seen in the
mitral position and it appears well seated. 4. Trace mitral
regurgitation seen . Peak gradient across the mitral valve is 6
mm Hg. No Systolic motion of the anterior mitral leaflet seen.
No LVOT obstruction. 5. Aorta intact post decannulation.
[**2141-7-20**] CXR: Bilateral pleural effusions are unchanged compared
to the examination from one day prior. There is some
subcutaneous emphysema present along the anterior aspect of the
chest seen on the lateral view, unchanged. No pneumothorax is
present. Bilateral lower lobe consolidations, posteriorly, are
also unchanged. Otherwise, the lungs are clear.
[**2141-7-10**] 09:21PM BLOOD WBC-6.9 RBC-4.44* Hgb-14.5 Hct-40.9
MCV-92 MCH-32.6* MCHC-35.4* RDW-13.8 Plt Ct-259
[**2141-7-18**] 03:00AM BLOOD WBC-8.7 RBC-3.25* Hgb-10.5* Hct-29.6*
MCV-91 MCH-32.2* MCHC-35.4* RDW-14.0 Plt Ct-135*
[**2141-7-22**] 05:40AM BLOOD WBC-6.6 RBC-3.27* Hgb-11.0* Hct-29.3*
MCV-90 MCH-33.6* MCHC-37.5* RDW-13.4 Plt Ct-248
[**2141-7-10**] 09:21PM BLOOD PT-12.1 PTT-27.4 INR(PT)-1.0
[**2141-7-18**] 03:00AM BLOOD PT-14.3* PTT-31.8 INR(PT)-1.3*
[**2141-7-10**] 09:21PM BLOOD Glucose-120* UreaN-20 Creat-1.1 Na-137
K-4.2 Cl-104 HCO3-26 AnGap-11
[**2141-7-22**] 05:40AM BLOOD UreaN-11 Creat-1.1 Na-137 K-4.2
Brief Hospital Course:
As mentioned in the HPI, Mr. [**Known lastname **] was admitted from OSH with
MV endocarditis. He was appropriately worked-up which included
cardiology, infectious disease, and dental consults. He also
underwent an echocardiogram and cardiac cath along with
appropriate lab work. Broad spectrum antibiotics were started
until blood culture results. Dental required to remove several
teeth which was done on hospital day five. Over the next several
days he remained stable while recovering from his dental
extraction and receiving antibiotics. On [**7-17**] he was brought to
the operating room where he underwent a coronary artery bypass
graft x 2 and mitral valve repair. Please see operative report
for details. Following surgery he was transferred to the CSRU
for invasive monitoring in stable condition. Within 24 hours he
was weaned from sedation, awoke neurologically intact and
extubated. On post-op day one beta blockers and diuretics were
started and he was gently diuresed towards his pre-op weight.
Later on post-op day one he was transferred to the step down
floor. Chest tubes were removed on post-op day two. Epicardial
pacing wires removed on post-op day three. He continued to
progressively improve and worked with physical therapy for
strength and mobility. Ortho consulted on patient on post-op day
three for his wrist fracture. On post-op day five he was
discharged home with VNA services and 3 weeks of antibiotics.
Medications on Admission:
ASA 81 PO daily
Motrin 600 mg PO PRN
Percocet PRN
Meds for outside hospital:
Ampicillin 2 gms IV q 4 hours
Gentamycin 60 mg IV q 8 hours
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 packets* 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*60 ML(s)* Refills:*2*
8. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
Mitral Regurgitation s/p Mitral Valve Repair
Endocarditis
PMH: Left wrist fracture
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Do not use creams, lotions, or powders on wounds.
Shower daily, let water flow over wounds, pat dry with a towel.
Call our office for sternal drainage, temp>101.5.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks.
Make an appointment with the Hand Clinic for Tues. [**8-24**]. Pls.
call [**Telephone/Fax (1) 73248**].
Make an appointment with Cardiologist.
Completed by:[**2141-7-24**]
|
[
"E878.2",
"521.00",
"511.9",
"998.81",
"421.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"36.12",
"23.19",
"88.56",
"37.21",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
7211, 7286
|
4492, 5929
|
342, 409
|
7473, 7479
|
1088, 4469
|
7807, 8053
|
880, 898
|
6116, 7188
|
7307, 7452
|
5955, 6093
|
7503, 7784
|
913, 1069
|
283, 304
|
437, 718
|
740, 775
|
791, 864
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,975
| 101,833
|
20033+57110
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-5-30**] Discharge Date: [**2182-6-5**]
Date of Birth: [**2099-9-16**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 33015**]
Chief Complaint:
Shortness of [**First Name3 (LF) 1440**]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness:
.
82 year old male with complicated PMH including metastatic
adenocarcinoma to liver of unknown primary (possibly
cholangiocarcinoma), systolic HF with EF45%, CAD, CRI, MICU
transfer following 3 day admission in the MICU. Has experienced
functional decline in the setting of new dx of met. adenoca.
found incidentally in 09. Of note, he was recently discharged
from [**Hospital1 18**] on [**2182-5-24**] following 10 day admission for acute on
CRI(peak Cr 4.7) thought related to prerenal phsyiology in
setting of ESBL UTI. During admission, his home lasix and
lisinopril were discontinued and his metoprolol and imdur were
decreased. He was discharged to rehab to complete 2L NS
infusion. He was evaluated by speech and swallow for dysphagia
and palliative care was involved in goals of care discussion
where family was clear about wishes for continued aggressive
measures during that stay.
.
Pt returned to the ED on [**2182-5-30**] with following vitals: HR 116
BP 198/119 RR 28 POx 100 O2 sat. Found to have O2 sat of 94% on
NRB. Patient was given 80mg IV lasix with 600cc output, nitro
gtt, 4mg IV morphine, antibiotic coverage for suspected hospital
acquired pneumonia (ceftriaxone 1gm, levaquin 750mg IV, and
vancomycin 1gm IV). He was placed on CPAP with improvement. Labs
were significant for troponin 0.36, creatinine 1.7, WBC 11.6
with left shift.
EKG with ST changes laterally.
.
Pt was admitted to the ICU p/w s/s of flash pulmonary edema in
the setting of hypertensive urgency, likely secondary to CRI
where meds were decreased. He was diuresed with 80mg IV lasix.
Due to low clinical suspicion regarding hospital-acquired
pneumonia, pt was discontinued from ceftriaxone and vancomyin
and kept on levaquin. Palliative care was involved. Pt now
stable and ready for transfer to the floor.
.
Review of systems: denies CP, abdominal pain, nausea, vomiting,
diarrhea
Past Medical History:
H/o PNA with MRSA
GERD
CAD: NSTEMI in [**2180**] that was medically managed
CHF: Systolic dysfunction, EF 45-50%
HTN
Hyperlipidemia
Parkinson's disease: Diagnosed in [**2166**], on dopamine agonists,
disease course complicated by autonomic dysfunction
Adenocarcinoma in the liver: Incidentally discovered in [**2181**],
moderate to poorly differentiated adenocarcinoma metastasis from
unknown primary
Chronic renal insufficiency: Baseline Cr 1.3-1.6
BPH
H/o mulitple UTIs: has been complicated by sepsis in the past
Renal cysts on R
Melanoma s/p excision (R ear) in [**2177**]
Anterior subluxation of L4/L5
Incomplete paraplegia: [**1-7**] spinal stenosis, s/p surgery
Depression, anxiety
Social History:
The patient is a retired sociology and IR professor. He has been
residing in [**Hospital 100**] Rehab for several years now. He is a former
smoker but quit 45 years ago. Rare alcohol. His wife and
daughter live in the great [**Name (NI) 86**] area
Family History:
The patient has one daughter with breast cancer. No other h/o
malignancy. Both his son and daughter have renal cysts
Physical Exam:
Physical Exam:
.
Vitals: T: 98.2 BP: 145/59 P: 68 R: 15 O2: 98% on 3L O2. Water
balance: negative 2252 cc.
.
General: Alert, no acute distress, pleasant
HEENT: Sclera anicteric, dry mucous membranes
Neck: supple, JVP elevated to clavicle, no LAD
Lungs: no accessory respiratory muscle use; rales in bilateral
lobes with decreased [**Name (NI) 1440**] sounds; expiratory rhonchi
CV: Regular rate and rhythm, normal S1 + S2, HS distant, no
murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, mildly-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, chronic venous stasis changes in legs, well perfused,
2+ pulses, 3+ pitting edema to knees, slight resting tremor of
both arms, mild cogwheeling
Left brachial PICC line - appears to be pulled out, no erythema
skin: pale
Psych: alert and oriented to person, place, and time
Pertinent Results:
[**2182-6-4**] 07:48AM BLOOD WBC-7.0 RBC-3.37* Hgb-9.3* Hct-30.1*
MCV-89 MCH-27.7 MCHC-31.0 RDW-16.5* Plt Ct-184
[**2182-6-3**] 07:25AM BLOOD WBC-8.1 RBC-3.42* Hgb-9.5* Hct-30.5*
MCV-89 MCH-27.8 MCHC-31.2 RDW-16.6* Plt Ct-190
[**2182-6-2**] 06:25AM BLOOD WBC-8.5 RBC-3.36* Hgb-9.3* Hct-30.1*
MCV-90 MCH-27.6 MCHC-30.8* RDW-16.6* Plt Ct-188
[**2182-6-1**] 04:30AM BLOOD WBC-8.1 RBC-3.18* Hgb-8.9* Hct-28.6*
MCV-90 MCH-28.1 MCHC-31.2 RDW-16.7* Plt Ct-184
[**2182-5-31**] 03:35AM BLOOD WBC-12.5* RBC-3.40* Hgb-9.5* Hct-30.8*
MCV-91 MCH-27.9 MCHC-30.8* RDW-16.6* Plt Ct-224
[**2182-5-30**] 09:30PM BLOOD WBC-11.7*# RBC-4.02*# Hgb-11.1*#
Hct-36.4*# MCV-90 MCH-27.7 MCHC-30.6* RDW-16.6* Plt Ct-288#
[**2182-5-30**] 09:30PM BLOOD Neuts-81.6* Lymphs-11.1* Monos-4.1
Eos-2.5 Baso-0.7
[**2182-6-4**] 07:48AM BLOOD Plt Ct-184
[**2182-6-3**] 07:25AM BLOOD Plt Ct-190
[**2182-6-2**] 06:25AM BLOOD Plt Ct-188
[**2182-6-1**] 04:30AM BLOOD Plt Ct-184
[**2182-5-31**] 03:35AM BLOOD Plt Ct-224
[**2182-5-30**] 09:30PM BLOOD Plt Ct-288#
[**2182-5-30**] 09:30PM BLOOD Plt Ct-288#
[**2182-5-30**] 09:30PM BLOOD PT-13.3 PTT-24.0 INR(PT)-1.1
[**2182-6-4**] 02:35PM BLOOD Glucose-143* UreaN-34* Creat-1.7* Na-138
K-4.1 Cl-99 HCO3-31 AnGap-12
[**2182-6-3**] 07:25AM BLOOD Glucose-129* UreaN-35* Creat-1.7* Na-137
K-4.2 Cl-99 HCO3-30 AnGap-12
[**2182-6-2**] 06:25AM BLOOD Glucose-153* UreaN-37* Creat-1.7* Na-138
K-4.3 Cl-100 HCO3-30 AnGap-12
[**2182-6-1**] 04:30AM BLOOD Glucose-145* UreaN-40* Creat-1.7* Na-140
K-4.2 Cl-101 HCO3-31 AnGap-12
[**2182-5-31**] 03:35AM BLOOD Glucose-220* UreaN-39* Creat-1.6* Na-141
K-4.8 Cl-103 HCO3-31 AnGap-12
[**2182-5-30**] 09:30PM BLOOD Glucose-246* UreaN-39* Creat-1.7*# Na-139
K-5.3* Cl-103 HCO3-24 AnGap-17
[**2182-5-31**] 03:35AM BLOOD CK(CPK)-61
[**2182-5-30**] 09:30PM BLOOD CK(CPK)-74
[**2182-5-31**] 03:35AM BLOOD CK-MB-NotDone cTropnT-0.36*
[**2182-5-30**] 09:30PM BLOOD cTropnT-0.36*
[**2182-6-4**] 02:35PM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1
[**2182-6-3**] 07:25AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8
[**2182-6-2**] 06:25AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
[**2182-5-31**] 03:35AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.2
[**2182-5-30**] 09:30PM BLOOD TotProt-6.9 Albumin-3.3* Globuln-3.6
Calcium-8.9 Phos-4.1 Mg-2.2
[**2182-5-31**] 04:34AM BLOOD Type-ART pO2-151* pCO2-41 pH-7.43
calTCO2-28 Base XS-3
[**2182-5-31**] 01:36AM BLOOD Type-ART pO2-113* pCO2-47* pH-7.39
calTCO2-30 Base XS-3 Intubat-NOT INTUBA
[**2182-5-30**] 09:39PM BLOOD Type-[**Last Name (un) **] Comment-GREEN TOP
[**2182-5-31**] 01:36AM BLOOD Lactate-1.2
[**2182-5-30**] 09:39PM BLOOD Glucose-235* Lactate-2.7* Na-140 K-5.3
Cl-103 calHCO3-24
[**2182-5-31**] 01:36AM BLOOD O2 Sat-99
[**2182-5-30**] 09:39PM BLOOD Hgb-12.0* calcHCT-36 O2 Sat-97
[**2182-6-5**] 05:33AM BLOOD WBC-5.7 RBC-3.21* Hgb-8.8* Hct-28.6*
MCV-89 MCH-27.3 MCHC-30.6* RDW-16.4* Plt Ct-174
[**2182-6-5**] 05:33AM BLOOD Plt Ct-174
[**2182-6-5**] 05:33AM BLOOD Glucose-130* UreaN-32* Creat-1.7* Na-139
K-3.8 Cl-100 HCO3-29 AnGap-14
Brief Hospital Course:
Pt is an 82 year old white male with complicated past medical
history of metastatic adenocarcinoma, systolic heart failure
with an ejection fraction of 45%, chronic renal insufficiency,
parkinson's disease, transfer from 3 day medical intensive care
unit admission who presents from rehab after recent admit for
acute on chronic renal insufficiency, flash pulmonary edema in
the setting of hypertensive urgency likely [**1-7**] to the holding of
antihypertensive medication.
.
Acute pulmonary edema with acute on chronic systolic heart
failure: likely due to flash pulmonary edema in setting of
hypertensive urgency and acute exacerbation of heart failure.
Prior to the MICU admission, lisinopril and lasix had been
discontinued, while the imdur and BB had decreased. - [**1-7**] flash
pulmonary edema in setting of HTN urgency. Prior to MICU, the
lisinopril/lasix had been d/c'd, and imdur and BB decreased. Pt
tolerated diuresis and responded well to IV lasix, which was
later switched to PO administration. Creatinine levels held
steady at around 1.6-1.7, with a baseline level at around
1.4-1.6. Strict input and output levels were maintained, and
showed that pt was tolerating aggressive diuresis. The goal of
diuresis for each day was approximately 500cc-1L per day.
.
There was also a suspected right lower lobe pneumonia that was
treated with levofloxacin for a 1 week duration (renal dosage).
Sputum and blood cultures were negative.
.
Aspiration Risk: Evidently a chronic issue, thought to be due to
worsening decline of Parkinson's Disease as well as fluctuating
mental status. Speech and swallow had evaluted patient and
deemed him unable to take anything by mouth, and pt was kept NPO
until family and patient could agree upon next step in
management, with guidance from medical team. Lengthy family
discussion occurred while hospitalized to discuss feeding
options, including a repeat video swallow vs. a temporary NG
tube. Pt and family ultimately decided for him to undergo repeat
video swallow study which he passed, and the following
recommendations were made: moist, ground solids, nektar
thickened liquids, pills crushed with applesauce, and sips of
thin liquids in between meals. If he is choking/coughing on the
thin liquids, this should be discontinued. Patient should
continue to be monitored by speech and swallow back at rehab. He
is still a known chronic aspirator despite the results of video
speech and swallow, and goals of care for nutrition should
continue to be addressed at rehab.
.
Metastatic adenocarcinoma of unknown primary: thought to be due
to cholangiocarcinoma. Pt is not a candidate for any
chemotherapy due to multiple comorbidities and acute medical
issues. Family still wants aggressive treatment. Palliative care
was involved.
.
Dysphagia: Was evaluated on last admission by speech and swallow
team as well. Due to chronic medical issues and worsening of
parkinson's disease, patient's ability to swallow worsened
during admission. He was unable to tolerate thickened liquids,
and was ultimately sent for repeat video swallow analysis as per
above.
.
Hypertension: Was controlled with hydralazine and isosorbide,
with a goal SBP of 130-140 range. Aggressive BP lowering was
avoided.
.
During this admission, pt also developed constipation, which was
treated with senna, colace, dulculax, and finally enema.
.
Coronary artery disease: history of NSTEMI. Troponin mildly
elevated on admission, likely [**1-7**] demand in setting of
hypertensive urgency. Patient was given aspiring, beta blockers,
imdur, statin, and diuresis.
.
Chronic renal insufficency: patient maintained a stable
creatinine level that was close to baseline despite aggressive
diuresis.
.
Prophylaxis: Subcutaneous heparin, aggressive bowel regimen,
home PPI
.
Access: PICC, PIV x2
.
Code: full
.
Communication: Patient, wife and daughter
Medications on Admission:
Docusate Sodium 250 mg PO daily
Senna 8.6 mg Tablet PO BID
Polyethylene Glycol One (1) packet PO DAILY
Aspirin 325 mg PO DAILY
Finasteride 5 mg PO DAILY
Tamsulosin 0.4 mg SR 24 hr PO HS
Pramipexole 0.125 mg PO tid
Gabapentin 300 mg PO Q24H
Omeprazole 40 mg PO once a day.
Simvastatin 40 mg PO DAILY (Daily).
Carbidopa-Levodopa 25-100 mg PO 5 TIMES DAILY
Carbidopa-Levodopa 25-100 mg half a pill Tablet PO TID at 6 am,
11 am and 4 pm.
Ferrous Sulfate 325 mg PO DAILY (Daily).
Sertraline 25 mg PO once a day.
Primidone 25mg PO once a day.
Vitamin D 1,000 unit PO once a day.
Acetaminophen 325 mg 1-2 Tablets PO Q6H prn pain
Metoprolol Succinate 25 mg Tablet SR PO DAILY
Isosorbide Mononitrate 30 mg SR 24 hr PO DAILY (Daily).
Oxycodone 10 mg Tablet SR 12 hr PO Q12H (every 12 hours).
oxycodone IR 10mg Q4H prn pain
Morphine oral [**Male First Name (un) **] 4mg Q6H
Medications upon transfer to [**Hospital Ward Name 121**] 2:
Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
Levofloxacin 750 mg IV Q48H day #1 [**5-31**]
Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
Metoprolol Tartrate 25 mg PO BID
hold for HR <60 sBP<100 Order date: [**5-31**] @ 0054
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheezing
Morphine Sulfate (Oral Soln.) 4 mg PO Q6H pain
Aspirin 325 mg PO DAILY Start
Carbidopa-Levodopa (25-100) 1 TAB PO 5X/DAY
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Carbidopa-Levodopa (25-100) 0.5 TAB PO TID
please administer at 6, 11, 16
OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
Docusate Sodium 250 mg PO DAILY
Polyethylene Glycol 17 g PO DAILY
Finasteride 5 mg PO DAILY
Pramipexole *NF* 0.125 mg Oral TID
Furosemide 80 mg IV ONCE
PrimiDONE 25 mg PO HS
Gabapentin 300 mg PO HS
Senna 1 TAB PO BID
Heparin 5000 UNIT SC TID
Sertraline 25 mg PO DAILY
HydrALAzine 37.5 mg PO TID
Give with 20 mg of isosorbide dinitrate
Simvastatin 40 mg PO DAILY
Insulin SC
Sliding Scale
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob, wheezing
Tamsulosin 0.4 mg PO HS
Isosorbide Dinitrate 20 mg PO TID
20 mg of hydralazine
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet [**Month/Year (2) **]: [**12-7**] Tablet PO TID (3
times a day): please administer at 6, 11, 16 .
2. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
3. Carbidopa-Levodopa 25-100 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO
5X/DAY (5 Times a Day).
4. Finasteride 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
5. Lasix 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
6. Aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
Tablet(s)
7. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: 2.5 Tablets
PO DAILY (Daily).
8. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: [**12-7**] PO DAILY (Daily).
9. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day).
10. Polyethylene Glycol 3350 100 % Powder [**Month/Day (2) **]: One (1) PO DAILY
(Daily).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Month/Day (2) **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Pramipexole 0.125 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3
times a day).
13. Gabapentin 250 mg/5 mL Solution [**Month/Day (2) **]: One (1) PO HS (at
bedtime).
14. Simvastatin 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
15. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
16. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: One (1) PO Q6H
(every 6 hours) as needed for pain.
17. Isosorbide Dinitrate 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID
(3 times a day).
18. Oxycodone 10 mg Tablet Sustained Release 12 hr [**Month/Day (2) **]: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
19. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: One (1) PO Q4H (every 4
hours) as needed for pain.
20. Primidone 50 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO HS (at bedtime).
21. Sertraline 50 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO DAILY (Daily).
22. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
23. Levofloxacin in D5W 750 mg/150 mL Piggyback [**Last Name (STitle) **]: One (1)
Intravenous Q48H (every 48 hours).
24. Hydralazine 25 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO TID (3 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
acute pulmonary edema secondary to acute on chronic heart
failure
pneumonia
.
Secondary:
metastatic adenocarcinoma with unknown primary
systolic heart failure with EF of 45%
coronary artery disease
chronic renal insufficiency
GERD
high blood pressure
hyperlipidemia
parkinson's disease
benign prostatic hypertrophy
Discharge Condition:
afebrile, vitals signs stable
Discharge Instructions:
You were admitted for shortness of [**Hospital6 1440**] due to fluid in the
lungs. Following stabilization in the medicine intensive care
unit, you were given a diuretic to remove this fluid in your
lungs. You were found have a pneumonia and were treated with
antibiotics. Also, you developed difficulty in regards to
swallowing, making you at risk for aspiration pneumonia.
Following a video swallow study, we decided to recommend 1)
moist, ground solids 2) nektar thick liquids 3) sips of thin
liquids in between meals 4) pills crushed with applesauce.
.
If you develop worsening shortness of [**Hospital6 1440**], CP, fever, chills,
please contact your doctor or go to the emergency room.
.
Please continue to take 40mg lasix by mouth every day. Please
continue all other medications prior to your admission to the
hospital.
.
Followup Instructions: Please contact your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
at [**Telephone/Fax (1) 27593**] to schedule a follow up appointment within 1
week of discharge.
Followup Instructions:
Please make the following appointments within 1 week of
discharge:
.
Primary Care Provider:
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 53953**]
Name: [**Known lastname 10025**],[**Known firstname 2636**] DR [**Last Name (STitle) 4221**] [**Name (STitle) **]: [**Numeric Identifier 10026**]
Admission Date: [**2182-5-30**] Discharge Date: [**2182-6-5**]
Date of Birth: [**2099-9-16**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 10027**]
Addendum:
Pt has been discharged with the following medications:
Discharge Medications/Orders:
Carbidopa-Levodopa 25-100 mg Tablet [**First Name3 (LF) 1649**]: [**12-7**] Tablet PO TID (3
times a day): please administer at 6, 11, 16 .
Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) 1649**]: One (1)
Injection TID (3 times a day).
Carbidopa-Levodopa 25-100 mg Tablet [**Month/Day (2) 1649**]: One (1) Tablet PO
5X/DAY (5 Times a Day).
Finasteride 5 mg Tablet [**Month/Day (2) 1649**]: One (1) Tablet PO DAILY
(Daily).
Lasix 40 mg Tablet [**Month/Day (2) 1649**]: One (1) Tablet PO once a day.
Aspirin 325 mg Tablet [**Month/Day (2) 1649**]: One (1) Tablet PO DAILY (Daily).
Tablet(s)
Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) 1649**]: 2.5
Tablets PO DAILY (Daily).
Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) 1649**]: [**12-7**] PO DAILY
(Daily).
Senna 8.6 mg Tablet [**Month/Day (2) 1649**]: One (1) Tablet PO BID (2 times a
day).
Polyethylene Glycol 3350 100 % Powder [**Month/Day (2) 1649**]: One (1) PO DAILY
(Daily).
Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Month/Day (2) 1649**]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Pramipexole 0.125 mg Tablet [**Month/Day (2) 1649**]: One (1) Tablet PO TID (3
times a day).
Gabapentin 250 mg/5 mL Solution [**Month/Day (2) 1649**]: One (1) PO HS (at
bedtime).
Simvastatin 40 mg Tablet [**Month/Day (2) 1649**]: One (1) Tablet PO DAILY
(Daily).
Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) 1649**]: One (1) Tablet PO BID
(2 times a day).
Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) 1649**]: One (1) PO Q6H
(every 6 hours) as needed for pain.
Isosorbide Dinitrate 20 mg Tablet [**Month/Day (2) 1649**]: One (1) Tablet PO
TID (3 times a day).
Oxycodone 10 mg Tablet Sustained Release 12 hr [**Month/Day (2) 1649**]: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Oxycodone 5 mg/5 mL Solution [**Month/Day (2) 1649**]: One (1) PO Q4H (every 4
hours) as needed for pain.
Primidone 50 mg Tablet [**Month/Day (2) 1649**]: 0.5 Tablet PO HS (at bedtime).
Sertraline 50 mg Tablet [**Month/Day (2) 1649**]: 0.5 Tablet PO DAILY (Daily).
Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) 1649**]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Hydralazine 25 mg Tablet [**Last Name (STitle) 1649**]: 1.5 Tablets PO TID (3 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) 986**] [**Last Name (NamePattern1) 10028**] MD [**Last Name (un) 10029**]
Completed by:[**2182-6-5**]
|
[
"197.7",
"285.21",
"412",
"600.00",
"486",
"518.81",
"V10.82",
"156.1",
"585.9",
"428.23",
"428.0",
"530.81",
"332.0",
"403.00",
"414.01",
"787.20",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20393, 20622
|
7275, 11131
|
313, 320
|
16085, 16117
|
4273, 7252
|
17238, 20370
|
3249, 3368
|
13201, 15629
|
15739, 16064
|
11157, 13178
|
16141, 16971
|
3398, 4254
|
2199, 2254
|
233, 275
|
376, 2180
|
2276, 2967
|
2983, 3233
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,412
| 193,352
|
43541
|
Discharge summary
|
report
|
Admission Date: [**2190-7-10**] Discharge Date: [**2190-7-22**]
Service: MEDICINE
Allergies:
Penicillins / Tetracycline Analogues / Hydralazine / Ace
Inhibitors
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
s/p racemic epinephrine and heliox in the ICU
History of Present Illness:
88 yo F with hx of esophageal dysmotility (secondary to
radiation therapy to neck indicated for thyroid cancer) who is
s/p aspiratioin event on evening on admission. According to
patient's son, she finished her meal without sequelae tonight;
however, while on toilet after the meal she regurgitated her
food (as she often does). What was different about this event
was that she complained of fatigue after vomiting and went to
her bed. Her son went to check on her and she was complaining of
difficulty breathing. She was coughing and was continuing to
regurgitate food. Son called PCP's office who called an
ambulance. Prior to arrival of ambulance, patient's son reports
several witnessed apneas and some somnolence which terrified
him. EMTs arrived shortly after she became unresponsive and
noted an oxygen sat of 59%. They began to bag her and got her
sats up to 90% quickly and her mental status improved.
.
In the ED, initial vs were T 96.8, HR 74, BP 181/77, RR 22,
O2Sat 95% on NRB. A CXR was obtained. Patient was given
ceftriaxone, levofloxacin, and metronidazole. Reportedly desats
into 80s quickly off of non-rebreather, though is in mid-90s
while on NRB. Is fully alert and answering questions. Prior to
transfer to the floor, vitals were T 96.7, HR 60, BP 126/44, RR
18, O2Sat 98% NRB.
.
On the floor, patient reports that she is having slight dyspnea.
She denies chest pain. Reports some wheezing. She notes that she
has dyspnea "all the time", though it is worse today. She has
not been able to drink any fluids due to more frequent
regurgitation. Denies nausea.
.
Review of systems:
(+) wheezing, dyspnea, vomiting, cough, weight loss, decreased
PO intake, fatigue, constipation
(-) fever, chills, night sweats, recent weight loss or gain,
headache, sinus tenderness, rhinorrhea, congestion, chest pain,
chest pressure, palpitations, weakness, nausea, diarrhea,
abdominal pain
Past Medical History:
1) Papillary thyroid CA diagnosed [**2169**] s/p recurrence with
excisional surgery and XRT in [**2182**]
2) Hypothyroidism
3) Hypertension
4) Anemia of chronic disease
5) Thoracic aortic aneurysm s/p repair: pathology revealed giant
cell arteritis
6) Temporal arteritis
7) Espohageal dysmotility with chronic aspiration reported in
prior imaging
8) Macular degeneration
9) Lung mass LUL stable in size on CT chest comparing [**11/2189**] to
[**2190-6-24**]
10) Left hip fracture in [**1-/2190**] s/p ORIF
Social History:
Patient lives alone in an [**Hospital3 **] facility.
Tobacco: Denies
Alcohol: Denies
Illicits: Denies
Family History:
Father - hemorrhagic stroke
Sister - glaucoma
Sister - lupus, vasculitis
Physical Exam:
Vitals: T 95, HR 77, BP 114/64, RR 23, O2Sat 100% NRB
General: Patient breathing comfortably
HEENT: PERRL, bilateral arcus senilis, sclera anicteric, oral
mucosa dry, oropharynx clear
Neck: supple, no LAD
Lungs: Anterior exam with crackles along left field, right field
with rub and inspiratory squeaks
CV: RR, nl S1, nl S2, no appreciable murmurs
Abdomen: Thin, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: No foley
Ext: no clubbing, cyanosis or edema, radial pulse 2+ bilaterally
Pertinent Results:
[**2190-7-10**] 10:45PM BLOOD WBC-18.1*# RBC-3.75* Hgb-11.1*#
Hct-33.1*# MCV-88# MCH-29.5 MCHC-33.4 RDW-15.4 Plt Ct-321
[**2190-7-11**] 05:45AM BLOOD WBC-18.0* RBC-3.53* Hgb-10.7* Hct-31.3*
MCV-89 MCH-30.3 MCHC-34.2 RDW-15.7* Plt Ct-257
[**2190-7-12**] 04:40AM BLOOD WBC-20.5* RBC-3.65* Hgb-10.6* Hct-32.3*
MCV-88 MCH-28.9 MCHC-32.7 RDW-15.6* Plt Ct-303
[**2190-7-10**] 10:45PM BLOOD Neuts-94.6* Lymphs-3.8* Monos-1.3*
Eos-0.2 Baso-0.2
[**2190-7-11**] 05:45AM BLOOD Neuts-83* Bands-12* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2190-7-11**] 05:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
[**2190-7-10**] 10:45PM BLOOD PT-12.6 PTT-30.5 INR(PT)-1.1
[**2190-7-10**] 10:45PM BLOOD Glucose-160* UreaN-45* Creat-1.8* Na-141
K-3.9 Cl-105 HCO3-23 AnGap-17
[**2190-7-11**] 05:45AM BLOOD Glucose-87 UreaN-43* Creat-1.6* Na-143
K-3.9 Cl-109* HCO3-23 AnGap-15
[**2190-7-12**] 04:40AM BLOOD Glucose-52* UreaN-44* Creat-1.4* Na-144
K-4.1 Cl-110* HCO3-17* AnGap-21*
[**2190-7-12**] 04:40AM BLOOD ALT-PND AST-PND LD(LDH)-PND AlkPhos-PND
TotBili-PND
[**2190-7-11**] 05:45AM BLOOD CK(CPK)-88
[**2190-7-10**] 10:45PM BLOOD proBNP-3202*
[**2190-7-10**] 10:45PM BLOOD cTropnT-0.04*
[**2190-7-11**] 05:45AM BLOOD CK-MB-6 cTropnT-0.04*
[**2190-7-10**] 10:45PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8
[**2190-7-11**] 05:45AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.6
[**2190-7-12**] 04:40AM BLOOD Albumin-PND Calcium-8.2* Phos-3.7 Mg-1.6
[**2190-7-10**] 10:48PM BLOOD Lactate-1.6
.
IMPRESSION:
Mild pulmonary edema and bilateral small pleural effusion are
unchanged.
Brief Hospital Course:
88 yo F with hx of esophageal dysmotility (secondary to
radiation therapy to neck indicated for thyroid cancer) who is
s/p aspiration event on evening on admission.
## Aspiration/Goals of CARE
Likely cause of the hypoxia, this is a chronic issue. She has
also not had any swallowing rehab or therapy since her radiation
treatment in [**2182**]. She had tried numerous outpatient therapies,
including peppermint but without success. Speech and swallow
evaluated her on hospital day 3, however due to her acute change
in mental status was unable to perform a swallow evaluation.
Multiple family meetings were performed with the son concerning
possible solutions, which include allowing continued aspiration
or possible G/J-tube placement. TPN was started in the ICU. Pt
was reevaluated by speech and swallow therapy after her ICU stay
and had severe evidence of aspiration. Pt was made strict NPO as
it was not safe for her to continue eating at that time. Pt
expressed on several occasions her wish to return to eating and
enjoy sweets. Therefore, a family meeting was held on [**7-19**] with
patient's son's, including [**Location (un) **] the HCP, niece, palliative
care, speech and swallow therapy and the chaplain. Pt has intact
cognition, has capacity, and clearly expressed her wishes to
return to eating regardless of the consequences as well as to
return home if possible. In addition, she also stated that she
would not want to be resuscitated. Therefore, pt's diet was
advanced. S+S worked with the patient in order to offer dietary
options that may prove less choking/aspiration and her diet was
modified to a soft solid, thin liquid diet. Pt and son were
given information by the speech and swallow therapists regarding
eating techniques that may lessen risk of aspiration. However,
pt is allowed to eat whatever she desires as the goal of eating
is for pleasure and comfort. Pt will aspirate, does spit up food
contents after meals, and may choke and pt and her family are
aware of this. If a significant choking/aspiration episode were
to occur, the goals of care are again comfort oriented and pt
should be given IV morphine or IV ativan prn choking or dyspnea
according to her wishes. These were not administered in the
hospital setting as pt did not require them. Pt has made it very
clear on several occasionals that she would not want aggressive
measures, "tubes and wires", would not want to be a "burden" and
desires to eat while acknowledging the risks associated with it.
In addition, she also is clear that in the event of an
aspiration/hypoxic/choking episode she would want to be made
comfortable and not have aggressive measures taken.
.
## Hypoxia, secondary to aspiration pneumonia and pneumonitis-
The patient was acutely hypoxic and required a non-rebreather
initially on coming from the emergency room. This was weaned
rapidly first to venti-mask then to nasal cannula. There was
also a marked leukocytosis and left shift, and therefore the
patient was placed on IV levofloxacin for pneumonia and
completed a 7 day course. However, symptoms were most likely
related to aspiration pneumonitis. She currently remains on 1L
NC.
## Stridor: On hospital day 3 the patient developed acute
stridor and respiratory distress, with evidence of retraction
and accessory muscle use. ENT was urgently consulted and
performed laryngoscopy, which showed bilateral vocal cord
paralysis. Outside hospital records from [**Hospital1 756**] were obtained
which showed that the patient had long standing left sided
paralysis and vocal cord stripping, but there was no evidence of
right sided paralysis. The patient's blood gas initially showed
hypoxia and hypercarbia, and an a-line was placed for close
monitoring of gas exchange. The patient was placed on heliox
with subsequent improvement in her respiratory status as the
racemic epinephrine did not work. Expiratory stridor continued
during the [**Hospital 228**] hospital stay, but she continued to sat
well with 1-2L NC and was not in respiratory distress.
## Delirium: On hospital day 2 the patient became acutely
delirious in the setting of a blood glucose level of 39. She
was given D50 with subsequent improvement of her blood sugars.
Delerium had resolved by the time the patient was called out of
the ICU.
## [**Last Name (un) **]:
Patient with Cr up to 1.8 on admission with most recent prior
being 1.2 in 3/[**2190**]. This resolved with fluid challenges and on
day of call out from MICU had trended down to 0.9 and remained
normal.
##anemia-Studies show anemia of chronic disease. Her HCT
continued to slowly trend downward. She did not show any signs
of bleeding.
Medications on Admission:
1) Atenolol 50 mg daily
2) Levothyroxine 125 mcg daily
3) Nitroglycerin 0.4 mg SL PRN chest pain
4) Valsartan 320 mg daily
5) Amlodipine 10 mg daily
6) Vitamin D 1000 units daily
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day: if
patient desires.
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO once a
day: if patient desires.
3. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day: if
patient desires.
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day: if
pt desires.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
6. Lorazepam in 0.9% Sod Chloride 100 mg/100 mL (1 mg/mL)
Solution Sig: One (1) mg Intravenous every 4-6 hours as needed
for shortness of breath or wheezing: prn dyspnea. This has not
yet been given.
7. Morphine 100 mg/4 mL Solution Sig: 1-2 mg Intravenous every
4-6 hours as needed for shortness of breath or wheezing: prn
dyspnea associated with significant aspiration. This has not yet
been given.
8. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation: if patient desires.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: if
patient desires.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for fungal rash.
11. medications
Please offer patient her medications. They should be crushed and
offered to patient in a puree. She may decline her medications.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Major:
aspiration pneumonia
aspiration pneumonitis
hypoxia
vocal cord dysfunction
esophageal dysmotility-severe due to past radiation
.
Minor:
papillary thyroid cancer s/p radiation
HTN
hypothyroid
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted after having low oxygen levels due to choking
(aspirating). This is likely related to past radiation that you
have had, from your thyroid cancer, in addition to having vocal
cords that are not very mobile. For this, you were evaluated by
specialists who determined that it was unsafe for you to
continue eating or drinking by mouth. We had a family meeting
with speech and swallow therapy, palliative care, the internal
medicine team, and your family where you expressed your wishes
to be able to eat and return to your home.
We have arranged services in order to honor this request. Your
diet was advanced with the goals of eating being comfort and
pleasure.
.
Medications:
1.Continue prior medications- These can be crushed up and given
in a pureed food if you desire to take them.
2. You may be given IV ativan 0.5-1mg IV prn for comfort related
to shortness of breath or choking episode. This was not yet
given in the hospital.
3. You may be given IV morphine 1-2mg IV prn comfort related to
shortness of breath or choking episode. This was not yet given
in the hospital.
4.You may take bisacodyl suppositories for constipation.
.
Please take all of your medications as prescribed (if you are
able) and follow up with your appointments below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
When: Wednesday, [**7-28**], 8:30AM
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
|
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"530.5",
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"293.0",
"478.31",
"584.9",
"564.00",
"285.21",
"E879.2",
"251.2",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"99.15",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
11444, 11510
|
5228, 9885
|
283, 331
|
11752, 11752
|
3576, 5205
|
13219, 13458
|
2918, 2993
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10114, 11421
|
11531, 11731
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11928, 13196
|
3008, 3557
|
1959, 2254
|
235, 245
|
359, 1940
|
11767, 11904
|
2276, 2783
|
2799, 2902
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,453
| 155,332
|
3692
|
Discharge summary
|
report
|
Admission Date: [**2172-10-20**] Discharge Date: [**2172-10-22**]
Date of Birth: [**2120-3-3**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Tunneled catheter fell out while in shower
Major Surgical or Invasive Procedure:
Placement of temp line catheter on [**2172-10-22**]
History of Present Illness:
52 yo woman with h/o ESRD due to lupus nephritis as well as
antiphospholipid antibody syndrome on coumadin presenting after
her left tunneled IJ HD line apparently fell out when she bent
down in the shower earlier on the day of presentation. There was
no significant bleeding. She came into the ED for line
replacement. In the ED, renal dialysis and surgery were called
and a plan was made for the patient to get a line as an
outpatient tomorrow am at AV care. The patient refused stating
she had bad experiences at AV care in the past so she was
admitted to medicine for line placement.
In the ED, VS were: 98.4 78 142/97 18 100% RA. Her exam was
noted to be benign. A CXR was done and was unremarkable.
She otherwise has no complaints and feels at her baseline.
Review of systems:
(+) 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:
1. ESRD [**1-13**] WHO Stage IV Lupus nephritis (bx at [**Hospital1 112**] [**2166**]) on HD
since [**11/2168**]) c/b E coli line sepsis [**8-/2170**] - Followed by
Nephrology and currently on Transplant list. Dialyzed through
catheter in RIGHT chest wall after AV fistula was deemed
unsalvagable earlier this year. Last HD on Wednesday.
2. HTN - Medical admission for hypertensive urgency [**2-/2171**]
3. Thyroid nodule - 1.3 cm, observed on imagining for the first
time in [**2159**], followed up by Endocrinology. TFTs unremarkable.
Previously refused FNA of nodule.
4. Antiphospholipid antibody (not syndrome). C/b AV fistula
thrombosis [**2171-7-10**]. Managed off of anticoagulation, but may
require coumadin in peri-transplant period. No dvt or abortion
history.
5. SLE - Followed by Dr. [**Last Name (STitle) 1667**] in Rheumatology. Managed with
Plaquenil prophylaxis therapy. Diagnosed around year [**2162**].
6. Hypercholesterolemia
7. LEFT Ankle Pain (although some notes document pain was on
RIGHT side) - seen in ED [**2171-7-13**] - joint aspirate negative. cx
guided bx cx negative , followed up in [**Hospital **] clinic with Dr. [**First Name (STitle) **].
8. 4 children, 3 vaginal births, 1 section, last 22 yrs ago.
9. osteonecrosis of the distal fibula (Right); Hosp [**2086-9-29**]
Social History:
The patient was born in [**Country 2045**] and immigrated to the United
States in [**2144**]. She was widowed in 6/[**2169**]. She is on disability
since she has been on dialysis over the last three years. She
walks without a cane and takes care of her ADLs. She lives alone
in [**Location (un) **], but she has one son who is at BC. Her other three
children are still in [**Country 2045**] and her husband died two years ago.
She denies any tobacco, ethanol or illicit drug use.
Family History:
Significant for a maternal uncle with hypertension; otherwise
denies any family history of heart disease, cancer or diabetes.
Mother died of unclear causes when patient was 7 yo. Father died
of unclear causes in [**2152**].
Physical Exam:
VS: 98 128/87 73 18 100% RA 63.8kg
GENERAL: Very pleasant woman resting in bed, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear.
NECK: Supple, No LAD.
CARDIAC: RRR. Normal S1, S2. No m/r/g.
LUNGS: CTAB, no wheeze or crackle.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Prior AV fistula site Left arm.
Pertinent Results:
PT-24.7* PTT-29.7 INR(PT)-2.4*
GLUCOSE-129* UREA N-33* CREAT-9.2*# SODIUM-144 CHLORIDE-106
TOTAL CO2-24
VIT B12-935* FOLATE-8.9 FERRITIN-1048*
TSH-0.33
C3-108 C4-27
WBC-7.6 RBC-3.40* HGB-10.5* HCT-31.3* MCV-92 MCH-30.9 MCHC-33.5
RDW-15.5
NEUTS-63.0 LYMPHS-27.1 MONOS-4.1 EOS-5.3* BASOS-0.6
Brief Hospital Course:
52 yo F with lupus, ESRD on HD, and antiphospholipid antibody
syndrome on coumadin admitted after HD catheter fell out.
# Absence of HD Catheter: Prior to replacement of catheter, INR
was reversed by giving FFP given an initial INR on admission of
2.4. After 2 [**Location 16678**], Ms [**Known lastname 16675**] started to complain of a
sore throat. About 10 minutes into transfusion of 3 U, Ms
[**Known lastname 16675**] started to develop swelling under chin and around the
lips. The FFP was stopped. Benadryl was given. Respiratory
status was 100% on RA although patient endorsed some difficulty
with swallowing. Angiography was called and they agreed to
attempt to place the line despite presumed allergic reaction.
In the angiography suite, she continued to endorse difficulty
swallowing. IV steroids were given. She was transferred back
up to floor without line as IR felt uncomfortable giving
conscious sedation in the setting of possible larygneal
swelling. ENT was consulted. ENT determined there was mild
laryngeal swelling although airway was patent. Suspicion raised
for angioedema possibly in response to FFP or lisinopril which
the patient has been on chronically. Lisinopril was
discontinued. Was transferred to MICU overnight for observation.
IV benadryl was given around the clock. Epinephrine was not
administered given stable respiratory status. Overnight in MICU
her symptoms improved. In morning she was retransferred to
floor with no worsening of symptoms. FFP was added to her
allergy list. Given continued elevated INR, a temporary HD line
was placed. Ms [**Known lastname 16675**] was tired of being in the hospital
given above events and decided to leave AMA with temporary HD
line in place. She refused in-house dialysis. She was referred
to AV care where she normally gets her dialysis for emergent
dialysis that afternoon and she agreed to keep this appointment.
She was also scheduled for an appointment with her primary care
doctor as well as with allergy given possible angioedema in
reaction to FFP/ lisinopril. She was discharged without
lisinopril and advised not to restart this medication. Blood
bank was notified of possible reaction.
# End stage renal disease: was continued on nephrocaps,
cinacalcet, [**Known lastname **] and hydroxychloroquine. Was discharged
with emergent dialysis at her usual dialysis site with her
temporary HD line.
# Antiphospholipid antibody syndrome:
Warfarin was held given temp line placement. She was advised to
restart warfarin under direction of her primary care doctor.
# Hypertension: Her lisinopril was discontinued given above
possible reaction. Metoprolol was continued as per home
regimen.
Medications on Admission:
Warfarin 2 mg 3 tabs PO daily as directed
Lisinopril 5 mg by mouth every other day
Metoprolol Tartrate 25mg [**Hospital1 **]
Hydroxychloroquine 200mg daily
Cetirizine 5mg daily
Diphenhydramine HCl 25 mg PO Q6hrs PRN itching
Docusate prn
Senna prn
[**Hospital1 7222**] HCl 1600mg PO TID
Cinacalcet 30 mg Tablet by mouth DAILY
Camphor-Menthol 0.5-0.5 % Lotion topical QID
B Complex-Vitamin C-Folic Acid 1 mg PO daily
Discharge Medications:
Metoprolol Tartrate 25mg [**Hospital1 **]
Hydroxychloroquine 200mg daily
Cetirizine 5mg daily
Diphenhydramine HCl 25 mg PO Q6hrs PRN itching
Docusate prn
Senna prn
[**Hospital1 7222**] HCl 1600mg PO TID
Cinacalcet 30 mg Tablet by mouth DAILY
Camphor-Menthol 0.5-0.5 % Lotion topical QID
B Complex-Vitamin C-Folic Acid 1 mg PO daily
Discharge Disposition:
Home
Discharge Diagnosis:
1. Replacement of tunneled line with temporary line
2. Angioedema (secondary to FFP and/or lisinopril)
Discharge Condition:
Stable for home. Ambulating well on room air. Resolution of
swelling around lips and chin.
Patient left AMA before paperwork was given.
Discharge Instructions:
Patient left AMA before paperwork was given.
You were admitted because your tunneled catheter line fell out
at home. Before replacing your line, we had to stop your
coumadin and give you plasma to make sure you did not bleed
during placement of your line. After giving you plasma, you
developed an allergic reaction, which you experienced as throat
discomfort, swelling of your lips, and difficulty swallowing.
To treat this, we gave you medicines including benadryl and
steroids, which helped calm the reaction. We also watched you
overnight in the hospital in the intensive care unit to ensure
that you did not have any trouble breathing overnight. You did
well in the intensive care unit, and by morning, your swelling
had decreased. In the morning, we rechecked your swelling and
your throat and we found substantial improvement. At that time
we decided to place a temporary line for dialysis.
Following the temp line placement we wanted to do dialysis.
Unfortunately you wanted to leave the hospital and left against
medical advice.
We made one important medication change while you were here:
(1) You should stop taking lisinopril, a blood pressure
medication, which may have played a part in the swelling that
you had while you were here. You should not take this medicine
again. Please consult with your primary care physician for [**Name Initial (PRE) **]
better medicine to use in its place.
While you were here, you did experience an allergic reaction,
most likely due to FFP (fresh frozen plasma). This has been
added on your list of allergies so that on future
hospitalizations, they will know about your reaction.
You will need a permanent line placed for future dialysis
sessions. We were unable to place a permanent line because it
will take a few days off coumadin to ensure you don't have any
bleeding when a permanent line is placed. [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 15170**] will
contact you.
If you experience worsening swelling, difficulty swallowing,
trouble breathing, or any other concerning symptoms, please let
your primary care doctor know or return to the emergency
department.
Followup Instructions:
1. You should follow up with the allergy doctor for the
reaction you experienced on Wednesday [**11-18**] at 845 AM. Their
office is located at [**Hospital1 **] on the [**Location (un) 436**] in
the [**Hospital Ward Name 23**] building, and your doctor's name is Dr. [**Last Name (STitle) 9313**].
2. You should follow up with your primary care doctor's office
on [**10-30**] at 130 PM.
***The patient was advised to go to Hemodialysis the next
morning after discharge for urgent hemodialysis.***
|
[
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icd9cm
|
[
[
[]
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[
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,454
| 149,824
|
36314
|
Discharge summary
|
report
|
Admission Date: [**2175-8-27**] Discharge Date: [**2175-8-30**]
Date of Birth: [**2141-1-18**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Thiamine
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Chest pain
Reason for MICU admission: EtOH withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
34 yo male with hypertension and known h/o EtOH abuse p/w chest
pain x 3days. Pt reports being sober since his admission for
EtOH abuse and displaced left humeral fracture in [**5-18**] but
reports resuming heavy EtOH use, approximately 2 pints of vodka
daily for the past 8 days, in the setting the drowing death of
15-yo daughter from a diving accident on [**2175-8-18**]. His last drink
was reportedly Friday night. Pt developed left chest pressure 3
days ago while at rest accompanied by diaphoresis, nausea,
shortness of breath, and left arm pain; no lightheadedness. He
reports being at rest when this occurred although he was upset
about his daughter's death. He presented to the ED for ongoing
chest pressure. He was given ASA 325mg by EMS as well as NTG x 2
with some relief.
.
In ED, VS on arrival: T 99.2, HR 97, BP 170/91 (ativan), RR 18,
O2 98% 2LNC. In the ED, patient reported to have a brief
unresponsive episode with quick recovery. EKG in ED initially
with SR 82 with question of isolated ST depression in III which
resolved in ED with control of tachycardia. CXR with low lung
volumes. CTA without PE or aortic dissection but notable for
small hematoma around minimally displaced left clavicular head
fracture. Labs significant for EtOH level 270 and anion gap of
17. He also had a K of 5.6 on a hemolyzed sample; given
kayexalate. He was intermittently hypertensive and treated for
EtOH withdrawal, receiving a total of valium 20mg IV and ativan
5mg IV along with banana bag x 1 L and NS IVF x 5 L. Also given
Zofran for nausea, tylenol and morphine for pain. He was
admitted to the MICU for further management.
.
On the floor, pt reports continued left chest presure with
reproducible tenderness, worse on inspiration and cough. Anxiety
and tremors currently improved with valium. Feels depressed but
denies SI/HI. He reports multiple episodes of blacking out in
setting of EtOH intoxication with one prior admission for EtOH
withdrawal (as noted prior); denies h/o withdrawal seizures or
DT.
.
Review of sytems:
Denies fever, chills, recent weight loss or gain. Had headache,
now improved after tylenol. No sinus tenderness. Cough
productive of scanty white sputum x 1 week. Currently without
nausea, vomiting. No diarrhea, constipation, or abdominal pain.
No recent change in bowel or bladder habits. No dysuria.
Paresthesias in left arm with residual weakness s/p humeral
fracture. Multiple ecchymoses over thorax and extremities of
unclear etiology.
Past Medical History:
Left closed midshaft humerus fracture
Alcohol abuse
Hypertension
Social History:
Born in MA. Lived in CA x several years with ex-wife and
children. Remaining 15 yo daughter (twin) and 13 yo son with
difficulty coping as present at time of daughter's death.
Currently 3rd year law student here with plans to return to
[**State 4565**]. Has girlfriend here, [**Name (NI) 1356**]; prior notes allude to
possible issues with abuse. EtOH history as above. Denies
smoking and illicit drug use.
Family History:
Father with EtOH abuse. Maternal aunt with CAD. No h/o cancer.
Physical Exam:
Vitals: T 98.9, BP 140/74, HR 94, RR 17, O2sat 97%RA
General: Mild tremor but not agitated.
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: No foley
Skin: Ecchymoses over left upper chest, left ribs, left upper
arm, knees b/l, left dorsum of foot, and buttocks.
Ext: Warm, well perfused, 2+ pulses, no edema.
Neuro: AAO x 3. CN II-XII grossly intact. Strength 5/5 in all
extremities except 5-/5 i LUE. Mild b/l UE tremors but able to
do finger-to-nose. No pronator drift. DTR symmetric. Gait not
assessed.
Psych: Depressed with mild anxiety but denies SI/HI.
Pertinent Results:
On admission:
[**2175-8-27**] 03:00AM BLOOD WBC-6.5 RBC-4.63 Hgb-14.6 Hct-43.1 MCV-93
MCH-31.6 MCHC-33.9 RDW-14.2 Plt Ct-76*#
[**2175-8-27**] 03:00AM BLOOD Neuts-63.7 Lymphs-30.8 Monos-4.5 Eos-0.2
Baso-0.9
[**2175-8-27**] 03:00AM BLOOD Glucose-188* UreaN-5* Creat-0.9 Na-136
K-5.6* Cl-94* HCO3-25 AnGap-23*
[**2175-8-27**] 03:00AM BLOOD Calcium-9.0 Phos-2.0* Mg-2.0
[**2175-8-27**] 03:00AM BLOOD ALT-51* AST-104* LD(LDH)-721*
CK(CPK)-236* AlkPhos-177* TotBili-0.7
[**2175-8-27**] 03:00AM BLOOD Lipase-45
.
[**2175-8-27**] 03:00AM BLOOD ASA-NEG Ethanol-270* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2175-8-27**] 03:08PM BLOOD Lactate-1.7
.
[**2175-8-27**] 03:00AM BLOOD CK(CPK)-236* CK-MB-3 cTropnT-<0.01
[**2175-8-27**] 09:00AM BLOOD CK(CPK)-154 CK-MB-3 cTropnT-<0.01
[**2175-8-27**] 02:50PM BLOOD CK(CPK)-131 CK-MB-3 cTropnT-<0.01
On discharge ([**2175-8-30**]): Tbili 1.4 ALT 151 AST 299 Platelets 44
Peripheral smear ([**2175-8-29**]): Negative for schistocytes
.
[**2175-8-27**] CXR: Lung volumes are low. However, the lungs appear
clear bilaterally with no evidence of focal consolidation. The
cardiomediastinal silhouette is within normal limits given the
lordotic view. Visualized osseous structures appear intact.
There is no pneumothorax or pleural effusions. IMPRESSION: No
acute intrathoracic process.
.
[**2175-8-28**] CTA Chest: 1. No evidence of pulmonary embolism.
2. Minimally-displaced fracture of the left clavicular head with
a small
surrounding hematoma. Adjacent vascular structures remain patent
and intact.
.
[**2175-8-28**] Left Humerus Xray: FINDINGS: In comparison to the study
of [**7-25**], there is further position of exuberant callus. The
degree of distraction may be slightly less than on the previous
study. Similarly, the amount of angulation is less and the
degree of apposition is somewhat enhanced.
[**2175-8-29**] U/S abdomen with dopplers: IMPRESSION:
1. Increased echogenicity of the liver consistent with fatty
infiltration. Please note that other forms of more advanced
liver disease including significant hepatic fibrosis/cirrhosis
cannot be excluded on this study. No focal liver lesion
identified.
Brief Hospital Course:
34 yo M with h/o alcohol abuse who presents with chest pain and
L clavicular head fracture, admitted to MICU for EtOH
withdrawal.
1. EtOH use and withdrawal: The patient admits to binge drinking
in setting of daughter's death with last drink reportedly 24-36
hours prior to presentation to ED. He was transfer to the ICU
because he was showing signs of withdrawal, which was controlled
with po valium. On [**2175-8-29**], he was transferred to the general
medical floors, where he had no signs of withdrawal for >36
hours. The patient reports not wanting to drink, but is not
interested in rehabilitation despite extensive efforts by our
social worker. [**Name (NI) **] is interested in possible medications to help
in his efforts to stop drinking, and will follow up with his PCP
regarding this issue at his appointment on [**2175-8-31**]. Psychiatry
follow up might also be needed in light of grief issues, and
should be set up by PCP if felt to be necessary.
Serum tox and urine tox were negative for other substance use.
The patient was continued on multivitamin, folate, and IV
thiamine while in house. He reports tongue swelling with PO
preparation of thiamine, likely secondary to inert substance in
the preparation. He had no reaction to IV thiamine. He was
discharged with MVI, folate, and vitamin B complex (400mcg
thiamine contained).
2. Chest pain: Chest pain was most likely musculoskeletal given
ecchymoses, TTP, and visualized clavicular fracture. Patient
does not recall fall but had been intoxicated from EtOH abuse
and had fresh bruises. Constellation of nausea, diaphoresis, and
shortness of breath were concerning for cardiac etiology, but
EKG baseline with neg cardiac enzymes x 3. CTA negative for
pulmonary embolism. His pain may have been exacerbated by
grief/adjustment disorder or panic attack, and could also be
complicated by EtOH withdrawal.
3. Grief/adjustment disorder: Pt reports feelings of depression
and guilt in setting of daughter's unexpected death. Recommend
follow up by PCP and possible psychiatric referral if patient is
willing. In-house patient was not willing to see a psychiatrist
as outpatient.
4. Left clavicular injury: There was evidence of a small
hematoma around minimally displaced fracture of the left
clavicular head. Conservative management per [**Date Range 1957**] was
recommended, with a sling and non weight bearing status in LUE.
Hematocrit remained stable. He was discharged with a sling and
advised to follow up with orthopedics as an outpatient.
5. Left humeral fracture: Presented with this in [**5-18**] and
conservatively managed. Patient will be followed by [**Date Range **] as an
outpatient.
6. Anion gap metabolic acidosis: Gap was present on admission
and likely [**3-13**] alcoholic and starvation ketosis. He received
aggressive IVF and PO intake was encouraged. The gap was
resolved and the patient was tolerating PO well at time of
discharge.
7. Transaminitis: AST predominance was suggestive of EtOH as
etiology. LFT's were continuing to gradually trend up, but
bilirubin was trending down. Tylenol was discontinued on
transfer to the floors and he was told not to restart this for
pain as an outpatient. The elevated LFT's are likely secondary
to alcoholic hepatitis. Ultrasound with dopplers showed fatty
infiltration of liver, but could not rule out cirrhosis. He will
see Dr. [**Last Name (STitle) **] in hepatology on [**2175-8-31**].
8. Thrombocytopenia: This was likely due to bone marrow
suppression from EtOH abuse. Platelets remained stable in 40's.
Heparin prophylaxis was held (in light of possible HIT).
Peripheral smear showed no schistocytes, so ITP not likely. U/S
with dopplers could not rule out cirrhosis, so it is possible
that liver disease could play a role, but this would not be
likely to drop platelets so low and so acutely. Platelet count
should be followed as an outpatient, and would expect platelets
to trend up gradually if indeed [**3-13**] bone marrow suppression from
ETOH abuse.
Medications on Admission:
Amlodipine 5mg
Thiamine 100mg
Folic acid 1mg
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
3. B-100 Complex Tablet Sig: One (1) Tablet PO once a day.
4. Multivitamins Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. non-cardiac chest pain
2. alcohol withdrawal
3. left clavicular head fracture
4. thrombocytopenia
5. transaminitis
Discharge Condition:
Vital signs stable, afebrile. AAOx3, no signs or symptoms of
withdrawal.
Discharge Instructions:
You were admitted to the hospital on [**2175-8-27**] for chest pain. We
determined that you were not having a heart attack based on your
EKG and blood enzymes. We suspect that the pain is secondary to
the recent fall you sustained.
You were also drinking a large amount of alcohol prior to being
admitted to the hospital. You went to the intensive care unit
because you were in danger of having serious withdrawal
symptoms. You received medications because you did, in fact,
begin to have withdrawal. You were then transferred to the
medical floors where we continued to monitor you. When you were
discharged, you were no longer in danger of having withdrawal
symptoms. You were counciled extensively regarding alcohol use
and you are advised to discuss this with Dr. [**Last Name (STitle) 5717**] tomorrow at
your appointment.
You also sustained a fracture to your left clavicle. The
orthopedic doctors saw [**Name5 (PTitle) **] and determined that no operation
should be done at this point for your fracture. You were
managed on pain medications and should follow up with the
orthopedic doctors as [**Name5 (PTitle) **] outpatient. You can take ibuprofen
600mg every 6 hours as needed for pain. You should avoid
tylenol.
Your platelet levels in your blood have been low. We looked at
your blood under the microscopy and there were no other changes
in your blood cells. Your low platelets are likely due to your
alcohol use and liver disease. An ultrasound of your liver
showed fatty changes and could not rule out cirrhosis. You will
see a liver doctor as an outpatient tomorrow.
Please return to the ER or call your doctor if you experience
chest pain, shortness of breath, hallucinations, confusion,
severe anxiety, fevers, chills, or any other symptoms concerning
to you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2175-8-31**] 10:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (orthopedics) [**Location (un) 830**],
[**Hospital Ward Name 23**] 2, [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 1228**]; Date/Time:
[**2175-10-5**], 8:50am Xray, 9:10am appointment
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10924**], [**Last Name (NamePattern1) 77317**],
[**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2422**] Date/Time: [**2175-8-31**], 8:15am
Provider: [**First Name8 (NamePattern2) 1521**] [**Last Name (NamePattern1) 61279**], [**Name12 (NameIs) **]/L Phone:[**Telephone/Fax (1) 2484**]
Date/Time:[**2175-9-7**] 2:50
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2175-10-24**] 12:40
|
[
"V15.51",
"810.00",
"E888.9",
"303.01",
"790.4",
"291.81",
"309.0",
"786.59",
"276.2",
"287.5",
"401.9",
"571.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
11011, 11017
|
6512, 10528
|
334, 341
|
11179, 11254
|
4330, 4330
|
13096, 14072
|
3374, 3438
|
10624, 10988
|
11038, 11158
|
10554, 10601
|
11278, 13073
|
3453, 4311
|
240, 296
|
2403, 2846
|
369, 2385
|
4344, 6489
|
2868, 2934
|
2950, 3358
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,917
| 162,921
|
43063
|
Discharge summary
|
report
|
Admission Date: [**2166-2-21**] Discharge Date: [**2166-2-25**]
Date of Birth: [**2119-1-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine
Attending:[**Known firstname 922**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
[**2166-2-21**] Coronary Artery Bypass Graft x 4 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
diagonal, saphenous vein graft to obtuse marginal, saphenous
vein graft to posterior descending artery)
History of Present Illness:
This is a 47 year old gentleman had a cardiac catheterization on
[**2165-12-13**] at [**Hospital1 18**] after presenting with continuous left arm pain
and an abnormal stress test. Angiography revealed an 80%
stenosis at the ostium of the first diagonal branch, a 60% long
diffuse LCX stenosis and a 90% stenosis before Om2. OM2 had a
40% proximal stenosis and OM1 had an ostial 80% stenosis. The
RCA had mild to moderate disease throughout. The patient
underwent successful PTCA and stenting
of OM2 with a 3.0 x 13mm Cypher stent proximally and a 3.0 x 8mm
Promos [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 22595**]. He also had direct stenting of the
proximal and mid LCX with a 3.0 x 23mm Cypher DES and PTCA of
the ostial OM1 with a 3.0 x 9mm Maverick balloon.
Following the patient's procedure in [**Month (only) 1096**], he felt well for
one week with improvement in his arm discomfort. However, after
the first week, he started to experience chest discomfort,
intermittent arm discomfort and shortness of breath after
walking less than [**12-30**] of a mile. He was seen by Dr.[**Name (NI) 3733**]
and was referred for a follow up stress test which revealed
probable ischemic ECG changes with reversible defects on nuclear
imaging.
Cardiac cath on [**2166-1-31**] revealed two vessel coronary artery
disease. Including IVUS of the LMCA revealing a 50-55% stenosis.
He was referred for surgical revascularization.
Past Medical History:
Coronary Artery Disease s/p DES to LCX and OM [**2165-11-26**]
Hypertension
Hyperlipidemia
History of Hodgkins Lymphoma s/p radiation
Diabetes mellitus Type II diagnosed 6 months ago
Hypothyroidism
Erectile dysfunction
Depression/Anxiety
Past Surgical History:
-[**2148**] Right Inguinal Lymph Node Resection
-[**2145**] Right Parotid Lymph Node Resection
-Left Wrist ORIF
-Left Arm Skin Grafting
Social History:
Race: Caucasian
Lives: Lives alone
Occupation: Does not work, on disability
Tobacco: Denies
ETOH: Occasionally
Family History:
Father died at age 47 after having an MI, as well as multiple
uncles dying in their late 40s from CAD.
Physical Exam:
BP 140/103 Pulse: 94 Resp: 18 O2 sat: 96% RA
Height: 5'8" Weight: 184 lbs
General: WDWN male in no acute distress. Extremely nervous,
occasional tremors noted
Skin: Dry [x] intact [x] - multiple tattoos
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - none
Abd: Soft[x] non-distended[x] non-tender[x] bowel sounds +[x]
Extremities: Warm [x], well-perfused [x]
Edema - none / Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2166-2-21**] Echo: Pre-CPB: No spontaneous echo contrast is seen in
the left atrial appendage. A smalll patent foramen ovale is
present. Overall left ventricular systolic function is low
normal (LVEF 50-55%). LVOT-VTI = 17.
Right ventricular chamber size and free wall motion are normal.
Peak RV pressure = 20. There are complex (>4mm) 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 leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. There is no pericardial
effusion.
Post-CPB: The patient is in NSR, on low dose Neo. Preserved
biventricular systolic fxn. Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact.
[**2166-2-23**] 05:42AM BLOOD WBC-15.7* RBC-3.05* Hgb-8.7* Hct-25.7*
MCV-84 MCH-28.5 MCHC-33.9 RDW-14.2 Plt Ct-314
[**2166-2-21**] 11:41AM BLOOD WBC-20.8*# RBC-3.39*# Hgb-9.3*#
Hct-27.9*# MCV-82 MCH-27.5 MCHC-33.4 RDW-13.8 Plt Ct-208#
[**2166-2-22**] 01:08AM BLOOD PT-12.9 PTT-28.4 INR(PT)-1.1
[**2166-2-21**] 11:41AM BLOOD PT-13.1 PTT-38.7* INR(PT)-1.1
[**2166-2-23**] 05:42AM BLOOD Glucose-137* UreaN-20 Creat-0.8 Na-136
K-4.0 Cl-102 HCO3-28 AnGap-10
[**2166-2-21**] 07:19PM BLOOD UreaN-14 Creat-0.8 Na-140 K-4.4 Cl-107
[**2166-2-24**] 06:40AM BLOOD WBC-14.7* RBC-3.32* Hgb-9.1* Hct-28.1*
MCV-85 MCH-27.5 MCHC-32.6 RDW-14.1 Plt Ct-364
[**2166-2-24**] 06:40AM BLOOD Glucose-121* UreaN-25* Creat-1.0 K-4.3
[**2166-2-25**] 05:35AM BLOOD WBC-11.9* RBC-3.10* Hgb-8.8* Hct-26.0*
MCV-84 MCH-28.2 MCHC-33.8 RDW-14.4 Plt Ct-388
[**2166-2-24**] 06:40AM BLOOD WBC-14.7* RBC-3.32* Hgb-9.1* Hct-28.1*
MCV-85 MCH-27.5 MCHC-32.6 RDW-14.1 Plt Ct-364
[**2166-2-22**] 01:08AM BLOOD PT-12.9 PTT-28.4 INR(PT)-1.1
[**2166-2-25**] 05:35AM BLOOD Glucose-160* UreaN-26* Creat-1.0 Na-140
K-4.8 Cl-102 HCO3-30 AnGap-13
[**2166-2-23**] 05:42AM BLOOD Glucose-137* UreaN-20 Creat-0.8 Na-136
K-4.0 Cl-102 HCO3-28 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 92200**] was a same day admit after undergoing
pre-operative work-up as an outpatient. On [**2-21**] he was brought
directly to the operating room were he underwent a coronary
artery bypass graft x 4. Please see operative note for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
Please refer to operative report for further details. All
pressors were weaned to off.
Beta-blocker/Statin/Aspirin/diuresis initiated. All lines and
drains were discontinued in a timely fashion. POD#1 he was
transferred to the step down unit for further monitoring.
Physical therapy was consulted for evaluation of strength and
mobility. The remainder of his postoperative course was
essentially uncomplicated. He continued to progress and on POD#
4 he was cleared by Dr. [**Last Name (STitle) 914**] for discharge to home. All
follow up appointments were advised.
Medications on Admission:
Aspirin 325mg qd, Plavix 75mg qd, Imdur 30 mg qd, Levothyroxine
100mcg qd, Lisinopril 2.5mg qd, Metformin 500mg qd, Metoprolol
succinate 25mg [**Hospital1 **], Crestor 40mg qd
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every [**4-1**]
hours.
Disp:*40 Tablet(s)* Refills:*0*
9. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
11. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
Disp:*28 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
Past Medical History:
s/p DES to LCX and OM [**2165-11-26**]
Hypertension
Hyperlipidemia
History of Hodgkins Lymphoma s/p radiation
Diabetes mellitus Type II diagnosed 6 months ago
Hypothyroidism
Erectile dysfunction
Depression/Anxiety
Past Surgical History:
-[**2148**] Right Inguinal Lymph Node Resection
-[**2145**] Right Parotid Lymph Node Resection
-Left Wrist ORIF
-Left Arm Skin Grafting
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:
Recommended Follow-up:Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] #([**3-25**] 1:15 PM
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-28**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**12-28**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will
Completed by:[**2166-2-25**]
|
[
"272.4",
"413.9",
"244.9",
"V45.82",
"250.00",
"V10.72",
"607.84",
"414.01",
"401.9",
"300.4",
"V17.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8248, 8306
|
5413, 6433
|
303, 540
|
8805, 8900
|
3410, 5390
|
9439, 9905
|
2567, 2671
|
6659, 8225
|
8327, 8388
|
6459, 6636
|
8924, 9416
|
8647, 8784
|
2686, 3391
|
232, 265
|
568, 2003
|
8410, 8624
|
2439, 2551
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,828
| 143,500
|
52389
|
Discharge summary
|
report
|
Admission Date: [**2200-2-17**] [**Month/Day/Year **] Date: [**2200-2-27**]
Date of Birth: [**2149-10-17**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Penicillins / Ampicillin / Motrin / Bactrim / Lithium /
Doxycycline
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Pleuritic Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 1968**] is a 50 yo female with COPD (FEV1 0.6), hx of PE
recently admitted (d/c [**2199-2-16**]) for ?CAP and still on
azithromycin presents after noting a blood sugar of 450 at home
and developing pain under her right breast. Patient reports that
the chest pain developed while in the hospital on [**2-15**] and has
been getting steadily worse since then; it became so severe this
a that she finally came to the ED. Pain is in the R lower chest
under her R breast, is worse w/ inspiration. Has had mild
nausea, no vomiting. She reports feeling chills at home, but no
fevers. Has had increased wheezing at home, also cough but not
increased from baseline, no increased mucous production. She has
been taking all of her meds as prescribed. No headache, syncope,
abd pain, diarrhea/constipation, melena, BRBPR, dysuria,
hematuria, lower ext edema, or calf pain/tenderness. No changes
in weight.
Vitals in the ED T 99.8 HR 90-100 SBP 120 R 20-40 O2 sats 95% on
4L. ABG 7.39/45/63; lactate 3.1. CXR was done and demonstrated
increased bilat infiltrates. Blood cx were obtained and patient
was started on levofloxacin, vancomycin, solumedrol and
combivent nebs. Given her hx of PE, her respiratory distress,
and pleuritic R sided chest pain, she was started empirically on
heparin gtt to cover a possible PE. CTA could not be performed
[**2-28**] renal failure. While in the ED patient grew very shaky,
blood glucose was 54 so she was given one amp D50. Repeat FS was
354 - covered with 6 units reg insulin.
Past Medical History:
1)COPD: on home O2 at 4 L -PFTs [**8-31**]: FEV1 0.61 (30%), FVC 1.66
(60%), FEV1/FVC 37 (48%), h/o intubation x 2, h/o steroid tapers
[**3-30**] x per year
2)PFO - documented right to left atrial shunt on ECHO in 11/00
3)Atypical angina
4)DM2 - HgbA1c 5.8% on [**2198-11-12**]
5)h/o small pulomonary microemboli - finished coumadin x 6
months
6)CRI (baseline 1.5)
7)Bipolar d/o
8)HTN - no BB due to copd
9)DI - nephrogenic [**2-28**] Li use
10)Chronic anemia
11)Migraines
Social History:
Lives w/ her daughter in [**Location (un) 686**]. Smoked 1 PPD x since age
10, quit 1 yr ago. Denies EtOH, illicits.
Family History:
Father: MI at 41, died at 72
Son: died at 31 of MI
Mother: DM and multiple other medical problems, died at 73 of
stroke
Brother:prostate Ca
Physical Exam:
vitals: T 99.6 HR 91 BP 124/73 RR 20 sat 95% on 4 L nc
Gen: NAD, able to speak in full sentences, but slightly labored
HEENT: perrla, eomi, op - clear, mucous membranes dry
Neck: no lad, no jvd
Lungs: diffuse insp/exp wheezes, decreased air movement b/l
Chest: anterior rib cage under R breast - tender to palp, no
erythema or echymoses
Heart: reg, no mrg
Abd: + BS, soft, mild distention, minimal RUQ, no
rebound/guarding
Ext: no edema, DP 2+ bilat
Neuro: aao x 3
Pertinent Results:
CXR [**2200-2-17**]: increased bilat infiltrate R > L
.
EKG: NSR hr 91, nl axis/intervals, ST seg elevation , 1 mm V1,
V2 unchanged from baseline
.
CT CHEST W/O CONTRAST [**2200-2-18**]
IMPRESSION:
1. Severe emphysema with small areas of consolidation could
represent either pneumonia or aspiration.
2. Occlusion of lateral segment RML bronchus, could be due to
secretions or lymph node. Reevaluation with contrast injection
is recommended.
Brief Hospital Course:
Ms. [**Known lastname 1968**] is a 50 yo female w/ COPD, diet-controlled diabetes
mellitus, history of small pulmonary embolus in [**2198**] who was
recently discharged on [**2-16**] after being admitted for
hyperkalemia and treated with azithromycin for COPD
exacerbation. Patient now admitted with COPD exacerbation,
pleuritic chest pain and poorly controlled diabetes. Her
hospital course is summarized below by problem.
1)COPD. Initially presented with hypoxia, likely due to acute
COPD exacerbation with underlying poor reserve, FEV1 0.6L. On
home 4 liters O2 at baseline, reports that she has been
compliant w/ meds (antibiotics, inhalers, nebs) although
question her ability to use these meds correctly. She was
initially moving very little air, subsequently became more
wheezy. Started on high dose steroids, tapered to Prednisone 60
mg daily upon transfer to the floor. She was attempted on MDI's
although had difficluty with these. Had been on Q4 hours
albuterol nebs, Q2 prn. Started Atrovent nebs (on spiriva at
home). Patient also may have underlying PNA based on non
contrast chest CT although clinically no fever or sputum
production. Sputum that was obtained was negative x 2. She
developed a leukocytosis in the setting of corticosteroids, but
was afebrile and had no other source of infection. Initially
concern for PE given past history and pleuritic chest pain. EKG
without evidence of ischemia. Decision was made against CTA
given primarily hypoxic failure with poor air movement and
wheezing. CTA was thought to be risky with her underlying
chronic renal failure (secondary to lithium toxicity in the
past). Patient was treated with empiric Levofloxacin and
Vancomycin. Vancomycin discontinued on [**2-22**] due to negative
sputum cultures and levofloxacin stopped prior to [**Month/Year (2) **]
after course was completed. Of note, patient's nasal cannula
oxygen was weaned to 1 liter prior to [**Month/Year (2) **], as she
tolerated it with saturations greater than 93%. Her O2
saturations should titrated to as low a level as possible to
keep her saturations greater than 93%.
2)DM2. Poorly controlled on admission with FS in 400'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consulted and recommended increasing HISS and Glargine. Patient
continued to have FS in 400's while on high dose steroids.
Glargine increased to 25 untis with agressive humalog insulin
sliding scale. Patinet was recently started on NPH at home but
prior to that was on glipizide. Patient's insulin sliding
scale and glargine (Lantus) should be titrated down according to
her fingersticks, as she is weaned off of the prednisone.
3)Pleuritic CP. Patient has had atypical chest pain for several
week any possibly months. EKG was negative multiple times,
cardiac enzymes repeatedly negative. Initial concern for PE
given pleuritic chest pain and tachycardia. Tachycardia thought
to be [**2-28**] to frequent Albuterol treatments and since her beta
blocker at home was held (restarted at low dose on [**2-22**]).
Bilateraly LENI's were ngative. TnT negative, BNP 73 on this
admission. Patient treated with IV morphine prn, non responsive
to sl ntg, also rx with maalox and PPI for possibly GERD. Of
note, her LFTs were wnl as well.
4)Renal failure. Secondary to lithium toxicity in the past,
baseline 1.6-1.8, elevated to 2.0 on admission, now stable.
Medications on Admission:
Meds on DC [**2200-2-16**]:
Insulin - NPH 7 units SQ QAM.
Tiotropium Bromide 18 mcg Capsule QD
Adviar 250-50 mcg Disk [**Hospital1 **]
Albuterol 1-2 Puffs Q4-6H prn
Albuterol nebs
Atorvastatin 20 mg po qd
Valproic Acid 250 mg qam
Valproic Acid 500 mg qhs
Prilosec OTC 20 mg qd
Diltiazem HCl SR 360 mg qd
Glipizide 5 mg qd
Docusate Sodium 100 mg [**Hospital1 **]
Senna one tab [**Hospital1 **]
Quetiapine 125 mg qhs
Nifedipine SR 30 mg qd
Azithromycin 500 mg po qd day 3 of 5
[**Hospital1 **] Medications:
1. Pulmonary rehab
Patient requires outpatient pulmonary rehabilitation.
2. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day.
Disp:*1 disk* Refills:*2*
3. Prednisone 10 mg Tablet Sig: As per instructions below Tablet
PO once a day: See attached calendar
40mg/day until [**3-2**]
30mg/day [**Date range (1) 108273**]
20mg/day [**Date range (1) 23017**] 17.5mg/day [**Date range (1) 86424**]
15mg/day [**Date range (1) 108274**]
12.5mg/day [**Date range (1) 69193**]
10mg/day [**Date range (1) 108275**]
9mg/day [**Date range (1) 38893**]
8mg/day [**Date range (1) **]
7mg/day [**Date range (1) 1813**]
6mg/day [**Date range (1) 104987**]
5mg/day [**Date range (1) 22379**]
5mg & 4mg alternating daily [**Date range (1) 47784**]
4mg/day [**Date range (1) 82517**]
4mg & 3mg alternating daily [**Date range (1) 66812**]
3mg daily [**Date range (1) **]
3mg & 2mg alternating daily [**Date range (1) 72403**]
2mg/day [**Date range (1) 31153**]
2mg & 1mg alternating daily [**Date range (1) 82134**]
1mg/day [**Date range (1) 108276**]
1mg every other day [**Date range (1) 102994**]
. Tablet(s)
4. Valproic Acid 250 mg Capsule Sig: One (1) Capsule PO QAM
(once a day (in the morning)).
5. Valproic Acid 250 mg Capsule Sig: Two (2) Capsule PO QHS
(once a day (at bedtime)).
6. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
8. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Quetiapine 50 mg Tablet Sig: 2 and 1/2 Tablets PO QHS (once a
day (at bedtime)).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO BID (2
times a day).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day).
15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
17. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
18. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
19. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding
scale Injection four times a day: Please [**Hospital1 15123**] sliding scale as
patient's steroids are tapered.
20. Caltrate-600 Plus Vitamin D3 600-200 mg-unit Tablet Sig: One
(1) Tablet PO three times a day.
21. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) capsule Inhalation once a day.
22. Albuterol 0.083% Neb Soln Sig: One (1) nebulizer every
four (4) hours as needed for shortness of breath or wheezing.
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Location (un) 38**] Landing
[**Location (un) **] Diagnosis:
COPD Exacerbation
Secondary diagnoses
Hyperglycemia
Acute on chronic renal failure
Bipolar disorder
Hypertension
Constipation
[**Location (un) **] Condition:
Vital signs stable, breathing comfortably.
[**Location (un) **] Instructions:
You were admitted for a flare of COPD. You received a breathing
tube and were subsequently weaned off a breathing machine. You
were started on prednisone for COPD along with insulin for high
blood sugars while receiving the predisone. Please follow the
[**Location (un) 15123**] of prednisone as shown on the attached calendar. Please
follow the insulin sliding scale while you are on the
prednisone. You were on 4 liters of nasal oxygen at home, and
this was reduced to 1-2 liters while you were in the hospital.
Please continue to keep it at 1-2liters unless you are found to
have a saturation less than 93%.
Followup Instructions:
You have the following appointments [**Location (un) 1988**].
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2200-3-3**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) 9141**] Phone:[**Telephone/Fax (1) 1387**] Date/Time:[**2200-3-14**]
1:30
Completed by:[**2200-2-26**]
|
[
"296.80",
"250.00",
"276.1",
"584.9",
"486",
"491.21",
"585.6",
"403.91",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3698, 7074
|
378, 385
|
3231, 3675
|
11632, 12056
|
2587, 2729
|
7100, 7577
|
2744, 3212
|
10751, 10880
|
318, 340
|
10912, 10957
|
10662, 10719
|
7607, 10632
|
10992, 11609
|
413, 1940
|
1962, 2437
|
2453, 2571
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,559
| 119,658
|
45716
|
Discharge summary
|
report
|
Admission Date: [**2190-3-13**] Discharge Date: [**2190-3-21**]
Date of Birth: [**2131-3-10**] Sex: M
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: This is a 59-year-old male with
coronary artery disease status post CABG, and status post
cadaveric renal transplant in [**2190-1-4**], complicated by
delayed graft function. He was admitted to [**Hospital6 3426**] with presyncope and complete heart block with the
heart rate in the 20s and blood pressure in the 60s/palp.
Temporary transvenous pacing wire was placed at [**Hospital6 3426**], and he was transferred to [**Hospital1 **]
after initial treatment for hyperkalemia of 8.3. With
correction of his hyperkalemia, his heart block reversed, his
sodium corrected, and his hyperglycemia also came into much
better range.
He was admitted initially at [**Hospital1 **] [**First Name (Titles) **]
[**3-10**] to the Cardiac Care Unit for management of the
temporary pacer. He was managed there for 2 days, but once
he was stabilized, the temporary pacing wires were removed,
and it was determined that his heart block was completely due
to various medications, namely Diovan, bactrim and Prograf
interactions, and that he was not in need of a permanent
pacer.
He was transferred to the transplant team once he arrived on
the floor, and the remaining week of his stay was spent
stabilizing his blood sugar regimen and his antihypertensive
regimen.
PAST MEDICAL HISTORY:
1. CABG.
2. Coronary artery disease.
3. Renal transplant on [**2190-1-23**].
4. Diabetes mellitus for 25 years.
5. Status post appendectomy.
6. Status post cholecystectomy.
7. Status post AV fistula.
8. History of CHF.
9. History of hypertension.
MEDICATIONS ON ADMISSION:
1. Labetalol 200 mg po bid.
2. Aspirin 81 mg po qd.
3. Bactrim SS 1 tab po qd.
4. Nifedipine SR 60 mg po qd.
5. Valcyte 450 mg po qd.
6. Protonix 40 mg po qd.
7. Imuran 50 mg po qd.
8. Reglan 10 mg qid.
9. Fluconazole 200 mg po qd.
10.Prednisone 7.5 mg po qd.
11.Sertraline 100 mg po qd.
12.Insulin sliding scale.
13.Tacrolimus 5 mg po bid.
14.Lantus 20-26 units.
15.Humalog sliding scale.
16.Diovan 160 mg qd.
ALLERGIES:
1. Augmentin.
2. Codeine.
DISCHARGE MEDICATIONS:
1. Labetalol 250 mg po bid.
2. Nifedipine 120 mg qd.
3. Sertraline 50 mg qd.
4. Lipitor 10 mg qd.
5. Valcyte 450 mg qd.
6. Tacrolimus 5 mg [**Hospital1 **].
7. Prednisone 5 mg po qd.
8. Insulin sliding scale.
9. Aspirin 81 mg po qd.
10.Azathioprine 100 mg po qd.
DISCHARGE INSTRUCTIONS: He was sent home with instructions
to follow his new insulin sliding scale, to follow-up with
his primary care physician regarding his hypertension, and to
follow-up with the Transplant Center. He was also instructed
to have his labs drawn every Monday and Thursday.
CONDITION ON DISCHARGE: Stable to home.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 7589**]
MEDQUIST36
D: [**2190-3-23**] 11:04
T: [**2190-3-23**] 12:22
JOB#: [**Job Number 97431**]
|
[
"401.9",
"996.81",
"276.7",
"412",
"250.53",
"362.01",
"V45.81",
"428.0",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2203, 2467
|
1730, 2180
|
2492, 2761
|
180, 1434
|
1456, 1704
|
2786, 3076
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,120
| 180,728
|
34342
|
Discharge summary
|
report
|
Admission Date: [**2178-7-29**] Discharge Date: [**2178-8-19**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
right sided flank and neck pain
Major Surgical or Invasive Procedure:
[**2178-7-29**] Type A dissection repair
History of Present Illness:
Mr. [**Known lastname **] is [**Age over 90 **] year old gentleman who emergently was brought to
the ED with right flank and neck pain
Past Medical History:
HTN
GERD remote GI Bleed
Mild dementia
Social History:
Lives in [**Location 79026**] living.Mild memory loss but makes own
decisions.
[**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1059**], church member given medical proxy in [**Name (NI) **]
Family History:
unavailable
Physical Exam:
Admission:
VS:BP72/27, SB at 51. RR 20 Sa02 100 on 2liters
Neuro:Awake, alert and answering questions.
CV RRR.
Pulm: scattered rhonchi
Abd: benign.
Ext:Weak pulses all 4exts.
Discharge
Expired
Pertinent Results:
[**2178-8-18**] 03:40AM BLOOD WBC-18.3* RBC-2.26* Hgb-7.0* Hct-21.5*
MCV-95 MCH-31.0 MCHC-32.7 RDW-22.5* Plt Ct-200
[**2178-8-18**] 09:25AM BLOOD PT-16.7* PTT-60.7* INR(PT)-1.5*
[**2178-8-7**] 10:21PM BLOOD D-Dimer-8032*
[**2178-8-18**] 03:40AM BLOOD Glucose-104 UreaN-31* Creat-2.3*# Na-135
K-5.1 Cl-110* HCO3-16* AnGap-14
[**2178-7-29**] 11:54PM HGB-7.3* calcHCT-22
[**2178-7-29**] 11:01PM GLUCOSE-143* LACTATE-1.5 NA+-137 K+-4.0
CL--110
[**2178-7-29**] 05:50PM UREA N-20 CREAT-1.2
[**2178-7-29**] 05:50PM AMYLASE-893*
[**2178-7-29**] 05:50PM PLT COUNT-154
[**2178-7-29**] 05:50PM PT-13.8* PTT-27.4 INR(PT)-1.2*
[**2178-7-29**] 04:23PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2178-7-29**] 04:23PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) 819**] J.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) 819**] J on FRI [**2178-8-14**] 3:08 PM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 79027**]
Service: Date: [**2178-8-8**]
Surgeon: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(1) 79028**]
PREOPERATIVE DIAGNOSIS: Intra-abdominal catastrophe.
POSTOPERATIVE DIAGNOSIS: Intra-abdominal hemorrhage.
INDICATIONS FOR OPERATION: Mr. [**Known lastname **] is a [**Age over 90 **]-year-old
gentleman who underwent an aortic valve replacement and
developed worsening abdominal pain. Based on his exam which
demonstrated peritonitis, he was taken to the operating room
for exploratory laparoscopy.
PROCEDURE IN DETAIL: After informed consent was obtained,
the patient was taken to the operating room where general
endotracheal anesthesia was established without complication.
Time-out was called to verify patient and site.
A midline, approximately 1-cm incision was made. This was
carried down to the fascia. The fascia was opened, and we
were immediately greeted with some old blood. The laparoscope
was placed, and there was approximately 1 L of blood with a
large hematoma on the liver. We washed out the abdomen with
approximately 4 L of saline and removed as much blood as we
could. We looked at the stomach. It looked normal. We looked
at the duodenum. It looked normal. We looked at the liver. It
looked normal except for a large hematoma on the surface,
which we washed away. We looked at the bowels, which looked
normal. We looked at the pelvis, which looked normal. We
looked for the appendix. There was no evidence of any
inflammation around the cecum. We looked at the right colon,
the transverse colon, and the left colon and no obvious intra-
abdominal pathology was found. The gallbladder was soft and
noninfected. At this point, we were confident that with
avoiding anticoagulation bleeding would not be a further
problem. The port site was closed with 0 Vicryl, and the
second 5-mm port site was closed with a subcuticular. The
patient tolerated the procedure well. There were no
complications.
I, Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 816**], as the attending responsible surgeon,
was present for the entire operation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Date: [**2178-8-5**]
Signed by [**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD on [**2178-8-5**] Affiliation: [**Hospital1 18**]
Cosigned by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2178-8-11**]
[**Age over 90 **] yo M s/p Emergency repair of type A aortic dissection with
ascending aorta and hemi-arch replacement with a size 26
Gelweave graft on [**2178-7-29**]. Complicated by axillary artery
dissection s/p exploration of right axillary artery with repair
of dissection and bovine patch angioplasty by Dr. [**Last Name (STitle) **] on [**7-30**]
08. Had left radial arterial line this afternoon left hand and
fingers were seen to be dusky and A-line was removed. Vascular
surgery consulted for no doppplerable pulses in Left hand.
Patient had A-line replaced to right.
PMH: HRN, GERD, dementia, anemia, h/o GI bleed
PSH: as per HPI
[**Last Name (un) 1724**]: colace
All: NKDA
SocH: Pt has family living in [**State **], and local health care
proxy appointed by the state.
FH: n/a
98.4 97 124/73 23 100% CPAP+PS 480x25 .6 [**10-2**] (7.48/27/107/-1)
Neo 1 Fentanyl 12.5
CVP 19
Intubated
scrotal edema
Left hand cool with dusky fingers
brachial tripahsic dopp
radial nondopp
Ulnar dopp
Right brachial tripashic dopp
radial with A-line
Ulnar dopplerable
LE
non dopplerable R DP, PT mono. L PT mono, DP mono. palp L and R
femoral.
Labs: WBC:18.8 HCT 32.6 Plat 76
18.6/40.7/1.7 pt/ptt/INR
144 111 86 glu 122
3.8 21 3.3
A/P:
reccomend heparinazation in the setting of pt's age and evidence
of both ulnar and brachial pulses no indication to explore
radial
at this time.
Discussed with Dr. [**Last Name (STitle) 6193**]
Addendum by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2178-8-11**]:
pt seen and examined on [**8-6**]. agree with above
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) 251**] C.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) 251**] on FRI [**2178-7-31**] 11:40 AM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 79027**]
Service: Date: [**2178-7-30**]
Surgeon: [**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 41313**]
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **]
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] V on MON [**2178-8-3**]
11:23 AM
Name: [**Known lastname **], [**Known firstname **]
Unit No: [**Numeric Identifier 79027**]
Service: [**Last Name (un) 7081**]
Date: [**2178-7-29**]
Sex: M
Surgeon: [**Name6 (MD) 59497**] [**Name8 (MD) **], [**MD Number(1) 79029**]
OPERATION: Emergency repair of type A aortic dissection with
ascending aorta and hemi-arch replacement with a size 26
Gelweave graft.
ASSISTANT: Dr. [**Last Name (STitle) 59499**]
PREOPERATIVE DIAGNOSIS: This [**Age over 90 **]-year-old patient, who
presented to the emergency room with sudden onset chest pain,
was investigated was found have aortic dissection on the CT
scan extending from just about the aortic root into the
descending thoracic aorta. The dissection false and true
lumen was extending into the cerebral vessels, too, but there
was intact flow into the true lumen in both the innominate
and the left common carotid arteries. Even though he was [**Age over 90 **]
years old, he was very active with no major medical issues in
the past, and after discussing extensively the risk of
operation with the patient and the health proxy, decision was
made to proceed with emergency aortic dissection repair.
An intraoperative transesophageal echocardiogram showed good
cardiac function. He had a tricuspid valve with mild stenosis
with minimal calcification and the plan was to leave the
native valve in and repair the aortic dissection alone.
INCISION: Routine median sternotomy and right
infraclavicular incision for axillary artery cannulation.
FINDINGS: There was minimal blood-stained the pericardial
fluid. The ascending aorta was obviously dissected. On
opening the aorta, there was a clot in the false lumen and
the tear was at the junction of the ascending and the arch
without extending into the cerebral vessels. The true lumen
was intact, supplying the arch vessels. There was no tear
seen in the arch vessels. The aorta was quite fragile at the
point of suturing distally and proximally, given his age and
the dissection. The aortic valve was tricuspid with minimal
calcification. The coronary ostia were in the normal
location. The axillary artery was a good size artery and
quite fragile.
PROCEDURE: After informed consent, the patient was taken
emergently from the emergency room to the operating room and
was anesthetized, prepped and draped in routine fashion.
First the right infraclavicular incision was made and the
right axillary artery was exposed, and after giving 5000
units of heparin, the vascular clamps were applied to
proximally and distally to gain control of the vessel. This
was opened and a size 8 Hemashield graft was sutured in using
5-0 Prolene sutures to be used as arterial inflow cannula, as
well as for antegrade cerebral perfusion during circulatory
arrest.
Once this was done, a median sternotomy incision was made.
Pericardium was opened. The fluid was evacuated. The patient
was fully heparinized after immobilizing the aorta and the
arch vessels.
The venous cannula was inserted using the 3-stage cannula on
the right atrium and IVC and a size 21 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3924**]
cannula was connected to the Hemashield graft supplying the
axillary artery. Retrograde coronary sinus catheter, as well
as left ventricular vent, inserted through the right superior
pulmonary vein were used. The patient was put on full
cardiopulmonary bypass and was cooled down for a circulatory
arrest. During the stage of cooling, the ascending aorta was
cross-clamped. Myocardial protection obtained by infusion of
retrograde multidose cold blood cardioplegia.
The ascending aorta was transected below the cross-clamp and
the proximal end of the aorta was trimmed down to the
sinotubular junction. The 2 dissected flaps were put together
using the BioGlue. The coronary ostia were not involved in
the dissection.
At this stage, the patient was ready for circulatory arrest
at a temperature of 15 degrees Centigrade. After putting the
patient appropriate position, the circulation was arrested,
the cross-clamp was removed. The rest of the ascending aorta
was excised, including the tear and the junction of the
ascending and the arch. During this time, the arch vessels
were occluded and antegrade cerebral perfusion was commenced
through the axillary artery. During the period of lower body
circulatory arrest, further repair was continued.
After trimming of the distal aorta with an aggressive hemi-
arch resection to excise the tear, the distal ends of the
aorta were brought together by BioGlue. A size 26 Gelweave
graft was chosen. This was cut across to create a bevel for
the distal anastomosis, and using a piece of felt all around
the anastomosis, the graft was sutured onto the distal aorta.
The distal aorta was very brittle, given his age, and the
dissection and suturing was very carefully done. There was a
linear tear extending along the lesser curve of the arch of
the aorta. This was individually sutured with aorta fully
opened using 4-0 Prolene pledgeted sutures.
Once the anastomosis was completed, the circulation was
recommenced. Graft was thoroughly de-aired and cross-clamped
and the rewarming commenced. During this time, the proximal
end of the aorta was trimmed to size and the graft was
trimmed to size and the proximal anastomosis carried out
using 4-0 continuous Prolene sutures with a piece of felt all
around the anastomosis. Once this was completed, the cross-
clamp was removed and further rewarming was continued. During
the rewarming process, further sutures were put in to control
bleeding at the suture lines.
At this stage, there was bleeding noted along the underside
of the arch away from the suture line, presumably caused by a
tear in the native aorta. This was very difficult to control
and multiple pledgeted sutures were applied to control this.
After obtaining a reasonable control of this, thorough de-
airing of the heart was done through the aortic root cannula.
This was confirmed by echo. After full rewarming to 37
degrees Centigrade, the patient was taken off cardiopulmonary
pass uneventfully with minimal inotropic support.
Good biventricular function was confirmed by echo. Heparin
was reversed with protamine. The area of concern in the arch
of the aorta along the greater curve was thoroughly packed
and heparin was reversed with protamine. Multiple blood
products were given to control bleeding. The area along the
greater curve away from the suture line was still bleeding.
It was very difficult to control. BioGlue and Surgicel were
applied to that area. Suturing was very difficult because of
the fragile nature of the tissues; and finally, this was
brought under control by using BioGlue, Surgicel and thymic
fat applied and a bovine pericardial patch applied onto that
area and sutured all around it, isolate it and controlling
the bleeding.
After obtaining reasonable control of the bleeding, sternum
was closed with sternal wires. The wound was closed in
layers.
The patient was transferred back to intensive care unit with
minimal chest tube drainage and minimal inotropic support.
COUNTS: The swabs, needles and instrument counts were
reported correct at the end of the procedure.
SPECIMENS: The excised aorta was sent for histopathologic
examination
[**Name6 (MD) 59497**] [**Name8 (MD) **], MD
[**MD Number(2) 69417**]
Dictated By:[**Name8 (MD) 79030**]
PREOPERATIVE DIAGNOSIS: Right upper extremity ischemia.
POSTOPERATIVE DIAGNOSIS: Right axillary artery dissection.
PROCEDURE: Exploration of right axillary artery with repair
of dissection and bovine patch angioplasty.
ASSISTANT: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27576**], MD
ANESTHESIA: General endotracheal anesthesia.
FLUIDS: 1.5 liters crystalloid.
ESTIMATED BLOOD LOSS: 100 cc.
URINE OUTPUT: 300 cc.
SPECIMENS: There was no specimen.
FINDINGS: A dissection of the axillary artery from an injury
due to clamping during his aortic dissection. The patient
tolerated the procedure well was taken back to the
cardiovascular intensive care unit in critical condition.
INDICATIONS: This is a [**Age over 90 **]-year-old male who had earlier in
the evening undergone a repair of a type A aortic dissection.
He had an 8-mm Hemashield axillary conduit and this was
oversewn. Postoperatively he was found to have no distal
pulses in the arm and no dopplerable signal; so the decision
was made take him for urgent repair in the operating room. Of
note, consent was attempted to be obtained from the
healthcare proximally; but this was unable to be obtained, so
due to the emergent nature of the case, this patient was
taken to the operating room.
PROCEDURE: The patient was taken to the operating room on
[**2178-7-30**], and laid on the table in the supine position.
The patient's right arm was prepped and draped in sterile
fashion. The patient had already been under general
endotracheal anesthesia, and he was prepped and draped in
sterile fashion. A time-out was performed.
The axillary incision was opened and the stump of the
Hemashield graft was identified. The axillary artery was
dissected free proximally and distally and encircled with
blue vessel loops. The branches of the axillary artery were
encircled with red vessel loops. The artery was clamped and
the graft was removed. Upon opening the artery, there was
noted to be thrombus immediately and there was an obvious
dissection distally from the Hemashield graft, presumably
from a clamp.
This dissection was then tacked down with 6-0 Prolene
sutures. There was excellent backbleeding, at this point,
from the artery and good forward flow. Of note the patient
was administered a small dose of only 3000 units of heparin
given his recent cardiac surgery.
At this point a bovine patch was anastomosed to the opening
in the artery, and then all the arteries were forward flushed
and back bled. There was excellent flow and a good distal
pulse following completion of the bovine patch angioplasty.
The wound was closed in layers of 2-0 and 3-0 Vicryl with
staples for the skin. At the completion of the case, the
patient had a palpable brachial and radial pulse and
dopplerable ulnar signal.
SURGEON'S STATEMENT: Of note, Dr. [**Last Name (STitle) **] was present and
scrubbed for the entire case.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 41315**]
Dictated By:[**Last Name (NamePattern4) 41316**]
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man s/p Asc. ao. hemiarch replacement
REASON FOR THIS EXAMINATION:
infiltrate
Final Report
CHEST PORTABLE AP
COMPARISON: [**2178-8-14**].
HISTORY: Ascending aortic repair.
FINDINGS: There is a widened mediastinum which is slightly
increased from
prior exam and concerning for hematoma. An ET tube is
approximately 4.2 cm
above the carina. A left-sided central line terminates in the
brachiocephalic/SVC junction. Bilateral pleural effusions are
unchanged. Fluid
within the right major fissure is new when compared to prior
exam. Dense
retrocardiac opacity with loss of the hemidiaphragm and the
ascending aorta
contour, consistent with partial left lower lobe collapse.
IMPRESSION:
1. Widened mediastinum, concerning for hematoma. This is
slightly increased
when compared to prior exam.
2. Bilateral pleural effusions with small amount of fluid seen
within the
right major fissure.
3. Partial left lower lobe collapse.
Findings discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38136**] via telephone.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8648**] [**Name (STitle) 8649**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 79031**] (Complete)
Done [**2178-7-29**] at 10:23:15 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2084-9-18**]
Age (years): [**Age over 90 **] M Hgt (in): 62
BP (mm Hg): / Wgt (lb): 150
HR (bpm): BSA (m2): 1.69 m2
Indication: Intra-op TEE for Type A dissection
ICD-9 Codes: 786.51, 441.00, 424.1
Test Information
Date/Time: [**2178-7-29**] at 22:23 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW03-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Ascending aortic intimal flap/dissection.. Aortic arch
intimal flap/dissection. Descending aorta intimal flap/aortic
dissection.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (3). Trace AR.
MITRAL VALVE: Mild (1+) MR.
TRICUSPID VALVE: No TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. 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. No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen.
5. Mild (1+) mitral regurgitation is seen.
6. There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is in
sinus rhythm.
1. An ascending aortic graft is seen.
2. LV function is normal.
3. RV function was initially normal. RV deterioted to mild to
moderate hypokinesis.
4. Mild Tricuspid regurgitation is seen, RA appears dilated.
5. Dissection is still seen in Descending aorta and arch
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2178-8-7**] 14:08
Brief Hospital Course:
Mr. [**Known firstname **] [**Known lastname **] underwent an emergent type A aortic dissection
repair with an ascending aorta and hemiarch replacement with a
26mm gelweave tube graft on [**2178-7-29**] by Dr. [**Last Name (STitle) **]. The
patient was then transferred in critical but stable condition to
the surgical intensive care unit. His vasoactive drips were
weaned over the next couple of days. His chest tubes were
removed. Multiple attempts to extubate Mr. [**Known lastname **] failed
secondary to respiratory distress.
His creatinine of 1.1 rose to 2.3 with oliguria. He was b egun
on CVVH on [**8-6**].He had transient oropharyngeal bleeding of
uncertain souce and this was packed by the ENT service.
He developed a tender abdomen with a CT scan showing fluid and
an exploratory lap on [**8-8**] demonstrated old blood only.
Despite all efforts, he had persistent multisystem organ failure
and required CVVH, ventilator support, had a cold cadaveric LT
hand and was encephalopathic.
On [**8-19**], after lengthy discussion with his health care proxy he
was made [**Name (NI) 3225**]. Dialysis had been discontinued, he was extubated
and expired at 1527.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Type A ascending aortic aneurysm
Dissection Right Axillary Artery
Acute renal Failure
Ischemic LT arm
Aspiration Pneumonia
Hemoperitoneum
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
NONE
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2178-8-25**]
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23833, 23843
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61,659
| 178,644
|
8341
|
Discharge summary
|
report
|
Admission Date: [**2133-3-30**] Discharge Date: [**2133-4-6**]
Date of Birth: [**2062-4-4**] Sex: M
Service: VSU
CHIEF COMPLAINT: A nonhealing right foot ulceration and rest
pain.
HISTORY OF PRESENT ILLNESS: This is a 71-year-old male, with
a 30-pack year history of smoking and insulin dependent
diabetes, coronary artery disease status post coronary artery
bypasses x 4 with peripheral vascular disease, who underwent
a left BKA and a left fem-[**Doctor Last Name **] bypass graft which failed, who
comes in with a nonhealing right foot ulcer on the fifth
digit, and a history of rest pain in the right calf. He is a
longstanding patient of Dr.[**Name (NI) 1392**], and has been seen for
these symptoms. He is here for an arteriogram and vascular
work-up.
He has had an ulcer for three to four weeks. He has not been
treated with antibiotics. He has been exuding purulence and
sanguineous material, and is painful on ambulation. The
patient also complains of one episode of rest pain of the
right calf (cramping pain at night alleviated with standing).
These symptoms occur in a leg status post fem-[**Doctor Last Name **] bypass and
femoral endarterectomy. The patient's left leg was amputated
after multiple revascularization procedures. The patient has
a long history of coronary artery disease. Denies any chest
pain, shortness of breath. The patient now is admitted for
IV hydration prior to undergoing diagnostic arteriogram.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Metformin 1,000 mg [**Hospital1 **].
2. Hydrochlorothiazide 25 mg once daily.
3. Avapro 75 mg once daily.
4. Lisinopril 40 mg once daily.
5. Lipitor 10 mg once daily.
6. Metoprolol 100 mg [**Hospital1 **].
7. Insulin, Humalog 70/30, 55 units q am and 30 units q pm.
PAST MEDICAL HISTORY: Coronary artery disease.
Type 2 diabetes, insulin dependent x 5 or 6 years.
Peripheral vascular disease.
Hypercholesterolemia.
Renolithiasis.
Hypertension.
PAST SURGICAL HISTORY: Left BKA with revision in [**2127-10-24**].
Left internal carotid artery ligation with a carotid
endarterectomy of a common carotid with a patch angioplasty
in [**2130-7-24**].
Right common femoral endarterectomy and Dacron patch in
[**2130-8-24**].
Coronary artery bypasses x 4 in [**2121**].
Bilateral fem-popliteal bypasses in [**2122**].
Left fem-popliteal bypass in [**2125**].
Cholecystectomy.
Colon resection for cancer.
PHYSICAL EXAM: VITAL SIGNS: 97.7, 120/70, 74, 80, fasting
glucose 98. GENERAL APPEARANCE: Alert, cooperative white
male in no acute distress. CHEST EXAM: Lungs are clear to
auscultation. Heart has a regular rate and rhythm without
murmur, gallop or rub. ABDOMINAL EXAM: Benign. VASCULAR
EXAM: There is a right carotid bruit. The femoral pulse is
palpable bilaterally. The graft pulse on the right is
palpable, 1 plus. The popliteal is faint by palpation. The
DP has dopplerable triphasic. The PT is a dopplerable signal
only on the right. The right fifth toe plantar aspect shows
a 2 x 1 cm ulceration with erythematous margins and tender to
palpation.
HOSPITAL COURSE: The patient was admitted to the hospital,
vascular service, and placed on bed rest. Wound cultures
were obtained, IV antibiotics were instituted, and IV
hydration for anticipated arteriogram. The patient's white
count on admission was 8.9, hematocrit 42.3, BUN 17,
creatinine 1.0. Chest x-ray was no acute disease, status
post open heart surgery. Ultrasounds of the carotids were
obtained which showed a totally occluded left internal
carotid artery. The right internal carotid artery showed 40-
59 percent.
The patient underwent arteriogram on [**2133-3-31**] which was
uncomplicated. The films were reviewed, and Dr. [**Last Name (STitle) 1391**]
felt the patient was revascularable. His post angio labs
remained stable with BUN of 17, creatinine 0.4, hematocrit
44.5. [**Last Name (un) **] followed the patient during his hospitalization
for glycemic management. The patient was preopped on
[**2133-4-1**] for anticipated surgery.
The patient underwent on [**2133-4-2**] a right common femoral
endarterectomy with a patch angioplasty, a right superficial
femoral artery to peroneal bypass using nonreversed saphenous
vein, angioscopy and valve lysis. She tolerated the
procedure well and was transferred to the PACU in stable
condition. In the recovery room, the patient had an episode
of hypotension, systolic, to the 60s. He was given Neo-
Synephrine with good response. The patient denied any chest
pain, although he was diaphoretic. He denied nausea or
vomiting. EKG showed no changes from previous EKG. Cardiac
enzymes were sent. The patient's total CK's peaked at 382,
and over the next 72 hours returned to baseline of 169. The
patient's CK-MB's rose gradually from 3, peaked at 7, and
returned to baseline at 72 hours to 2. The patient's
troponin levels were 0.3.
On postoperative day 1, there were no overnight events, and
the patient's exam was unremarkable. Pulse exam showed
dopplerable monophasic DP, PT and peroneal. His diet was
advanced as tolerated. IV fluids were Hep-Locked. His
Lopressor was increased for rate control, and his insulin
dosing was increased. He continued to be followed by [**Last Name (un) **].
On postoperative day 2, there were no overnight events. T-
max was 100.4-99.2. Exam was unremarkable. Lungs were clear
to auscultation. Wounds were clean, dry and intact. Pulse
exam remained unchanged. Ambulation to chair was begun. PT
was requested to see the patient for touchdown weightbearing
essential distances only. He required adjustment in his
Lopressor dosing for systolic hypertension of 161. Heart
rate was 86. Physical therapy did see the patient. They
felt initially that the patient would benefit from [**Hospital 3058**]
rehab to improve compliance with touchdown weightbearing.
The remaining hospital course was unremarkable. Physical
therapy would assess the patient prior to discharge and
determine whether or not he would be safe to be discharged to
home. An addendum will be dictated at that time.
DISCHARGE MEDICATIONS:
1. Hydrochlorothiazide 25 mg once daily.
2. Irbesartan 75 mg once daily.
3. Atorvastatin 10 mg once daily.
4. Aspirin 325 mg once daily.
5. Metformin 1,000 mg [**Hospital1 **].
6. Lisinopril 40 mg once daily.
7. Darvocet N 100, 1-2 tablets q 4 h prn pain.
8. Metoprolol 75 mg [**Hospital1 **].
9. Insulin 70/30, 55 units at breakfast and 30 units at
dinner.
10. Humalog sliding scale.
FOLLOW UP: The patient should follow-up with Dr. [**Last Name (STitle) 1391**] in
2 weeks time. He should ambulate essential distances only.
He is to keep the foot elevated when not ambulating. He
should not drive a car until he is seen in follow-up. He is
to continue stool softeners until he is finished with his
narcotics.
DISCHARGE DIAGNOSES: Peripheral vascular disease, tibial
disease, with a nonhealing right heel ulcer and rest pain,
status post a right common femoral endarterectomy with patch
angioplasty, status post right superficial femoral to
peroneal bypass with nonreversed greater saphenous vein.
Type 2 diabetes, insulin dependent, controlled.
Coronary artery disease, status post coronary artery bypass
graft x 4 in [**2121**], stable.
Hypertension, controlled.
Carotid disease with totally occluded left and a 40-59
percent right carotid stenosis, asymptomatic.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2133-4-6**] 11:06:17
T: [**2133-4-6**] 11:54:43
Job#: [**Job Number 29521**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"38.18",
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] |
icd9pcs
|
[
[
[]
]
] |
6906, 7715
|
6158, 6553
|
1533, 1804
|
3138, 6135
|
2013, 2449
|
2465, 3120
|
6565, 6884
|
152, 203
|
232, 1507
|
1827, 1989
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,668
| 113,525
|
4176
|
Discharge summary
|
report
|
Admission Date: [**2145-12-15**] Discharge Date: [**2145-12-27**]
Date of Birth: [**2067-7-11**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percodan / Percocet / Codeine / Talwin / Demerol /
Valium / Aspirin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
Central Venous Catheter L subclavian
Also attempted RIJ.
History of Present Illness:
patient is a 78 yo female with MMP including RA, afib,
osteoporosis with compression fractures, AS and CHF presenting
with 3 days of LBP. Patient said that she woke up 3 days ago
with LBP that has worsening over the past couple of days. Denies
trauma, but admits that she sometimes "bounces on the bed" when
she comes back to bed from commode. Pain is [**10-20**] localized to
low back withour radiation to the legs. Denies numbness,
tingling, LE weaknes, bowel or bladder incontinence. She has not
had pain in this area before but has had pain in the areas of
her compression fractures in the past. Took some tylenol with
little effect, so came in ED.
.
In the ED T 97 Bp 92/60 HR 68 O2 sats91-95% on RA
She trasient dropped her SBPs of low 80s but went back up to low
100s after 1 liter NS. Received a total of 2 liters NS in ED.
Of, note she was started on lisinopril 10 mg Po QD on [**12-13**]. She
also receievd cipro 500 mg x1 for UTI, tylenol 1 g x1 and
morphine 2 mg x1.
.
Past Medical History:
# Aortic stenosis - valve area 1.1 on [**2144-4-3**]
# CHF (EF of 60%)
# atrial fibrillation - on warfarin
# s/p femur fx [**8-16**]
# s/p R BKD [**2144-10-28**]
# COPD
# Rheumatoid arthritis - on prednisone
# RA/SLE/positive [**Doctor First Name **] antibody - in remission
# osteoporosis
# venous stasis
# peripheral neuropathy
# h/o Clostridium difficile in the past
# spinal stenosis
Social History:
lives alone in home, able to do ADL's, has [**Name (NI) 269**], PT, home aid at
home. +tob hx, quit 40 years ago, no ETOH, no drugs
Family History:
arthritis, mother - liver cancer, father - CVA
Physical Exam:
Admission
T 96.7 BP 100/62 HR 72 RR 22 O2 sat 93% on RA 400 cc out foley
Gen - Elderly female sleeping in bed in NAD becoming very
uncomfortable with movement in bed
HEENT - MM dry, Op clear, EOMI
Neck: could not appreciate JVD, no thyroid nodules, no LAD
CV - irregularly irregular, nl S1, S2, 3/6 SEM at RUSB radiating
to carotids
Lungs - CTA with crackles at lung bases, L>R
Abd - obese, soft, NT/ND, NABS
Back - tenderness to palpation in lumbar spine and paraspinal
region, no CVAT
Rectal - normal rectal tone per ED and guaiac negative
Ext - s/p BKA on right, venous stasis changes on LLE with trace
edema, well healed scar over knee, negative SLR
Neuro - AAOx3, CN II-XII intact, strength in upper and LE
extremtities [**5-15**], sensation to light touch grossly intact
Skin - venous stasis changes on LLE, erythema under breast
bilaterally
.
Discharge
T 98.8 BP 130/90 HR 90 RR 2O O2 sat 91% on RA
Gen - NAD
HEENT - MMM
Neck: difficult to evaluate JVD, no LAD
CV - irregularly irregular, nl S1, S2, 3/6 SEM at RUSB radiating
to carotids
Lungs - CTA with crackles at lung bases increased from
yesterday, L>R
Abd - obese, soft, NT/ND, NABS
Back - point tenderness to palpation in lumbar spine and right
paraspinal region, no CVAT
Neuro - AAOx3, CN II-XII intact, strength in upper and LE
extremtities [**5-15**], sensation to light touch grossly intact
Skin - venous stasis changes on LLE, improving erythema under
breast bilaterally
Pertinent Results:
CT abd/ Pelvis:
CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Bilateral small pleural
effusions have resolved in the interval. Chronic atelectasis and
bronchiectasis is noted at the left lung base.
Non-contrast evaluation of the liver is suboptimal, however
unremarkable. The patient is status post cholecystectomy. The
common bile duct is dilated, however, unchanged in appearance
compared to the prior study. Hypodense lesions within the head
of the pancreas noted on the prior study are not appreciated on
this limited non-contrast evaluation. Spleen and adrenal glands
are within normal limits. There is a large type 1 hiatal hernia,
with almost the entire stomach located in the thorax. This
appearance is stable from prior study of [**2144-10-11**] and
appears uncomplicated by obstruction. Several hypodensities are
noted in the renal parenchyma bilaterally, likely representing
simple cysts. There is no free air, no free fluid, and no
pathologically enlarged mesenteric or retroperitoneal lymph
nodes. There is scattered diverticulosis of the descending and
ascending colon without evidence of acute diverticulitis.
CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, urinary
bladder, uterus are unremarkable. The sigmoid is redundant.
There is no evidence of acute diverticulitis. There is no
retroperitoneal hematoma. There is right-sided femoral hernia,
containing small bowel loops without evidence of obstruction or
incarceration. The evaluation of the pelvis is somewhat limited
by large streak artifact produced by right-sided total hip
arthroplasty. No free pelvic fluid and no pathologically
enlarged pelvic or inguinal lymph nodes.
BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic
lesions. There are multiple compression fracture deformities in
the lumbar and thoracic spine, the degree of compression on T10
as well as inferior endplate of L1 has increased in the
interval.
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Interval increase in degree of compression of T10 and L1
vertebral bodies.
3. Type 1 hiatal hernia.
4. Stable right femoral hernia containing nonobstructed small
bowel loops.
5. Interval resolution of pleural effusions.
6. Coronary artery and aortic arch calcifications.
.
MRI T/L spine:
IMPRESSION:
1. Acute/subacute compression of inferior endplate of L1.
2. Chronic compressions of L2, L4 and L5 vertebrae.
3. Degenerative changes at multiple levels as described above
with moderate left subarticular recess narrowing and mild spinal
stenosis at L4-5 level.
6. Multiple chronic compressions in the thoracic region with
increased kyphosis. No spinal stenosis or extrinsic spinal cord
compression. No evidence of acute compression fracture in the
thoracic spine.
CT dated [**2145-12-15**].
FINDINGS: The right kidney measures 10.1 cm and the left 10.8
cm. The renal parenchymal thickness is normal without evidence
of calculi or hydronephrosis. Multiple renal cysts, the largest
one measuring 2.2 x 1.8 cm in the upper pole of the right
kidney.
IMPRESSION: No evidence of hydronephrosis.
.
CHEST (PORTABLE AP) [**2145-12-20**] 3:48 AM
Moderate left pleural effusion and mild pulmonary edema have
increased. Cardiomegaly is moderate and unchanged partially
obscured by the large intrathoracic stomach. No pneumothorax.
Pleural effusion is probably moderate on the left and small on
the right. No pneumothorax.
.
CHEST (PORTABLE AP) [**2145-12-22**] 4:04 AM
There is motion artifact and rotation of the patient. Allowing
for the technical limitations the left subclavian catheter tip
is in the SVC. moderate pulmonary edema, cardiomegaly and small
bilateral pleural effusions are stable. Left retrocardiac
opacity is due to a large intrathoracic stomach. There is no
pneumothorax.
.
ECHO:
Conclusions
The left atrium is elongated. The right atrium is markedly
dilated. No atrial septal defect is seen by 2D or color Doppler.
The estimated right atrial pressure is 10-20mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are moderately thickened. There is
moderate to severe aortic valve stenosis (area 0.9 cm2). No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2144-12-28**],
the aortic valve area has further decreased (now moderate to
severe aortic stenosis, [**Location (un) 109**] 0.9 cm2).
Brief Hospital Course:
#)LBP: The patient was admitted with lower back pain located at
L5/S1 and somewhat latterally near the SI joint as well. There
was no clinical evidence for cauda equina syndrome or sciatica.
The patient received A CT abd/pelvis was performed in the ED,
which ruled out RP bleed and also found old T10/L1 compression
fracture. An MRI was performed which showed no cord compression,
chronic compressions of L2, L4 and L5 vertebrae and
Acute/subacute compression of inferior endplate of L1. This may
be the source of her pain although on physical exam her point
tenderness appears to be much lower. She should have a pelvic
MRI as an outpatient to evaluate the SI joint. The patient's
pain was not controlled on tylenol, lidocaine patch and small
doses of PRN Morphine. Calcitonin 200 units daily was added.
Oxycontin SR was added with continued [**2148-8-20**] pain. A pain
consult was obtained, and the patient was placed on Oxycotonin
SR TID 20mg-10mg-20mg and IV morphine breakthrough. Home dose of
neurontin was also increased. This combination prooved too
sedating. The patient became somnolent, and the oxycontin was
discontinued. She was subsequently controlled with neurontin,
tylenol and lidocaine patch. She was evaluated by PT who
recommended acute rehab which the patient refused. She will
receive home PT.
.
#Hypoxia: On admission, the patient's lasix was held due to
acute renal failure and low blood pressures. In the ED, she
initially received IVF. On the evening of [**12-19**], she began having
difficulty breathing. She was found to have SOB, wheezing as
well as crackels. O2 sats were low 80s on 2L NC and she was
placed on a 35% shovel mask. She received nebulizers. ABG was
7.32/54/87. EKG showed known atrial fibrillation. a CXR showed
now change. She received lasix 120mg IV with transient
improvement in O2 sats. Later on that evening, she was once
again hypoxic. Second ABG with 7.31/53/69 on 6L NC and 35%
shovel mask. Pt still only satting 94% on NRB. Patient was
transferred to MICU for BiPap. In the MICU, she received Bipap.
She also developed a fever, rigors and a leukocytosis to 22.
Hospital acquired pneumonia vs aspiration pneumonia was deemed
likely and she was started on Vanc/levo/flagyl. Although there
was no infiltrate seen on CXR, patient subsequently improved and
her leukocytosis trended down. She was also restarted her home
doses of lasix when her blood pressure improved. On [**12-23**], Vanc
was discontinued due to no evidence of MRSA on culture.
.
#)UTI: Pt was found to have UTI in the ED. Started on Bactrim.
ABx were switched to vanc/levo/flagyl while in the MICU for
pneumonia. However, Ucx grew 2,000 E.Coli resistant to Cipro.
Given the low organism count and negative UA, the patient was
not restarted on Bactrim. UA and Ucx were followed and showed no
subsequent infection.
.
#) Hypotension: On admission, the patient was hypovolemic on
exam with SBP 90-100. Lasix and Lisinopril were held in the
setting of hypotension and ARF. IVF hydration was given. Her
blood pressure improved while on the floor. However, after
transfer the the MICU, she became hypotensive and required
pressors likely secondary to PNA sepsis versus morphine. She was
briefly on dopamine then switched to levophed and quickly weaned
off. IV hydration was given. Her blood pressure remained stable
after that, and she was restarted on 80 mg Lasix ([**1-12**] home dose)
given pulmonary edema and hx CHF.
.
#) ARF: Pt was found to have a Cr of 1.8 on admission with a
baseline of 1.3. The is was thought to be due to recent addition
of Lisinopril and increase of Lasix causing pre-renal acute
renal failure. Creatinine peaked at 2.0 after transfer to MICU
and improved with IVF and BP control with pressors. The
creatinine returned to below baseline with good UOP. On [**12-23**],
she was restarted on [**1-12**] dose home lasix (80mg QD) with good UOP
and BPs tolerated. As her creatinine and blood pressure remained
stable, lasix was increased to her home dose 120 [**Hospital1 **] and her
lisinopril was also restarted. She will need outpatient labs
with Chem 7 to monitor her creatinine.
.
#)CHF: On admission, the patient appeared hypovolemic, so
lisinopril and lasix were held in the setting of ARF and
hypotension. The patient's acute hypoxia on the floor was
thought to be due to a pneumonia with some associated pulmonary
edema. She was treated in the ICU with Bipap and lasix as above.
Cardiac enzymes were negative. An echo was performed which
showed EF>55% without change in wall motion or systolic function
but continued worsening AS. She was restarted on lasix at 1/2
home dose and then titrated up as her blood pressure improved.
She had increased crackles at the bases on the morning of
discharge without worsening hypoxia. She received an additional
Lasix 20 IV with improvement prior to discharge. She was also
restarted on Lisinopril.
.
#)Afib: INR was closely monitored given that pt received cipro
in ED and was then given bactrim for UTI. INR was found to 3.1
on HD1 and 3.7 on HD2. Her warfarin was held. Patient
subsequently became subtherapeutic on INR. Coumadin was
restarted on [**12-22**]. On the day of discharge, her INR was low at
1.8 and she was given an elevated dose of coumadin 5mg. She
should have her INR drawn in two days prior to seeing her PCP [**Last Name (NamePattern4) **]
[**12-29**].
Medications on Admission:
Lisinopril 10 mg PO Qday just started on [**2145-12-13**]
Ascorbic Acid 500 mg PO once a day
Calcium-Cholecalciferol (D3) [Calcium 600 + D] 1 Tablet PO BID
COLACE 50MG PO BID
Dorzolamide 2 % Drops 1 gtt od twice a day glaucoma
Ergocalciferol (Vitamin D2) [Vitamin D] 400 unit PO QDAY
Furosemide 40 mg Tablet 3 Tablet(s) by mouth in am, 3 in pm
Gabapentin [Neurontin] 300 mg PO TID
Ibandronate 150 mg by mouth q mo for osteoporosis
Latanoprost 0.005 % Drops 1 ggt od ut dict
Metoprolol Succinate 50 mg PO QDAY
Multivitamin 1 Tablet(s) by mouth once a day
Protonis 40 mg by mouth once a day
Potassium Chloride 10 mEq by mouth once a day
Prednisone 10 mg by mouth once a day
Warfarin 3 mg Tablet [**1-12**] Tablet(s) by mouth once a day ut dict
afib
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic QDAY ().
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 30
days: Apply in the morning and take off at night.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily) for 3 days.
Disp:*qs * Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day.
13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once
Daily at 16).
15. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
17. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day.
18. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
19. Ibandronate 150 mg Tablet Sig: One (1) Tablet PO once a
month.
20. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 10 doses.
Disp:*10 Tablet(s)* Refills:*0*
21. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days: Day 1 is [**12-20**].
Disp:*6 Tablet(s)* Refills:*0*
22. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 days: Day 1 is [**12-20**].
Disp:*18 Tablet(s)* Refills:*0*
23. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
24. Outpatient Lab Work
INR checked x 30
- Please draw on the morning of [**12-29**]
- Fax results to Dr. [**Last Name (STitle) 7790**] [**Telephone/Fax (1) 11038**]
25. Outpatient Lab Work
Check creatinine x10
- please check on [**2145-12-29**]
- Fax results to Dr. [**Last Name (STitle) 7790**] [**Telephone/Fax (1) 11038**]
Discharge Disposition:
Home With Service
Facility:
All Care [**Telephone/Fax (1) 269**] of Greater [**Location (un) **]
Discharge Diagnosis:
Lumbar Compression Fracture
Pneumonia
Discharge Condition:
Improved
Discharge Instructions:
You were admitted for back pain which is most likely due to a
compression fracture. You will need to have another MRI of the
pelvis as an outpatient. You should use the lidocaine patch,
neurontin and tylenol for pain. You also developed Pneumonia.
You will need to finish a course of antibiotics for the
Pneumonia.
.
If you have any difficulty breathing or high fevers, please call
your doctor or go to the emergency room. If you have weakness in
your legs, trouble urinating or worsening back pain, call your
doctor or go to the emergency room.
.
For your heart failure:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Your coumadin on discharge was slightly low: INR 1.8. You were
given an increased dose of 5mg once prior to discharge. You
should have your INR check in the next 2-3 days.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]: [**12-29**] 1:50pm
.
Please obtain an outpatient MRI of your pelvis: [**Telephone/Fax (1) 327**]
Date/Time:[**2146-1-7**] 1:00
[**Hospital Ward Name 517**], basement level.
.
Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2146-2-1**] 12:10
Provider: [**Name10 (NameIs) 2352**] ECHO Phone:[**Telephone/Fax (1) 15347**] Date/Time:[**2146-2-4**]
1:30
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2146-3-15**] 1:00
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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"584.9",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
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|
8344, 13706
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353, 411
|
17308, 17319
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2062, 3503
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304, 315
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439, 1422
|
1444, 1834
|
1850, 1983
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,258
| 183,354
|
28731
|
Discharge summary
|
report
|
Admission Date: [**2154-10-11**] Discharge Date: [**2154-10-13**]
Date of Birth: [**2080-5-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
STEMI, cardiogenic shock
Major Surgical or Invasive Procedure:
1. Cardiac catheterization
2. Arterial line placement
3. Intra-Aortic Balloon Pump placement
History of Present Illness:
74 yo M with h/o DM, seizure disorder, HTN, and remote history
of MI (10 years ago s/p angioplasty) who was brought in by EMS
with CC of CP. Pt. was reported to be in his normal state of
health until this afternoon when he was noted to be unable to
descend or ascend his stairs after being able to do so twice
before as he left his house to go to the store. He was
complaining of severe, left-sided chest pain without radiation.
He never lost consciousness, denied any SOB, N/V and had no
accompanying diaphoresis. His sister thought he looked weak and
checked a finger stick which was elevated to 400. EMS was called
and the patient was brought to [**Hospital1 18**].
.
On arrival, per the EMS report, the patient was in SR with STE
in I, V5, V6 and STD in II, III, F and had BG of 525. He was
given NS bolus, started on dopamine and given ASA. In the ED he
was intubated, started on Heparin, and taken emergently to cath
lab. In cath lab, given atropine for HR in 40's. He had a DES
placed in LCX. He had VT/VF in cath lab with restoration of flow
and had CPR and DCCV. LAD was attempted but appeared to be
chronic. IABP was also placed. He was also started on levophed.
Past Medical History:
CAD s/p remote MI [**58**] years ago
DM Type 2
HTN
Hyperlipidemia
CHF(?)
A.fib (?)
CKD/BPH (?) - per pt's sister, the patient cannot urinate
Herpes Encephalitis ('[**27**]) with resultant seizure disorder
Asthma
Schizophrenia
Cholecystectomy
Social History:
Per daughter, patient has never used tobacco, alcohol or illicit
drugs.
Family History:
Two sisters died of [**Name (NI) **] CA; there is a family history of DM
and "Heart Disease"
Physical Exam:
Vitals: T: 96, HR: 118, BP: 89/50, RR: 14, O2: 100% -
AC/550/14/1.0/5
General: Intubated, NAD
HEENT: NC/AT, pupils equally round and minimally reactive to
light, intubated
Neck: supple, no appreciable JVD
Chest/CV: Could not appreciate heart sounds [**2-21**] to IABP (pt.
went into cardiac arrest with stopping IABP in lab. For this
reason, did not attempt to stop machine)
Lungs: CTAB b/l anteriorly
Abd: Soft, NT, ND, decreased BS; hematoma of right groin, soft,
no bruits, outlined in marker
Ext: no c/c/e; dopplerable pulses
Skin: warm, dry, no lesions
Pertinent Results:
Admission labs:
[**2154-10-11**] 11:51PM TYPE-ART TEMP-35.6 PO2-138* PCO2-41 PH-7.33*
TOTAL CO2-23 BASE XS--4
[**2154-10-11**] 11:51PM LACTATE-3.5*
[**2154-10-11**] 11:51PM O2 SAT-98
[**2154-10-11**] 11:38PM GLUCOSE-250* UREA N-18 CREAT-1.2 SODIUM-139
POTASSIUM-3.3 CHLORIDE-108 TOTAL CO2-21* ANION GAP-13
[**2154-10-11**] 11:38PM CALCIUM-7.2* PHOSPHATE-1.3*# MAGNESIUM-1.4*
[**2154-10-11**] 11:38PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2154-10-11**] 09:50PM TYPE-ART TEMP-35.6 PO2-202* PCO2-41 PH-7.28*
TOTAL CO2-20* BASE XS--6
[**2154-10-11**] 08:52PM HCT-33.3*
[**2154-10-11**] 07:20PM TYPE-ART PO2-64* PCO2-51* PH-7.20* TOTAL
CO2-21 BASE XS--8
[**2154-10-11**] 07:20PM GLUCOSE-508* LACTATE-10.3* NA+-137 K+-4.3
CL--102
[**2154-10-11**] 07:20PM freeCa-1.12
[**2154-10-11**] 07:10PM GLUCOSE-527* UREA N-17 CREAT-1.3* SODIUM-136
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-18* ANION GAP-20
[**2154-10-11**] 07:10PM ALT(SGPT)-120* AST(SGOT)-478* LD(LDH)-1200*
CK(CPK)-6483* ALK PHOS-135* TOT BILI-0.3
[**2154-10-11**] 07:10PM CK-MB-343* MB INDX-5.3 cTropnT-8.17*
[**2154-10-11**] 07:10PM CALCIUM-7.4* PHOSPHATE-2.9 MAGNESIUM-1.5*
CHOLEST-105
[**2154-10-11**] 07:10PM TRIGLYCER-9 HDL CHOL-55 CHOL/HDL-1.9
LDL(CALC)-48
[**2154-10-11**] 05:47PM TYPE-ART RATES-14/ TIDAL VOL-550 PEEP-5
O2-100 PO2-113* PCO2-37 PH-7.17* TOTAL CO2-14* BASE XS--14
AADO2-585 REQ O2-93 -ASSIST/CON INTUBATED-INTUBATED
[**2154-10-11**] 05:47PM GLUCOSE-639* K+-2.6*
[**2154-10-11**] 05:47PM HGB-12.3* calcHCT-37 O2 SAT-97
[**2154-10-11**] 05:23PM TYPE-ART PEEP-5 O2-100 PO2-191* PCO2-35
PH-7.25* TOTAL CO2-16* BASE XS--10 AADO2-509 REQ O2-83
-ASSIST/CON INTUBATED-INTUBATED
[**2154-10-11**] 05:23PM GLUCOSE-660* LACTATE-7.8* NA+-127* K+-3.8
CL--98*
[**2154-10-11**] 05:23PM HGB-13.8* calcHCT-41 O2 SAT-99
[**2154-10-11**] 05:00PM ALT(SGPT)-39 AST(SGOT)-66* CK(CPK)-539* ALK
PHOS-151* AMYLASE-51 TOT BILI-0.3
[**2154-10-11**] 05:00PM CK-MB-24* MB INDX-4.5 cTropnT-0.27*
[**2154-10-11**] 05:00PM ALBUMIN-3.7
[**2154-10-11**] 05:00PM WBC-13.7* RBC-4.05* HGB-13.1* HCT-37.9*
MCV-93 MCH-32.3* MCHC-34.6 RDW-13.2
[**2154-10-11**] 05:00PM PLT COUNT-270
[**2154-10-11**] 05:00PM PTT-150*
[**2154-10-11**] 04:35PM GLUCOSE-585* UREA N-15 CREAT-1.4* SODIUM-132*
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-24 ANION GAP-17
[**2154-10-11**] 04:35PM CK(CPK)-436*
[**2154-10-11**] 04:35PM CK-MB-18* MB INDX-4.1 cTropnT-0.23*
[**2154-10-11**] 04:35PM CALCIUM-9.0 PHOSPHATE-2.7 MAGNESIUM-1.6
[**2154-10-11**] 04:35PM DIGOXIN-0.8*
[**2154-10-11**] 04:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-10-11**] 04:35PM WBC-13.1* RBC-4.44* HGB-14.7 HCT-41.6 MCV-94
MCH-33.0* MCHC-35.3* RDW-13.0
[**2154-10-11**] 04:35PM NEUTS-90.3* BANDS-0 LYMPHS-7.2* MONOS-1.3*
EOS-0.7 BASOS-0.5
[**2154-10-11**] 04:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2154-10-11**] 04:35PM PLT SMR-NORMAL PLT COUNT-274
[**2154-10-11**] 04:35PM PT-12.7 PTT-24.1 INR(PT)-1.1
[**2154-10-11**] 04:35PM FIBRINOGE-253
.
Labs at time of death:
[**2154-10-12**] 06:30PM BLOOD WBC-17.1* RBC-3.35* Hgb-10.8* Hct-30.2*
MCV-90 MCH-32.1* MCHC-35.6* RDW-13.6 Plt Ct-155
[**2154-10-12**] 02:43AM BLOOD Neuts-91.3* Lymphs-3.9* Monos-4.5 Eos-0
Baso-0.3
[**2154-10-12**] 06:30PM BLOOD Plt Ct-155
[**2154-10-12**] 06:30PM BLOOD Glucose-130* UreaN-21* Creat-1.1 Na-130*
K-4.1 Cl-102 HCO3-20* AnGap-12
[**2154-10-12**] 10:03AM BLOOD CK(CPK)-6815*
[**2154-10-12**] 02:43AM BLOOD CK-MB-GREATER TH
[**2154-10-12**] 06:30PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2
[**2154-10-12**] 02:43AM BLOOD Digoxin-0.5*
[**2154-10-12**] 02:43AM BLOOD Ethanol-NEG
[**2154-10-12**] 04:47PM BLOOD Type-ART Temp-36.6 Rates-14/0 Tidal V-550
PEEP-5 FiO2-40 pO2-179* pCO2-26* pH-7.39 calTCO2-16* Base XS--7
-ASSIST/CON Intubat-INTUBATED
[**2154-10-12**] 02:12PM BLOOD Lactate-2.1*
[**2154-10-12**] 02:31AM BLOOD O2 Sat-99
[**2154-10-12**] 02:35PM BLOOD freeCa-1.04*
.
Microbiology:
[**2154-10-11**]: Blood and urine cultures no growth to date.
.
Imaging:
[**2154-10-11**] Cardiac Cath:
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system with
patent short LMCA. The LAD was chronically totally occluded with
modest
L->L collaterals. The LCX was thrombotic with slow flow and was
the
culprit vessel. RCA had no significant obstructive disease.
2. Left ventriculography was deferred.
3. Hemodynamic assessment showed low systemic aortic pressures
consistent with hemodynamic collapse. Right sided filling
pressures were
elevated.
4.
5.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe systolic ventricular dysfunction.
3. Acute inferior myocardial infarction, managed by acute ptca
and IABP
placement.
4. PTCA of vessel.
.
[**2154-10-12**] ECHO:
Conclusions:
Overall left ventricular systolic function is severely
depressed. There is focal hypokinesis of the apical free wall of
the right ventricle. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-21**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The
supporting structures of the tricuspid valve are
thickened/fibrotic. There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
.
Compared with the findings of the prior study (images reviewed)
of [**2154-10-12**], the left ventricular ejection fraction remains
severely
reduced.
Brief Hospital Course:
1. STEMI: The patient was urgently brought to the cath lab from
the ED given his clinical picture and EKG findings. He was
intubated and on heparin. Given low BPs, he was also bolused
normal saline and started on dopamine. In the cath lab, he was
bradycardic and was given atropine. He also went into VT/VF,
and was cardioverted. CPR was performed. An IABP was placed.
a stent was placed to the left circumflex artery. He was also
started on levophed, vasopressin, and lidocaine drips. Cath
findings are described above. He was transported to the CCU and
put on ASA, statin, ACEI, plavix, integrillin. He continued to
have hypotension despite being on three pressors and an IABP.
Attempts at weaning the pressors failed. Attempts at weaning
the IABP were unsuccessful. His groin also ad a hematoma. His
Hct dropped and the patient was given 2 units PRBCs. An Echo
was performed which showed severe RV/LV dysfunction, with an EF
of 10%. On the night of [**2154-10-13**], the patient went into afib
with NSVT. Per the family's request, the decision was made not
to start amiodarone. In fact, after numerous discussions with
the family regarding prognosis of the patient as well as his
condition, the decision was made to make the patient CMO. The
patient was kept comfortable, and all pressors were sequentially
stopped. For 1 hour, the patient maintained his tachycardic
rhythm. However, the patient eventually became bradycardic and
hypotensive. At 1:15AM, the patient went into asystole and
passed away. The family was present. The spouse denied an
autopsy. The CCU attending and PCP were [**Name (NI) 653**].
.
2. Aspiration: During his cardiac arrest, the patient was
thought to have aspirated and was started on Flagyl. He was
maintained on the ventilator in the CCU and was unable to be
weaned.
.
3. Anemia: The patient was anemic during the admission, likely
secondary to groin oozing and hematoma formation given
anticoagulation. He was transfused 2 units PRBCs during his
admission.
.
4. Acidosis: The patient was acidotic, with an elevated
lactate. His hemodynamics were optimized with pressors and an
IABP.
.
5. Code: The patient was DNR initially. The family was very
involved in the patients care. After thoughtful discussion of
the patients condition and wishes. the family decided to make
the patient CMO on the night of his death. the medical team
supported them in their decision. After all efforts were taken
to stabilize the patient, the patient was made CMO. Pressors
were withdrawn, and the patient expired at 1:15 AM on [**2154-10-13**].
The appropriate steps were made to support the patient and
family.
Medications on Admission:
Toprol XL 100
Lisinopril 40 mg (increased two weeks prior to admission from 20
mg)
Digoxin 0.125 mg
Benzotropine
NPH (35 units)
Lipitor
Aspirin 81 mg
Haldol 5 mg QHS
Cogentin 1 mg QHS
Dilantin 300 mg QAM
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnoses:
1. ST Elevation Myocardial Infarction
2. Cardiac Arrest
.
Secondary Diagnoses:
1. Respiratory failure
2. Acidosis
3. Anemia
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"998.12",
"414.01",
"785.51",
"276.2",
"424.0",
"585.9",
"410.41",
"780.39",
"428.0",
"250.00",
"295.90",
"427.31",
"401.9",
"493.90",
"E879.0",
"507.0",
"412",
"427.1",
"427.41",
"518.81",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"96.04",
"37.22",
"00.40",
"36.07",
"96.71",
"88.55",
"37.61",
"99.62",
"00.17",
"88.52",
"99.04",
"99.60",
"99.20",
"00.46"
] |
icd9pcs
|
[
[
[]
]
] |
11212, 11221
|
8261, 10925
|
341, 435
|
11407, 11416
|
2699, 2699
|
11472, 11482
|
2010, 2105
|
11180, 11189
|
11242, 11319
|
10951, 11157
|
7350, 8238
|
11440, 11449
|
2120, 2680
|
11340, 11386
|
277, 303
|
463, 1639
|
2716, 7333
|
1661, 1905
|
1921, 1994
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,427
| 183,494
|
51533
|
Discharge summary
|
report
|
Admission Date: [**2146-11-5**] Discharge Date: [**2146-11-18**]
Date of Birth: [**2078-1-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Seroquel / Fentanyl / Flagyl
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2146-11-7**] - Cardiac catheterization
[**2146-11-11**] - Coronary artery bypass grafting x4: With the left
internal mammary artery to left anterior descending artery and
reverse saphenous vein graft to the posterior descending artery,
the first and second obtuse marginal artery.
History of Present Illness:
Of note, pt is a poor historian. 68 y/o M with PMHx significant
for h/o atrial fibrillation, COPD, HTN, PVD, HLD, liver disease,
and ? h/o PE, who presented to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] with chest
pain and shortness of breath. Pt reports that he was initially
diagnosed with a PE approximately 2.5 months ago at [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. He had been on coumadin; however, he reports that his
coumadin had been stopped a few weeks ago for unclear reasons
(with plans to restart soon). Pt reports that when his visiting
nurse was at his house today, he reported some chest pain and
shortness of breath. Describes chest pain as pressure-like and
located in the left chest. It was associated with shortness of
breath and lightheadedness but no diaphoresis or nausea. It
lasted approximately 15 seconds. Pt reports similar episodes
over the past several months ever since he was diagnosed with
the PE. Each episode lasts anyhwere from 5 seconds to several
minutes. The visiting nurse [**First Name (Titles) 12690**] [**Last Name (Titles) **] and the patient was
brought to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for further evaluation.
.
In the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) **], the patient underwent a CT chest which
showed a stable PE in the RLL. There was some concern regarding
anticoagulation in this patient because he had a previous
hospitalization at [**Hospital1 18**] in [**8-30**] that was complicated by GI
bleeding. Therefore, he was transferred to [**Hospital1 18**] for further
management of his anticoagulation. On arrival to the [**Hospital1 18**] ED,
the patient's VS were 96.8; 144/90; 106; 16; 99% on 4L. He was
guaiac negative. He was started on lovenox for anticoagulation
and received his first dose (90 mg SC) at 00:00 on [**2146-11-5**]. Lab
wokr in the ED was significant for a sodium of 132 and a
negative set of CEs. No further imaging was performed. ECG was
not significant changed from prior. He was admitted for further
evaluataion. VS prior to transfer: 126/83 99 19 96%2L.
.
On arrival to the floor, the patient's VS were T 97.9; BP
122/83; HR 100; RR 20; SaO2 100% on 2L. He denied any current
chest pain or shortness of breath. He denied any other
complaints at this time. Of note, pt did report some LLE pain
(calf and shin) recently that has since resolved.
.
.
Review of sytems:
(+) Per HPI. The patient also reported some chronic R-sided
weakness. He also complained of recent episodes of epistaxis.
(-) Denies fever, chills, night sweats, recent weight changes.
Denies rhinorrhea, or nasal congestion. Denies cough,
palpitations. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain. Denies change in bladder habits, dysuria. Denies
arthralgias or myalgias.
Past Medical History:
- h/o atrial Fibrillation
- s/p Pacer ([**Company 1543**] DDD)
- COPD
- Hypertension
- PVD s/p Aortobifemoral bypass
- Hyperlipidemia
- Chronic liver disease [**2-22**] EtOH (sober now)
- Anemia: h/o maroon stools; colonoscopy in [**2146**] with
hemorrhoids, colon polyps, adenoma
- h/o epistaxis
- history of AAA that was repaired in 07
- h/o PE ~2-3 months ago per pt. Notes from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] mention
PE and imaging from today mentions stable PE. However, no
records at [**Hospital1 18**] mention PE.
- Wedge fractures - Noted in lumbar region on CT scan
- prolonged hospitalization at [**Hospital1 18**] in [**8-30**] for epiglottitis
requiring cric/trach, with hospital course complicated by GI
bleeding and pseudonomas bacteremia
Social History:
- Unemployed. Used to work in the stockroom at the [**Location (un) **]
Corportation. Lives alone. Has a scooter at home.
- Health care proxy is his friend [**Name (NI) 892**] [**Name (NI) 16471**], (c) [**Telephone/Fax (1) 106834**],
(h) [**Telephone/Fax (1) 106835**].
- Tobacco: used to smoke 1.5 ppd x ~50 years. Quit 3 months ago.
- Alcohol: per records, hx of heavy EtOH use. Quit 9 months ago.
- Illicits: none
Family History:
father and mother both died of CAD, dad died after age >50
Physical Exam:
ADMISSION PHYSICAL EXAM
T 97.9; BP 122/83; HR 100; RR 20; SaO2 100% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP ~6cm
Lungs: Diminished BS throughout, some scattered wheezes. No
rales or rhonchi.
CV: Distant HS. Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No calf tenderness.
Neuro: Chronic weakness in the RUE and RLE. Otherwise grossly
non-focal.
Pertinent Results:
ADMISSION PHYSICAL EXAM
[**2146-11-4**] 11:14PM BLOOD WBC-10.6 RBC-4.18*# Hgb-12.5* Hct-37.5*
MCV-90# MCH-29.9# MCHC-33.4 RDW-15.6* Plt Ct-265
[**2146-11-4**] 11:14PM BLOOD Neuts-67.4 Lymphs-21.8 Monos-7.1 Eos-2.6
Baso-1.0
[**2146-11-4**] 11:14PM BLOOD PT-14.2* PTT-27.1 INR(PT)-1.2*
[**2146-11-4**] 11:14PM BLOOD Glucose-92 UreaN-14 Creat-1.0 Na-132*
K-4.6 Cl-103 HCO3-21* AnGap-13
CARDIAC ENZYMES
[**2146-11-4**] 11:14PM BLOOD cTropnT-LESS THAN
[**2146-11-5**] 01:10PM BLOOD CK-MB-3 cTropnT-<0.01
[**2146-11-5**] 01:10PM BLOOD CK(CPK)-45*
[**2146-11-5**] 09:00PM BLOOD CK-MB-3 cTropnT-<0.01
[**2146-11-5**] 09:00PM BLOOD CK(CPK)-42*
[**2146-11-6**] 05:40AM BLOOD CK-MB-3 cTropnT-<0.01
[**2146-11-6**] 05:40AM BLOOD CK(CPK)-47
[**2146-11-6**] 01:45PM BLOOD CK-MB-3 cTropnT-<0.01
[**2146-11-6**] 01:45PM BLOOD CK(CPK)-50
Carotid Ultrasound [**2146-11-10**]
Findings are consistent with less than 40% stenosis bilaterally.
RUQ ULTRASOUND ([**2146-11-8**])-
1. Mild dilatation of the extrahepatic common duct and of the
pancreatic duct. This diatation is of unknown etiology. The
pancreatic duct is noted to be also dilated, but smaller than on
the CT of [**2146-8-21**]. No intrahepatic biliary dilatation noted.
2. Ectatic aorta measuring up to 2.8 cm at the widest diameter.
3. Small non obstructing stone in the left kidney.
CARDIAC CATH ([**2146-11-7**]) -
1. Selective coronary angiography in this right dominant system
demonstrated left main and two vessel coronary artery disease.
The LMCA
had a 60% stenosis in the distal vessel. There was an 80%
ostial LAD
stenosis. The LCx had a 40% stenosis at the origin. The RCA
was
calcified with a 90% stenosis in the mid-vessel.
2. Resting hemodynamics revealed normal right and left sided
filling
pressures with RVEDP 10 mmHg and LVEDP 14 mmHg. There was high
normal
pulmonary arterial systolic pressure with PASP 32mmHg. The
cardiac
index was preserved at 2.47 l/min/m2. There was normotension of
the
systemic arterial pressure 134/79 mmHg.
3. There was no evidence of gradient on careful pullback of the
angled
pigtail catheter from the left ventricle to the ascending aorta.
4. Left ventriculography was deferred.
Pulmonary function testing
SPIROMETRY 12:52 PM Pre drug Post drug
Actual Pred %Pred
FVC 4.41 5.02 88
FEV1 2.63 3.37 78
MMF 1.07 2.93 37
FEV1/FVC 60 67 89
Brief Hospital Course:
Mr. [**Known lastname 63108**] was admitted to the [**Hospital1 18**] on [**2146-11-5**] for further
management of his chest pain. Heparin was continued for
anticoagulation given his history of atrial fibrillation and
pulmonary embolism. He r/o for MI, but underwent cath which
revealed severe 3VD. PATs completed and he underwent surgery on
[**11-11**] with Dr. [**Last Name (STitle) **]. Transferred to the CVICU in stable condition
on epinephrine and phenylephrine drips. .Extubated later that
day. PICC line placed for access. Required neo drip and
treatment of recurrent A Fib. Transferred to the step down unit
on POD # 5 to begin increasing his activity level. Chest tubes
and pacing wires removed per protocol. Gently diuresed toward
his preop weight. Coumadin was resumed per Dr. [**Last Name (STitle) **] for treament
of PAF and PE (diagnosed at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2146-8-21**]).
Cleared by Dr. [**Last Name (STitle) **] for discharge to [**Hospital 70637**] Rehab on POD #7.
Medications on Admission:
- Aspirin 325 mg daily
- Nicotine 7 mg patch
- Protonix 40 mg daily
- Revatio 10 mg [**Hospital1 **]
- Calcium + D 600/400 daily
- Venotlin 90 mcg QID
- Advair 250/50 [**Hospital1 **]
- Simvstatin 80 mg daily
- Metoprolol 12.5 mg [**Hospital1 **]
- MVI
- Folic Acid 1 mg daily
- Digoxin 125 mcg daily
- Famotidine 20 mg daily
Discharge Medications:
1. sildenafil 20 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
2. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet
PO once a day.
6. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): do
not crush.
14. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
15. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
16. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) for 1 months.
18. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): sc injection.
19. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
20. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
for 7 days then decrease to 200mf po daily ongoing.
21. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
22. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-22**]
Puffs Inhalation Q6H (every 6 hours).
23. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
24. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
25. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
27. Coumadin 2.5 mg Tablet Sig: as directed for AFIB/PE Tablet
PO once a day: based on INR
goal INR 2.5.
28. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection three times a day: Stop when INR therapeutic.
Discharge Disposition:
Extended Care
Facility:
Maplewood Care & Rehabilitation Center - [**Location (un) 32944**]
Discharge Diagnosis:
coronary artery disease s/p cabg
- h/o atrial Fibrillation
- s/p Pacer ([**Company 1543**] DDD)
- COPD
- Hypertension
- PVD s/p Aortobifemoral bypass
- Hyperlipidemia
- Chronic liver disease [**2-22**] EtOH (sober now)
- Anemia: h/o maroon stools; colonoscopy in [**2146**] with
hemorrhoids, colon polyps, adenoma
- h/o epistaxis
- history of AAA that was repaired in 07
- h/o PE ~2-3 months ago per pt. Notes from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] mention
PE and imaging from today mentions stable PE. However, no
records at [**Hospital1 18**] mention PE.
- Wedge fractures - Noted in lumbar region on CT scan
- prolonged hospitalization at [**Hospital1 18**] in [**8-30**] for epiglottitis
requiring cric/trach, with hospital course complicated by GI
bleeding and pseudonomas bacteremia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema ..................
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2146-12-7**]
1:15
Cardiologist:[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2146-12-13**] 1:00
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 84032**] [**Telephone/Fax (1) 28612**] in [**4-25**] weeks
Schedule a follow up appointmnet with your hematologist in 2
weeks.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
INR goal 2.5
First draw on [**2146-11-19**]
Coumadin 2.5 mg on [**2146-11-18**]
Completed by:[**2146-11-18**]
|
[
"401.9",
"416.2",
"790.93",
"276.1",
"573.8",
"416.8",
"272.4",
"411.1",
"443.9",
"V58.61",
"733.00",
"414.01",
"V53.31",
"496",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"37.23",
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
11991, 12084
|
7906, 8946
|
307, 593
|
12949, 13197
|
5527, 7883
|
14121, 14990
|
4803, 4863
|
9323, 11968
|
12105, 12928
|
8972, 9300
|
13221, 14098
|
4878, 5508
|
257, 269
|
3144, 3538
|
621, 3126
|
3560, 4350
|
4366, 4787
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,259
| 164,383
|
7071
|
Discharge summary
|
report
|
Admission Date: [**2137-12-27**] Discharge Date: [**2137-12-30**]
Date of Birth: [**2107-7-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Chief Complaint: Dyspnea, Hyponatremia to 126
Reason For Admission to [**Hospital Unit Name 153**]: Pulmonary Embolism
Major Surgical or Invasive Procedure:
none
History of Present Illness:
30M w/ metastatic HCC s/p exlap w/ debulking, s/p sorafenib
therapy (d/c 3 weeks ago following R bloody pleural effusions)
today presented [**Hospital **] clinic, where he is followed for a malignant
effusion, and has pleurex catheter without recent drainage. The
pt complained there of worsening dyspnea, total body pain. In
clinic received 5FU/leukovorin in 1L NS when he was noted to be
dehydrated and hyponatremia to 126. He was called at home and
asked to come to the ED for evaluation. Of note Mr. [**Known lastname **] was
recently admitted on [**11-26**] for SOB and pleuritic chest pain to
the thoracic service. A CTA was negative for PE. A repeat
thoracentesis for his chronic right sided pleural effusion was
done with only 30cc of fluid removed. He was then transferred to
the omed service for pain control and further management. His
pain was adequately controlled with the addition of mscontin to
his home dilaudid regimen and he was d/c'd on [**2137-12-2**]. The
patient is currently off anticoaggulation [**3-9**] to hemorrhagic
pleural effusion in setting of sorafinib use.
.
In ED hr 85, 106/64, 216, 98% on 2.5L. The pt was noted to have
increased dyspnea from baseline. Pleurex, not much drainage. The
patient was seen IP. EKG was noted to have new lateral T-Wave
Inversions. CXR revealed a massive Pulmonary effusion. While CT
revealed progressive Pulmonary Emboli. The pt was guaiac neg. He
received levo/vanco for question post-obstructive pna in the
LUL. In addition there was a question of LLL infarct. His repeat
labs revealed a sodium of 132. He's admitted for further
evaluation. The patient also underwent a CT head to evaluate for
metastatic process. The pt was started on a Heparin gtt without
Bolus and transferred to the [**Hospital Unit Name 153**] for further management.
.
Currently reports [**10-16**] R.flank/back pain and SOB, reports
subjective fever/chills. Denies URI/cough, CP, +occasional palp,
-abd pain/n/v/d/ +poor appetite, no rash/joint pain.
Past Medical History:
Hepatocellular cancer with intra-abdominal and pulmonary METS-on
cycle 3 of 6 5FU
Hepatitis B with cirrhosis
IVC thrombosis
Pulmonary Embolism
.
PSH:
Liver mass biopsy [**2137-8-30**] ex lap, Debridement of liver tumor.
Resection and primary repair of diaphragm.
.
Social History:
Born in [**Country 3992**]; last in [**Country **] in [**2133**]. Moved to [**Location (un) 6847**] in
teens. The patient lives in [**Location 686**] with elderly cousin. [**Name (NI) **]
used to smoke tobacco on occasion, but has not smoked in 5
months. States now lives at rehab.
Family History:
The patient does not know his family history outside of
hepatitis B in the patient's mother
Physical Exam:
Physical exam:
Vitals in the E.D. T 99, BP 110/66, HR 96, RR16, 94% on 2L
.
Vitals: T 95.9 BP 104/78 HR 94, RR 21 sat 97% on 2L
GEN: sitting upright, can speak in full sentences, appears to be
in pain with movement
HEENT:nc/at, PERRLA, EOMI, no OP lesions.
chest:b/l AE decreased BS at bases, scattered crackles
heart:s1s2 rrr 4/6 systolic flow, loud P2, no r/g
abd:+bs, soft, TTP, RUQ/flank, no guarding/rebound
ext: no c/c/e 2+pulses, no calf tenderness
neuro:aa0x3, cn2-12 intact, non-focal.
Pertinent Results:
[**2137-12-27**] 11:25AM WBC-9.0 RBC-2.99* HGB-8.4* HCT-26.5* MCV-89
MCH-28.2 MCHC-31.8 RDW-18.3*
[**2137-12-27**] 11:25AM NEUTS-83.9* LYMPHS-12.1* MONOS-2.8 EOS-0.9
BASOS-0.2
[**2137-12-27**] 11:25AM PLT COUNT-274
.
[**2137-12-27**] 11:25AM PT-16.8* PTT-24.1 INR(PT)-1.5*
.
[**2137-12-27**] 11:25AM GLUCOSE-90 UREA N-10 CREAT-0.5 SODIUM-128*
POTASSIUM-4.1 CHLORIDE-91* TOTAL CO2-27 ANION GAP-14
[**2137-12-27**] 11:25AM ALT(SGPT)-31 AST(SGOT)-159* LD(LDH)-546*
CK(CPK)-72 ALK PHOS-180* TOT BILI-2.0*
[**2137-12-27**] 11:25AM LIPASE-31
.
[**2137-12-27**] 11:25AM HAPTOGLOB-84
.
CXR: [**12-27**]: Residual R sided pleural effusion slightly improved
from prior. Multiple nodules consistent with metastic disease.
Probable worsening underlying infectious process
.
CTA: [**12-27**] (Wet-Read)
Progression of left lower segmental PEs. Stable right segmental
PEs. Possible developing infarct of left lower lobe. Probable
infection process in left upper lobe.
.
CT Head: (Wet-Read)
No acute intranial hemorrhage or mass effect.
.
Brief Hospital Course:
Pt is a 30 man with metastatic HCC now with increased SOB, pain
found to have worsening PE's.
-
# Pulmonary Embolism: Pt with known PEs, worsened based on
symptoms and imaging findings. Pt recently taken off
anti-coagulation in setting of malignant hemorrhagic R pleural
effusion and concurrent chemotherapy with sorafenib. However,
per onc fellow pt has been off chemo for 3 weeks. Due increase
of clot burden, decision was made to start heparin without a
bolus.
.
#Pneumonia: Pt with subjective fever, normal WBC count, but CXR
findings of a LUL/?post-obstructive pneumonia. Patient was
given IV vanco for MRSA coverage, levoflox for CAP/atypicals
.
# Hyponatremia: 128 in ED, same on last [**Month/Year (2) **] draw [**12-24**]. Likely
secondary to SIADH. However, pt appears dry on exam and had
decreased PO intake.
.
#metastatic HCC/Hep [**Name (NI) **] Per pt's outpt oncologist, pt is s/p
cycle [**4-11**] of chemotherapy. Pt wants to give full regimen a try.
Known metastasis to the lung and abdomen. Head Ct appears to be
negative.
-pain control
-contiAdefovir 10 mg po qdaily ,Lamivudine 100 mg PO DAILY
.
[**12-28**]
- Patient incredibly uncomfortable with pain.
-[**Name (NI) **] pt's family at [**Telephone/Fax (1) 26386**]- Talked with woman who
called herself the pt's mother- [**Name (NI) 1022**] [**Name (NI) 26387**] [**Name (NI) 26388**] and pt's cousin-
[**Name (NI) 915**] [**Name (NI) **]. I told them the pt is here and very ill. They seemed
to be aware of his chronic illness and have apparently seen him
within the last week or so. The woman stated that the pt also
has an adoptive mother in [**Country 3992**] but she does not know where
this woman is. She will try to get contact info for this other
mother and bring it with her to the hospital tomorrow.... The
pt's relatives ("mother" [**Doctor Last Name 1022**], "father", and cousin) came in this
evening around 7pm. Through an interpreter, I informed them of
the pt's condition and that it is very serious. They will
attempt to contact the family in [**Country 3992**] themselves.
-Dr. [**Last Name (STitle) **] from oncology was [**Last Name (STitle) 653**] and noted that he was okay
with a decision to changed the patients code status/ goals of
care/ further tx to keep him more comfortable given his
intractable pain overnight.
-Decision was eventually made with help from [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] to make
patient CMO and he was changed to morphine gtt.
- Family came to visit and made patient CMO. Palleative care
facilitated family meeting and transition
- on [**12-29**] he passed at 0450 AM. Family was [**Month/Year (2) 653**] and
[**Name2 (NI) 26389**] post-mortem examination.
Medications on Admission:
Home Oxygen 2L
Adefovir 10 mg po qdaily
Lamivudine 100 mg PO DAILY
Warfarin 1 mg po q4pm which patient states he's not taking
Lidocaine 5 % patch qdaily
Docusate 100mg [**Hospital1 **]
Senna 1 tab [**Hospital1 **]
Morphine sustained release 60mg [**Hospital1 **]
Hydromorphone 2 mg PO Q 2 HOURS
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
Completed by:[**2138-1-5**]
|
[
"338.3",
"198.89",
"197.2",
"155.0",
"263.9",
"253.6",
"197.0",
"415.19",
"070.32",
"571.5",
"485"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.73"
] |
icd9pcs
|
[
[
[]
]
] |
7867, 7876
|
4757, 7481
|
436, 442
|
7935, 7952
|
3692, 4664
|
8016, 8061
|
3068, 3161
|
7827, 7844
|
7897, 7914
|
7507, 7804
|
7976, 7993
|
3191, 3673
|
295, 398
|
470, 2464
|
4673, 4734
|
2486, 2753
|
2769, 3052
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,506
| 101,979
|
42883+58566
|
Discharge summary
|
report+addendum
|
Admission Date: [**2183-1-15**] Discharge Date: [**2183-2-10**]
Date of Birth: [**2137-5-17**] Sex: M
Service: MEDICINE
Allergies:
Zoloft
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Hypotension in the setting of decompensated liver disease
Major Surgical or Invasive Procedure:
Arterial line placement [**2183-1-15**]
Right internal jugalar line [**2183-1-16**]
History of Present Illness:
45M h/o EtOH cirrhosis c/b massive ascites, EtOH cardiomyopathy
s/p AICD placement, and PUD c/b GIB s/p EGD is transferred from
an OSH with hypotension in the setting of decompensated liver
disease. Briefly, after undergoing scheduled large volume
paracentesis (6L), he was admitted to [**Hospital3 **] on [**2183-1-10**]
with confusion accompanied by ammonia of 64, with some
improvement in mental status following lactulose administration.
In light of elevated Cr to 2-2.4 on admission, up from 1-1.2 at
baseline, diuretics were held. Hospital course was also
complicated by persistent hyponatremia.
When he developed SBP to 70s accompanied by low-grade fever,
shortness of breath, progressive abdominal pain/distention,
lethargy, and bandemia earlier today, he was transferred to the
OSH MICU, where he received 500 cc IVNS and albumin 12.5 g x2,
with improvement in SBP to 80s without pressor requirement.
Empiric ceftriaxone 1g x1 and vancomycin 1g x1 were administered
prior to diagnostic paracentesis, which revealed 43 wbc.
On arrival to the MICU, he was minimally conversant, but
somnolent and unable to provide detailed history. He endorses
minimal shortness of breath coupled with nonproductive cough, as
well as non-bloody emesis just prior to arrival. He denies pain
in his abdomen or elsewhere or bloody/tarry stools.
Past Medical History:
EtOH cirrhosis c/b diuretic-resistant ascites requiring weekly
large volume paracentesis
EtOH cardiomyopathy (EF 30% on TTE in [**11-28**]) s/p AICD placement
PUD c/b GIB, now s/p EGD
Gastic Bypass
Social History:
- Tobacco: Endorses previous tobacco use; now quit.
- Alcohol: Per OSH notes, last drink on [**2183-8-28**].
Family History:
Unknown.
Physical Exam:
Physical Exam on admission:
Vitals: 95 80 78/47 16 100% on 5LNC
General: Alert, oriented x3, somnolent in no acute distress
HEENT: Sclera anicteric, MM dry, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, distant heart sounds
Lungs: Rhonchi/wheeze in anterior fields bilaterally
Abdomen: Non-tender, tensely distended, +fluid wave
Ext: Thready pulses throughout, no clubbing, cyanosis or edema,
positive asterixis
Neuro: AOx3, somnolent, but minimally conversant and following
commands, weak UE grip bilaterally
MSK: UE proximal muscle wasting bilaterally
Skin: Few scattered spider angiomata, multiple scattered
excoriations overlying U/LE bilaterally, minimal palmar
erythema, no abdominal caput
Physical Exam on discharge:
98.5 103/74 88 18 98%RA
BS: 199, 169, 201
GENERAL: cachectic appearing man, AOx3, no asterixis
HEENT: Sclera anicteric. PERRL, EOMI.
CARDIAC: RRR no m/r/g
PULM: CTAB.
ABDOMEN: Distended and tense, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 2+
[**Location (un) **] bilaterally to knees.
NEURO: difficulty with concentration, CNII-XII grossly intact no
apparent focal lesions, no asterixis, intermittently combative
Pertinent Results:
Labs on admission:
[**2183-1-15**] 08:31PM BLOOD WBC-3.8* RBC-3.93* Hgb-11.0* Hct-32.5*
MCV-83 MCH-28.0 MCHC-33.9 RDW-15.5 Plt Ct-114*
[**2183-1-15**] 08:31PM BLOOD Neuts-72.2* Bands-0 Lymphs-21.6 Monos-5.1
Eos-0.7 Baso-0.3
[**2183-1-16**] 02:10AM BLOOD PT-21.0* PTT-60.2* INR(PT)-2.0*
[**2183-1-15**] 08:31PM BLOOD Glucose-163* UreaN-40* Creat-3.0* Na-125*
K-5.0 Cl-97 HCO3-17* AnGap-16
[**2183-1-15**] 08:31PM BLOOD ALT-33 AST-35 LD(LDH)-251* CK(CPK)-39*
AlkPhos-109 TotBili-0.3
[**2183-1-15**] 08:31PM BLOOD CK-MB-6 cTropnT-0.06*
[**2183-1-16**] 02:10AM BLOOD CK-MB-5 cTropnT-0.04*
[**2183-1-15**] 08:31PM BLOOD Albumin-2.6* Calcium-8.0* Phos-5.4*
Mg-1.7
[**2183-1-18**] 05:50AM BLOOD Vanco-25.9*
[**2183-1-15**] 09:32PM BLOOD Type-ART pO2-32* pCO2-42 pH-7.24*
calTCO2-19* Base XS--9 Intubat-NOT INTUBA
[**2183-1-15**] 08:43PM BLOOD Lactate-3.0*
[**2183-1-15**] 11:44PM BLOOD freeCa-1.08*
[**2183-1-16**] 02:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2183-1-16**] 02:10AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2183-1-16**] 02:10AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
TransE-<1
[**2183-1-16**] 02:10AM URINE CastHy-25*
[**2183-1-16**] 02:10AM URINE Mucous-OCC
[**2183-1-16**] 02:10AM URINE Hours-RANDOM UreaN-395 Creat-225 Na-<10
K-22 Cl-<10
Microbiology:
C diff [**1-17**]: negative
Blood cx [**1-16**]: No growth
Urine cx [**1-16**]: negative
Imaging:
Chest x-ray [**12/2099**]:
Cardiomediastinal contours are normal. Left transvenous
pacemaker leads are in a standard position with tips in the
right atrium and right ventricle.
There are low lung volumes. There are faint ill-defined
opacities in the left perihilar region. This could be due to
atelectasis, but developing infection cannot be excluded. There
is no pneumothorax or pleural effusion.
There is dilatation of small bowel loops in the upper abdomen
Chest x-ray [**1-18**]:
CHEST, SINGLE AP VIEW: Low lung volumes. Compared with [**2183-1-17**],
there is
increased opacity in the left upper and mid zones, which could
represent
worsening asymmetric CHF. The possibility of a left-sided
pneumonic
infiltrate cannot be entirely excluded, but is considered less
likely. No
effusions.
A left-sided dual-lead pacemaker is present with lead tips over
right atrium and right ventricle. An NG tube is present -- the
tip is obscured in the lower mediastinum due to overlying soft
tissues and cannot be definitively identified. A right IJ
central line is present, tip over distal SVC.
IMPRESSION: Worsening asymmetric opacity, likely worsening CHF.
Echo [**1-16**]:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The mitral valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined.
IMPRESSION: Limited study as patient could not cooperate. Left
ventricular systolic function is probably normal, a focal wall
motion abnormality cannot be excluded. The right ventricle is
not probably normal. No significant valvular abnormality
CT abdomen and pelvis without contrast [**1-16**]:
IMPRESSION:
1. Large amount of non-hemorrhagic ascites throughout the
abdomen. No
evidence of intra-abdominal hemorrhage.
2. Intact Roux-en-Y anastomosis.
3. Cirrhotic liver. Gas-distended loops of bowel with decrease
of caliber
just distal to the J-J anastomosis. While this could represent
post-operative changes from gastric bypass, early partially
small bowel obstruction cannot be excluded.
4. Minimal-to-mild colonic wall edema, likely secondary to
patient's
end-stage liver disease. Fecal loading in the rectum.
RUQ US with dopplers [**1-17**]:
IMPRESSION:
1. Large amount of intra-abdominal ascites.
2. No concerning focal liver lesion identified.
3. Somewhat limited Doppler evaluation of the left hepatic lobe,
however, no evidence of portal venous thrombosis.
Brief Hospital Course:
Mr. [**Known lastname **] is a 45 year old man with EtOH cirrhosis c/b massive
ascites and cardiomyopathy s/p AICD placement who was
transferred from an OSH with hypotension in the setting of
decompensated liver disease. His course was complicated by
hepatorenal syndrome necessitating dialysis as well as
encephalopathy.
.
#[**Last Name (un) **] (Hepatorenal Syndrome): Elevated Cr at 3.0 on admisison,
reportedly up from 1-1.2 at baseline. Urine sodium of less than
10 narrowed differential to pre-renal dehydration vs. HRS. Pt
was given albumin challenge for the first two days as well as
boluses of NS. Creatinine did not respond to resuscitation over
the first few days, ruling in favor of HRS. Pt was also started
on midodrine/octeotide for presumed HRS. Renal US was negative
for post-renal obstruction. Pt was started on dialysis once he
was transferred back to the MICU with the hope of bridging him
until he is a candidate for liver transplant.
.
#Liver Tranpslantation Eligibility: To become a liver transplant
candidiate, Mr. [**Known lastname **] will need to have been sober out of the
hospital for approximately 3 months. Per the liver transplant
committee, he must demonstrate that he is comitted to sobriety
by engaging in an intesive outpatient alcohol treatment program.
Sobriety within the hospital or an inpatient rehabilition center
does not count towards transplant eligibility.
.
#Alcoholic Cirrhosis: MELD is 22 upon discharge. Last drink was
[**2182-8-28**] but in context of hospitalization/physical
rehab. Not a transplant candidate as abstinence occurred in
healthcare setting as explained above. Lactulose/rifaximin were
continued for encephalopathy. Folate and thiamine were
continued.
.
#Altered mental status: On admission he was somnolent, but
conversant. Likely secondary to hepatic encephalopathy and
sepsis from HCAP. Altered mental status initially improved after
copious lactulose infusion, but worsened as Mr. [**Known lastname **] became
progressively uremic. Following initiation of dialysis and
aggressive lactulose infusion, Mr. [**Known lastname **] was back at his
baseline mental status. Patient is discharged on 1mg PO Haldol
[**Hospital1 **].
.
#Aspiration: Mr. [**Known lastname **] was noted to aspirate on beside
swallowing study, and had several episodes of desaturation which
were thought to be potentially secondary to aspiration (as noted
above). Per last Video Swallow evaluation, Mr. [**Known lastname **] had
experienced a bit of relief from his dysphagia with biofeedback
swallowing training, and progressed from strict NPO to ground
solids and nectar thick liquids.
.
# Hypoxemia: Upon admission, Mr. [**Known lastname **] was treated for a HCAP
with 8 days of vanc/zosyn/levofloxacin. Initially Mr. [**Known lastname **]
had an oxygen requirement which improved with treatment of his
pneumonia. He experienced hypoxemia on [**1-20**] following completion
of antibiotics which improved spontaneously several hours later
and was likely secondary to a mucous plugging episode. A similar
event occurred on [**2-3**] and improved with aggressive pulmonary
toilet. A component of aspiration is also likely as Mr. [**Known lastname **]
has known microaspiration/penetration on videoswallow
evaluation. He had no further desaturations after being made
NPO.
.
#Hypotension: On admission SBP was persistently in the 70s-80s
with improvement following IVF administration. This likely
represented sepsis [**12-19**] HCAP given fever, chills and bandemia
seen at the OSH. Although no e/o SBP on the basis of OSH
diagnostic paracentesis, systemic infection with possible
intrabdominal source could not be excluded. He was therefore
started on Vanc/Cefepime from empiric coverage of HCAP. Pt's
goal map of 65 was maintained prior to transfer to the floor.
On the floor BP's remained stable and he was disconrtinued from
antibiotics on [**1-23**]. Midodrine was continued thereafter with SBP
ranging from 80-90.
Medications on Admission:
Vancomycin 1000 mg IV x1
Ceftriaxone 1g IV x1
Folate 1 mg PO qd
Lactobacillus 1 tab PO qd
Omeprazole 20 mg PO qd
Sertraline 50 mg PO qd
VitD 800 IU PO qd
Zinc sulfate 220 mg PO qd
Gabapentin 100 mg PO tid
Lactulose 30 ml PO tid
Ascorbic acid 500 mg PO bid
Ondansetron 4 mg IV q6-8h prn
Discharge Medications:
1. folic acid 1 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
2. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO QID (4
times a day).
4. rifaximin 550 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
5. B complex-vitamin C-folic acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
6. midodrine 5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a
day).
7. trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
8. thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
9. cholecalciferol (vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: Two (2)
Tablet PO DAILY (Daily).
10. zinc sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q2H (every 2 hours) as
needed for shortness of breath.
12. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
13. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
14. haloperidol 0.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
15. fluoxetine 10 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
Primary diagnosis:
Alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname **],
It was a pleasure caring for you at [**Hospital1 18**]. You were initially
transferred from another hospital to our intensive care unit.
You were quite sick and developed kidney failure due to your
worsening liver disease. Dialysis was initiated due to this
kidney failure. You continued to be very confused after
dialysis was started and required medications to help this.
Upon discussions with you and your family, we have decided not
to pursue aggressive measures like resuscitation (chest
compressions and shocks) and intubation (breathing tube) should
your heart stop pumping or you stop breathing. Your "code
status" has been changed to DNR/DNI to reflect this wish.
You will continue on dialysis outside of the hospital at your
rehabilitation facility. Remember that any further alcohol
intake could kill you and you should avoid this at all costs.
Further information about possible liver transplant will be
provided to you once you have maintained sobriety for at least 3
months once you return home from the rehabilitation facility.
You will be discharged with a feeding tube in place because your
swallowing muscles are weak and you are at risk of aspirating
foods and liquids which can cause a dangerous pneumonia. Once
the medical staff determines that you are safe to swallow, the
tube can come out. You will receive your medications through
the tube as well.
We have made the following changes to your medications:
STOP spironolactone, sucralfate, metoprolol, omeprazole, and
gabapentin, furosemide
START lansoprazole instead of omeprazole while you have your
feeding tube
START midodrine 15mg three times a day to keep your blood
pressure up for dialysis
START lactulose and rifaximin to prevent your episodes of
confusion from returning
START folic acid and thiamine for your nutrition
START trazadone as needed for sleep
START nephrocaps for nutrition while on dialysis
START Vitamin D
START Zinc
START Albuterol and ipratropium as needed for shortness of
breath
Followup Instructions:
Once you are discharged from the rehabilitation facility, you
should call [**Hospital3 **] to schedule an appointment
with Dr. [**First Name8 (NamePattern2) 7568**] [**Last Name (NamePattern1) 12130**] at ([**Telephone/Fax (1) 30825**].
.
With: Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 7033**]
When: Wednesday, [**3-12**]
Department: LIVER CENTER
Location: [**Hospital1 **]
Phone: [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Known lastname 2380**],[**Known firstname 116**] G Unit No: [**Numeric Identifier 14556**]
Admission Date: [**2183-1-15**] Discharge Date: [**2183-2-10**]
Date of Birth: [**2137-5-17**] Sex: M
Service: MEDICINE
Allergies:
Zoloft
Attending:[**First Name3 (LF) 6349**]
Addendum:
Labs should be drawn once or twice weekly and faxed over to the
Liver Center at [**Telephone/Fax (1) 14557**]: CBC, complete metabolic panel
including LFTs, alkaline phosphatase, bilirubin, and albumin.
He should continue to be evaluated by Speech and Swallow and a
nutritionist to determine his continued need for the nasogastric
tube for feedings and medication administration.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Location (un) 50**]
[**First Name11 (Name Pattern1) 904**] [**Last Name (NamePattern1) 905**] MD [**MD Number(1) 6350**]
Completed by:[**2183-2-10**]
|
[
"789.59",
"038.9",
"486",
"799.02",
"276.2",
"V49.87",
"V45.86",
"276.1",
"425.5",
"428.0",
"507.0",
"572.2",
"V49.86",
"303.90",
"571.2",
"572.4",
"V45.02",
"995.91",
"428.33",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93",
"54.91",
"38.95",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
17227, 17468
|
7570, 9305
|
327, 412
|
13652, 13652
|
3505, 3510
|
15872, 17204
|
2140, 2151
|
11878, 13464
|
13590, 13590
|
11567, 11855
|
13828, 15268
|
2166, 2180
|
2929, 3486
|
15297, 15849
|
229, 289
|
440, 1776
|
13609, 13631
|
3524, 7547
|
13667, 13804
|
1798, 1998
|
2014, 2124
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,836
| 106,153
|
871
|
Discharge summary
|
report
|
Admission Date: [**2187-9-3**] Discharge Date: [**2187-9-6**]
Date of Birth: [**2131-10-29**] Sex: M
Service: MEDICINE
Allergies:
Beta-Adrenergic Blocking Agents / Shellfish
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
CC:[**CC Contact Info 5995**]
Major Surgical or Invasive Procedure:
Upper endoscopy
Colonoscopy
History of Present Illness:
HPI: This is a 55 yo Male with a hx afib, HTN who had BRBPR
tonight then syncopized in the bathroom. Denies LOC or trauma to
his head. The patient denies CP/Abd Pain/dyspnea or other
symptoms. Weak x2days and 1 episode of loose stool yesterday.
Does report abdominal cramping. No history of prior GIB. Never
had colonscopy in past. No NSAID use; does take aspirin daily.
Denies nausea or vomiting.
In the ED, vitals were 98.9, HR 115, 105/48, 14, 100%4LNC.He had
2 large bore [**CC Contact Info **]'s placed, he was t&s, underwent NG lavage. He
had been given 1 L NS. His BP subsequently began to drift down
and pt had large 750cc bright red clot from below; pt
subsequently became bradycardic to 10 and vomited x1 (not blood
per report), appeared less responsive x30 seconds but then came
to. Pt was subsequently emergently given 2U prbcs, 10mg IV
Vitamin K. In addition, a head CT was also performed which was
negative for acute bleed (given his syncopal episode and
coumadin use).
He reports minimal abdominal tenderness, denies chest pain,
palpitations, lightheadedness, headache. ROS otherwise as listed
below. He was recieving 1 U prbcs on arrival (3rd unit).
Past Medical History:
Past Medical History:
Asymptomatic Atrial Fibrillation s/p failed cardioversion [**1-6**];
now rate controlled and on coumadin.
hypertension
obstructive sleep apnea -on cpap at night
Childhood asthma
Achilles tendon surgery
h/o thyroid disease in the mid 70s treated with radioactive
iodine
Social History:
Social History: Patient is married with one child. He is
employed
as a dentist. Denies current ETOH, tobacco or drug use.
Family History:
Family Medical History: mother who died at age 84 secondary to
trauma, and father who had an MI at age 65 and then died of
complications of a large MI in his late 70s. He has two younger
brothers and a sister, all of whom are healthy to his knowledge.
Physical Exam:
Physical Exam:
Vitals: T: 97 BP:121/65 HR: 100 RR:21 O2Sat: 100%RA
GEN: Middle aged male, no acute distress,
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP Clear
NECK: No JVD, no cervical lymphadenopathy
COR: irregularly irregular, no M/G/R, normal S1 S2
PULM: Lungs clear anteriorly, no W/R/R
ABD: Soft, NT, ND, +BS, no rebound/guarding
EXT: No C/C/E
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
========
GI
========
Colonoscopy Impression: Diverticulosis of the descending colon
and splenic flexure One of the diverticulum had evidence of clot
present. This one was located near the splenic flexure.
Otherwise normal colonoscopy to cecum
EGD Impression: Erythema at the GE junction, question of
Barrett's esophagus. Erosions in the antrum and stomach body No
source of GI bleed found Otherwise normal EGD to second part of
the duodenum
========
RADIOLOGY
========
Bleeding Scan INTERPRETATION: Following intravenous injection of
autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow
images and dynamic images of the abdomen for 90 minutes were
obtained. A left lateral view of the pelvis was also obtained.
Blood flow images show physiologic distribution of blood flow.
Dynamic blood pool images show no evidence of gastrointenstinal
system bleed.
IMPRESSION:
No evidence of GI bleed.
.
NON-CONTRAST HEAD CT: There is no evidence of infarction,
hemorrhage, edema, shift of normally midline structures or
hydrocephalus. The density values of the brain parenchyma are
within normal limits. The [**Doctor Last Name 352**]-white matter differentiation is
preserved. The soft tissues and surrounding osseous structures
are not remarkable.
IMPRESSION: Normal study.
========
ECG
========
Atrial fibrillation with mean rate of 96. Compared to the
previous tracing
ST segment changes are less pronounced.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
96 0 84 368/431 0 52 54
=========
LABS
=========
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2187-9-5**] 06:20AM 6.0 3.73* 11.2* 32.3* 86 29.9 34.6 14.6
126*
[**2187-9-4**] 09:25PM 31.0* 125*
[**2187-9-4**] 10:49AM 32.3*
[**2187-9-4**] 04:30AM 5.7 3.50* 10.8* 30.3* 87 30.8 35.6* 15.1
100*
[**2187-9-4**] 12:32AM 31.2* 101*
[**2187-9-3**] 08:54PM 31.8*
[**2187-9-3**] 03:53PM 29.5*
[**2187-9-3**] 12:34PM 33.0* 109*
[**2187-9-3**] 06:09AM 27.5*
Source: Line-[**Year (4 digits) **]
[**2187-9-3**] 04:11AM 10.3 3.39* 10.3* 29.3* 87 30.3 35.1* 14.4
121*
[**2187-9-3**] 12:57AM 10.5 3.72*# 11.4*# 33.5*# 90 30.5 34.0
14.2 172
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2187-9-3**] 04:11AM 91.3* 0 6.5* 1.9* 0.2 0.1
[**2187-9-3**] 12:57AM 72.0* 22.4 3.0 2.1 0.4
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2187-9-3**] 04:11AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2187-9-5**] 06:20AM 126*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2187-9-5**] 06:20AM 99 9 1.2 140 3.6 107 28 9
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2187-9-3**] 12:57AM Using this1
Using this patient's age, gender, and serum creatinine value of
1.6,
Estimated GFR = 45 if non African-American (mL/min/1.73 m2)
Estimated GFR = 55 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 50-59 is 93 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2187-9-4**] 04:30AM 19 42* 164 48 73 2.1*
[**2187-9-3**] 12:57AM 85
OTHER ENZYMES & BILIRUBINS Lipase
[**2187-9-4**] 04:30AM 19
CPK ISOENZYMES CK-MB cTropnT
[**2187-9-3**] 12:57AM <0.011
[**2187-9-3**] 12:57AM NotDone2
<0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
NotDone
CK-MB NOT PERFORMED, TOTAL CK < 100
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2187-9-5**] 06:20AM 8.3* 2.8 2.0
[**2187-9-4**] 04:30AM 3.5 8.0* 2.6* 1.9
[**2187-9-3**] 08:54PM 2.2* 2.0
[**2187-9-3**] 04:11AM 3.1* 7.2* 2.2* 1.8
ADD ON
PITUITARY TSH
[**2187-9-5**] 06:20AM PND
Brief Hospital Course:
1) GIB: Pt was admitted for BRPR. He has had a significant drop
in his hct from a baseline of 48 to 27.3 The pt had one more
bright red stool in the ED. NG lavage was negative. Pt receieved
7 U PRBC, 6 U FFP and Vitamin K. He was placed on an IV PPI.
Coumadin and Aspirin were held in the stting of a GIB.
Colonoscopy was significant for extensive diverticulosis with
the presence of clot. EGD was negative for bleeding, but
suspicious for Barrett's esophagus. The patient's Hct remained
stable in the low 30s and he was transferred to the medicine
floor. He had a normal stool before d/c and did not have any
further BRBPR.
.
2) Afib: Pt rate controlled at home on verapamil. This was
stopped in the setting of GIB. Pt required some prn Lopressor
in the MICU for rate control. Once pt was hemodynamically stable
his Verapamil was restarted. The pt triggered soon after he was
sent to the Medicine floor for HR >140. ECG demonstrated A fib.
Pt required Lopressor IV 5 mg x 1. His verapamil was titrated up
to his home dose and he remained rate controlled, but he did not
remain rate controlled. His dose was increased to 180 mg [**Hospital1 **] and
he was rate controlled thereafter. In the setting of a GIB, the
patient's coumadin and aspirin were stopped. He was given an
appointment with his cardiologist to decide whether these
medications should be restarted as an outpatient.
.
3) Syncope: likely from hypovolemia from blood loss. Recent
cardiac stress testing was good, showing no structural heart
disease. One set of cardiac enzymes were negative and EKG is
unchanged from priors. CT head negative.
.
4) Acute on chronic renal failure: last year, patient's
creatinine started to trend upwards to 1.3, today it is 1.6.
Likely prerenal azotemia in the setting of chronic renal
failure. With appropriate volume resusication, Cr trended down
to 1.2 on day of d/c.
.
# HTN: Initially home anti-HTN were held in the setting of
hemodynamic instablity. These were restarted in the MICU, and pt
had stable VS in the MICU and on the medicine floor.
.
# OSA: Pt on home CPAP. Pt was kept on CPAP during this
hospitlization.
.
# FEN: Diet was advanced as tolerated and tolerated fulls before
d/c
.
# Access- 2 Large bore PIVs; will get 3rd [**Last Name (LF) **], [**First Name3 (LF) **] need to
consider CVL
.
# PPx:pneumoboots given GI bleed, IV ppi
Medications on Admission:
verapamil 120 mg b.i.d.
warfarin per INR.
aspirin 325mg daily
MVI
Discharge Medications:
1. Verapamil 180 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Blood Loss Anemia secondary to gastrointestinal bleed
requiring blood transfusion and fresh frozen plasma
Anemia
Atrial Fibrillation
Acute Renal Failure
Hypertension
Obstructive Sleep Apnea
Discharge Condition:
stable, normal vital signs
Discharge Instructions:
You presented to the hospital with GI bleeding. In the ED you
syncopized and were found to have a heart rate of 10. You
received 10 units of red blood cells and 6 units of fresh frozen
plasma. Your blood counts were below your baseline but stable
thoughout your hospitilization. An upper endoscopy revealed
Barrett's esophagus, but no upper sources of bleeding. A
colonoscopy revealed extensive diverticulosis that were likely
the source of your bleed. There were no active lesions, but some
clot was observed. Your experienced some fast heart rates which
were likely secondary to stopping your at home Verapamil You
were transferred to the medical floor and your at home dose of
Verapamil was restarted. Your heart rate was well controlled at
this dose.
In the setting of a GI bleed, your coumadin and aspirin were
stopped. Please continue to hold these medications until you
follow up with your outpatient physicians.
Please seek immediate medical attention if you experience any
bleeding, diarrhea, abdominal pain, chest pain, shortness of
breath, palpitations, dizziness, syncope or any change in your
condition
Followup Instructions:
Please f/u with your Cardiologist Dr. [**Last Name (STitle) **] on [**9-14**] pm at
2:20 pm. Please f/u with Dr. [**Last Name (STitle) 4539**] (gastroenterology) on [**9-18**] at
2:30 pm. Please f/u with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**2187-10-3**] at 3:40
pm. If you need to see your PCP sooner, please call for an
urgent care appointment.
Completed by:[**2187-9-7**]
|
[
"287.5",
"493.90",
"276.52",
"584.9",
"403.90",
"427.89",
"530.85",
"427.31",
"V58.61",
"458.9",
"585.9",
"285.1",
"562.12",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23",
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9596, 9602
|
6873, 9226
|
331, 360
|
9842, 9871
|
2908, 3836
|
11037, 11450
|
2030, 2284
|
9342, 9573
|
9623, 9821
|
9252, 9319
|
9895, 11014
|
2314, 2889
|
263, 293
|
388, 1559
|
3845, 6850
|
1603, 1874
|
1906, 2014
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,119
| 130,951
|
8778
|
Discharge summary
|
report
|
Admission Date: [**2149-12-31**] Discharge Date: [**2150-1-5**]
Date of Birth: [**2104-6-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Ventricular fibrillation arrest
Major Surgical or Invasive Procedure:
Central line placement
Cardiac cath
History of Present Illness:
45M with a history of MI s/p BMS to RCA 10 years ago is admitted
s/p witnessed cardiac arrest. According to the report, he
collapsed while at work, a bystander found him breathing with a
bleeding laceration to his right forehead and initiated CPR x 20
minutes until EMS arrived, placed an AED, which delivered a
single shock. He received another 40 minutes of compressions and
atropine 1mg, epinephrine 1mg and lidocaine 100mg while
intransit to [**Hospital 4199**] hospital.
.
According to the report, on arrival to Widdham, he was in PEA,
he was treated with epinephrine 1mg x 3, Atropine 1mg x2, and
Amiodarone 300mg and converted to VF, he was cardioverted x 3
and re-entered PEA. He was treated with narcan 2mg, another
epinephrine 1mg x 4 amiodarone 150mg, and re-entered VF and was
cardioverted 2x after which return of spontaneous circulation
was noted. He was started on a amiodarone, heparin and dopamine
drips. In total, he received CPR for 48 minutes at Widdham with
possibly another 60 minutes of CPR in the field. Cooling
protocol was initiated and he was transfered to [**Hospital1 18**] for
evaluation and further management. Fixed and dialated pupils
were noted prior to transfer. On transfer, his vitals were
Temp:95, P:136 BP:94/58, rhythm strip showed afib with RVR.
.
On arrival to the ED, his vitals were: T:91.9 P:121 BP:117/84.
Initial EKG showed Atrial fibrillation with ventricular rate of
126BPM, STE in V4-5 STD II, III, aVF, q waves in II, III, aVF.
In comparison to the EKG from [**2139**], q waves are unchanged,
STD/STE are new. He was successfully cardioverted to sinus
rhythm. Repeat EKG showed improvement in STE/STD with decreased
ventricular rate. CT head showed no acute process, CTA chest
showed emphysematous blebs and no PE. He was admitted to the
CCU.
.
On admission to the CCU, his vitals were BP 123/94, P:83, 100%
on vent settings of 500/12/5 PEEP FIO2 0.5. He was taken to the
cath lab, which showed chronically occluded RCA and LAD with a
patent LCX. Given chronicity of lesions, no intervention was
performed. Ischemic cardiomyopath likely VT/VF arrest. After
cardiac cath patient entered sinus tachycardia and was given
metoprolol leading to hypotension and return of atrial
fibrillation, he was again cardioverted to sinus rhythm. Given
furosemide with appropirate urine output.
.
On discussion with the family, patient has not sought medical
care in the last 9 1/2 years. Following his cardiac cath in
[**2139**], patient was compliant with aspirin, plavix, atenolol,
lisinopril, and lipitor for roughly 6 months after which he
discontinued all medications except Aspirin 81mg and nitro PRN
which he has not taken recently. Accodording to the wife, he has
had long standing dyspnea on exertion, worse in the winter
months. She notes that he does not complain of orthopnea, PND,
palpatations. She reports that he has never had loss of
consciousness.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS:
--[**2139**] BMS x1 to RCA, cath showing 100% stenosis of mid LAD
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Hypertension
- Hyperlipidemia
- [**Year (4 digits) 30680**]
Social History:
- Tobacco history: 2ppd x 29 years (58 pack years)
- ETOH: 1-2 drinks / month
- Illicit drugs: none
Family History:
- Mother: Hypertension, hyperlipidemia, "silent" MI on EKG noted
early 50's
- Father: [**Name (NI) 30680**], first MI at 65
- Maternal GF: CAD 70
- Maternal uncle first MI [**87**]
- Maternal Cousin (female): 46 first MI
- Paternal GF: CAD
Physical Exam:
On admission
GENERAL: Middle aged male intubated, sedated, C-collar in place.
HEENT: 3cm laceration to right brow, sutures in place. Pupils
5mm and not reactive to light. Conjunctiva pink, no pallor or
cyanosis of the oral mucosa.
NECK: C- collar in place, JVP not assessed
CARDIAC: RRR, normal S1, S2. No m/r/g.
LUNGS: CTABL, no rales, wheezes or rhonchi.
ABDOMEN: Soft, ND, Bowelsounds absent
EXTREMITIES: Cool to the touch. Motteling and palor of toes BL,
ashen lower extremities.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP: 0 not dopperable PT: 0 not dopperable
Left: DP: dopplerable PT: 0 not dopperable
Access: Right radial sheath, Right femoral a/v sheaths, Left
femoral VL Left radial A-line.
Pertinent Results:
On Admission:
[**2149-12-31**] 03:30PM BLOOD WBC-19.8* RBC-5.03 Hgb-15.1 Hct-45.8
MCV-91 MCH-30.1 MCHC-33.1 RDW-14.0 Plt Ct-228
[**2149-12-31**] 03:30PM BLOOD PT-15.0* PTT-29.5 INR(PT)-1.3*
[**2149-12-31**] 03:30PM BLOOD Glucose-289* UreaN-11 Creat-1.0 Na-141
K-4.6 Cl-108 HCO3-20* AnGap-18
[**2149-12-31**] 03:30PM BLOOD ALT-240* AST-201* LD(LDH)-572*
CK(CPK)-1093* AlkPhos-60 TotBili-0.3
[**2149-12-31**] 03:30PM BLOOD Lipase-21
[**2149-12-31**] 03:30PM BLOOD cTropnT-0.85*
[**2149-12-31**] 03:30PM BLOOD CK-MB-59* MB Indx-5.4
[**2149-12-31**] 03:30PM BLOOD Albumin-3.3* Calcium-6.4* Phos-4.5 Mg-2.0
[**2149-12-31**] 04:24PM BLOOD %HbA1c-5.7 eAG-117
[**2149-12-31**] 03:30PM BLOOD TSH-1.4
[**2149-12-31**] 07:38PM BLOOD Type-ART Rates-/20 Tidal V-550 FiO2-100
pO2-378* pCO2-28* pH-7.28* calTCO2-14* Base XS--11 AADO2-307 REQ
O2-57 -ASSIST/CON Intubat-INTUBATED
[**2149-12-31**] 06:42PM BLOOD Lactate-3.0*
=
=
========================IMAGING=================================
CT CHEST (performed at OSH,[**2149-12-31**] read by [**Hospital1 18**])
The patient is intubated, with the ET tube terminating within
the distal
trachea. A transesophageal catheter terminates within the
stomach with the
side port at the GE junction.
.
Multiple large blebs are seen throughout both lungs,
predominantly in the
upper zones. There is neighboring interstitial fibrosis.
Moderate dependent atelectasis is seen with enhancement
throughout most of the parenchyma, although there are pockets of
hypoperfusion which may signify an early infectious process
(5:118). No pneumothorax is seen. The great vessels are patent
and normal in caliber. No pulmonary embolism is detected to the
subsegmental levels.
.
The heart size is normal. There is no pericardial effusion.
There is no
effusion or pulmonary edema.
.
Included views of the upper abdomen demonstrate a
normal-appearing liver,
stomach, spleen, and left adrenal gland.
.
OSSEOUS STRUCTURES: There is no acute fracture or dislocation.
No concerning
blastic or lytic lesions are detected.
.
IMPRESSION:
1. Multiple large blebs in a panlobar pattern, raising suspicion
for alpha-1 anti-trypsin deficiency.
2. Moderate dependent atelectasis with pockets of hypoperfused
lung
parenchyma, raising the possibility of early infection or
aspiration.
3. No PE detected to the subsegmental levels.
.
CT HEAD (performed at OSH,[**2149-12-31**] read by [**Hospital1 18**]):
FINDINGS: There is no evidence of acute intracranial hemorrhage,
edema, mass, mass effect, or large vascular territorial
infarction. The ventricles and sulci are normal in
configuration. No acute fracture is seen. A small mucous
retention cyst is present within the right maxillary sinus.
There is mucosal thickening seen within the sphenoid sinuses,
greater on the right. The middle ear cavities and mastoid air
cells are clear.
.
IMPRESSION:
1. No acute intracranial process.
2. Mild sinus disease.
.
ECHO [**2150-1-1**]
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is an apical left
ventricular aneurysm. Overall left ventricular systolic function
is severely depressed (LVEF= 25 %) secondary to multiple focal
wall motion abnormalities including extensive apical akinesis
with focal dyskinesis. Right ventricular chamber size is normal.
There is focal hypokinesis of the apical free wall of the right
ventricle. The aortic root is mildly dilated at the sinus level.
The aortic valve is not well seen. There is no aortic valve
stenosis. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
At time of expiration:
[**2150-1-4**] 03:35AM BLOOD WBC-9.1 RBC-3.84* Hgb-11.3* Hct-32.5*
MCV-85 MCH-29.3 MCHC-34.6 RDW-14.4 Plt Ct-136*
[**2150-1-4**] 03:35AM BLOOD PT-13.3 PTT-53.1* INR(PT)-1.1
[**2150-1-4**] 03:35AM BLOOD Glucose-118* UreaN-13 Creat-0.6 Na-135
K-4.0 Cl-103 HCO3-26 AnGap-10
[**2150-1-4**] 03:35AM BLOOD ALT-99* AST-281* AlkPhos-43 TotBili-0.5
[**2150-1-4**] 03:35AM BLOOD Albumin-2.4* Calcium-7.5* Phos-1.8*
Mg-2.3
[**2150-1-4**] 03:35AM BLOOD Phenyto-10.7
[**2150-1-4**] 03:56AM BLOOD Type-ART pO2-168* pCO2-43 pH-7.44
calTCO2-30 Base XS-5
[**2150-1-4**] 03:56AM BLOOD Lactate-1.0
Brief Hospital Course:
A 45 yoM with PMH Smoking, HTN, HL, CAD s/p BMS to RCX with poor
medical follow up was is transfered s/p Ventricular fibrillation
arrest for cooling protocol.
.
Neurological: Prior to arrival at [**Hospital1 18**], patient was
resuscitated with ACLS for 108 minutes. Per family, patient was
seen on security camera after collapse and was down for 8
minutes prior to the initiation of CPR. Arctic sun protocol was
initiated <6 hours post arrest. Neurologic examination on
admission was notible for fixed and dilated pupils, and absent
corneal reflex. CT head is negative for acute process. After 24
hours, patient was re-warmed and sedation was held. Off
sedation, patient remained unresponsive and was noted to have
clinical signs of seizure. EEG showed status epilepticus,
patient was loaded with keppra followed by dilantin with fair
control of seizure activity. EEG also showed GPEDS pattern which
is associated with high mortality. After a 48 hour period off
sedation, seizure activity increased. A family meeting was held
in which the poor prognosis was discussed and his care was
transitioned to comfort measures only with both the patient's
wife and son in agreement. He expired approximately 8 hours
after extubation with family at bedside. Autopsy was declined by
the family and not referred to the CME.
# CORONARIES: Patient underwent cardioversion in the field and
in PEA arrest at [**Hospital 21242**] hospital where ACLS was continued. He
was successfully resuscitated, intubated, placed on amiodarone
drip, pressors, sedation, and anticoagulation and transferred to
[**Hospital1 18**] for further management. In the ED he was noted to be in
afib with RVR, lateral STEMI. Echo performed at bedside showing
global hypokinesis with anterior, anteroseptal, lateral, and
apical wall motion abnormalities. Admission EKG showed rate
dependent STE elevations likely related to demand ischemia.
Cardiac cath showed old RCX and LAD lesions with patent LCX.
Given chronicity of lesions, no intervention was performed. VF
arrest is likely a result of arrythmagenic focus of infarcted
myocardium.
.
# RHYTHM: Initially in Afib with RVR in the ED. DCCV in the ED
with reuturn to sinus rhythm. Throughout remainder of
hospitalization, patient remained in sinus rhythm.
.
#: GI bleed: On admission, patient was noted to have sanguanous
return from OGT. HCT remained stable throughout hospitalization
and transfusion was not necesary. Stress ulcer is likely
etiology.
.
# Head trauma: Skin laceration on right brow noted by EMS at
time of arrest, likely post traumatic after syncope. Head CT
negative however C-collar could not be cleared without MRI given
neurologic dysfunction.
.
# CHF: Last echo in [**2139**] showed LVEF 40-45%, ECHO peformed on
admission showed severely depressed (LVEF= 25 %) secondary to
multiple focal wall motion abnormalities including extensive
apical akinesis with focal dyskinesis. According to the family,
the patient did not experience congestive heart failure
symptoms.
.
# Resarch: patient consented to participate in corticosteroid in
myocardial infarction study. He was randomized to receive
Hydrocortisone 100mg IV Q8H or placebo x7 days.
.
COMM: Wife [**Name (NI) 1439**] (HCP) (h)[**Telephone/Fax (1) 30681**] (c)[**Telephone/Fax (1) 30682**]
Medications on Admission:
Aspirin 81mg daily
Nitro sublingual PRN
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Anoxic brain injury
2. Cardiac arrest
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
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icd9cm
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[
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[
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12424, 12465
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12646, 12651
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4024, 4761
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3397, 3536
|
265, 298
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401, 3303
|
4794, 9092
|
3567, 3631
|
3325, 3377
|
3647, 3752
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,358
| 119,396
|
48850+48851
|
Discharge summary
|
report+report
|
Admission Date: [**2145-5-3**] Discharge Date: [**2145-5-8**]
Date of Birth: [**2073-11-20**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
shortness of breath, need for ICD
Major Surgical or Invasive Procedure:
none
History of Present Illness:
71 yo M with COPD on 2L home O2, CAD s/p CABG in [**2111**] with
repeat CABG in '[**25**] and residual Left hemidiaphragm paralysis,
PCI with BMS to the prox RCA, as well as a DES in [**2141**] to the
left main and left circ, h/o VT scheduled for an outpatient ICD
implant on [**2145-5-6**] was admitted to OSH on [**2145-5-1**] with increased
SOB x 1 week. There he received levofloxacin for RLL PNA, lasix
for acute on chronic systolic exacerbation, and IV solumedrol
and nebs for COPD flare. He was transferred to [**Hospital1 18**] on the
evening of [**2145-5-3**] for medical management of his CHF/COPD pre
device implantation. On [**2145-5-4**] he was noted to be transiently
somnolent and ABG obtained showing 7.34/109/69. His mental
status cleared and it was felt related to missing CPAP
overnight. On the am of transfer repeat ABG was obtained showing
7.29/130/71 and he was transferred to the MICU for hypercarbic
respiratory failure.
.
On the floor, prior to transfer to the MICU, patient was AAOx3
with mental status at baseline per the team. O2 requirement had
increased from 2 to 4L to maintain sats 90-95%. He received 80mg
IV lasix overnight into [**2145-5-4**] then his home po dose on [**5-4**] of
60mg po in am, 40mg po in pm with I/O -1L. The Pt was report
shortness of breath. He denied productive cough, chest pain,
palpitations, fevers, chills.
.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
.
Past Medical History:
Past Medical History:
CAD s/p CABG in [**2111**] (LIMA to LAD) c/b left phrenic nerve damage
MI in [**2125**] with CABG redo (SVG-OM and SVG-RCA - both known to be
totally occluded)
s/p PCI in [**4-/2142**] with a BMS to the proximal RCA, as well as a
Cypher drug-eluting stent in [**5-/2142**] to the LMCA into LCx.
-h/o VT, pulseless arrest in [**10/2144**]; taken off amiodarone after
EPS did not show inducible arrhythmia (thought due to acidosis)
-CHF, ischemic cardiomyopathy, EF 35%, AR and PR
-Abdominal aortic aneurysm s/p bifurcated graft repair in [**2127**]
-Popliteal aneurysm s/p repair [**2143**]
-COPD with L hemidiaphragm paralysis, leading to restrictive
lung disease. On home O2 (2.5 L/min) since summer [**2143**].
-Hyperlipidemia (dx over 30 years ago)
-Peptic ulcer disease (dx [**2139**])
-Peripheral vascular disease s/p left femoral-to-popliteal
artery bypass graft
-Benign prostatic hypertrophy
-Deep vein thrombosis in UE - patient unsure of details,
?following CABG, patient was in ICU and said both of his arms
were swollen
-Arthritis
Social History:
Smoked 1 pack per day for 30 years, quit 18 years ago. Denies
EtOH usage now as well as illicit drugs. His wife passed away
over 10 years ago from emphysema, and he has two sons. [**Name (NI) **] is a
retired steel worker, originally from [**Location (un) 22931**] and moved to
[**Location (un) 86**] in the [**2095**]. At baseline, able to ambulate around home
and do very minor tasks (wash dishes etc), general poor exercise
tolerance.
Family History:
Brother died of MI at 48. Mother with chronic angina and father
died at age 72 of either a heart attack or abdominal aortic
aneurysm (AAA).
Physical Exam:
VS: BP 135/57, HR 96, RR 18, O2 Sat 92% on 4L
GENERAL: lying in bed, sleeping but arousable
HEENT: moist mucous membranes
NECK: Thick neck; unable to assess JVP.
CARDIAC: regular, no murmurs, no S3/S4 ausculatated.
CHEST: + sternotomy scar
LUNGS: breathing comfortably. Not moving air well. Diffuse
crackles L>R. Much decreased breath sounds at R base. No
wheezing.
ABDOMEN: soft, nontender, nondistended. Bowel sounds present.
EXTREMITIES: no edema, strong distal pulses, + L SVG scar
SKIN: dry, no rashes
Pertinent Results:
Admission labs:
[**2145-5-3**] 10:50PM WBC-8.9# RBC-3.81* HGB-12.3* HCT-37.5* MCV-98
MCH-32.2* MCHC-32.7 RDW-13.4
[**2145-5-3**] 10:50PM GLUCOSE-143* UREA N-45* CREAT-1.7* SODIUM-141
POTASSIUM-5.1 CHLORIDE-87* TOTAL CO2-49* ANION GAP-10
[**2145-5-3**] 10:50PM CALCIUM-8.9 PHOSPHATE-4.6* MAGNESIUM-2.7*
Brief Hospital Course:
Mr. [**Known lastname **] is a 71-year-old man with an extensive coronary
history, systolic CHF with EF 30%, history of VT s/p ablation,
COPD, and CRI, who is transferred from OSH with SOB and
anticipating elective ICD placement.
.
# SOB: Thought to be multifactorial, related to COPD, possible
PNA, mild component of volume overload. On admission he required
4 L O2 (up from baseline 2.5L at home) to maintain O2 Sats
90-95%. He received an additional 80 mg IV lasix the first night
and subsequently was restarted on his home dose of 60 mg PO qam
/ 40 mg PO qpm. On this regimen he was net negative ~800 cc the
first day. For COPD exacerbation, prednisone 60 mg daily was
continued. For PNA, levofloxacin was continued. On the first
hospital day, he had an episode of depressed mental status and
increased RR, with ABG 7.34/109/69, with HCO3 elevated to 49,
consistent with chronic metabolic acidosis, though to be
secondary to COPD. This was similar to ABGs from OSH prior to
transfer, and his mental status and O2 Sats improved with
nebulizer treatments. Given his history of OSH, noctural CPAP
was instituted. On the second hospital day, his mental status
continued to be stable, but HCO3 rose to greater than assay, and
repeat ABG 7.28/130/71. Pulmonary was consulted and recommended
transfer to the MICU for bipap. He initially did not tolerated
BIPAP and was switched to CPAP. He tolerated this comfortably
and his ABG in the AM showed 7.44/81/66. His O2 was weaned and
steroids transitioned to PO. Of note, CPAP was recommened after
sleep study in [**7-10**], but patient doesn't seem to have CPAP at
home. He was continued on CPAP at nights and CPAP machine was
delivered to his home on the day of discharge.
.
# CORONARIES: He has a history of CABG x 2 with multiple stents.
EKG on admission without any changes, and no chest pain.
Troponin not significantly elevated (consistent with baseline,
and in the setting of ARF). ACEI was started. ASA, Plavix, beta
blocker, statin were continued.
.
# PUMP: EF 30%. He did not appear acutely overloaded, and weight
is below reported dry weight (186 lb=84.5 kg). Lasix was
continued at home dose 60 mg qam, 40 mg qpm lasix.
.
# RHYTHM: Patient was in normal sinus rhythm on admission.
History of VT arrest for which he was scheduled for ICD
placement however this was deferred this admission and possibly
indefinitely given respiratory issues. Will need to follow up as
outpatient with Dr. [**Last Name (STitle) **] in clinic in [**2-3**] weeks after
discharge.
.
# ACID/BASE: Patient had a severe respiratory acidosis on
admission, presumably secondary to obstructive pulmonary disease
(although PFTs [**2142**] show only a restrictive defect with normal
FEV1/FVC) with compensatory metabolic alkalosis. CO2 on
admission was well above prior baseline, with bicarb greater
than assay therefore he was transferred to the MICU for bipap,
as above. This resolved to what is presumed to be his baseline
in the high 40's
.
# ARF: Creatinine on admission 1.7 up from baseline 1.4-1.5.
Improved to 1.4 after diuresis.
Medications on Admission:
Home:
1. Aspirin 325 mg po daily
2. Simvastatin 10 mg po daily
3. Clopidogrel 75 mg Tpo daily
4. Albuterol q6h PRN SOB
5. Ranitidine 150 mg po daily
6. Acetaminophen 325 mg po q6h PRN pain
7. Carvedilol 12.5 mg po bid
8. Lasix 60 mg po daily
9. Furosemide 80 mg po qhs
.
at OSH:
Avolox 400 mg IV daily
Florastor 250 mg twice a day
Lovenox 30 mg daily
Lasix 40 mg twice a day
Plavix 75mg daily
Coreg 12.5 mg twice a day
Zantac 150 mg
Aspirin 325mg
Simvistatin 10mg
Duo nebs every 6 hours
Solumedrol 60 mg IV twice a day.
Discharge Medications:
1. CPAP
Nasal CPAP CPAP level: 10 cm/h2o with heated humidification to
maintain SpO2 to >90 and <92
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for SOB.
6. Ranitidine HCl 150 mg Capsule Sig: One (1) Tablet PO once a
day.
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
8. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Lasix 80 mg Tablet Sig: One (1) Tablet PO qpm.
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO daily () for
1 days.
Disp:*2 Tablet(s)* Refills:*0*
13. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO daily ()
for 1 days.
Disp:*3 Tablet(s)* Refills:*0*
14. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for
1 days.
Disp:*1 Tablet(s)* Refills:*0*
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO daily () for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
16. Prednisone 5 mg Tablet Sig: One (1) Tablet PO daily () for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Shortness of breath
Pneumonia, Community Acquired
COPD exacerbation
Acute on Chronic Systolic Heart Failure (EF 30%)
Discharge Condition:
Good. Hemodynamically stable and afebrile. Stable oxygen
requirement.
Discharge Instructions:
You were transferred to [**Hospital1 18**] with shortness of breath thought
to be related to your lung disease and heart failure. You were
treated with antibiotics, steroids and diuretics and your
breathing improved.
The following changes were made to your medications:
1) START prednisone taper as directed
2) START lisinopril 2.5mg daily
Prednisone taper:
Prednisone 40mg on [**2145-5-9**]
Prednisone 30mg on [**2145-5-10**]
Prednisone 20mg on [**2145-5-11**]
Prednisone 10mg on [**2145-5-12**]
Prednisone 5mg on [**6-13**]
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in clinic in [**2-3**] weeks.
Please follow up with Dr. [**Last Name (STitle) **] in [**12-4**] weeks. You may call his
office at [**Telephone/Fax (1) 1144**] to make this appointment.
You should also follow-up with Dr. [**Last Name (STitle) **] in 1 month to
discuss placement of ICD device. This appointment is being made
for you and you will contact[**Name (NI) **] with appointment time. Please
call [**Telephone/Fax (1) 62**] with questions.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2145-5-21**] Admission Date: [**2145-5-8**] Discharge Date: [**2145-5-9**]
Date of Birth: [**2073-11-20**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 7708**]
Chief Complaint:
S/P fall after discharge
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname **] is a 71 yo M with COPD on 2.5L home O2, CAD s/p CABG
in [**2111**] with repeat CABG in '[**25**] and residual Left hemidiaphragm
paralysis, PCI with BMS to the prox RCA, as well as a DES in
[**2141**] to the left main and left circ, h/o VT who was discharged
earlier this morning after being hospitalized from [**Date range (1) 61921**] for
shortness of breath [**1-4**] COPD exacerbation and pneumonia. He was
discharged home on a Prednisone taper.
.
As he was getting into the car, his son went to the other side
to place the oxygen tank into the back seat. He then noted that
his father had fallen down. Per report, the patient did not have
his oxygen on at this time and appeared bluish-grayish in color.
The patient denied any dizziness, chest pain, palpitations, SOB,
or abdominal pain prior to this episode. He states that he felt
week in his knees and fell. He is unsure if he felt like he was
going to pass out. A code blue was called at this time and the
patient was brought back to the ED for further work-up.
.
In the ED, initial vitals were T 98.3 BP 107/60 AR 94 RR 18 O2
sat 95% on 2L. He received calcium gluconate and kayexelate for
hyperkalemia as well as a combivent neb.
Past Medical History:
- CAD s/p CABG in [**2111**] (LIMA to LAD) c/b left phrenic nerve
damage
MI in [**2125**] with CABG redo (SVG-OM and SVG-RCA - both known to be
totally occluded)
- s/p PCI in [**4-/2142**] with a BMS to the proximal RCA, as well as a
Cypher drug-eluting stent in [**5-/2142**] to the LMCA into LCx.
-h/o VT, pulseless arrest in [**10/2144**]; taken off amiodarone after
EPS did not show inducible arrhythmia (thought due to acidosis)
-CHF, ischemic cardiomyopathy, EF 35%, AR and PR
-Abdominal aortic aneurysm s/p bifurcated graft repair in [**2127**]
-Popliteal aneurysm s/p repair [**2143**]
-COPD with L hemidiaphragm paralysis, leading to restrictive
lung disease. On home O2 (2.5 L/min) since summer [**2143**].
-Hyperlipidemia (dx over 30 years ago)
-Peptic ulcer disease (dx [**2139**])
-Peripheral vascular disease s/p left femoral-to-popliteal
artery bypass graft
-Benign prostatic hypertrophy
-Deep vein thrombosis in UE - patient unsure of details,
?following CABG, patient was in ICU and said both of his arms
were swollen
-Arthritis
- Of note, multiple ICU admissions in last year, requiring
multiple intubations
Social History:
Smoked 1 pack per day for 30 years, quit 18 years ago. Denies
EtOH usage now as well as illicit drugs. The patient is
currently living at home. He has two sons.
Family History:
Brother died of MI at 48. Mother with chronic angina and father
died at age 72 of either a heart attack or abdominal aortic
aneurysm (AAA).
Physical Exam:
Vitals T 99.1 BP 112/62 AR 72 RR 18 O2 sat 93% on 3L NC
Gen: Awake and alert, does not appear acutely ill
HEENT: MMM
Heart: Distant heart sounds, no m,r,g
Lungs: CTAB, poor air movement posteriorly likely [**1-4**] poor
effort
Abdomen: Obese, soft, NT/ND, +BS
Extremities: No LE edema, well perfused
Pertinent Results:
ADMISSION LABS:
.
[**2145-5-8**] 08:58PM BLOOD Neuts-83.4* Lymphs-9.8* Monos-5.9 Eos-0.7
Baso-0.1
[**2145-5-9**] 05:40AM BLOOD Glucose-98 UreaN-44* Creat-1.4* Na-139
K-4.6 Cl-89* HCO3-48* AnGap-7*
[**2145-5-9**] 05:40AM BLOOD CK(CPK)-29*
[**2145-5-9**] 05:40AM BLOOD CK-MB-NotDone cTropnT-0.03*
.
.
PERTINENT LABS/STUDIES:
.
ECG: RBBB, no ST-T wave changes, unchanged from prior ECG
.
CT head: Negative.
.
Cxray: No acute findings.
Brief Hospital Course:
Mr. [**Known lastname **] is a 71 M w CAD s/p CABG x 2, CHF EF 30%, h/o Vtach
s/p ablation, CRI, and severe COPD with home 2.5L O2 discharged
earlier today, who was readmitted s/p fall.
.
The patient was found to have hyperkalemia in the ED, where he
was given Kayexelate, calcium, and gluconate. The patient
remained stable overnight. On the morning of [**2145-5-9**], the
patient developed VTach. Given the fact that the patient was
DNR/DNI, he was given IV Amiodarone in an attempt to break the
rhythm. The patient's son was called, who confirmed the fact
that the patient was DNR/DNI. The patient ultimately became
unresponsive and expired 10 minutes later. The patient's family
was informed and an autopsy was declined. The case was reported
to the medical examiner's office, who also declined an autopsy.
Medications on Admission:
CPAP AS DIRECTED
Aspirin 325 mg PO daily
Simvastatin 10 mg PO daily
Clopidogrel 75 mg PO daily
Albuterol nebs Q6H PRN
Ranitidine HCl 150 mg PO daily
Acetaminophen 325-650 mg PO Q6H PRN
Carvedilol 12.5 mg PO BID
Furosemide 60 mg PO daily
Lasix 80 mg PO QPM
Lisinopril 2.5 mg PO daily
Prednisone 40 mg for 1 day, 30 mg for 1 day, 20 mg for 1 day, 10
mg for 3 days, 5 mg for 3 days
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**] MD [**MD Number(1) 7715**]
Completed by:[**2145-5-31**]
|
[
"428.0",
"519.4",
"428.22",
"403.90",
"V45.82",
"600.00",
"486",
"491.21",
"412",
"414.02",
"276.4",
"414.8",
"443.9",
"426.4",
"715.90",
"424.1",
"716.90",
"585.9",
"533.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
16427, 16436
|
15138, 15958
|
11607, 11614
|
16487, 16496
|
14681, 14681
|
16552, 16716
|
14205, 14346
|
16387, 16404
|
16457, 16466
|
15984, 16364
|
16520, 16529
|
14361, 14662
|
1725, 2058
|
11543, 11569
|
11642, 12860
|
15075, 15115
|
14697, 15066
|
12882, 14010
|
14026, 14189
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,671
| 164,773
|
32587
|
Discharge summary
|
report
|
Admission Date: [**2151-3-26**] Discharge Date: [**2151-3-31**]
Date of Birth: [**2093-3-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 75909**] is a 57 year-old male well known to Dr. [**Last Name (STitle) **]
with a history of Afib, PE, s/p left pneumonectomy on [**2151-3-4**]
for T3N2 squamous cell carcinoma
discharged home [**3-10**], w readmissiom on [**3-13**] for failure to
thrive now with syncopal episode while at rest in bed and
generalized left sided chest pain. The patient saw Dr
[**Last Name (STitle) **] in clinic today. He looked well at the time. He
awoke at midnight with generalized left chest pain and
diaphoresis. He "passed out" for 60s according to his daughter.
When he awoke he was alert and orientated and able to move all
extremities. He denied visual symptoms, loss of sensation, limb
weakness, and loss of balance. He denies fevers, chills,
nausea, vomitting, [**Last Name (LF) 75966**], [**First Name3 (LF) 691**] new neurological symptoms,
and any new muskuloskeletal symptoms.
Past Medical History:
1. T3N2 squamous cell carcinoma of the left main stem bronchus
diagnosed [**11-21**]. The initial tumor was a large, necrotic,
friable mass that completely occluded the left mainstem
bronchus; it was associated with left lung collapse and
bilateral hilar and right paratracheal adenopathy. The tumor
was debrided and a stent was placed in early [**11-21**]. Treatment
with combination chemotherapy and XRT was started on [**2150-11-30**].
2. Pulmonary embolism [**11-21**].
3. Post-obstructive pneumonia [**11-21**].
4. Chronic obstructive pulmonary disease.
5. Latent tuberculosis.
6. Pneumonia [**11-21**].
Social History:
70-pack-year smoking history. He is living with his daughter,
[**Name (NI) **]. [**Name2 (NI) **] has three children, two daughters and one son, and he
has grandchildren. He has not been smoking for one month. He
occasionally drinks alcohol and denies illicit drug use or
abuse. He was born in [**Country 5881**] and came to the U.S. roughly forty
years ago.
Family History:
Father died of laryngeal cancer.
Physical Exam:
General: 58 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple, no lymphadenopathy
Card: RRR normal S1,S2 no murmur/gallop or rub
Resp: decreased lungs sounds on left, clear on right
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm no edema
Neuro: non-focal
Pertinent Results:
[**2151-3-30**] WBC-5.6 RBC-3.77* Hgb-11.4* Hct-32.7 Plt Ct-205
[**2151-3-27**] WBC-11.1* RBC-2.63* Hgb-7.8* Hct-23.2 Plt Ct-231
[**2151-3-27**] WBC-10.0 RBC-3.24* Hgb-10.0*# Hct-27.7 Plt Ct-191
[**2151-3-26**] WBC-11.1*# RBC-3.48* Hgb-10.4* Hct-30.7 Plt Ct-317
[**2151-3-26**] PT-51.7* PTT-42.0* INR(PT)-6.0*
[**2151-3-26**] PT-20.1* PTT-33.2 INR(PT)-1.9 after 10 mg Vit K
[**2151-3-29**] PT-13.5* PTT-28.5 INR(PT)-1.2*
[**2151-3-29**] Glucose-120* UreaN-11 Creat-0.8 Na-139 K-3.4 Cl-100
HCO3-27
[**2151-3-26**] Glucose-171* UreaN-12 Creat-1.0 Na-136 K-4.2 Cl-100
HCO3-31
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2151-3-26**]
CT OF THE CHEST: The patient is status post left pneumonectomy.
In the pneumonectomy bed, there is heterogeneous fluid which
nearly fills the cavity as well as a small amount of residual
air. The fluid is quite heterogeneous with large foci of higher
density ([**Doctor Last Name **] 55-60) within it consistent with blood products.
Within this hemorrhage there are several blood-fluid levels both
in the intrapleural and extrapleural spaces in the left
hemithorax, generally seen in the setting of anticoagulation.
The hemorrhagic fluid extends into the left lateral chest wall,
as well. As reported on the concurrent chest radiographs, in the
span of one day, there has been reversal of the previously
leftward mediastinal shift. This suggests a short-interval
increase in the amount of fluid in the left pneumonectomy bed.
The post- contrast images demonstrate no area of active
extravasation, specifically, related to either the bronchial
arteries, or along the chest wall and the projected course of
the intercostal vessels.
The thoracic aortic contour is within normal limits. The heart
size is stable. There is a small non-hemorrhagic pericardial
effusion. Suture material is seen in the left hemithorax, where
there has been resection of the left pulmonary artery. The main
and right pulmonary arteries and their major segmental branches
are clear without evidence of pulmonary embolism. The right lung
demonstrates marked emphysema, as on the preoperative CT. There
is no area of consolidation. Minor dependent changes are noted.
There is no right pleural effusion. The left main stem bronchus
has been ligated. The right-sided bronchial tree is patent
without endobronchial lesion.
IMPRESSION:
1. Heterogeneous, predominantly high-density fluid within the
left pneumonectomy resection cavity, consistent with a prominent
component of acute hemorrhage. This in conjunction with the
reversal of the previously seen leftward mediastinal shift
suggests that the volume of fluid has increased substantially
since one day ago, due to acute bleeding.
2. No acute bleeding source identified at the pneumonectomy
margins. However, the presence of blood/fluid levels at time of
presentation is suggestive of underlying anticoagulation (or
coagulopathy).
3. No right-sided or central PE.
4. Non-aggressive appearing lesion in the left humeral head,
incompletely imaged, which may represent an enchondroma.
ECHO [**2151-3-26**]
IMPRESSION: Small loculated pericardial effusion without
evidence for hemodynamic compromise.
Brief Hospital Course:
Mr. [**Known lastname 75909**] was admitted on [**2151-3-26**] for a syncopal episode at
home. Upon arrival to the ED his blood results revealed an INR
of 6.0. A Chest CT was done and revealed heterogeneous,
predominantly high-density fluid within the left pneumonectomy
resection cavity, consistent with a prominent component of acute
hemorrhage. He was treated with 10 mg IV Vitamin K , 1 unit FFP
and 1 unit of PRBC and 10 mg Decadron. He was transferred to the
SCIU for monitoring and remained stable. He was seen by
endocrinology and cardiology and neurology for his syncopal
episode. No definite cause for his syncopal episode was found.
He had no further episodes while hospitalized. He transferred to
the floor and continued to do well with systolic blood pressures
in the 120-130's. On HD #3 he was started on heparin with a
goal PTT 50-60 and monitored for bleeding. On HD #6 he was
converted to LMW and discharged to home. He will follow-up
with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and [**Hospital 620**] [**Hospital 197**] Clinic for
anticoagulation management. He also will follow-up with Dr.
[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
Isoniazid 300 mg daily, pyridoxine 50 mg daily, fludrocortisone
0.1 mg [**Hospital1 **], famotidine 20 mg q12h, docusate 100 mg [**Hospital1 **],
fluticasone-salmeterol 250/50 [**Hospital1 **], oxycodone-acetaminophen
5-325mg q6h prn, warfin 5 mg qd
Discharge Medications:
1. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous every
twelve (12) hours.
10. Warfarin 2.5 mg Tablet Sig: Take as directed Tablet PO once
a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
T3N2 squamous cell carcinoma of the left main stem bronchus
diagnosed [**11-21**], Post-obstructive pneumonia [**11-21**], Chronic
obstructive pulmonary disease, Latent tuberculosis.Pneumonia
[**11-21**]. PE [**11-21**] (on coumadin), Paraoxymal atrial fibrillation,
syncope
Left pneumectomy [**2-20**]
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office 617-[**Telephone/Fax (1) 75967**] if experience:
-Fever > 101 or chills
-Increased shortness of breath
-Chest pain
-Lovenox 60 mg twice daily until INR > 2.0
-Start Coumadin on [**2151-4-6**] Take 5 mg (2 tablets) then 2.5 mg (1
tablet) daily INR Goal 2.0-2.5 indefinitely.
-Blood draw on Thursday [**4-8**] for INR: call Dr.[**Name (NI) 23247**] office
for further coumadin dosing.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] Date/Time:[**2151-4-15**] 4:00 on the
[**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment.
Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 17753**] for coumadin follow-up
until [**Hospital 620**] [**Hospital 197**] Clinic takes over.
Coumadin follow-up with [**Hospital 620**] [**Hospital 197**] Clinic [**Telephone/Fax (1) 10413**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2151-4-1**] 2:40
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2151-5-13**] 2:30
Completed by:[**2151-4-6**]
|
[
"E878.6",
"530.81",
"496",
"458.0",
"998.11",
"780.2",
"162.8",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8256, 8305
|
5878, 7069
|
330, 337
|
8653, 8660
|
2701, 5855
|
9127, 9983
|
2303, 2337
|
7369, 8233
|
8326, 8632
|
7095, 7346
|
8684, 9104
|
2352, 2682
|
282, 292
|
365, 1270
|
1292, 1905
|
1921, 2287
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,264
| 170,924
|
45673
|
Discharge summary
|
report
|
Admission Date: [**2108-7-1**] Discharge Date: [**2108-7-4**]
Date of Birth: [**2056-2-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
Urosepsis
Major Surgical or Invasive Procedure:
RIJ placement on [**7-1**]
History of Present Illness:
Ms. [**Known lastname **] is a 52F with a PMH s/f cholelithiasis who presented to
the ED with a one day history of abdominal pain. The patient
describes one day of sudden onset of right upper and lower
abdominal pain, sharp, severe "[**9-7**]", radiating to her right
flank. Associated symptoms include nausea, vomiting, polyuria,
and diaphoresis. The patient denies any dysuria. She notes
that she has had this pain chronically, and it had been worked
up over the past year with CT's and MRI's.
In the emergency department initial vital signs were 95.6,
140/115, 152 with 2:1 atrial flutter, 16, 98% RA. Her atrial
flutter converted to sinus rhythm spontaneously without
intervention. Given her history of cholelithiasis, the ED was
concerned about cholelithiasis and gave her ciprofloxacin 400mg
IV x1 and flagyl 500mg x1. The patient underwent an abdominal
ultrasound which showed no evidence of cholecystitis, and a 7 mm
non-obstructing right renal stone. Her blood pressure dropped
to systolics in the 70s, a RIJ was placed, and the patient
recieved 7L of NS. UOP initially showed frank pus, and a UA was
positive. After fluid resuscitation, the patient began to make
urine. She was given a dose of ceftriaxone 1g IV x1 for
presumed urosepsis. Labs were notable for a lactate of 4.0, a
leukocytosis of 16.2, and a TSH of 41. Repeat lactate after IVF
was 2.0
Past Medical History:
Cholelithiasis
HTN
[**Doctor Last Name 933**] Disease
-s/p radioiodine, now on levothyroxine
Anxiety
Gastritis with barrett's esophagus
Migraine headaches
Social History:
The patient lives in [**Location 686**] with her husband. She works as
a school bus driver. She has smoked 1ppd x 20 years, denies
ETOH or illegal drugs
Family History:
Both parents with "kidney stones"
Physical Exam:
T=96.6 BP=124/64 HR=89 RR=25 O2=97% RA
GENERAL: Pleasant african american female in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. 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.
ABDOMEN: Distended, dull to percussion, positive tenderness to
palpation at the right upper, lower quadrants and right flank.
No CVA tenderness, or HSM.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2108-7-1**] 09:17PM TYPE-CENTRAL VE TEMP-35.9 PO2-147* PCO2-26*
PH-7.45 TOTAL CO2-19* BASE XS--3 COMMENTS-GREEN TOP
[**2108-7-1**] 09:17PM LACTATE-1.6
[**2108-7-1**] 09:17PM O2 SAT-98
[**2108-7-1**] 08:31PM GLUCOSE-133* UREA N-24* CREAT-2.9*#
SODIUM-140 POTASSIUM-3.4 CHLORIDE-111* TOTAL CO2-18* ANION
GAP-14
[**2108-7-1**] 08:31PM CALCIUM-7.2* PHOSPHATE-2.5* MAGNESIUM-1.5*
[**2108-7-1**] 04:14PM URINE HOURS-RANDOM
[**2108-7-1**] 04:14PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2108-7-1**] 03:05PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014
[**2108-7-1**] 03:05PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2108-7-1**] 03:05PM URINE RBC-[**10-18**]* WBC->50 BACTERIA-FEW
YEAST-NONE EPI-0
[**2108-7-1**] 02:25PM LACTATE-2.0
[**2108-7-1**] 01:17PM GLUCOSE-157* UREA N-29* CREAT-4.7*#
SODIUM-139 POTASSIUM-3.3 CHLORIDE-97 TOTAL CO2-23 ANION GAP-22*
[**2108-7-1**] 01:17PM estGFR-Using this
[**2108-7-1**] 01:17PM ALT(SGPT)-41* AST(SGOT)-38 ALK PHOS-82 TOT
BILI-0.5
[**2108-7-1**] 01:17PM LIPASE-26
[**2108-7-1**] 01:17PM ALBUMIN-4.4
[**2108-7-1**] 01:17PM TSH-41*
[**2108-7-1**] 01:17PM HCG-17
[**2108-7-1**] 01:17PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-7-1**] 01:17PM PT-12.6 PTT-22.1 INR(PT)-1.1
[**2108-7-1**] 01:12PM GLUCOSE-169* LACTATE-4.0* NA+-123* K+-GREATER
TH CL--89* TCO2-23
[**2108-7-1**] 01:00PM WBC-16.2* RBC-6.16* HGB-17.4* HCT-50.7*
MCV-82 MCH-28.2 MCHC-34.2 RDW-14.8
[**2108-7-1**] 01:00PM NEUTS-80.0* LYMPHS-15.8* MONOS-2.8 EOS-1.0
BASOS-0.4
[**2108-7-1**] 01:00PM PT-12.2 PTT-25.1 INR(PT)-1.0
[**2108-7-1**] 01:00PM PLT COUNT-275
Brief Hospital Course:
Ms. [**Known firstname 97353**] [**Known lastname **] was seen in the ER qith a HT of 150 and then
patient converted spontaneously to NS without any intervention.
The patient was started on ciprofloxacin/flagyl for concern of
colelithiasis; her BP dropped to the 70s and she had an RIJ
placed, was fluid resusitated. UOP showed frank puas, UA was
very positive and she was started to the MICU.
In the MICU patient was continued on ciprofloxacin, was volume
resusitated and monitored. Patient had a USG to r/o
pyelonephritis, that showed a non-obstructive stone in the R
kidney. Creatinine was elevated from baseline to 4.7. Patient
was resusitated with more fluids and antibiotics.
Patient was stable for 24 hours and was transfered to the floor
in HD 3, where the IVF were continued as well as the
antibiotics. Her creatinine improved up to 0.8 and she was
discharged on a 14-day course of ciprofloxacin.
Medications on Admission:
HYDROCHLOROTHIAZIDE 25mg daily
LEVOTHYROXINE 137mcg daily
LISINOPRIL 40mg daily
METOPROLOL SUCCINATE 50mg daily
Discharge Medications:
1. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Urosepsis
Nephrolithiasis
Discharge Condition:
Stable, on antibiotics.
Discharge Instructions:
You were seen and evaluated for a severe urinary tract infection
that was felt to have led to a wide-spread infection in your
body (sepsis) that required an admission to the intensive care
unit. Since then, you've been treated with antibiotics and were
found to be stable during the rest of your hospitalization,
allowing you to be transferred to a general medicine floor. The
urinary tract infection was felt to be due to a kidney stone,
which you should be able to pass on your own, though it will
likely be very painful. You are being discharged home with
antibiotics for this infection as well as a strainer to catch
the kidney stone, which you should use every time you urinate.
Once you have passed the stone, bring it in to your primary care
physician to be analyzed.
.
Take all of your medications as directed. You are being
discharged on antibiotics as well as pain medications, which you
can take as needed. Also, one of your blood pressure
medications, Hydrochlorothiazide (HCTZ) is being held until you
see your primary care doctor, since this medication can affect
your calcium, which is sometimes the cause of kidney stones.
.
Keep all of your follow-up appointments.
.
Call your doctor or go to the ER for any of the following:
fevers/chills, nausea/vomiting, back pain, abdominal pain,
continued or worsened burning/pain with urination, chest pain,
shortness of breath or any other concerning symptoms.
Followup Instructions:
Call your primary care physician to schedule [**Name Initial (PRE) **] follow-up
appointment in [**4-4**] days or sooner, depending on when you pass
the kidney stone.
|
[
"244.9",
"300.00",
"535.50",
"786.59",
"584.5",
"346.90",
"590.10",
"401.9",
"038.42",
"995.91",
"530.85",
"427.31",
"592.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6335, 6341
|
4691, 5598
|
323, 351
|
6411, 6437
|
2892, 4668
|
7904, 8074
|
2122, 2157
|
5761, 6312
|
6362, 6390
|
5624, 5738
|
6461, 7881
|
2172, 2873
|
274, 285
|
379, 1755
|
1777, 1934
|
1950, 2106
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,821
| 108,288
|
18109+18110
|
Discharge summary
|
report+report
|
Admission Date: [**2148-9-4**] Discharge Date: [**2148-10-2**]
Date of Birth: [**2088-6-29**] Sex: M
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
gentleman with a history of left hip replacement in [**2145**],
bladder cancer, and degenerative joint disease who presented
to [**Hospital3 **] Hospital on [**8-29**] with neck pain and back
pain times one week that radiated to his legs and a pustular
rash over his arms bilaterally and his left leg. He was
admitted for a fever of unknown origin and was subsequently
found to have methicillin-resistant Staphylococcus aureus
bacteremia, for which he was treated with oxacillin and
levofloxacin.
On [**9-4**], he was transferred to [**Hospital1 190**] for further evaluation. The patient was also
noted to have a septic right ankle and suspected left wrist
infection. Of note, the patient was complaining of one month
of low back pain and headache with total spine and neck pain.
His temperature maximum prior to admission was 103.1 degrees
Fahrenheit. The patient was noted to have arthralgias and
myalgias as well as tachycardia at the outside hospital.
The patient had a transthoracic echocardiogram done at the
outside hospital which was negative for vegetations. He had
low-grade hemolysis with slight anemia. A bone scan was done
also at the outside hospital which was negative for
osteomyelitis, discitis, or infection of the prior hip
surgery. The patient also had a magnetic resonance imaging
done of his head which was negative for acute infarction and
negative for abnormal parenchymal or left meningeal
enhancement.
PAST MEDICAL HISTORY: (The patient's past medical history
included)
1. Bladder cancer.
2. Degenerative joint disease.
3. Hyperlipidemia.
4. Left hip surgery replacement secondary to degenerative
joint disease in [**2145**].
5. Low back pain.
6. Status post herniorrhaphy in [**2148-1-27**].
MEDICATIONS ON ADMISSION: (His medications on admission
were)
1. Oxacillin 2 g intravenously q.4h.
2. Levofloxacin 500 mg intravenously once per day.
3. Rifampin 900 mg by mouth once per day.
4. Protonix 40 mg by mouth once per day.
5. Morphine 2 mg to 4 mg intravenously q.2h. as needed.
6. Heparin 5000 units subcutaneously q.12h.
7. Toradol 15 mg intravenously q.6h. as needed.
8. Ativan 0.5 mg by mouth q.6h. as needed.
9. Bowel regimen.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in [**Location 30150**]. He
works as a stock broker. No tobacco. Positive alcohol of
one to two drinks per day.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's physical
examination on admission revealed vital signs with a
temperature of 100.9 degrees Fahrenheit, his blood pressure
was 147/78, his heart rate was 102, his respiratory rate was
20, and his oxygen saturation was 97% on 4 liters nasal
cannula. In general, the patient was anxious and awake.
Alert and oriented times three. In no significant distress.
Head, eyes, ears, nose, and throat examination revealed the
mucous membranes were moist. Pupils were equal, round, and
reactive to light. Extraocular muscles were intact. The
neck was supple. No lymphadenopathy. The lungs were clear
to auscultation bilaterally. Cardiovascular examination
revealed positive first heart sound and positive second heart
sound. A systolic ejection murmur at the left upper sternal
border. No gallops. No additional heart sounds. The
abdomen was soft, nontender, and nondistended. Positive
bowel sounds. No masses. Extremity examination revealed no
clubbing or cyanosis. There was 1+ lower extremity edema to
the midshin bilaterally. Skin examination revealed an
erythematous left arm with papular lesions in a heterogenous
distribution. A papular nontender rash without sloughing
skin was present in the bilateral inner thighs without
extension to genitals.
PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent
laboratories and studies on admission revealed his white
blood cell count was 19.8, his hematocrit was 27, and his
platelets were 364. Chemistry-7 revealed his sodium was 140,
potassium was 4, chloride was 106, bicarbonate was 20, blood
urea nitrogen was 24, creatinine was 0.8, and his blood
glucose was 132. Calcium was 7.2, magnesium was 2.7, and his
phosphorous was 4.7. His liver function tests revealed his
albumin was low at 1.9. His alkaline phosphatase was
elevated at 382. His total bilirubin was elevated at 3.7.
His direct bilirubin was 2.1. His AST was elevated at 81.
His ALT was elevated at 117. His creatine kinase was
elevated at 425. His troponin was less than 0.01.
DR.[**Doctor Last Name **].[**Doctor First Name **] 12-ABJ
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2148-10-1**] 16:26
T: [**2148-10-1**] 16:34
JOB#: [**Job Number 50104**]
Admission Date: [**2148-9-4**] Discharge Date: [**2148-10-2**]
Date of Birth: [**2088-6-29**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 60 year old male with
a history of bladder cancer, degenerative joint disease,
status post left total hip replacement in [**2145**], and low back
pain, who was admitted to an outside hospital on [**2148-8-29**],
presenting with two weeks of increasing neck and back pain
and pustular rash on his bilateral upper extremities and left
leg. The patient was found to have a Methicillin sensitive
Staphylococcus aureus bacteremia at the outside hospital and
was treated with Oxacillin, Levofloxacin, Rifampin. He had a
negative chest x-ray at the outside hospital and negative
transthoracic echocardiogram for vegetations. His
sedimentation rate was 126. He also had a bone scan done at
the outside hospital which was negative for osteomyelitis,
discitis or signs of infection of the prior hip surgery. The
patient was transferred to [**Hospital1 188**] on [**2148-9-4**], for transthoracic echocardiogram. The
patient was complaining at the time of admission to having
subjective fevers and chills, tachycardia, arthralgias,
myalgias, as well as the continued pustular rash.
PAST MEDICAL HISTORY:
1. Bladder cancer.
2. Hyperlipidemia.
3. Peripheral neuropathy.
4. Status post left total hip replacement [**2145**].
5. Low back pain.
6. Status post herniorrhaphy [**2148-1-27**].
7. Degenerative joint disease.
8. Status post dental surgery [**2148-6-25**].
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS FROM OUTSIDE HOSPITAL:
1. Oxacillin two grams intravenously q4hours.
2. Cyclobenzaprine.
3. Zofran.
4. Miconazole Powder.
5. Morphine PCA.
6. Ibuprofen.
7. Ambien.
8. Ativan.
9. Colace.
10. Heparin subcutaneous.
11. Protonix.
12. Lipitor at home.
13. Percocet p.r.n.
14. Levofloxacin 500 mg intravenously once daily.
15. Rifampin 900 mg p.o. once daily.
SOCIAL HISTORY: The patient lives in [**Location 30150**]. He
denies tobacco use and positive alcohol use one to two drinks
per day.
PHYSICAL EXAMINATION: On admission, temperature maximum was
100.9, blood pressure 147/78, pulse 102, respiratory rate 20,
oxygen saturation 97% on four liters nasal cannula. In
general, he is anxious, awake and alert and oriented times
three. Head, eyes, ears, nose and throat examination -
Mucous membranes are moist. The pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
are intact. Neck is supple with no lymphadenopathy noted.
Anicteric sclera. The lungs are clear to auscultation
bilaterally. Cardiovascular revealed a systolic murmur at
the left upper sternal border, regular rate and rhythm,
positive S1 and positive S2, no rubs or gallops. The abdomen
is soft, nontender, nondistended, positive bowel sounds.
Extremities - no cyanosis, clubbing with 1+ pedal edema
bilaterally. He has an erythematous pustular rash of the
left arm, heterogeneous distribution. He has a papular rash
bilateral lower thighs but without extension to genitals.
LABORATORY DATA: On admission, his white blood cell count
was 21.0, hematocrit 31.0, platelet count 507,000,
differential with 91% neutrophils, 7% lymphocytes, 2%
monocytes, no bands. Chem7 revealed sodium 142, potassium
4.0, chloride 106, bicarbonate 30, blood urea nitrogen 21,
creatinine 0.7, glucose 84. Total bilirubin elevated at 2.9,
AST 48, ALT 72, alkaline phosphatase elevated at 297. INR
1.2, partial thromboplastin time 31.0. TSH was normal at
4.0. His urinalysis was pH 5.0, white blood cells [**10/2095**],
occasional bacteria.
He had a magnetic resonance scan done on [**2148-8-30**], of his
head which showed no acute infarct, no abnormal parenchymal
or leptomeningeal enhancement. A chest x-ray on [**2148-9-2**],
showed minimal left base atelectasis, negative for congestive
heart failure, negative for pneumothorax. Abdominal CT done
on [**2148-8-29**], showed mild hepatomegaly with diffuse fatty
changes and minimal diverticulosis of the distal descending
and sigmoid colon. Head CT [**2148-8-29**], was negative for
hemorrhage or infarct, negative for mass lesion. Left hip CT
on [**2148-8-30**], showed no lucency or evidence of infection of
the left hip.
HOSPITAL COURSE: This is a 60 year old male with no
significant past medical history aside from a left hip
replacement and degenerative joint disease who now presents
with Methicillin sensitive Staphylococcus bacteremia of high
grade and pustular rash as well as persistent fevers.
1. Infectious disease - The patient had a repeat
transthoracic echocardiogram done on [**2148-9-5**], which showed
no definite vegetations seen on any cardiac valves, however,
a technically suboptimal study was reported. The patient
also had a spinal magnetic resonance scan done on [**2148-9-5**],
due to his persistent back pain which showed significant
paraspinal process in the cervical spine involving C5-C6,
C6-C7 disc spaces, as well as lumbar disc disease at L1-L2,
L2-L3, and L5-S1 with signs of possible osteomyelitis.
The patient was continued on Oxacillin two grams
intravenously q4hours and Gentamicin was added for
synergistic effects. Given the patient's magnetic resonance
scan results positive for osteomyelitis, discitis and
epidural abscesses, neurosurgery was consulted. Dr. [**Last Name (STitle) 1338**]
performed a cervical spinal procedure on [**2148-9-10**], which
included C6 corpectomy and resection of epidural abscess as
well as C5 to C7 fusion with an allograft placement from
iliac crest. The procedure was complicated by tracheal edema
requiring Medical Intensive Care Unit course.
The patient was briefly put in the Intensive Care Unit after
his intubation from his cervical spinal procedure. The
patient also had a transesophageal echocardiogram done at
that time while under anesthesia and was found to have no
vegetations by transesophageal echocardiogram. In the Post
Anesthesia Care Unit, he became hypotensive with the blood
pressure in the 80s which responded to intravenous fluids.
The patient was extubated on the next hospital day.
The patient's blood cultures remained negative throughout his
hospital stay, were obtained daily and then increased to
every other day. Epidural tissue obtained during his
cervical spinal procedure was positive for gram positive
bacteria, Methicillin sensitive. The remainder of the tissue
bone and abscess culture remained negative. It was
recommended by neurosurgery to get a repeat magnetic
resonance scan in three weeks to evaluate the lumbar
abscesses and discitis found on spinal magnetic resonance
scan on [**2148-9-5**].
In addition, the patient had paraspinal masses consistent
with abscess in the psoas muscles bilaterally. The patient
continued to be febrile despite antibiotic treatment and was
noted to develop lower extremity abscesses most significant
in his thighs bilaterally. General surgery was consulted
regarding these fluctuant areas in his bilateral thighs. A
CT of his pelvis was obtained and bilateral lower extremities
on [**2148-9-14**], which showed large multiloculated fluid
collection with enhancing rim in the right lateral thigh,
10.0 by 5.0 centimeters deep to superficial muscles. In
addition, he had multiple small areas in the left thigh with
largest in the quad measuring 4.5 by 2.3 centimeters and no
definitive osteomyelitis by that examination. General
surgery performed an incision and drainage of the patient's
right thigh abscess on [**2148-9-16**], in the operating room.
The patient also had a left thigh abscess that was drained by
interventional radiology by CT guidance on [**2148-9-17**]. The
cultures of the thigh abscesses remained without growth
throughout the [**Hospital 228**] hospital stay.
After these procedures, the patient began to complain of some
right sided flank pain and right low back pain. It was
thought that this pain was possibly related to
musculoskeletal, however, given his history of multiple
abscesses, a reimaging of the patient's lumbar spine and
abdomen was performed. The CT of his abdomen showed no new
abscesses with resolution of his left diaphragmatic
collection found on [**2148-9-19**]. The patient had a repeat
magnetic resonance scan of his lumbar spine which showed an
infection in the inferior L1, L2, L3, crossing the disc
space. A small paraspinal fluid collections at L5 on the
left. Evidence of infection at S1. Question of epidural
involvement as well. He had increased cord signal at the
conus and proximal cauda equina. He had a small right psoas
abscess at L3.
Therefore, given the evidence of progression of lumbar spine
fluid collections despite antibiotic treatment, Dr. [**Last Name (STitle) 1338**]
was again called for neurosurgical intervention. So the
patient had changes of osteomyelitis and discitis in L1-L2,
L2-L3, L5-S1. Dr. [**Last Name (STitle) 1338**] performed on [**2148-9-24**], a
complicated lumbar spinal surgery which included a L5-S1
laminectomy and discectomy as well as L2-L3 discectomy, and
L1-L2 discectomy and L2-L3 fusion with allograft placement.
The patient was noted to have extensive bone destruction and
necrotic discs throughout his lumbar spine on neurosurgical
intraoperative evaluation. The patient had an epidural
catheter placed at that time for pain control. Lumbar disc
was sent and the lumbar disc tissue taken at that procedure
on [**2148-9-24**]. showed 2+ polys and the culture had no growth.
The patient continued to have low grade temperatures despite
intravenous Oxacillin treatment and was changed to
Clindamycin and Vancomycin combination given that his
Methicillin sensitive Staphylococcus aureus may have been a
misinterpretation and the patient may have had Methicillin
resistant Staphylococcus aureus. A mech AG analysis was
attempted on a prior isolate, however, no prior isolates were
available for this examination.
In addition to the patient's cervical spinal abscesses and
lumbar spinal abscesses, he had multiple lower extremity
collections noted on physical examination which were
evaluated by CT scan and ultrasound. The CT scan showed four
total fluid collections in the lower extremity, number one
being the right popliteal fossa 3.0 by 1.6 centimeters,
number two being the left medial portion of the distal third
of the femur, 3.0 by 2.0 centimeters, one in the lateral
portion of the distal third of the femur, 3.0 by 1.0
centimeters, and a left calf posterior medial collection
noted to be 2.5 by 1.0 centimeters.
The patient had an ultrasound done following this
examination, which showed no fluid to be collected by
ultrasound guidance according to their criteria. Therefore,
the fluid was not aspirated by ultrasound guidance. The
patient also had a procedure done of his left hip where the
prosthetic was in place for fluoroscopy guided aspiration of
the hip to see if there was any infection there. The
aspirate showed 4+ polys but no organism and no growth to
date.
Given the amount of fluid and the presence of
polymorphonuclear leukocytes, there is concern that the left
prosthetic was infected possibly seeding other areas of the
body. The patient was evaluated by orthopedics while in
hospital and it was felt there was need for a "washout"
surgery of his left hip. There was discussion the patient
will likely be transferred to [**Hospital6 2910**]
where his original orthopedic surgeon, Dr. [**Last Name (STitle) 21839**], would
perform the washout procedure.
2. Pain control - The patient was seen by the acute pain
service throughout his hospital stay. He had pain moderately
controlled throughout his stay with occasional complaints of
uncontrolled pain and his pain medication was adjusted
appropriately. He was discharged on 30 mg of Oxycontin twice
a day as well as Oxycodone for breakthrough pain 5 to 10 mg
every three to four hours.
3. Hypertension - The patient had occasional episodes of
hypertension while in hospital which was likely related to
his pain. He was started on low dose Metoprolol as well as
Hydrochlorothiazide. He will be discharged on 25 mg of
Metoprolol twice a day as well as once daily 50 mg
Hydrochlorothiazide. Upon discharge, his blood pressure was
controlled, the majority of his pressures being under 125/75.
DISPOSITION: The patient was to be sent to [**Hospital6 11896**] for a brief period of time for a washout
procedure of his left hip and will likely return to [**Hospital1 1444**] for final medical management
after the procedure and stabilization. Dr. [**Last Name (STitle) 21839**] will
perform the procedure at [**Hospital6 2910**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To likely be transferred to [**Hospital6 11896**].
MEDICATIONS ON DISCHARGE:
1. Famotidine 20 mg p.o. twice a day.
2. Heparin subcutaneous q12hours.
3. Acetaminophen 325 mg to 650 mg q4-6hours as needed for
fever and pain.
4. Senna 2.6 mg one tablet twice a day.
5. Colace 100 mg p.o. three times a day.
6. Metoprolol 25 mg twice a day.
7. Bisacodyl 10 mg per rectum at bedtime as needed.
8. Lactulose 30cc q8hours as needed.
9. Hydrochlorothiazide 50 mg once daily.
10. Oxycodone 5 to 10 q3-4hours p.r.n.
11. Morphine Sulfate 30 mg q12hours.
12. Zofran p.r.n.
13. Ativan 1 to 2 mg intravenously p.r.n.
14. Vancomycin one gram intravenously q12hours.
15. Clindamycin 300 mg intravenously q6hours.
FOLLOW-UP: The patient was likely to return to [**Hospital1 346**] following his left hip washout
surgery done by Dr. [**Last Name (STitle) 21839**] on [**2148-10-2**].
DR[**Last Name (LF) **],[**First Name3 (LF) **] 12-ABJ
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2148-10-1**] 17:17
T: [**2148-10-1**] 18:06
JOB#: [**Job Number 50105**]
|
[
"324.1",
"730.08",
"728.89",
"401.9",
"038.9",
"682.6",
"722.91",
"V10.51",
"722.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"80.51",
"86.22",
"81.62",
"81.08",
"77.69",
"81.91",
"03.4",
"81.02"
] |
icd9pcs
|
[
[
[]
]
] |
2607, 5063
|
17732, 18754
|
1974, 2438
|
9244, 17601
|
7060, 9226
|
5092, 6180
|
6202, 6901
|
6918, 7037
|
17626, 17706
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,618
| 110,247
|
36612
|
Discharge summary
|
report
|
Admission Date: [**2197-6-4**] Discharge Date: [**2197-6-12**]
Service: CARDIOTHORACIC
Allergies:
Vicodin / Propoxyphene
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Pneumothorax -chest pain and Shortness of Breath
Major Surgical or Invasive Procedure:
Right thoracoscopy and wedge resection of bulla
involving right lower and right middle lobe.
History of Present Illness:
Pt is an 89 yo F originally admitted to an OSH on [**5-23**] w/ c/o 1
episode of hemoptysis w/ assoc chest pain, SOB. Pt was admitted
w/ diagnosis of secondary spontaneous PTX. Initial CXR showed a
50% right sided PTX. Her initial EKG showed sinus tachy (HR =
113) but no evid of ischemia, and her SpO2 was 98% on 100%
nonrebreather. A right sided chest tube was placed and the
patient had resolution of her PTX, but maintained a persistent
air leak. CT Chest was obtained and indicated two
Aveolar-pleural
fistulas, and a bronchoscopy was performed w/ no major
pathology.
The outside hospital evaluated her and determined that she would
not tolerate a thoracatomy and requested transfer and evaluation
for bronchopleural fistula at [**Hospital1 **].
Past Medical History:
COPD, Emphysema.
Pt on 3L home o2
Social History:
Quit tob [**2191**], prior 1ppd x 70 years
Denies EtOH
No illicits
Lives with daughter
Family History:
+HTN
+EtOH abuse
+Cancer
Pertinent Results:
[**2197-6-4**] 09:40PM BLOOD WBC-8.3 RBC-3.67* Hgb-11.2* Hct-35.2*
MCV-96 MCH-30.6 MCHC-31.9 RDW-14.5 Plt Ct-162
[**2197-6-4**] 09:40PM BLOOD Neuts-86.7* Lymphs-10.1* Monos-2.4
Eos-0.6 Baso-0.2
[**2197-6-4**] 09:40PM BLOOD Plt Ct-162
[**2197-6-4**] 09:40PM BLOOD PT-12.9 PTT-22.1 INR(PT)-1.1
[**2197-6-4**] 09:40PM BLOOD Glucose-237* UreaN-21* Creat-0.7 Na-143
K-4.1 Cl-99 HCO3-34* AnGap-14
[**2197-6-4**] 09:40PM BLOOD Calcium-8.5 Phos-2.6* Mg-2.1
[**2197-6-9**] 03:54AM BLOOD WBC-11.1* RBC-3.23* Hgb-10.1* Hct-32.6*
MCV-101* MCH-31.4 MCHC-31.1 RDW-14.8 Plt Ct-202
[**2197-6-10**] 05:53AM BLOOD Glucose-96 UreaN-11 Creat-0.5 Na-142
K-3.6 Cl-102 HCO3-33* AnGap-11
[**2197-6-8**] 02:40AM BLOOD Type-ART pO2-96 pCO2-43 pH-7.52*
calTCO2-36* Base XS-11
[**2197-6-7**] 09:01PM BLOOD Type-ART pO2-68* pCO2-50* pH-7.43
calTCO2-34* Base XS-7
[**2197-6-7**] 02:34PM BLOOD Glucose-188* Lactate-1.1 Na-139 K-3.6
Cl-96*
Brief Hospital Course:
89 yo female with an extensive smoking history with COPD on home
oxygen, osteoporosis s/p recent hip fracture s/p ORIF, sacral
decub, who presents from an OSH for evaluation of surgical
intervention of a R bronchopulmonary fistula. According to OSH
records, the patient reported to the OSH on [**5-23**] with complaints
of hemoptysis x 1. Pt reports she was in rehab x 3 days and then
discharged home from rehab on [**5-23**]. That night, she went home
and had hemoptysis x 1 while eating dinner-- never happened
before. Denied any increased SOB at this time. Her son in law
witnessed the event, and then brought her to the OSH ED. In the
OSH ED, a
CXR then revealed a large R sided PTX with >50 percent of the R
lung involved. A chest tube was placed and pulmonary was
consulted. The patient's PTX failed to improve, and a CT chest
subsequently revealed two bronchopulmonary fistulas. A BAL was
performed, which according to ID notes grew aspergillus and
Stenotrophomonas, and the patient was started on voriconazole
for presumptive invasive aspergillus infection. She was started
on empiric Flagyl for diarrhea. The patient was then transferred
to [**Hospital1 18**] on [**2197-6-4**] for further management and possible surgical
intervention. [**2197-6-5**] a the chest tube placed to water seal,
patient did not tolerate this with SOB and chest pain. On CXR
30% PTX noted patient placed back to suction. [**2197-6-6**] ID
consult and rec commended to continue voriconazole and Flagyl.
Also Palliative care meet with patient to discuss up coming
surgery and post-op plan. Patient is a DNR/DNI and does not with
to have prolonged life support. Family meeting was also held to
review surgery risks benefits and post-op course.
On [**2197-6-7**] to operating room for:Right thoracoscopy and wedge
resection of bulla
involving right lower and right middle lobe. admitted to the ICU
intubated and sedated. POD#1 Chest tube trial to water seal
failed with continued air leak, placed back to suction.
Continued with sedation and mechanical ventilation. POD#2
patient extubated, chest tube continued with air leak also
continued requiring pressors. POD#3 Air leak in chest tube
continues, BP, hr and uop labile, remains on pressors. POD#4
Continue with labile BP, HR and UOP requiring pressors, also
patient having increased o2 requirement and less responsive. On
POD#5 [**2197-6-12**] Patient non responsive, requiring more pressors
and oxygen. Daughter at bedside, after discussion with Dr. [**First Name (STitle) **]
following patients wishes life supportive measures stopped and
patient deceased.
Medications on Admission:
Advair 250/50
Norvasc
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
Discharge Condition:
death
Completed by:[**2197-6-12**]
|
[
"496",
"458.29",
"263.9",
"733.00",
"788.20",
"512.8",
"707.03",
"787.91",
"707.21",
"117.3",
"518.5",
"510.0",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"32.20"
] |
icd9pcs
|
[
[
[]
]
] |
4992, 5001
|
2315, 4920
|
284, 379
|
5065, 5101
|
1383, 2292
|
1337, 1364
|
5022, 5044
|
4946, 4969
|
196, 246
|
407, 1160
|
1182, 1217
|
1233, 1321
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,187
| 141,931
|
143
|
Discharge summary
|
report
|
Admission Date: [**2142-5-31**] Discharge Date: [**2142-6-8**]
Date of Birth: [**2070-2-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain, dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2142-5-31**] Four Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary to left anterior descending artery,
with vein grafts to ramus intermedius, obtuse marginal and PDA.
History of Present Illness:
This is a 72 year old with known coronary artery disease. Over
the last several months, he began to experience worsening chest
pain and dyspnea on exertion. He recently underwent stress
testng which was positive for ischemia. Stress ECHO in [**Month (only) 216**]
[**2140**] was notable for an LVEF of 55-60%. Subsequent cardiac
catheterization on [**2142-5-11**] revealed severe three vessel coronary
artery disease. Based upon the above results, he was referred
for coronary surgical intervention.
Past Medical History:
Coronary Artery Disease
History of PTCA(ramus) [**2128**]
History of Myocardial Infarction [**2125**]
Diabetes Mellitus Type II
Hypertension
Hyperlipidemia
History of Prostate Cancer - s/p Radical Prostatectomy
Arthritis
Gout
Tonsillectomy
Social History:
Married with grown children. He is a very active volunteer. He
worked at the Mass Transit Authority prior to retiring/ Social
history is significant for the absence of current tobacco use,
quit in [**2091**]. There is no history of alcohol abuse and no
current alcohol use.
Family History:
There is no family history of premature coronary artery disease
or sudden death. His father had CHF in his 80s.
Physical Exam:
Vitals: BP 167/80, HR 56, RR 18
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, no carotid bruits
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2142-6-8**] 06:50AM BLOOD WBC-8.6 RBC-3.41* Hgb-10.1* Hct-31.0*
MCV-91 MCH-29.6 MCHC-32.6 RDW-14.6 Plt Ct-455*
[**2142-6-8**] 06:50AM BLOOD PT-24.3* INR(PT)-2.4*
[**2142-6-8**] 06:50AM BLOOD Glucose-120* UreaN-32* Creat-1.8* Na-138
K-4.7 Cl-101 HCO3-28 AnGap-14
RADIOLOGY Final Report
CHEST (PA & LAT) [**2142-6-8**] 9:23 AM
CHEST (PA & LAT)
Reason: evaluate ?pneumomediastinum
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with h/o MI [**2125**], presented for cath found to
have 3VD.
REASON FOR THIS EXAMINATION:
evaluate ?pneumomediastinum
INDICATIONS: 72-year-old man with recent coronary artery bypass
graft surgery.
CHEST, PA AND LATERA: Cardiac and mediastinal contours are
[**Year (4 digits) 1506**]. There is persistent large left-sided pleural effusion
with atelectasis. A small [**Year (4 digits) 1506**] right pleural effusion is
also noted. A tiny focus of air in the anterior mediastinum
persists.
IMPRESSION: Similar large left-sided pleural effusion. Tiny
post-operative air collection of 8 mm in diameter, [**Year (4 digits) 1506**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Cardiology Report ECHO Study Date of [**2142-5-31**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for CABG procedure
Height: (in) 71
Weight (lb): 206
BSA (m2): 2.14 m2
BP (mm Hg): 135/76
HR (bpm): 56
Status: Inpatient
Date/Time: [**2142-5-31**] at 10:07
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 50% (nl >=55%)
Aorta - Ascending: 3.1 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.3 m/sec
Mitral Valve - E/A Ratio: 2.33
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA
and extending into the RV. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly
depressed LVEF.
No resting LVOT gradient.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid
anteroseptal - hypo; anterior apex - hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in ascending
aorta. Simple atheroma in aortic arch. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral
annular calcification. Moderate (2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
Conclusions:
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2.There is mild regional left ventricular systolic dysfunction
with mild
hypokinesia of the apex of the anterior wall, mid and apical
portions of the
anterior septum. Overall left ventricular systolic function is
mildly
depressed.
3. Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the ascending aorta. There are
simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic
aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is
not present. No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. There is no
mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The mitral
annulus is
not dilated.
Post bypass: Pt is being AV paced and is on an infusion of
phenylephrine
1. Biventricular function is preserved.
2. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**] in severity
3. Aorta and interatrial septum are intact post decannulation
4. Other findings are [**Last Name (Titles) 1506**]
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2142-6-1**] 13:19.
Brief Hospital Course:
Mr. [**Known lastname 1503**] was admitted and underwent coronary artery bypass
grafting surgery. For surgical details, please see seperate
dictated operative note. Following the operation, he was brought
to the CSRU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. He
maintained stable hemodynamics and transferred to the SDU on
postoperative day one. Given his renal insufficiency, BUN and
creatinine were monitored very closely. His creatinine peaked to
2.2 on postoperative day two. By discharge, his renal function
returned to baseline. He was also noted to have diffuse ST
elevation on electrocardiogram consistent with pericarditis and
eventually went on to develop atrial flutter. Beta blockade was
advanced. K and Mg levels were monitored and repleted per
protocol. He otherwise continued to make clinical improvements
with diuresis and physical therapy. He developed LUE
thrombophlebitis on POD#7 and was treated with Vanco and
evaluated by Vasc. [**Doctor First Name **]. who felt surgical intervention was not
indicated. His forearm improved and he was discharged to home
on POD#8 in stable condition. He was anticoagulated with
coumadin and will have his INR followed by Dr. [**First Name (STitle) 1511**].
Medications on Admission:
Aspirin 325 qd, Lisinopril 10 qd, Lovastatin 20 qd, Metformin
500 qd, Toprol XL 25 qd, Tricor 145 qd, Caltrate 600 [**Hospital1 **],
Centrum qd, Glucosamine qd
Discharge Medications:
1. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days: For left forearm phlebitis.
Disp:*28 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. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
take 400mg daily for one week, then 200mg daily.
Disp:*60 Tablet(s)* Refills:*0*
9. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day:
Please take coumadin as directed by Dr. [**First Name (STitle) 1511**].
Disp:*30 Tablet(s)* Refills:*0*
10. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day:
please take as directed by Dr. [**First Name (STitle) 1511**].
Disp:*60 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
Please draw an INR on saturday [**2142-6-8**] and fax results to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1511**] at ([**Telephone/Fax (1) 1512**]. Phone number ([**Telephone/Fax (1) 1513**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1514**] Regional VNA
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Postop Atrial Flutter
History of PTCA [**2128**]
History of Myocardial Infarction [**2125**]
Diabetes Mellitus Type II
Hypertension
Hyperlipidemia
History of Prostate Cancer - s/p Prostatectomy
Arthritis
Gout
Discharge Condition:
Stable
Discharge Instructions:
Patient should shower daily, no baths. No creams, lotions or
ointments to incisions. No driving for at least one month. No
lifting more than 10 lbs for at least 10 weeks from the date of
surgery. Monitor wounds for signs of infection. Please call
cardiac surgeon if start to experience fevers, sternal drainage
and/or wound erythema.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-15**] weeks, call for appt
Dr. [**Last Name (STitle) 120**] in [**1-13**] weeks, call for appt
Dr. [**First Name (STitle) 1511**] in [**1-13**] weeks, call for appt
Completed by:[**2142-6-11**]
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70,078
| 109,181
|
4309
|
Discharge summary
|
report
|
Admission Date: [**2167-1-20**] Discharge Date: [**2167-1-22**]
Date of Birth: [**2097-4-29**] Sex: M
Service: MEDICINE
Allergies:
Ranitidine
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
chest pain/shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization [**2167-1-20**]
History of Present Illness:
69M CAD s/p CABG in [**2152**], DM2, CKD on HD, radiation cystitis
complicated by enterococcal UTI ([**1-21**]) and history of
enterococcal endocarditis presenting with chest pain and dyspnea
on exertion for several weeks responsive to nitroglycerin. He
noticed that pain occasionally radiated to bilateral arms. He
denies fevers, chills, nausea/vomiting. He also denies PND or
orthopnea.
Patient was due for outpatient c. cath on Thursday with his
cardiologist Dr. [**Last Name (STitle) **]. He was advised to present to the ED
given increased frequency and intensity of chest discomfort. He
initially presented to OSH and was transferred here due to
cardiology care here. He states that the reason why he came
today was that he usually uses oxygen at HD sessions, but his
doctor told him that he can't do that on a regular basis. It was
also ascertained that for the past 3 weeks that he was using
[**8-21**] SLNTGs a day for chest discomfort occuring both at rest and
with exertion. This represents increased frequency of his
symptoms - intensity has been the same.
Of note, he also was complained about needing oxygen and
subsequently is doing well on 3 L NC. He does endorse some chest
congestion now.
.
In the ED, initial VS: 22:34 0 98.1 91 101/51 18 100% 3L.
ECG showed SR at 95 bpm with lateral ST depression and no STEMI.
There were some dynamic depressions in V4-V5 while patient was
chest pain free on arrival here.
OSH labs at 8 PM showing WBC 6.3, Hgb 12.4, Plt 156. Chemistry
panel was Na 134, K 3.7, Cl 90, HCO3 30, BUN 35, Cr 2.8 and
Glucose 132. Troponin I was 0.03.
A bedside ECHO in the ER showed no effusion with an EF of about
40 % with poor lateral squeeze. CXR showed mild volume overload
and airspace pulmonary edema. He was guiaic negative on exam.
He also did have active chest pain at 11:15 PM relieved by
sublingal nitroglycerin. A repeat ECG did showed worsening
depression in V3 and improved in V5. The attending cardiologist
assessed him in the ER, recommended heparin infusion and
nitroglycerin infusion given frequent chest discomfort.
Initial labs showed Cr 3.4 (HD patient), anion gap 22, TropnT
0.04. Hgb was 12.3 near baseline.
VS on transfer were: 105/49, 88, 18, 100% 3L nc
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG x 4 '[**52**] (LIMA-LAD, SVG-OM, SVG-D1, SVG-PDA)
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2160**]: Two 2.5 Cypher
stents and a 3.0 Cypher stent were placed in the LM and RI.
in [**2161**]: drug-eluting stent placed in the ramus intermedius.
- History of enterococcal endocarditis
.
3. OTHER PAST MEDICAL HISTORY:
Prostate Cancer s/p Radical prostatectomy and XRT in [**2162**]
Radiation cystitis s/p 60 hyperbaric oxygen treatments in [**2164**],
Clot irrigation [**10-21**], transfusions, silver nitrate irrigation,
Colon cancer stage III s/p colectomy/postop FOLFOX
GERD
Sigmoid colectomy, [**2162**]
Cystoscopy, clot evacuation, [**10/2165**]
Cystoscopy, formulin instillation [**2165-12-28**]
Hypertension
Diabetes Mellitus Type 2
.
PSH:
s/p CABG x4 [**2152**]
s/p prostatectomy
s/p appendectomy in [**2160**]
s/p cholecystectomy [**2159**]
s/p ear, tonsil and adenoid surgery
s/p femoral rodding
s/p back surgery
Social History:
Retired estimator for an environmental company. Lives with wife.
Quit smoking in [**2165-12-11**], but previously smoked [**1-12**] ppd (~120
pack years). Previously drank ~ [**1-12**] case of beer daily, now
sober for many years. Denies illicit drug use.
Family History:
Unknown, as the patient does not know his biological parents.
Physical Exam:
ADMISSION EXAM
VS T 97.9 BP 110/62 HR 98 RR 20 pOx 95 on 2L Weight: 59.6 kg
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, + SEM, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
+ bruit in LUE dialysis fistula
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength 5/5 throughout, sensation grossly intact throughout,
DTRs 2+, gait deferred.
DISCHARGE EXAM
pt pulseless, without corneal reflex, without heart sounds.
Pertinent Results:
# LABORATORY DATA
.
ADMISSION LABS
[**2167-1-19**] 11:30PM BLOOD WBC-5.9 RBC-3.64* Hgb-12.3* Hct-36.2*
MCV-99* MCH-33.9* MCHC-34.1 RDW-14.2 Plt Ct-165
[**2167-1-19**] 11:30PM BLOOD Neuts-77.9* Lymphs-14.5* Monos-5.5
Eos-1.8 Baso-0.4
[**2167-1-19**] 11:30PM BLOOD PT-12.7* PTT-29.0 INR(PT)-1.2*
[**2167-1-19**] 11:30PM BLOOD Glucose-142* UreaN-42* Creat-3.4* Na-137
K-4.2 Cl-97 HCO3-22 AnGap-22*
[**2167-1-22**] creatinine up to 3.5
CARDIAC BIOMARKERS
[**2167-1-19**] 11:30PM BLOOD cTropnT-0.04*
[**2167-1-20**] 07:40AM BLOOD CK-MB-1 cTropnT-0.04*
[**2167-1-20**] 07:40AM BLOOD CK(CPK)-8*, CKMB 1
# IMAGING
CXR (Portable) [**2167-1-19**]
CHEST, AP: Right dialysis catheter again terminates in the mid
right atrium. Lungs are overinflated, with biapical
hyperlucency. There is new right lower lobe opacity with
obscuration of the hemidiaphragm. Increasing volume overload
with mild cardiomegaly, central venous congestion, and
interstitial/early airspace pulmonary edema. Probable small left
effusion. CABG changes are noted, with median sternotomy wires
and mediastinal clips.
IMPRESSION:
1. Possible right lower lobe pneumonia.
2. Increasing volume overload.
.
cardiac cath
# CARDIAC CATHETERIZATION [**2167-1-20**]
(Prelim report was up)
COMMENTS:
1. Selective native coronary angiography of this right dominant
system
demonstrated severe 2 vessel coronary artery disease. The RCA
was not
engaged due to it having a known total occlusion. The LMCA had
minimal
non-angiographically significant coronary artery disease with a
patent
stent. The LAD had a proximal total occlusion. The LCX had a
proximal
total occlusion. The ramus had a patent stent with minimal
non-angiographically significant coronary artery disease.
2. Selective venous conduit angiography demonstrated widely
patent SVG
to PDA, and SVG to Diagnoal grafts. The SVG to OM graft was
patent,
with a 60% stenosis at the ostium of the bypassed OM at its
point of
attachment to the LCX.
3. Selective arterial conduit angiography demonstrated a widely
patent LIMA to LAD graft. The distal native LAD had a 80%
lesion.
4. Successful balloon angioplasty of the LAD with a 2.0 x 8 mm
balloon
(see PTCA comments).
FINAL DIAGNOSIS:
1. Severe two vessel native coronary artery disease (RCA not
evaluated
due to a known total occlusion)
2. Patent LIMA to LAD graft with an 80% stenosis in the distal
native
LAD.
3. Patent SVG to Diagonal, SVG to PDA, and SVG to OM grafts.
4. Mild asymptomatic systemic arterial hypotension.
5. Successful POBA of the LAD with a 2.0 x 8 mm balloon.
.
TTE [**2167-1-20**]
Moderately dilated left ventricle. Regional left ventricular
systolic dysfunction c/w CAD. Probable small vegetation on
aortic valve, right coronary cusp. Moderate aortic
regurgitation. Moderate mitral regurgitation. At least moderate
pulmonary hypertension. Mild right ventricular global
hypokinesis. Compared with the prior study (images reviewed) of
[**2166-9-12**], regional left ventricular systolic dysfunction is more
extensive (distal LAD territory). The severity of pulmonary
hypertension has increased. There is right ventricular
dysfunction. The aortic valve vegetation appears similar in
size.
Brief Hospital Course:
69 yo M with CAD s/p CABG ([**2152**]), DMII, and ESRD presenting with
worsening chest pains and DOE. He had been taking multiple
nitroglycerin tabs daily ([**8-21**]) in addition to his long acting
nitrates. He was scheduled for outpatient cath 2 days from
admission, however presented to the ED with worsening frequency
and severity of his chest pains. He was started on heparin and
nitro drips and admitted to the cardiology floor. He continued
to have chest pains overnight and was was taken to the cath lab
on the morning of [**1-20**]. Received 600mg plavix, bivalirudin, no
stents placed. balloon angioplasty to LAD. During the cath, he
continued to have chest pains. He contined to have lateral ST
depressions on his EKG after the procedure. He was initially
chest pain free after the procedure, however his chest pains
have returned and he was to be transferred to the CCU for
further management.
.
# Acute coronary syndrome - presented with increased freq of CP
including at rest with troponins slightly elevated. Pt to cath
lab [**2167-1-20**], with severe 2 vessel native disease RCA with total
occlusion, patent grafts, balloon angioplasty to LAD, unable to
access circ lesion. Cath also showed patent LIMA to LAD graft
and patent SVG to OM, SVG to Diagonal, and SVG to PDA grafts. Pt
to CCU for monitoring. He was given 25mg metoprolol after cath.
On transfer to the CCU (after several hours chest pain free) pt
developed [**6-21**] chest pressure. Nitro drip was increased to 1.2
with good resolution of pain. ECG with 1mm elevations in V1, V2
with 1mm depressions V3-V5. Pt was sleeping calmly following
this episode. That afternoon pt with acute episode of
diaphoresis, chest pain, and dyspnea. O2 sats 95 on 3L nc, BP
80s/40s so limited in ability to uptitrate nitro drip which was
at 1.2. ECG showed depressions in antero-lateral leads unchanged
from ECGs from prior. got ipratropium nebs (HR was high 90s) and
klonipin. within 10-20 minutes pt was without dyspnea/CP, stated
that he had a lot of anxiety about the procedure not able to
open up the circ lesion.
Nitro gtt was continued, eventually weaned and pt put on home
dose imdur. Pt continued to have episodes of [**6-21**] chest pain but
ECGs were all with stable anterolateral depressions. Even when
CP resolved ECGs with those findings. Pt was continued on
atorvastatin, aspirin, plavix, and metoprolol. His blood
pressures remained in the 80s/40s, appears his b/l roughly
around this range, but this limited our ability to increase
nitro. Imdur was held.
.
#PEA ARREST - on the day of arrest [**2167-1-22**] pt had been asx with
hypotension 70s-80s during the morning via NIBP. Pt continuing
to c/o of recurring dull aching chest pain which was pleuritic
and reproducible with palpation. Pt very anxious when staff not
in room with him. Pt given ativan 0.5mg po x 1 at 0730hrs and
tylenol with slight decrease in anxiety and pain. No further c/o
of chest pain since 1100hrs. Rt radial Aline placed by team
with ABP initially 90s decreasing to 70-80s. Obtained double
lumen PICC line Right brachial. Started po midodrine for low BP.
Started Neo with little effect on SBP SBP 78 on 3mcg/kg/min.
Initally attempting to start CRRT at 1330hrs with slight
decrease in SBP but filter malfunctioned and blood returned and
new filter set up re-set up. CRRT re-started with no fluid
removal at 1500hrs ?????? titrated up Neo to 5mcg/kg/min when sBP
started to decreased to low 70s ?????? for ~2min had increased fluid
removal rate to remove only IVF that were being given to patient
for CRRT but turned it back down to zero for no fluid removal
when SBP decreasing to low 70s then turned off CRRT when BP
dropped to 60s ?????? pt became unresponsive and CODE called. Pt was
in PEA, then junctional, back to PEA then vfib ?????? shocked 6
times, CPR throughout code situation, multiple code meds given
including epi, amio, lido. return of blood pressure and pulse
after initiation of 5 pressors. Family was in contact with CCU
team ?????? code called at 1555hrs after 45 minutes of coding. Family
stated not to escalate care. Approximately 2L IVF given during
code. ABP 70s with a bradycardic rhythm with weak pulse until pt
became hypotensive and asystolic, time of death 1631hrs. Family
+ HCP [**Name (NI) 18659**] notified and one Son [**Name (NI) 12239**] and Grandson came in to
visit, rest of family staying home, belongings given to family.
.
#CAD: Pt with ACS, cath showed 2 vessel disease see ACS above.
Echo showed compared with the prior study of [**2166-9-12**], regional
left ventricular systolic dysfunction is more extensive (distal
LAD territory). The severity of pulmonary hypertension has
increased. There is right ventricular dysfunction. The aortic
valve vegetation appears similar in size. Started pt on beta
blocker (not part of home regimen).
.
#hypotension - pt with blood pressure in 80s/40s which appears
to be around his baseline. He receives midodrine at dialysis as
he has a history of hypotension with dialysis. Was placed on
nitro gtt for continued chest pain but eventually weaned and
placed back on home imdur. Hypotension was felt most likely [**2-12**]
underlying cardiac dysfunction exacerbated by nitro drip,
although hypotension persisted. Pt was monitored on telemetry.
.
#dyspnea - pt with new O2 requirement of 2-3L nasal cannula but
satting high 90s-100 on this regimen. Satting well. Seems that
he probably needed to be on O2 at home as he c/o significant
dyspnea prior to admission. H/o 50 years of smoking, likely pt
with component of COPD - on advair at home which was continued.
Pt also given nebulizer treatments with good effect. O2 sats
consistently monitored and remained in the mid-high 90s.
.
# Chronic systolic heart failure
Patient last had dialysis on Monday with CXR suggesting mild
volume overload, now also requiring oxygen. Uncertain if pt
presented with true heart failure exacerbation from increased
demand ischemia vs. insufficient HD. Echo in [**2166-9-11**] showed
LVEF of 50-55%. Volume status closely monitored. Pt was putting
out minimal urine and lasix bolus and drip were attempted
without good effect. See ESRD below.
.
# ESRD - pt receiving HD twice weekly. Pt gets midodrine prior
to HD to maintain BPs. Medications were renally dosed.
Renal/dialysis was following the patient. CRRT was initiated on
[**2167-1-22**] around 2pm for worsening renal function as seen via
creatinine and potassium elevations. It was also felt that
significant fluid overload could be contributing to pulmonary
edema which would explain his dyspnea.
.
Pt was maintained as full code throughout the course of this
hospitalization.
.
contact: son [**Name (NI) 18659**] cell [**Telephone/Fax (1) 18660**]
Medications on Admission:
1. Mucinex 600 mg PO BID
2. ASA 81 mg PO qAM
3. Renal Caps PO qAM
4. Trazodone 50 mg PO qHS
5. Clonazepam 0.5 mg PO before dialysis and qHS
6. Midodrine 5 mg PO before dialysis
7. Albuterol 2.5 mg ? INH 2x/day
8. Align PO qD
9. Levemir insulin
10. Clobetasol propionate ointment
11. Pravastatin 40 mg PO qHS
12. Isosorbide 60 mg PO BID
13. Ranexa 1000 mg PO qAM
14. Nitrostat prn chest pain
15. Symbicort 4.5 mg
16. Diphen/atropine 2-3x/day (per patient)
Discharge Medications:
n/a pt expired
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired
Discharge Condition:
pt expired
Discharge Instructions:
pt expired
Followup Instructions:
pt expired
|
[
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"V45.82",
"V10.46",
"585.6",
"428.0",
"414.01",
"272.4",
"799.02",
"403.91",
"530.81",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"39.95",
"00.66",
"38.97",
"88.56",
"00.40",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15304, 15313
|
8029, 14760
|
302, 343
|
15367, 15379
|
4830, 7011
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15438, 15451
|
3907, 3970
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15265, 15281
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15334, 15346
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14786, 15242
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7028, 8006
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15403, 15415
|
3985, 4811
|
2690, 2980
|
232, 264
|
371, 2586
|
3011, 3618
|
2608, 2670
|
3634, 3891
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,433
| 102,735
|
34317
|
Discharge summary
|
report
|
Admission Date: [**2180-11-22**] Discharge Date: [**2180-11-28**]
Date of Birth: [**2121-2-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
(History is per records and patient's husband, pt is unable to
complete a full sentence [**3-4**] severe dyspnea)
59 yo F, s/p wedge resection [**2180-10-4**] with tracheobronchomalacia
s/p reconstruction. Coming in with 'mild confusion' from rehab
facility but A&O. Also reports pleuritic CP, feels 'not
herself'. She reports being on oxygen and steroid taper since
discharge from the hospital. About one week prior she developed
low grade fever, chills and vomiting. She apparently had several
tests done and a CXR at rehab per her husband, with no clear
etiology. Two days prior to admission, she was taken off her
supplemental O2 and reports feeling worse. She also reported CP,
but this has been somewhat a chronic issue since discharge s/p
thoracotomy. The day of admission, she became acutely SOB while
at rehab, and was transported to [**Hospital1 18**] for further evaluation.
EKG with sinus tachycardia and concern for Q in III, T-wave
changes laterally concerning for acute change. Given need for
large amounts supplemental O2 and dyspnea, concerned about PE.
CTA (per report of ED resident) revealed massive b/l saddle
emboli with R heart strain on CT. ED resident u/s heart with
signs of strain, dilated ventricle with e/o hypokinesis. A&O x 3
now. Upon transfer VS with SBP 94, HR 115, 24 on 95/6L. Given 1L
NS to increase preload, another to hang on way. Heparin given
with a bolus. Access is 18g x 3.
.
Upon arrival to the ICU, patient with severe dyspnea. Cannot
participate in full ROS, but does nod to having CP, but no
abdominal pain or leg pain.
Past Medical History:
[**2180-10-4**]: Right thoracotomy and thoracic tracheoplasty with
mesh, right mainstem bronchus/bronchus intermedius bronchoplasty
with mesh, left mainstem bronchoplasty with mesh, right upper
lobe wedge resection.
OSA
COPD with CPAP, on home O2
Tracheomalacia
Tonsillectomy
Back surgery
Appendectomy
Social History:
Remote smoking history, none currently, quit 6 years ago. No
alcohol or other drug use. Has been at rehab since most recent
discharge.
Family History:
Reports father had a blood clot and was on Coumadin, but cannot
provide further details [**3-4**] dyspnea.
Physical Exam:
98.2, 111, 105/68, 20, 96/4L NC
Gen: Appears distressed, difficulty speaking
HEENT: NCAT, MM mildly dry, symmetric
CV: Tachycardia, regular, without m/g/r
Chest: Well healing incision, CTAB anteriorly without w/r/r;
symmetric shallow expansion with tachypnea
Abd: Active BT, obese, without TTP or masses
Ext: WWP with 2+ DP pulses b/l, symmetric, no erythema, warmth
or TTP
Neuro: Nonfocal, moving all limbs equally, speaking coherently
in short, 2-word sentences
Pertinent Results:
[**2180-11-22**] 04:50PM BLOOD WBC-7.7 RBC-4.29# Hgb-13.1 Hct-37.7
MCV-88# MCH-30.5 MCHC-34.7 RDW-14.7 Plt Ct-168#
[**2180-11-28**] 07:45AM BLOOD WBC-5.6 RBC-3.58* Hgb-10.9* Hct-32.2*
MCV-90 MCH-30.5 MCHC-33.9 RDW-15.6* Plt Ct-183
[**2180-11-22**] 04:50PM BLOOD Neuts-83.4* Lymphs-12.7* Monos-3.3
Eos-0.4 Baso-0.1
[**2180-11-28**] 07:45AM BLOOD PT-23.2* PTT-123.7* INR(PT)-2.2*
[**2180-11-23**] 05:23AM BLOOD Glucose-110* UreaN-18 Creat-0.5 Na-139
K-3.1* Cl-105 HCO3-24 AnGap-13
[**2180-11-28**] 07:45AM BLOOD Glucose-107* UreaN-6 Creat-0.6 Na-142
K-3.4 Cl-107 HCO3-25 AnGap-13
[**2180-11-22**] 04:50PM BLOOD CK(CPK)-31
[**2180-11-22**] 09:00PM BLOOD CK(CPK)-26
[**2180-11-23**] 05:23AM BLOOD CK(CPK)-22*
[**2180-11-22**] 04:50PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 78974**]*
[**2180-11-22**] 04:50PM BLOOD cTropnT-0.04*
[**2180-11-22**] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2180-11-23**] 05:23AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2180-11-23**] 05:23AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.8
[**2180-11-22**] 05:25PM BLOOD Type-ART O2 Flow-2 pO2-62* pCO2-29*
pH-7.56* calTCO2-27 Base XS-4 Intubat-NOT INTUBA
[**2180-11-22**] 05:05PM BLOOD Glucose-165* Lactate-3.3* Na-140 K-3.7
Cl-94* calHCO3-26
[**2180-11-26**] 08:06AM BLOOD Lactate-1.3
[**2180-11-22**] 05:50PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-NEG
[**2180-11-22**] 05:50PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2180-11-23**] 05:24AM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-6.5 Leuks-NEG
[**2180-11-23**] 05:24AM URINE RBC->1000 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
.
Blood cultures ([**2180-11-22**]): Pending, no growth to date.
C Diff toxin assay ([**2180-11-23**]): Negative.
.
Head CT noncontrast ([**2180-11-23**]): No acute intracranial
hemorrhage.
.
Bilateral LENI's ([**2180-11-23**]): Bilateral deep vein thromboses.
.
CXR ([**2180-11-23**]): As compared to the previous radiograph, there
are no signs suggesting slight overhydration. Otherwise, the
radiograph is unchanged. No interval appearance of parenchymal
opacity suggestive of pneumonia. Unchanged size of the cardiac
silhouette.
.
TTE ([**2180-11-23**]): Severly dilated right ventricle with moderate
hypokinesis and moderate pulmonary artery systolic hypertension
consistent with hemodynamically significant pulmonary emboli.
Left ventricle has preserved regional and global function and is
probably underfilled.
.
CTA ([**2180-11-22**]): 1. Massive acute pulmonary embolism with CT
signs of right heart strain. 2. Emphysema. 3. Focal area of
airspace opacity in the right lower lobe, and may be infectious,
inflammatory, or secondary to aspiration.
.
EKG ([**2180-11-22**]): Sinus tachycardia. Normal axis and intervals. Q
wave in III. Right bundloid pattern. Prominent S wave in I and q
wave in III compared to prior dated [**2180-9-4**].
.
Brief Hospital Course:
A/P: 59 yo F with tracheobronchomalacia s/p recent thoracic
tracheo- and broncho-plasty with right upper lobe wedge
resection admitted on [**2180-11-22**] with severe dyspnea, found to
have large bilateral PE's and evidence of right heart strain.
.
The patient underwent right thoracotomy with thoracic tracheo-
and broncho-plasty with right upper lobe wedge resection on
[**2180-10-4**]. She was discharged to rehab on [**2180-10-11**]. At rehab the
patient was maintained on supplemental oxygen and a prednisone
taper. One week prior to re-admission she developed some fevers,
shortness of breath and nausea. The patient presented from rehab
on [**2180-11-23**] with acute severe dyspnea and was found to have
bilateral sub-massive PE's with bilateral lower extremity DVT's
and signs of right heart strain on EKG and echo. She received
systemic anticoagulation with marked improvement in her
symptomatic dyspnea and oxygen requirement back to her baseline
home oxygen supplementation by nasal cannula. At the time of
discharge the patient was therapeutic on warfarin with 24 hours
of overlap with therapeutic heparin. The patient will follow-up
with her PCP for further discussion of:
- Ongoing INR monitoring and warfarin dosage adjustment.
- Hypercoaguable work-up and duration of anticoagulation.
- Elective outpatient TTE in the future to evaluate for signs of
resolution of right heart strain.
The patient did have a small amount of hematuria with a single
episode of clot passage in the urine and a nosebleed while on
dual therapeutic anticoagulation with heparin and warfarin. She
was counselled to discuss any ongoing hematuria with her PCP and
to consider outpatient referral to urology if necessary. No
visible blood was seen on urination on the day of discharge.
Of note the patient had some lower extremity edema and a
positive fluid balance while in the hospital and her home lasix
had been held during her hospitalization. The patient was
restarted on her home lasix and will follow-up with her PCP for
ongoing monitoring.
The patient has significant baseline lung diseaes including
COPD. She was continued on an oral prednisone taper consistent
with her admission medications. She was transitioned to 5mg
daily of prednisone for 7 days to complete the taper at the time
of discharge. She did not require insulin while on a sliding
scale in the hospital on 10mg of prednisone and was therefore
not discharged on an insulin regimen. She will also continue on
nebulizer treatments with albuterol and ipratropium as well as
steroid inhalers and tiotropium.
Tracheobronchomalacia s/p recent thoracotomy, resection and
tracheo/bronchoplasty. Thoracic surgery followed the patient in
house. She is scheduled for outpatient follow-up with repeat CT
trachea in the future. Pain from recent surgery was
well-controlled with anti-inflammatories alone at the time of
discharge.
OSA. She continued on her home CPAP.
Medications on Admission:
Acetaminophen 325-650 mg PO Q6H:PRN pain or fever > 101
Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
Acetylcysteine 20% 3-5 mL NEB [**Hospital1 **] AT 6AM AND 9PM
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Lasix 80mg po daily (HELD)
Prochlorperazine 25mg PR Q8H PRN nausea
Docusate Sodium 100 mg PO BID Hold for loose stools
PredniSONE 20 mg PO DAILY
Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
Ranitidine 150 mg PO DAILY
Sodium Chloride Nasal [**2-2**] SPRY NU [**Hospital1 **] Order date: [**11-22**] @ 2124
Tiotropium Bromide 1 CAP IH DAILY Order date: [**11-22**] @ 2124
Insulin SC (per Insulin Flowsheet)
Omeprazole 40mg po daily
Oxycodone 10mg po Q6H
Oxycodone 5mg po Q4H PRN:breakthrough
Nasal saline [**Hospital1 **]
Prednisone taper, sheduled to have 20mg [**11-22**], with 10mg x 4days
after
MOM PRN
Bisacodyl PRN
Fleet enema PRN
Senna PRN
Zantac 150mg [**Hospital1 **] PRN:stomach upset
Discharge Medications:
1. Outpatient Lab Work
Lab work: PT/INR. To be drawn at primary care doctor's office
every 3 days until told otherwise by your doctor. Please obtain
recommendations from your doctor based on the results regarding
dosage adjustment of warfarin.
2. Home Oxygen
Please continue your home oxygen by nasal cannula at 3L/min.
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever > 101.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*120 nebs* Refills:*5*
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO once
a day as needed for cough.
Disp:*30 Capsule(s)* Refills:*1*
11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*100 ML(s)* Refills:*0*
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-2**] Sprays Nasal
[**Hospital1 **] (2 times a day).
13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM as needed for pulmonary embolism.
Disp:*30 Tablet(s)* Refills:*3*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
- Sub-massive pulmonary embolism
- Bilateral DVT's.
Secondary:
- Tracheobronchomalacia s/p tracheobronchoplasty and wedge
resection of the right upper lung lobe
- COPD
- OSA
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with severe shortness of breath. This was due
to blood clots that formed in your legs and travelled to your
lungs. You must take a blood thinning medication called coumadin
to prevent recurrence or enlargement of the blood clots for at
least the next 6 months and potentially longer. Please have your
blood drawn at your primary care doctor's office every 3 days
until further notice from your doctor to monitor the coumadin
level. Discuss the blood results with your doctor and change the
dosing of your coumadin based on their recommendations. Please
discuss a work-up for the cause of your clot formation with your
doctor.
Please discuss scheduling a repeat echocardiogram in the future
for further evaluation of your heart function after this recent
injury.
You did have a small amount of blood in the urine after starting
your blood thinning medication. If this persists please discuss
this further with your primary care doctor.
Follow-up as previously scheduled with your thoracic surgeon
with repeat CT scan in [**Month (only) 1096**].
Take all medications as prescribed.
Follow-up with your primary care doctor and thoracic surgeon.
Call your doctor or return to the hospital for any new or
worsening shortness of breath, chest pain, significant blood
clots in the urine or difficulty making urine or any other
concerning findings.
Followup Instructions:
Dr. [**Last Name (STitle) 11907**] Wednesday, [**2180-11-29**] 2:15PM. Please discuss:
- Ongoing monitoring of your coumadin level and dosage changes
in your coumadin.
- A work-up for the cause of your clot formation.
- Scheduling an echocardiogram in the future to re-evaluate your
heart function.
- Blood in the urine and whether or not you should see a
urologist.
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2181-1-9**] 9:00
Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2181-1-9**] 9:30
Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2181-1-9**] 10:00
|
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"E932.0",
"599.71",
"453.42",
"V58.61",
"518.82",
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icd9cm
|
[
[
[]
]
] |
[
"38.91",
"93.90"
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icd9pcs
|
[
[
[]
]
] |
11524, 11582
|
5974, 8900
|
324, 331
|
11809, 11818
|
3031, 5951
|
13231, 13993
|
2423, 2531
|
9869, 11501
|
11603, 11788
|
8926, 9846
|
11842, 13208
|
2546, 3012
|
277, 286
|
359, 1928
|
1950, 2255
|
2271, 2407
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,029
| 181,943
|
52698
|
Discharge summary
|
report
|
Admission Date: [**2103-5-7**] Discharge Date: [**2103-5-10**]
Date of Birth: [**2039-2-13**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
right leg weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient seen and examined, in brief, 64 yo female with h/o PUD,
CAD, Crohn's disease who presented to the ER with right leg
heaviness and subsequently became hypotensive to 70's and
admitted to MICU. Pt was seen in clinic for f/u of recent GIB
and noted sudden onset of R leg "heaviness" and difficulty
ambulating prior to her visit. She does have a long history of
back/left leg pain on oxycontin and ambulates with a cane. She
does note increased diarrhea in the past few weeks but was not
specifically feeling dehydrated prior to admission. She also
noted intermittent headaches for a week relieved by ASA. Prior
to her office visit today she noted difficulty w/ambulating d/t
heaviness in her leg. No bowel or bladder incontinence. She had
no weakness or numbness in any other part of her body, but
thought she may have had slurred speech. In clinic her BP was
90/56. She was noted to have [**4-14**] R deltoid strenthg and
tremulousness of the right LE. She was referred to the ER.
.
In the ER her VS were: T:97.2 HR 80 BP 70/60 and O2 sat 100% 4L
She was seen by neurology for a code stroke. A head CTA showed
unchanged small bilateral basal ganglia chronic lacunar infarcts
and no stenosis, occlusion, or aneurysm formation. Neuro did not
feel presentation was c/w stroke. She was given 3L of IVF and 10
mg decadron, with improvement in her pressures to the systolics
of 130s. CXR and UA neg. She had a non-contrast abd CT that
preliminary showed no source for infection. Creatinine on admit
was 3.4 but this improved to 1.7 with iv fluids.
Past Medical History:
1. CAD s/p RCA w/BMS on [**2102-2-2**]
2. Diastolic CHF (Recent EF~55%)
3. Crohn's Disease: h/o pancolitis w/o small bowel involvement;
colonoscopy [**10-15**] showed no active disease
4. Chronic Renal Failure (Cr~1.4 at baseline).
5. DM Type II
6. Hypertension
7. h/o idiopathic dilated CMP now resolved
8. Peptic ulcer disease.
9. Alcoholic cirrhosis.
10. GERD.
11. Rheumatoid arthritis.
12. Pulmonary embolus in [**2098**].
13. Total right knee replacement with subsequent chronic pain.
14. [**Doctor Last Name **] mal seizure in childhood.
15. Cervical disc disease.
16. L5/S1 radiculopathy with anterolisthesis of L4 on L5 on X-
Ray with EMG consistent with mild radiculopathy.
Social History:
Patient lives with a disabled son in [**Name (NI) 669**]. She has one other
son who is currently incarcerated. She was married but divorced
a long time ago. 4 pack year smoking history, quit 6 years ago.
Drank ~1 pint alcohol/day x 10 years, quit 6 years ago.
Family History:
Mom died of colon cancer. Father with DM requiring bilateral
below the knee amputation. One sister has had cervical
cancer(cured) and rheumatoid arthritis. Most members of her
family have trouble with hypertension. No one else with IBD.
Physical Exam:
Admission:
VS: T: 98.1F 98.1F 91(84-108) 128/62(101-144/50-80's) 17 96RA
Gen: obese, well appearing, NAD
HEENT: PERRL, anicteric sclera, EOMI
Neck: obese, unable to assess JVP
Cardio: RRR, nl S1 S2, soft systolic murmur loudest LUSB
Pulm: CTAB
Abd: obese, mild RUQ tenderness with no rebound, ND, + BS
Ext: trace peripheral edema b/l, surgical scar abover right knee
Neuro: A&Ox3, CN 2-12 intact,
Muscle strength 5/5 in b/l upper extremities
[**5-14**] in in bilateral LEs, sensation to light touch intact
throughout
1+ Patellar reflexes bilaterally
Downgoing babinskis b/l
Back: spinal and b/l paraspinal tenderness in the lumbosacral
region
.
Discharge:
Vitals t 97.0 BP 162/78 P 56 RR 20 SAO2 100%
Gen: obese, well appearing, NAD
HEENT: PERRL, anicteric sclera, EOMI
Neck: obese, unable to assess JVP
Cardio: RRR, nl S1 S2, soft systolic murmur loudest LUSB
Pulm: CTAB
Abd: obese, mild RUQ tenderness with no rebound, ND, + BS
Ext: trace peripheral edema b/l, surgical scar abover right knee
Neuro: A&Ox3, CN 2-12 intact,
Muscle strength 5/5 in b/l upper extremities
[**5-14**] in in bilateral LEs, sensation to light touch intact
throughout
1+ Patellar reflexes bilaterally
Downgoing babinskis b/l
Back: spinal and b/l paraspinal tenderness in the lumbosacral
region
Pertinent Results:
Diagnostics:
EKG: NSR, rate 71, No STE or depressions, q in III
.
CXR: Limited study with no acute cardiopulmonary process.
.
CTA Head and Neck: 1. No evidence of perfusion abnormality.
2. Small infarct in the left internal capsule, new since prior
CT of [**2101-3-9**], and of uncertain chronicity. If there remains
concern for ischemia, MRI with DWI is more sensitive for acute
infarct.
3. Mild atherosclerotic disease within the proximal left ICA,
with 25% stenosis at this level.
CT perfusion: normal
.
CT Abd/Pelvis: 1. No evidence of perfusion abnormality.
2. Small infarct in the left internal capsule, new since prior
CT of [**2101-3-9**], and of uncertain chronicity. If there remains
concern for ischemia, MRI with DWI is more sensitive for acute
infarct.
3. Mild atherosclerotic disease within the proximal left ICA,
with 25% stenosis at this level.
.
.
MRI L-spine [**5-16**]: No evidence of epidural abscess or canal
compromise. Multilevel degenerative changes. Midline soft tissue
edema at L1 through L4, unchanged from [**2101-6-4**], and may
relate to soft tissue edema from patient immobility.
.
CBC
[**2103-5-7**] 05:30PM BLOOD WBC-8.7 RBC-3.32*# Hgb-9.8* Hct-28.6*
MCV-86# MCH-29.4 MCHC-34.1 RDW-14.1 Plt Ct-293
[**2103-5-8**] 12:02AM BLOOD WBC-7.5 RBC-3.55* Hgb-10.4* Hct-31.7*
MCV-90 MCH-29.3 MCHC-32.8 RDW-14.7 Plt Ct-270
[**2103-5-8**] 05:46AM BLOOD WBC-6.5 RBC-3.59* Hgb-10.2* Hct-31.0*
MCV-86 MCH-28.4 MCHC-32.9 RDW-14.2 Plt Ct-297
[**2103-5-9**] 06:10AM BLOOD WBC-11.3*# RBC-3.04* Hgb-8.8* Hct-26.1*
MCV-86 MCH-29.0 MCHC-33.8 RDW-15.3 Plt Ct-272
[**2103-5-9**] 09:45AM BLOOD Hct-29.4*
.
Chem 7
[**2103-5-10**] 05:30AM BLOOD WBC-9.6 RBC-3.93*# Hgb-11.3*# Hct-34.2*
MCV-87 MCH-28.9 MCHC-33.1 RDW-14.7 Plt Ct-344
[**2103-5-7**] 05:30PM BLOOD Glucose-119* UreaN-40* Creat-3.4*#
Na-128* K-5.7* Cl-97 HCO3-23 AnGap-14
[**2103-5-8**] 12:02AM BLOOD Glucose-173* UreaN-34* Creat-2.4* Na-135
K-6.7* Cl-106 HCO3-19* AnGap-17
[**2103-5-8**] 05:46AM BLOOD Glucose-174* UreaN-31* Creat-2.2* Na-136
K-6.4* Cl-110* HCO3-19* AnGap-13
[**2103-5-8**] 10:02AM BLOOD UreaN-30* Creat-2.0* K-5.9*
[**2103-5-8**] 01:48PM BLOOD K-5.3*
[**2103-5-8**] 08:09PM BLOOD UreaN-28* Creat-1.7* K-4.8
[**2103-5-9**] 06:10AM BLOOD Glucose-59* UreaN-24* Creat-1.5* Na-142
K-4.7 Cl-108 HCO3-23 AnGap-16
[**2103-5-10**] 05:30AM BLOOD Glucose-47* UreaN-17 Creat-1.4* Na-141
K-4.4 Cl-106 HCO3-19* AnGap-20
.
MISC
[**2103-5-7**] 05:30PM BLOOD CK(CPK)-989*
[**2103-5-8**] 06:58AM BLOOD CK(CPK)-1323*
[**2103-5-10**] 05:30AM BLOOD CK(CPK)-355*
[**2103-5-7**] 05:30PM BLOOD CK-MB-29* MB Indx-2.9 cTropnT-0.09*
proBNP-854*
[**2103-5-8**] 12:02AM BLOOD CK-MB-50* cTropnT-0.04*
[**2103-5-8**] 06:58AM BLOOD CK-MB-36* MB Indx-2.7 cTropnT-0.03*
Brief Hospital Course:
64 yo female with h/o CAD, Crohn's, DM2 and lumbar radiculopathy
who presents with RLE weakness, ARF and hypotension resolved
with hydration. Pt was initially admitted to MICU but responded
to fluids rapidly and had no further hypotension; was called out
to the floor the following am.
.
#Weakness: Pt has had R sided backpain over the past week with
sudden onset of weakness. History c/w radiculopathy possibly d/t
disc bulge or nerve irritation. No saddle anesthesia,
bowel/bladder incontinence to suggest cauda equina or cord
compression. She received a CT/CTA which showed a likely old
internal capsule lesion but no areas of acute stroke. The day
after admission, her new symptoms had resolved, but she
continued to complain of left leg pain and right knee numbness
(all old symptoms). She was followed by neurology who
recommended against further work up.
.
#Hypotension: The patient had transient hypotension on
admission, likely dehydration from chronic diarrhea and
diuretics as outpt. Antihypertensives were held. Intially, the
her HCT came down slightly which was concerning given her
history of GIB. She was monitored overnight on the floor and her
HCT recovered without intervention. She then was hypertensive;
toprol and valsartan were restarted.
.
#Acute on Chronic renal insufficiency: Baseline Cr is 1.3- 1.4.
On admission, the creatitine was 3.4 but trended down to 1.7
with hydration. Lasix and valsartan were held until her
creatinine improved. Given that her EF has improved and that she
has chronic diarrhea, she was told to discontinue lasix for the
time being and to re-evaluate the need for lasix with her
cardiologist.
.
# Elevated CK: The patient has had elevated in the past, but was
elevated to 1300 during admission. Her statin was stopped, and
her CK came down to 355 two days later. It is unclear if she
truely had a statin induced myopathy or if her CK was elevated
due to ARF.
Medications on Admission:
MEDS ON TRANSFER:
Aspirin 325 mg PO DAILY
Mesalamine 1200 mg PO TID
Calcium Carbonate 500 mg PO TIDAC
Nystatin Oral Suspension 10 mL PO QID:PRN
Ciprofloxacin HCl 250 mg PO Q12H
Clopidogrel 75 mg PO DAILY
Oxycodone SR (OxyconTIN) 40 mg PO Q8H
OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN
Creon 10 2 CAP PO TID W/MEALS
Pantoprazole 40 mg PO Q24H
Simvastatin 20 mg PO DAILY
Cyclobenzaprine 5 mg PO TID:PRN
Duloxetine 60 mg PO DAILY
FoLIC Acid 1 mg PO DAILY
Gabapentin 300 mg PO Q24H
Topiramate (Topamax) 100 mg PO DAILY
Vitamin D 800 UNIT PO DAILY
Heparin 5000 UNIT SC TID
Insulin SC sliding scale
Discharge Medications:
1. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
6. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
7. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
8. Topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TIDAC (3 times a day (before meals)).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
13. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day) as needed for muslce spasm.
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
16. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
18. Lantus 100 unit/mL Solution Sig: Sixty Eight (68) units
Subcutaneous at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Radiculopathy
Discharge Condition:
improved
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
You were admitted with neurologcial symptoms in your right leg.
You did not have a stroke or any other neurological disease.
.
You were found to have elevated muscle enzymes. Your lipitor was
stopped. You should discuss restarting a different kind of
cholesterol medication with your primary care doctor.
.
You had several medications changes:
1. You should stop taking lipitor.
2. You should stop taking lasix for now. You may need to restart
this in the future. If you have trouble breathing, please call
your heart failure doctor.
.
If you have reccurent symptoms of inability to walk, slurred
speech, facial droop or other new neurological deficitis, please
return to the emergency room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 108724**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2103-5-14**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2103-5-14**] 4:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2103-6-28**]
2:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"555.9",
"428.32",
"403.90",
"276.1",
"571.2",
"V45.82",
"250.02",
"414.01",
"428.0",
"729.2",
"714.0",
"530.81",
"584.9",
"585.9",
"787.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11474, 11480
|
7164, 9077
|
287, 294
|
11546, 11557
|
4419, 7141
|
12399, 12993
|
2873, 3111
|
9723, 11451
|
11501, 11525
|
9103, 9103
|
11581, 12376
|
3126, 4400
|
229, 249
|
322, 1873
|
1895, 2579
|
2595, 2857
|
9121, 9700
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,766
| 115,341
|
17392
|
Discharge summary
|
report
|
Admission Date: [**2109-11-25**] Discharge Date: [**2109-12-7**]
Date of Birth: [**2066-5-8**] Sex: M
Service: MEDICINE
Allergies:
Azithromycin / Augmentin / Klonopin / Aspirin / Atorvastatin /
Escitalopram / Amlodipine
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Decreased MS
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
History of Present Illness:
43 year-old male with PMH of CAD, [**Hospital **] transferred from the MICU.
Originally, presented with after a week of flu like illness with
altered mental status and thought to have seroquel OD (prior OD
on CCB/BB). Intubated at [**Hospital1 **] [**Location (un) 620**] for airway protection. Of
note, U Tox, S Tox are negative. (though were + for TCA at OSH).
However, it was determined that no meds were missing when
partner counted them. Therefore, episode of altered mental
status is not completely understood. While in the MICU,
patient's sedation was lightened and he self extubated. An LP
was performed for HAs and showed xanthochromia in all 4 tubes.
to exclude possibility of a traumatic tap, LP was repeated and
showed 3550 RBCs in tube 4 without any microorganisms. This was
concerning for SAH vs herpes vs mycotic aneurysm. PCR for HSV is
currently pending. CTA was performed on day of transfer and read
pending at time of this note. MRI spine was ordered to rule out
aneurysm/AVM but patient could not tolerate the procedure
secondary to nausea. He now feels back to normal in terms of his
thinking and fairly decent in terms of his mood. However, he
continues to experience vertigo and nausea especially when he
lays flat. Patient now without headaches.
Past Medical History:
Past Medical History:
1. CAD- s/p multiple stents with stent to LAD, pRCA, RCA, D1,
mid LCX at various times within the past 8 months. Cath [**2108-4-13**]
showed no flow limiting disease with EF=50%. 6 caths since [**11-20**].
His outpatient cardiologist notes that he has a severe coronary
vasculopathy (based on his having quickly developed seperate
coronary occlusions in rapid succession; this is why the stents
were each inserted on seperate occassions; this is also in the
context of presently having clear coronaries)
2. Hypertension
3. Hyperlipidemia
4. Tremor--essential
5. s/p hernia repair
PCP is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Cardiologist is [**Doctor Last Name 5293**] at [**Hospital1 18**].
Past Psychiatric History:
Has had inpatient admissions x 2 on D4 this summer. Both of
these were serious suicide attempts by OD, prompting ICU
admissions. Had stay at [**Location (un) 1475**] for ETOH in past. Followed
outpatient by Dr. [**Last Name (STitle) 48615**] in [**Location (un) 620**] ([**Telephone/Fax (1) 48618**].
4 prior suicide attempts: deliberately crashing car @ 18yo wnen
intoxicated (reported on this interview), OD ~10 years ago
(noted to SW), OD about 2 months ago leading to MICU admit and
OD on Benadryl also leading to brief MICU admit.
Has had ECT since [**2108-5-17**], which has
been helpful. Was receiving maintenance therapy once per week
until late [**Month (only) 216**], then increased to 3x/week secondary to
continued symptoms of depression. Last ECt tx was at least 1
week ago (delayed secondary to medical issues).
Social History:
Born in [**State 5111**], 2nd of 6 children (5 sisters). Moved around
as a child secondary to father's position in Navy, ultimately
settling
on Cape for high school. Had 1 and half years at [**Hospital3 **]
Community College. Took care of mother before she died from
cancer, took care of prior parner before he died from cancer.
Lives with partner ([**Name (NI) **]), partner's sister and mother. [**Name (NI) **] 3
year old Yorkshire terrier, [**Doctor Last Name 3077**]. Enjoys playing with dog,
tending to garden, unable to do much of either secondary to
illness. Works in kitchen at [**Hospital1 **]-[**Last Name (un) 4068**]. Currently applying for
disability.
Substance Abuse History:
Smokes one pack tobacco a day. H/o EtOH dependence with Section
35 to [**Location (un) 1475**] ~15 years ago, in AA, sober since with just
one day of drinking in the spring. Distant h/o experimentation
with MJ as teenager.
Family History:
Father with EtOH dependence. Great aunt with ?depression,
completed suicide.
Physical Exam:
Vitals: T:97.2 P:75 R:12 BP:117/79 SaO2:100% on AC 650/125 x 12
100%
7.24/42/335
General: Intubated and sedated
HEENT: NC/AT, PERRLA, but sluggish, EOMI without nystagmus, no
scleral icterus noted, ET at 21cm
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RR, nl. S1S2, no M/R/G noted
Abdomen: Obese, soft, NT/ND, hypoactive bowel sounds, no masses
or organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted.
Neuro: Sedated. no hypertonia
Pertinent Results:
[**2109-11-25**] 09:00PM GLUCOSE-298* UREA N-33* CREAT-2.5*#
SODIUM-142 POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-17* ANION
GAP-17
[**2109-11-25**] 09:00PM ALT(SGPT)-17 AST(SGOT)-18 CK(CPK)-95 ALK
PHOS-79 AMYLASE-51 TOT BILI-0.2
[**2109-11-25**] 09:00PM LIPASE-60
[**2109-11-25**] 09:00PM cTropnT-<0.01
[**2109-11-25**] 09:00PM CK-MB-NotDone
[**2109-11-25**] 09:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2109-11-25**] 09:00PM URINE HOURS-RANDOM
[**2109-11-25**] 09:00PM URINE HOURS-RANDOM
[**2109-11-25**] 09:00PM URINE GR HOLD-HOLD
[**2109-11-25**] 09:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2109-11-25**] 09:00PM WBC-18.9*# RBC-3.77* HGB-12.4* HCT-34.7*
MCV-92 MCH-32.9* MCHC-35.8* RDW-12.9
[**2109-11-25**] 09:00PM NEUTS-88.1* BANDS-0 LYMPHS-8.1* MONOS-0.7*
EOS-2.4 BASOS-0.7
[**2109-11-25**] 09:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2109-11-25**] 09:00PM PLT SMR-NORMAL PLT COUNT-401#
[**2109-11-25**] 09:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2109-11-25**] 09:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2109-11-25**] 09:00PM URINE RBC->50 WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-0
[**2109-11-25**] 08:28PM TYPE-ART PO2-335* PCO2-42 PH-7.24* TOTAL
CO2-19* BASE XS--8 INTUBATED-INTUBATED
[**2109-11-25**] 08:28PM TYPE-ART PO2-335* PCO2-42 PH-7.24* TOTAL
CO2-19* BASE XS--8 INTUBATED-INTUBATED
[**2109-11-25**] 08:28PM TYPE-ART PO2-335* PCO2-42 PH-7.24* TOTAL
CO2-19* BASE XS--8 INTUBATED-INTUBATED
[**2109-11-25**] 08:28PM TYPE-ART PO2-335* PCO2-42 PH-7.24* TOTAL
CO2-19* BASE XS--8 INTUBATED-INTUBATED
CXR: 1.9
IMPRESSION: Appropriate placement of endotracheal tube and
nasogastric tube. Prominence of the pulmonary vasculature likely
relates to patient position.
CXR:[**11-27**]
FINDINGS: The patient has been extubated. There is a left-sided
subclavian central venous catheter with the tip in the upper to
mid SVC. Cardiac and mediastinal silhouettes appear within
normal limits. No focal pulmonary opacities, pleural effusions,
or evidence of pneumothorax. Osseous structures appear
unremarkable.
CT HEAD: [**11-26**]
FINDINGS: There is no sign for the presence of an intracranial
hemorrhage, mass effect, or shift of normally midline
structures. There is no evidence for minor or major vascular
territory infarction. The density values of the brain parenchyma
are normal. There is no overt extracranial pathology seen other
than mild bilateral ethmoid sinus mucosal thickening.
MR HEAD [**11-27**]
FINDINGS: The right vertebral artery distal to the origin of the
right posterior inferior cerebellar artery is extremely
hypoplastic. Additionally, there are bilateral fetal-type
posterior cerebral arteries, the latter finding presumably
correlating with the rather diminutive basilar artery. Within
the limitations of MR angiography, there is no definite sign for
the presence of an aneurysm, although conventional angiography
remains the standard study necessary to more unequivocal
exclusion of this pathological process. There are no areas of
hemodynamically significant stenosis identified. Within the
limitations of coverage of this study, there is no overt sign
for the presence of a vascular malformation.
CTA HEAD: [**11-29**]
IMPRESSION: No evidence of aneurysm.
A preliminary report of no subarachnoid hemorrhages seen, no
aneurysm detected on axial images was provided by Dr. [**Last Name (STitle) 41684**] and
confirmed by Dr. [**Last Name (STitle) **].
Echo: [**12-3**]
Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Tissue velocity imaging demonstrates an E/e' <8 suggesting a
normal left ventricular filling pressure. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic
pressure could not be quantified. There is no pericardial
effusion.
Compared with the report of the prior study (tape unavailable
for review) of [**2108-6-7**], the findings are similar.
Based on [**2100**] AHA endocarditis prophylaxis recommendations,
the echo findings indicate a low risk (prophylaxis not
recommended). Clinical decisions regarding the need for
prophylaxis should be based on clinical and echocardiographic
data.
MRCSpine [**12-4**]
CONCLUSION: No radiological explanation for the clinical and
laboratory abnormalities noted in your history.
ADDENDUM: There is a mild Chiari I malformation of the
cerebellar tonsils, with the tonsillar tips approximately 5 mm
below the plane of the foramen magnum. Additionally, there are
type 2 degenerative endplate changes involving the C5-6 and C6-7
interspaces. Finally, there is a mild degree of congenital
narrowing of the AP diameter of the cervical spinal canal from
the C3 through C6-7 levels.
MR [**Last Name (Titles) 48643**] [**12-4**]
CONCLUSION: No radiological explanation for the clinical and
laboratory abnormalities noted in your history.
ADDENDUM: There is a mild Chiari I malformation of the
cerebellar tonsils, with the tonsillar tips approximately 5 mm
below the plane of the foramen magnum. Additionally, there are
type 2 degenerative endplate changes involving the C5-6 and C6-7
interspaces. Finally, there is a mild degree of congenital
narrowing of the AP diameter of the cervical spinal canal from
the C3 through C6-7 levels.
MR [**Last Name (Titles) **] 1//18
FINDINGS: There is mild facet joint degenerative change
bilaterally at the L5-S1 interspace, with a 2 mm subchondral
cyst involving the left S1 superior articular facet. There is no
other overt lumbar spinal pathology seen. The rootlets of the
cauda equina do appear apposed at the L4-5 interspace level.
Most probably, this finding relates to the relatively diminished
size of the thecal sac secondary to the presence of abundant
epidural fat at this locale.
CONCLUSION:No definite signs for the presence of spinal
pathology accounting for the clinical and laboratory findings
noted in your history. However, meningitis can be easily
overlooked by even contrast enhanced MRI.
Brief Hospital Course:
43 yo male with multiple h/o of SI, CAD s/p PCI, p/w
apnea/bradycardia/hypotension in setting of OD. Per HCP, only
Seroquel was unaccounted for at home (2300mg...is usually on
150gm/day). Further inquiry revealed a HA preceding the pt's
unresponsiveness. The patient's running problems were MS
changes, Infection, hypotension, Acidosis, respiratory failure,
CAD, ARF, nausea and vertigo.
.
MS changes: Initially thought to be due to seroquel OD, but
history did not ultimately support this initial diagnosis. Ddx
includes CNS infection (likely viral given non-toxic appearance
and prodrome 1 week prior), SAH (supported by xanthochromia on
LP x 2), trauma (no outward evidence of this), HIV sequela.
Intubated [**12-19**] airway protection and self extubated. MS cleared.
However, story remains unclear. Psych consultant believed that
he was not actively SI and felt that suicide attempt with OD was
unlikely the cause of episode. U Tox, S Tox were negative.
(though were + for TCA at OSH). Pt was stabalized in the ICU
and eventually transferred on HD 3 to the floor. His MS [**First Name (Titles) **] [**Last Name (Titles) 48644**]y improved in this process without a clear diagnosis. Pt
had fever on [**11-27**] and so was covered with levo/flagyl and was
cultured. Culture data as follows:
[**11-26**]: BCx with MSSA (1/4 bottles), GNR (1/4 bottles)
[**11-26**]: Sputum with staph aureus [**Last Name (un) 36**] pending
[**11-27**]: Sputum with staph aureus
[**11-28**]: Sputum with staph aureus
Treated with Clinda rather than levo/flagyl since [**11-28**] (emperic
to cover poss comm acquired MRSA). CXR does not indicate a PNA
from aspiration (though there did seem to be an aspiration while
pt was intubated). It was later decided that levo/vanc was a
preferable treatment while pt was in house. Suspician for a
true infection was low per clinical picture, and it was rather
suspected that the growth may have been an unusual contaminant,
however, antiobiotics were administered in case culture was
true. Pt was discharged to finish 14 day course of levo.
.
The CSF revealed persistant blood and xanthocromia and high
protein on two occasions. Pt was covered with empiric acyclovir
until CSF PCR demonstrated no HSV. On workup, pt had MRI
suggesting chiari malformation hypoplastic r vert, small
posterior art, no aneurysm seen, no acute stroke. CTA was also
negative for aneurism or bleed. Defect of the spinal cord such
as AVM or aneurism was suspected due to hyperasthesia in chest
but MR showed no abnormality. The last possibility that had to
be ruled out was a sentinal bleed from a small cranial aneurism
that was being missed by MR/CTA, so a angiogram was performed
which did not demonstrate any major abnormalities on discussion
with the radiologist, however a formal read is pending as of
discharge date.
.
Hypotension: Pt presented with hypotension, considered a
seroquel vs neurovasc event. Resolved on [**11-27**]. Pt [**Name (NI) **] by
enzymes.
.
Acidosis: PT was in primary metabolic on arrival. Which
resolved after stabilization and intubation.
.
Resp Failure: Pt presented with respiratory failure and was
intubated on [**11-26**]. Self extubated [**11-27**] and doing well.
.
CAD: ASA, Plavix (allergies noted; only makes him bleed), held
BB/CCB due to low blood pressure.
.
ARF: Cr 2.2 on presentation: (baseline 0.7): Kept MAP >65mm.
FENA was elevated. ATN is likely given hypotension and high
FeNa. Slowly resolved over course of stay to a Cr=1.3. UA
appears infected, but UCx showed no growth.
Pt was stabalized, feeling well in good mood with no headache,
pain, vertigo, nausea, or any other major complaints and
discharged on [**2109-12-7**]
Medications on Admission:
Atorvastatin Calcium 40 mg Tablet PO QD
Amlodipine Besylate 5 mg PO QAM
Clopidogrel Bisulfate 75 mg qAM
Metoprolol Tartrate 75 mg PO BID
Aspirin 325 mg qd
Quetiapine Fumarate 25mg qAM, 50mg noon, 75mg qHS
Gemfibrizole 600mg po bid
Topomax 75mg po qd
Neurontin 800mg po qHS
Cymbalta 60mg po qd
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. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Quetiapine 25 mg Tablet Sig: Five (5) Tablet PO HS (at
bedtime).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*4 Tablet(s)* Refills:*0*
7. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day): speak
with your doctor about returning to your normal dose.
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
9. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
10. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
11. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) for 7 days.
Disp:*42 Tablet(s)* Refills:*0*
13. 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*
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
16. Outpatient Lab Work
please ask your doctor's office to check your chem 7 and draw a
blood culture in 1 week. The results must be called to Dr. [**Name (NI) 42449**] office.
Discharge Disposition:
Home
Discharge Diagnosis:
altered mental status
depression
bacteremia
h.flu pneumonia
hematochezia
CAD sp stents
Discharge Condition:
good
Discharge Instructions:
Please continue your home medications, as administered by your
partner. [**Name (NI) **] were found to have blood in your stool, so you need
to have this followed up. Please ask your doctor [**First Name (Titles) **] [**Last Name (Titles) **] you
for a colonoscopy. Please call your doctor if you have further
confusion, fevers, headaches, or notice blood in your stool.
Please discuss further adjustment of your psych medications with
your outpatient psychiatrist.
We've stopped your amlodipine. Instead you will be on toprol and
lisinopril. Please have your doctor's office check your blood
pressure and your lab work. Please finish a course of levaquin.
Followup Instructions:
Please [**Last Name (Titles) **] an appointment to see your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **]
[**Telephone/Fax (1) 17753**] in the next 2 weeks. Please request a repeat guiac
as you were positive during your stay and may require a
screening colonoscopy. You should also see your psychiatrist in
the next 2 weeks. Please [**Telephone/Fax (1) **] an appointment to see Dr.
[**First Name (STitle) 9046**] [**Name (STitle) 7994**] in neurology Phone: [**Telephone/Fax (1) 541**] in the next [**12-20**]
weeks.
Completed by:[**2109-12-9**]
|
[
"790.7",
"414.01",
"276.2",
"V45.82",
"584.5",
"599.0",
"518.81",
"430",
"401.9",
"482.2",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.91",
"88.41",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
17211, 17217
|
11547, 15249
|
361, 401
|
17347, 17353
|
4986, 7285
|
18060, 18613
|
4308, 4387
|
15592, 17188
|
17238, 17326
|
15275, 15569
|
17377, 18037
|
4402, 4967
|
309, 323
|
429, 1701
|
7294, 11524
|
1745, 3358
|
3374, 4292
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,106
| 186,531
|
36759
|
Discharge summary
|
report
|
Admission Date: [**2154-8-2**] Discharge Date: [**2154-8-10**]
Date of Birth: [**2096-12-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
Coronary artery bypass grafting x3 (LIMA-LAD, SVG-PDA, SVG-OM)
[**2154-8-6**]
History of Present Illness:
57-yo female w/ HTN, dyslipidemia, and 40 pack-year smoking
history transferred from cardiac cath with atypical chest pain.
She initially presented [**7-29**] with sudden onset crushing chest
pain radiating to her jaw and both arms, SOB and diaphoresis
while at rest. She went to [**Hospital3 **] where she works as
[**Name8 (MD) **] RN. There her pain continued with 3 nitroglycerin but
resolved with Morphine roughly 1 hour after onset. Her enzymes
were negative and she had only shallow TWI in III and aVF.
Subsequent stress test, LENIs, CTA chest and RUQ u/s were all
negative. Just before she was to go home, decision was made for
trasnfer to [**Hospital1 18**] for cardiac cath.
Cardiac cath today showed 90% LAD occlusion with serial lesions,
90% proximal and 40% distal LCx occlusion and 50% proximal and
90% distal RCA occlusion, as well as LV diastolic dysfunction.
She is planned to have a CABG mid next week. Shortly after the
cath, she began having [**6-16**] pressure under her left breast
radiating as a sharpness to her back. Pain persisted with a
nipride drip but decreased to [**3-19**] with Versed. She says that
she feels very anxious about the prospect of major cardiac
surgery.
On review of systems she denies recent cough, fever, chills,
vomiting, diarrhea or constipation. At [**Hospital3 **] she had
occasional headaches that seemed to correlate with spikes in her
blood pressure. She suffers from chronic left arm pain that she
typically treats with NSAIDs. She does not have any shortness
of breath at baseline, though she admits that she rarely exerts
herself. She had one other episode of chest pain 2 weeks prior
to [**7-29**] when she had sharp chest pain shortly after waking up
that persisted for about half an hour and improved
spontaneously. She has had no recent weight loss or gain.
Past Medical History:
Hypertension
Hyperlipidemia
Familial Mediterranean fever with mild IgA nephropathy
Chronic L arm pain s/p multiple surgeries after humerus fracture
Bilateral cataracts
PNA [**3-/2153**] requiring 5 day hospitalization
TAH/BSO [**2146**]
L 5th metatarsal surgery
Appendectomy
Social History:
Occupation: Case Manager
Smokes (1 pack/day X 40 years), social EtOH, no
illicit/recreational drugs
Family History:
Family history: Father had diabetes, MI in 50s, then A Fib and
CHF.
Mother had Lupus and COPD.
Physical Exam:
On admission
Vital signs: per R.N.
Height: 62 inches BP right arm: 116 / 74 mmHg
Weight: 66.5 kg
T current: 37.2 C
HR: 56 bpm
RR: 17 insp/min
O2 sat: 96 % on Supplemental oxygen: 2L NC
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums
and palette: Abnormal, Poor dentition)
Neck: (Right carotid artery: No bruit), (Left carotid artery: No
bruit), (Jugular veins: Not visible), (Thyroid: WNL)
Back / Musculoskeletal: (Chest wall structure: WNL)
Respiratory: (Effort: WNL), (Auscultation: WNL)
Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL),
(Auscultation: S1: WNL, S2: Normal)
Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Hepatosplenomegaly: No)
Genitourinary: (Foley in place)
Femoral Artery: (Right femoral artery: Catheter site clean dry
and intact., No bruit)
Extremities / Musculoskeletal: (Muscle strength and tone: WNL),
(Dorsalis pedis artery: Right: 1+, Left: 1+), (Posterior tibial
artery: Right: 1+, Left: 1+)
Skin: (Abnormal, Erythematous rash on flanks)
Pertinent Results:
OSH Lab results:
TropT [**2068-7-27**]: 0.08, 0.14, 0.03
Lipid panel [**7-31**]: TChol 173, HDL 28, LDL 75, Trig 446.
.
[**2154-8-2**]
12.9
8.2>---<169
36.9
.
134 | 104 | 12 / 152
3.8 | 23 | 0.9 \
COAG's: PT-14.0 PTT-30.0 INR(PT)-1.2
LFT's: ALT(SGPT)35 AST(SGOT)46 CK(CPK)54 ALK PHOS59 AMYLASE73
TOT BILI-0.4
%HbA1c-6.6
.
MICRO: urine cx [**2154-8-2**] negative
.
Tests
ECG: (Date: [**2154-8-2**]), NSR at 52 bpm, left-deviated axis, TW
flattening in II and aVF.
Echocardiogram: (Date: [**2154-7-31**]), EF 60%, no wall motion
abnormalities, trace MR/TR
.
Most recent PCI results ([**2154-8-2**]):
1. Selective coronary angiography of this right-dominant system
revealed three-vessel coronary artery disease. The LMCA had mild
plaquing but no significant stenoses. The LAD had serial 90%
stenosis
and heavy calcification. The LCX was calcified and had a 90%
proximal
and 40% distal stenosis. The RCA had a calcified 50% proximal
stenosis
and a 90% distal stenosis.
2. Limited resting hemodynamics demonstrated elevated left
ventricular
filling pressures with an LVEDP of 25 mmHg, and no significant
gradient
across the aortic valve.
.
Carotid U/S ([**2154-8-5**]):
IMPRESSION: No evidence of internal carotid artery stenosis on
either side.
[**2154-8-8**] 12:55PM BLOOD WBC-12.1* RBC-3.43* Hgb-10.7* Hct-31.6*
MCV-92 MCH-31.1 MCHC-33.8 RDW-14.4 Plt Ct-135*
[**2154-8-6**] 04:21PM BLOOD PT-13.9* PTT-34.0 INR(PT)-1.2*
[**2154-8-8**] 12:55PM BLOOD Glucose-156* UreaN-16 Creat-1.1 Na-133
K-4.6 Cl-98 HCO3-24 AnGap-16
PRE-BYPASS: No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>60 %). Right
ventricular chamber size and free wall motion are normal. There
are focal calcifications in the aortic arch. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. Physiologic mitral regurgitation
is seen (within normal limits). There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine.
Biventricular function is intact.
Aortic contours appear intact post decannulation.
Other findings are unchanged
Brief Hospital Course:
57-yo female w/ HTN, dyslipidemia, and 40 pack-year smoking
history transferred from cardiac cath with atypical chest pain.
Originally presented with crushing chest pain [**7-29**] and had an
extensive negative workup at [**Hospital3 **] before being
transferred here for cardiac cath. On catheterization she was
found to have three vessel disease and is scheduled for CABG
next week. Following cath, she began having new [**6-16**] chest
pressure and was transferred to the CCU. Brief hospital course
by problem list is as follows:
.
# Chest pain: It is unclear whether the blockages in her
coronary arteries are the source of her chest pain. Her initial
symptoms on [**7-29**] were typical for an acute coronary syndrome,
but she ruled-out by all standard criteria (enzymes, serial ECGs
and stress test). Other possible sources include
musculoskeletal pain, pleuritic pain and GI pain. PE, gall
stones, and pericardial effusion were all tested for at the
[**Hospital3 **]. Pt's pain was well-controlled in the CCU; pt
was also given Versed for anxiety re: upcoming CABG. CXR ruled
out pleuritic sources for her CP (pneumothorax, pneumonia).
.
# Coronaries: Three vessel disease on cardiac cath, too
extensive for stenting and clearly suitable for CABG. Patient
was continued on IV heparin in CCU. Pre-op ECHO, CXR, carotid
U/S, PFTs, UA/UC were ordered per CT surgery. Pre-op LFTs,
HbA1c, coags were also ordered. Pt continued to be on ASA and
high dose statin for her CAD. Also stressed the importance of
smoking cessation to patient, who tolerated the nicotine patch
well.
.
# Hypertension: Hypertensive at baseline, tolerated up-titration
of her Lisinopril at the OSH. Pt was continued on higher dose
Lisinopril (20 mg) and home dose Atenolol in the CCU. She
complained of headaches which she believes are associated with
high blood pressures. Her BP during these headaches were SBP
150-170's, and they were controlled with Percocet.
.
# Hyperlipidemia: Simvastatin was increased to 80 mg daily and
lipid panel checked.
.
# Familial Mediterranean Fever: Pt was continued on colchicine
Pt was transferred out to [**Hospital Ward Name 121**] 3 on [**8-3**].
Cardiac Surgery Summary:
The patient underwent CABGx3 on [**2154-8-6**] with Dr. [**Last Name (STitle) **]. She
received vancomycin for surgical prophylaxis as she was
inpatient for over 24 hours. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in critical but stable condition. By POD 1 the patient was
extubated, alert and oriented and breathing comfortably. She
was neurologically intact and hemodynamically stable on no
inotropic or vasopressor support. She was transferred to
telemetry on POD 1 where she continued to make progress. Chest
tubes and pacing wires were discontinued without complication.
Physical therapy was consulted for post-operative strength and
mobility. On the day of discharge, the patient was noted to
have some erythema about the superior 3" of her sternal
incision, approximately [**2-8**]" wide. She was afebrile and there
was no drainage. Keflex was started. Post-operative course was
uneventful and the patient was discharged home with VNA services
in good condition on POD 4.
Medications on Admission:
Colchicine 0.6mg [**Hospital1 **]
Lisinopril 2.5mg daily (increased to 10mg, then 20mg in
hospital)
Atenolol 100mg daily
Premarin 1.25 mg daily
Magnesium Oxide 400 mg [**Hospital1 **]
Simvastatin 20 mg daily
Discharge Medications:
1. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Conjugated Estrogens 0.625 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*27 Capsule(s)* Refills:*0*
11. Diflucan 150 mg Tablet Sig: One (1) Tablet PO once a day for
1 days.
Disp:*1 Tablet(s)* Refills:*0*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] N [**Telephone/Fax (1) 12551**] in 1 week
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**3-12**] weeks
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2154-8-10**]
|
[
"428.0",
"305.1",
"300.00",
"583.9",
"411.81",
"272.4",
"496",
"277.31",
"401.9",
"414.01",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"88.56",
"37.22",
"88.72",
"88.53",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
11321, 11404
|
6301, 9543
|
289, 394
|
11472, 11479
|
3882, 6278
|
12018, 12445
|
2707, 2788
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9802, 11298
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11425, 11451
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9569, 9779
|
11503, 11995
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2803, 3863
|
239, 251
|
422, 2258
|
2280, 2557
|
2573, 2675
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,268
| 190,470
|
41831
|
Discharge summary
|
report
|
Admission Date: [**2117-4-9**] Discharge Date: [**2117-4-15**]
Date of Birth: [**2031-9-6**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Arterial catheter
History of Present Illness:
85 yof with hx of Afib with new diagnosis of nephrotic syndrome
p/w AMS.
.
Patient recently admitted and discharged 5 days ago.
.
The pt went to [**Country 2045**] on [**2117-2-16**]. While there she noted increasing
chest heaviness and DOE, decreased appetite, decreased energy.
She felt increasing swelling of her extremities, and weight
gain. Due to her husband's concern the pt returned to [**Location 86**].
She then went into her PCP for evaluation and was sent to the ED
for concern re: new hypervolemia.
.
Her admission from [**Date range (3) 90853**], by Problem:
# Found to have Nephrotic Syndrome likely Secondary to Focal
Segmental
Glomerulosclerosis (anasarca, pr:cr ratio 15.3, Albumin of 1.9,
LDL 225, + oval fat body casts, and Cr of 5.0 up from her prior
normal baseline of 0.9). Full evaluation below. She was started
on 60mg of prednisone (Day 1 = [**3-23**]) which she tolerated well
with only mild improvement in her renal function over the first
2 week period (5.0 -> 4.2). She was also started on Vit D and
calcium supplements and continued on her PPI for steroid
prophylaxis. Repeat Prot/Cr ratio was down to 12.
# Positive Quantiferon Gold: She was tested with quantiferon
gold prior to initiation of steroids and had a positive result
which likely represents past exposure to TB. She was without
symptoms and had a negative CXR. ID was consulted and she was
started on INH 300mg daily with pyridoxine 50mg PO daily x 9
months
# RUE Chronic Arterial Thrombus S/P Thrombectomy: Patient
triggered twice for hypotension and found to have asymmetrical
blood pressures in in her arms and partiallly occlusive thrombus
in her right axillary/brachial artery and underwent arterial
thrombectomy which was complicated by right arm hematoma. Per
the surgical report and speaking with the surgeons, the thrombus
was quite large and felt to be chronic and atherosclerotic in
nature. Discharged on coumadin with a goal INR of [**3-19**].
.
For the last two days at [**Hospital1 1501**] they were unable to draw labs. This
am, the pt was very sleepy. At 11 am on [**2117-4-9**], she was 129/91,
98, 20, 99%, 98.7 temp. Patient's family reports that her mental
status change in the last couple of days. She really doesn't
have any specific complaints.
.
In the ED:
- triage: 98.7 98 129/91 16 99% RA
- Bedside Echo: pericardial effusion
-Became hypotensive to 60 systolic
- given 2L NS
- came up to high 80's
- CVL - Left IJ
- Levophed
- K 5.9 - insulin and glucose
- Cardiology - TTE - effusion but no tamponade
- given Vanc and Cefepime
- Sores in Perineum
- EKG - no peaked T's
- CXR - vascular congestion.
- 100 mg Hydrocort
- BP 102/70, 102, 18, 100% RA
.
In the MICU
- BiPAP
- attempted a-line
- CVVH initiated
- Flagyl initiated for presumptive c-diff
Past Medical History:
Nephrotic Syndrome with a
POAG (primary open-angle glaucoma)
Severe stage glaucoma
Weight loss
Anorexia
Gait Disorder
OBESITY UNSPEC
COLONIC ADENOMA
HELICOBACTER PYLORI INFECTION
COMMON BILIARY DUCT STRICTURE
LEUKOPENIA
ATRIAL FIBRILLATION
HYPERCHOLESTEROLEMIA
OSTEOARTHRITIS
Cataract
Anticoagulant long-term use
POAG (primary open-angle glaucoma)
Severe stage glaucoma
Weight loss
Anorexia
Gait Disorder
OBESITY UNSPEC
COLONIC ADENOMA
HELICOBACTER PYLORI INFECTION
COMMON BILIARY DUCT STRICTURE
LEUKOPENIA
ATRIAL FIBRILLATION
HYPERCHOLESTEROLEMIA
OSTEOARTHRITIS
Cataract
Social History:
Pt lives in [**Location 86**] but spends winter in [**Country 2045**]. Says when she was
in [**Country 2045**] was in the Plateau Central, drank water that was
purchased or boiled, but did eat fresh fruits and vegetables.
Did not swim, used overhead shower from the tap. No
antimalarials.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
DISCHARGE VS: 97.5, Tm 99.3, BP 133/84 (118-150/60-100), HR 71
(68-93), RR 18, SpO2 100RA
Admit - BP 102/70, 102, 18, 100% RA
GENERAL - Eyes closed, laboured breathing, nonpurposeful
response to verbal stimulation
HEENT - Cataracts bilaterally, MMM
LUNGS - Air movement to bases, decreased BS, rhochi and loud
stridorous sounds
HEART - 2/6 systolic murmur, irregularly irregular rhythm
ABDOMEN - obese, tender to deep palpation globally, nd, NABS, no
organomegaly. Anasarca
EXTREMITIES - Anasarca
PULSES: 1+ on my exam at b/l radials, non-palpable pulses in
PT's and DP's bilaterally (dopplerable per vascular surgery)\
.
DISCHARGE EXAM:
Expired
Pertinent Results:
ADMISSION LABS
[**2117-4-9**] 12:55PM BLOOD WBC-38.7*# RBC-3.23* Hgb-9.5* Hct-28.2*
MCV-87 MCH-29.5 MCHC-33.9 RDW-14.9 Plt Ct-158
[**2117-4-9**] 12:55PM BLOOD Neuts-96.1* Lymphs-2.4* Monos-1.0*
Eos-0.2 Baso-0.2
[**2117-4-9**] 12:55PM BLOOD PT-36.7* PTT-38.4* INR(PT)-3.6*
[**2117-4-10**] 09:39PM BLOOD Fibrino-492*
[**2117-4-9**] 12:55PM BLOOD Glucose-136* UreaN-174* Creat-4.2* Na-145
K-5.9* Cl-118* HCO3-16* AnGap-17
[**2117-4-9**] 12:55PM BLOOD ALT-18 AST-29 AlkPhos-68 TotBili-0.5
[**2117-4-10**] 07:37AM BLOOD LD(LDH)-534* Amylase-521*
[**2117-4-10**] 07:37AM BLOOD Lipase-49
[**2117-4-9**] 12:55PM BLOOD Albumin-1.9* Calcium-8.3* Phos-6.3*
Mg-3.6*
[**2117-4-9**] 02:49PM BLOOD Type-MIX pO2-36* pCO2-29* pH-7.37
calTCO2-17* Base XS--6
[**2117-4-9**] 02:49PM BLOOD O2 Sat-60
[**2117-4-9**] 07:33PM BLOOD freeCa-1.20
PERTINENT LABS
[**2117-4-9**] 01:02PM BLOOD Lactate-3.4*
[**2117-4-9**] 02:49PM BLOOD Lactate-2.8*
[**2117-4-9**] 06:23PM BLOOD Lactate-3.2* K-5.3*
[**2117-4-9**] 07:33PM BLOOD Lactate-2.8*
[**2117-4-10**] 06:56PM BLOOD Lactate-1.8
[**2117-4-9**] 02:49PM BLOOD O2 Sat-60
[**2117-4-9**] BLOOD CULTURE X2 PENDING
ECHO [**2117-4-9**] Overall left ventricular systolic function is
normal (LVEF>60%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. The mitral valve leaflets are structurally normal.
Mild (1+) mitral regurgitation is seen. There is a moderate to
large sized circumferential pericardial effusion, measuring 1.0
cm overlying the right ventricle, 0.7 cm overlying the right
ventricular apex, 1.5 cm adjacent to the left ventricular apex,
and 2.4 cm adjacent to the basal left ventricle. Adjacent to the
right ventricle, the effusion is echo dense, consistent with
blood, inflammation or other cellular elements. Adjacent to the
left ventricle, the effusion is echolucent, with occasional
stranding is visualized within the pericardial space c/w
organization. Though there is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows, there
is no sustained right atrial or right ventricular diastolic
collapse. There is minimal invagination of the right ventricle
during diastole. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
IMPRESSION: Moderate to large circumferential pericardial
effusion (largely adjacent to left >> right ventricle) without
frank echocardiographic signs of tamponade. Echodense effusion
adjacent to right ventricle suggests cellular organization.
Normal biventricular systolic function. Mild mitral
regurgitation.
.
CXR [**2117-4-9**] New left IJ line with tip in the proximal SVC. No
visualized
pneumothorax. Potential progression of the left greater than
right opacities suggestive of effusions with underlying airspace
disease not excluded.
.
CT HEAD WITHOUT CONTRAST [**2117-4-9**] No acute intracranial process.
.
[**2117-4-9**] 01:15PM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2117-4-9**] 01:15PM URINE RBC-7* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
.
CXR ([**2117-4-15**]):
There has been mild interval increase in size in moderate left
pleural
effusion. The cardiomediastinum is shifted towards the left side
consistent with left lower lobe collapse and new left upper lobe
collapse. Right lower lobe atelectases are stable. There is a
small right pleural effusion. Left IJ catheter tip is in the
mid-to-lower SVC. There is no evident pneumothorax.
Brief Hospital Course:
Primary Reason for Admission: 85F with hx of Afib with new
diagnosis of nephrotic syndrome p/w AMS.
.
Active Problems:
.
# Goals of Care: On admission, the pt was DNR/DNI. On [**2117-4-15**] a
lengthy family meeting was held and the patient status was
changed to focus on comfort as the priority (CMO), consistent
with the patient's previously expressed wishes. She expired
within minutes of discontinuation of pressors with family at the
bedside.
.
# Altered mental status - Multifactorial. 1) Infection -
Pneumonia, concern for c.diff given very elevated leukocytosis
but no stool makes this less likely; at admission was
empirically started on flagyl. C.diff assay was never completed
[**3-18**] absence of BM and flagyl was stopped empirically. For
pneumonia, the patient was empirically treated for HCAP with
Vanc and Zosyn. This was discontinued when the pt was made CMO
on [**2117-4-15**]. 2) Uremia, started on CVVH. 3) Poor substrate given
prior strokes. The pt never regained her baseline mental status
and expired within hours of being made CMO after a lengthy
family meeting.
.
# Hypotension: Likely related to decreased intravascular volume
in the setting of nephrotic syndrome and distributive physiology
in the setting of pneumonia. The pt became markedly hypotensive
early in her course in the setting of attempted volume removal
with CVVH. She was started on Norepinephrine, which was
discontinued when she was made CMO.
.
# Anasarca/Nephrotic Syndrome: She was started on CVVH at time
of admission. Renal consult was obtained and CVVH was continued
until the pt was made CMO. Her Hydrocortisone was also
continued, though her renal function never recovered.
.
# Afib, Arterial thromboses: Partial reversal with FFP for CVVH
catheter. She was started on a heparin gtt thereafter, which was
stopped when she was made CMO.
.
# Bullae: Pt was noted to have tense bullae of the BLEs.
Dermatology c/s was obtained and the bullae were felt to be [**3-18**]
severe edema in the setting of nephrotic syndrome. Derm
recommended volume removal per renal.
.
Transitional Issues: Pt expired with family at the bedside.
Medications on Admission:
Warfarin 3 mg
Latanoprost qhs
Dorzolamid/Timolol [**Hospital1 **]
Metop Succ 25 qd
Isoniazid 300
B6 50
Pre 60
Simva 20
Calcium Acetate 667, 3 caps TID
Omeprazole 20 q
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"785.52",
"420.90",
"365.11",
"272.4",
"276.7",
"581.0",
"423.3",
"038.9",
"715.90",
"486",
"584.9",
"995.92",
"365.73",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10700, 10709
|
8328, 10392
|
324, 343
|
10760, 10769
|
4782, 8305
|
10825, 10961
|
4065, 4083
|
10671, 10677
|
10730, 10739
|
10479, 10648
|
10793, 10802
|
4098, 4737
|
4753, 4763
|
10413, 10453
|
263, 286
|
371, 3145
|
3167, 3741
|
3757, 4049
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,947
| 145,379
|
39453
|
Discharge summary
|
report
|
Admission Date: [**2167-7-26**] Discharge Date: [**2167-8-12**]
Date of Birth: [**2141-8-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p MVC
Major Surgical or Invasive Procedure:
[**7-26**] Exploratory laparotomy. Left lobe resection/debridement.
[**7-26**] Bolt placement
[**7-29**] External fixation of right femur
[**7-31**] Stent graft repair of transected descending thoracic
aorta with a [**Company 1543**] Valiant endograft.
[**2167-8-5**]
1. Debridement of skin to muscle around wound right knee with
complex closure wound and right knee.
2. Removal external fixator under anesthesia.
3. IM nail right femur.
History of Present Illness:
25 y.o. male transferred from OSH s/p MVC with hypotension and
tachycardia. Patient reportedly was involved in MVC with
ejection. GCS in the field was 3 and SBP was 90/p. He arrived at
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital and was intubated for airway protection.
He was found to be hypotensive with SBP 78, and was transfused a
total of 5 units pRBCs at OSH.
He was transferred to [**Hospital1 18**], and received an additional 2 units
of pRBCs in route. Upon arrival to [**Hospital1 18**], he was found to have
ABG 7.12/57/108, a positive FAST exam, and RLE exam concerning
for right open knee fracture. He was expeditiously taken to the
OR due to his hypotension and positive FAST.
Past Medical History:
depression
Social History:
+ETOH
Family History:
NC
Physical Exam:
T 98.4 HR 102 BP 114/60 RR 20 Sat 97% RA
Gen: A and O x 3, NAD
Card: RRR no MRGC
Pulm: CTA B
Abd: soft, nontender, nondistended. incision c/d/i healing well.
ext: no edema.
Pertinent Results:
[**8-6**]:CXR Removal of left chest tube. No large ptx. Otherwise
chest is similar in
appearance
[**7-26**] CT C-spine - no acute fx or traumatic malalignment of the C
spine.
[**7-26**] CT Head -Small extra-axial hyperdense collection overlying
the left vertex, tracking along the anterior falx, and extending
along the right tentorium, compatible with a small subdural
hematoma. Close followup imaging is recommended. Equivocal
hypodensity of the anterior aspect of the frontal lobes may
represent trauma-related contusion. THere is no evidenc of
herniation or large vascular territorial infarction.
[**7-26**] CT Torso - Multiple parenchymal hypodensities in the liver
with subcapsular extension. Large hematoma extending from the
segment II/[**Doctor First Name 690**] laceration. Surgical drain terminates in the GB
fossa. No e/o IVC injury. Multiple contiguous b/l rib fx
(nondisplace 6th-8th on the right, [**4-2**] left with displacement of
the 6th and 7th. Consolidative opacity in the bilateral lungs
could represent contusion or aspiration. Associated high density
pleural effusion, L > R, suggestive of hemothorax. Linear
hypodensity in the proximal descending aorta could indicate
aortic injury. No focal intramural hematoma or pseudoaneurysm.
Attention on follow up is recommended.
[**7-26**] Right Knee/Ankle/Foot - There are multiple displaced
comminuted fractures of the proximal second, third and fourth
metatarsal with edema and air in the adjacent soft tissues.
There is dislocation of the proximal second metatarsal.
[**7-26**] Right Femur - There is a comminuted transverse displaced
fracture of the mid femoralshaft with edema of the surrounding
soft tissues. There is no right hip dislocation.
[**7-26**] Left Ankle - no fracture.
[**7-26**] Port line placement CXR - right subclavian vein catheter
with no complications
[**7-27**] CT head: Little change in known left subdural hematoma,
which tracks along the anterior falx. There are no findings to
suggest cerebral edema.
[**7-27**] CTA chest: An intimal flap is seen within the descending
aorta originating just distal to the left subclavian artery and
extending approximately 4 cm caudally, consistent with traumatic
aortic dissection. There is no evidence of a pseudoaneurysm.
Moderate bilateral infiltrates with associated atelectatic
changes and
bilateral nodular opacities. Multiple bilateral rib fractures.
[**7-28**] CT chest: Unchanged extent of the bilateral pleural
effusions, the right pleural effusion is minimal. On the left,
the pleural effusion has mean densities suggesting a
non-hemorrhagic cause.
2. The subsequent bilateral areas of atelectasis have minimally
increased in extent. 3. The bilateral lateral opacities, more
severe on the right than on the left, could reflect contusions.
The right opacity has slightly increased in extent.
[**7-28**] CT head: Stable, with increased soft tissue swelling in the
scalp bilaterally.
[**7-29**] CXR: (Prelim)-no evidence of PTX, chest tube in L apex.
Bilateral appical areas of consildation c/w ?aspiration (stable
from CT chest [**7-28**]). Bilateral basilar areas of atelectasis.
[**7-30**]: CTA Chest- no PE, LLL near total colapse, LUL with
increased opacity, RML with increased opacity, RLL
airbronchograms with increasing density from prior studies.
[**8-4**] CXR: In comparison with the study of [**8-3**], there is
increasing
opacification at the right base with a configuration suggesting
volume loss in addition to possible superimposed pneumonia.
Multifocal areas of increased opacification persist bilaterally
again, consistent with post-traumatic contusion or multifocal
pneumonia.
[**8-5**] CXR: As compared to the previous radiograph, today's image
is limited by moderate motion artifacts. There appears to be no
relevant change. The monitoring and support devices are in
unchanged position. Unchanged moderate cardiomegaly without
evidence of pulmonary edema. Unchanged bilateral perihilar and
right basal parenchymal opacities.
[**8-10**] CT abdomen:
1. Slight retraction of surgically placed drain, which now
terminates in the
portal hilum. No fluid collection to suggest need for additional
drain
placement or continued drain placement.
2. Marked involution of multiple hepatic lacerations.
3. Slight increase in size of small-to-moderate bilateral
pleural effusions
with associated bibasilar atelectasis.
4. 1-cm hypodensity in the upper pole of the left kidney, not
clearly
apparent on the prior exam, which may represent a small
hematoma.
Brief Hospital Course:
On HD 1 the patient was taken to the operating room for an
emergency exploratory laparotomy and resection/debridement of
the left lobe of the liver. Orthopedics was consulted for right
midshaft femur fracture and right foot fractures. A bedside bolt
was performed by neurosurgery. His CK's were elevated so IVF
were increased. A bedside traction pin was placed in the right
femur by orthopaedics. He was also started low dose
norepinephrine for hypotension. On HD 2 a CTA was done and
demonstrated an aortic injury. Vascular [**Doctor First Name **] and Cardiac [**Doctor First Name **]
were consulted and they recommended HR and BP control with plans
to return to the OR for an endovascular repair. CKs peaked at
[**Numeric Identifier **]. On HD 3, esmolol was held for low bp's, and his BP was
difficult to control. CT head was repeated for ?AMS and was
stable. On HD 4 the patient acutely desaturated to 70%. There
was a concern for PE so a CTPE was done which was negative for
PE. On HD 5 a bronch was done. TF were started.
On HD 6, ortho did an external fixation of the femur at the
bedside. On HD 10, the patient was persistently febrile with
leukocytosis so CVL, and femoral A-line replaced.
[**8-5**]: to OR with ortho for R fem fix. Continued vent weaning to
PSV. Started methadone.
[**8-6**]: Successfully extubated. Cleared c-collar. CT pulled with
no PTX on CXR. Started on clears. Significant agitation treated
with haldol q1h, QTc q shift and clonidine patch.
[**8-7**]: Doing well, delirium much improved. Worked with PT - OOB
to chair.
He was transferred to the surgical floor as he remained stable.
His abdominal staples were removed on [**8-8**]. Psychiatry was
consulted and they did not believe he needed a 1:1 sitter nor
does he need acute inpatient psychiatry. He was tolerating a
regular diet. He was ambulating with physical therapy however
they believe he is an appropriate rehab candidate. On the day of
discharge his pain was well controlled and he was voiding
without assistance.
Medications on Admission:
None
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. 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) as needed for constipation.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
7. Methadone 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
8. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Polytrauma s/p Motor vehicle accident
Liver laceration (Grade IV)
Blood loss anemia, hemorrhagic shock
Blunt aortic injury/dissection
Displaced Right femur fracture
R 2nd, 3rd and 4th metatarsal fractures
Bilateral rib fractures
Subdural hematoma
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:
See d/c summary and warning signs
Staples on knee need to be taken out between [**8-16**] and [**8-20**]. If
this cannot be done at rehab then needs to be done in followup
with the orthopedic clinic
Followup Instructions:
Cardiac Surgery:
Appointment for CT scan and appointment with Dr. [**Last Name (STitle) 914**]:
CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2167-11-3**] 11:45
[**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2167-11-3**] 1:00
General/Trauma Surgery: Please call for followup with the [**Hospital 2536**]
clinic (Tuesday and Thursdays) in [**1-28**] weeks. [**Hospital **] Medical
Building [**Location (un) 470**], [**Hospital Unit Name **]. [**Telephone/Fax (1) 600**].
Orthopedics: Please call for followup. If your staples can be
removed at rehab between [**8-16**] and [**8-20**] then followup can be in
[**1-28**] weeks, otherwise needs followup in 1 week. Call for
appointment ([**Telephone/Fax (1) 2007**].
Neurosurgery: Please call ([**Telephone/Fax (1) 88**] to schedule a follow-
up appointment with Dr. [**Last Name (STitle) 739**] in [**1-28**] weeks, with a
Non-contrast CT scan of the head. [**Hospital **] Medical Building, [**Hospital Unit Name **].
|
[
"868.03",
"E958.5",
"863.0",
"860.2",
"807.08",
"868.02",
"285.1",
"864.04",
"518.5",
"311",
"821.11",
"V70.7",
"901.0",
"997.31",
"852.26",
"958.4",
"825.25"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.15",
"79.35",
"96.72",
"01.10",
"83.45",
"39.73",
"38.93",
"50.3",
"96.6",
"78.15",
"33.24",
"79.05",
"38.91",
"88.42",
"84.72",
"78.65"
] |
icd9pcs
|
[
[
[]
]
] |
9360, 9407
|
6329, 8343
|
322, 765
|
9698, 9698
|
1802, 3657
|
10106, 11162
|
1590, 1594
|
8398, 9337
|
9428, 9677
|
8369, 8375
|
9881, 10083
|
1609, 1783
|
275, 284
|
793, 1517
|
4656, 6306
|
9713, 9857
|
1539, 1551
|
1567, 1574
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,182
| 112,599
|
42310
|
Discharge summary
|
report
|
Admission Date: [**2116-12-26**] Discharge Date: [**2117-1-1**]
Date of Birth: [**2047-9-10**] Sex: M
Service: SURGERY
Allergies:
XIBROM
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Necrotizing hemorrhagic pancreatitis
Failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69M with necrotizing hemorrhagic pancreatitis complicated by
abdominal compartment syndrome, now transferred from OSH at
family's request for management. Patient was admitted at [**Hospital1 18**]
from [**2116-10-1**] to [**2116-11-24**] after transfer from OSH for cardiac
arrest in the setting of necrotizing pancreatitis. On arrival,
he was found to have abdominal compartment syndrome for which he
underwent decompressive laparotomy with significant improvement
in hemodynamics. During his stay, he had a prolonged ICU course
complicated by MSSA/Ecoli pneumonia, acute renal failure
requiring hemodialysis, and pseudomonas bacteremia, requiring
re-exploration with placement of [**Last Name (un) **] gastrostomy and
debridement of subcutaneous tissue, muscle, and fascia in the
suprapubic region and placement of a 16 French pigtail catheter
into a right complex air and fluid collection. Patient was
eventually weaned from the ventilator, extubated, weaned from
dialysis and discharged to rehab on [**2116-11-24**] (please see
discharge summary for details).
On [**2116-12-1**], patient was found in "pool of blood" by rehab nurse
and transferred to OSH for evaluation. On arrival, patient's Hct
was 15, he was febrile to 39, and hemodynamically unstable. He
was intubated and taken to OR for ex lap. Intraop, drainage of
multiple hemorrhagic abscess was performed with placement of 3
[**5-17**] inch triple lumen sump drains and a wound vac. He was taken
back to the OR twice for washouts and ultimately closed on [**12-10**].
He was initially broadly covered with vanc/ linezolid/ cipro/
zosyn/ fluc for pseudomonas pneumonia and UTI and VRE in
abdominal abscess. VRE became resistant to linezolid, and
patient completed 14 day course with tigecycline and all
antibiotics were stopped on [**2116-12-16**]. On [**12-21**], patient spiked a
fever and was restarted on vanc/zosyn, but eventually weaned to
zosyn alone
with ID recommendations. Due to his pneumonia, he required
prolonged intubation, ultimately requiring tracheostomy on
[**2116-12-24**], with exchange of trach on [**2116-12-25**].
Over the last week, he was having difficulty tolerating tube
feeds with episodes of witnessed aspiration, for which tube
feeds were stopped and TPN initiated. He has also had persistent
liquid stools which were cdiff toxin and pcr negative. Today,
patient's Hct dropped from 27 to 22, prompting a CT
abomen/pelvis. Due to poor progress over the last week,
patient's family requested transfer to [**Hospital1 18**] for second opinion.
Past Medical History:
PSH: Cataract removal with lens prosthesis, [**2116-10-2**]- Bedside
exploratory laparotomy for abdominal compartment syndrome,
[**2116-10-21**]- Re-exploration with placement of [**Last Name (un) **] gastrostomy
and
debridement of subcutaneous tissue, muscle, and fascia in the
suprapubic region; [**2116-11-17**] - Uncomplicated placement of a 16
French pigtail catheter into the right complex air and fluid
collection, [**2116-12-2**]: ex lap, drainage of infected hemorrhagic
collections with placement of sump drains x3, [**12-4**] & [**12-7**]:
wash
out and partial closure of abdominal wound, [**2116-12-10**]: closure of
abdominal wound, [**2116-12-24**]: Open tracheostomy, [**2116-12-25**]:
Tracheostomy exchange
.
PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease
2. Vitamin deficiency
3. Hypertension
4. B12 deficiency anemia
5. Gastritis
6. Benign prostatic hypertrophy
7. Hyperlipidemia
8. Calculus of the kidney
9. Macular degeneration of the retina
10. Cataracts, status post cataract removal with lens
prosthesis
Social History:
The patient lives with his wife. Denies tobacco and alcohol use
or other toxic habits
Family History:
No family history of pancreatitis or pancreatic malignancy
Physical Exam:
On Discharge:
Vital Signs: 98.8, 102, 132/80, 18, 99% on 50% Trach mask
General: Interactive, NAD
CV: RRR
Resp: Tracheostomy with stitches in place, decreased breath
sounds on left with rhonchi
Abd: Soft, nontender, mildly distended, large triple lumen sump
drains in LLQ, and RLQ with thick purulent drainage, midline
incision with steri strips and healing well with no erythema or
drainage. LUQ with G/J tube, site c/d/i
Ext: Warm, no edema
Pertinent Results:
[**2117-1-1**] 05:00AM BLOOD WBC-5.0 RBC-3.30*# Hgb-9.6*# Hct-28.9*#
MCV-88 MCH-29.0 MCHC-33.2 RDW-16.1* Plt Ct-186
[**2117-1-1**] 05:00AM BLOOD Glucose-115* UreaN-11 Creat-0.4* Na-143
K-3.5 Cl-113* HCO3-25 AnGap-9
[**2117-1-1**] 05:00AM BLOOD Calcium-7.6* Phos-2.1* Mg-1.8
[**2116-12-28**] 08:52AM BLOOD calTIBC-85* Ferritn-4287* TRF-65*
MICRO:
[**2116-12-26**] 10:18 pm BLOOD CULTURE Source: Line-L PICC.
**FINAL REPORT [**2117-1-1**]**
Blood Culture, Routine (Final [**2117-1-1**]): NO GROWTH.
[**2116-12-26**] 10:18 pm URINE Source: Catheter.
**FINAL REPORT [**2116-12-28**]**
URINE CULTURE (Final [**2116-12-28**]):
YEAST. >100,000 ORGANISMS/ML
[**2116-12-27**] 5:45 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2116-12-28**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2116-12-28**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2116-12-28**] 3:04 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2116-12-31**]**
MRSA SCREEN (Final [**2116-12-31**]): No MRSA isolated.
RADIOLOGY:
[**2116-12-28**] CXR: IMPRESSION: Small-to-moderate left pleural
effusion with associated atelectasis.
Brief Hospital Course:
The patient well know for Dr. [**First Name (STitle) **] was transferred to the
General Surgical Service from OSH. The patient was transferred
in ICU, blood, stool and urine cultures were sent, and IV Zosyn
was stared empirically. In ICU patient was started on Tube feed,
continued NPO, with Foley catheter and free H2o boluses for
hypernatremia. On HD # 3, he underwent replacement of his G-tube
to G/J-tube without any complications.
Neuro: The patient was stable from neurological standpoint, no
interventions were require. Pain was controlled with Morphine IV
prn.
CV: Sinus tachycardia in setting of SIRS, hemodynamically
normal. Patient was continued on IV metoprolol with good
respond.
Pulmonary: The patient was remained on 50% Trach mask with
stable O2 Sats. Pulmonary service and speech/swallow were
followed the patient. Chest PT and pulmonary toilet were
continued throughout hospitalization. Please see attached Speech
and Swallow consult for details.
GI: Patient's G-tube was changed to G/J tube on [**12-28**]. Tube feed
was restarted on [**12-29**] and advanced to goal. Patient was started
on tincture of opium and Creon for diarrhea. Diarrhea improved
and Creon was discontinued. Patient will require to continue
Speech and Swallow evaluations in Rehab.
Hypernatremia: The patient was hypernatremic on admission. He
was started on free water boluses and slow D5W IV. Serum sodium
improved to normal prior discharge.
GU: Foley was placed on admission to monitor urine output. After
Foley was d/cd, patient has condom catheter in place.
ID: Blood, urine and stool cultures were negative, IV Zosyn was
discontinued. Patient remained afebrile with WBC within normal
limits during hospitalization.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient has an anemia of chronic disease. He was
transfused with 2 units of RBC for HCT = 22.8 on HD # 6. Please
continue to monitor HCT as outpatient.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a tube
feed, voiding, and pain was well controlled. The patient
received discharge teaching and follow-up instructions and
family members verbalized understanding and agreement with the
discharge plan.
Medications on Admission:
Nexium 40 mg daily, ferrous sulfate 300 mg daily, haldol 5mg IV
q4h prn agitation, floranex TID, lopressor 10 mg IV q4h, zosyn
4.5 mg q8h
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. opium tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO DAILY
(Daily).
3. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
4. Thiamine 100 mg IV DAILY
5. 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.
6. Pantoprazole 40 mg IV Q24H
7. 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.
8. Metoprolol Tartrate 10 mg IV Q4H
hold for sbp <110 and hr <60
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 32674**] - [**Location (un) **]
Discharge Diagnosis:
1. Necrotizing hemorrhagic pancreatitis
2. Hypernatremia
3. Anemia of chronic disease
4. Intraabdominal fluid collections
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-19**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
Abdominal drains ([**Doctor Last Name 14837**] drains) will continue to wall suction in
Rehab
.
Tracheostomy - place the PASSY-MUIR VALVE during the day. ALWAYS
DEFLATE CUFF PRIOR TO PLACING THE PASSY-MUIR VALVE.
.
PICC Left Antecubital, Date inserted: [**2116-12-26**]
.
J/G tube, flush with 250 cc of tap water Q6H. Change dressing
daily and prn. Monitor for signs and symptoms of infection or
dislocation.
Followup Instructions:
Please call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 91667**] to schedule a
follow up appointment in 2 weeks.
Completed by:[**2117-1-1**]
|
[
"567.22",
"272.4",
"362.50",
"995.93",
"V13.02",
"707.03",
"276.0",
"600.00",
"707.22",
"511.9",
"V12.53",
"585.9",
"577.0",
"V44.0",
"V45.61",
"783.7",
"599.0",
"577.1",
"482.1",
"266.2",
"285.29",
"261",
"403.90",
"V85.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"97.02"
] |
icd9pcs
|
[
[
[]
]
] |
9290, 9365
|
5945, 8361
|
321, 328
|
9531, 9531
|
4629, 5922
|
11230, 11384
|
4090, 4150
|
8550, 9267
|
9386, 9510
|
8387, 8527
|
9709, 10290
|
10305, 11207
|
4165, 4165
|
4179, 4610
|
227, 283
|
356, 2896
|
9546, 9685
|
3668, 3969
|
3985, 4074
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,574
| 133,190
|
596
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 4666**]
Admission Date: [**2196-6-29**]
Discharge Date: [**2196-7-24**]
Date of Birth: [**2127-1-18**]
Sex: M
Service:
Per dictator: "Please note, discharge summary is a year old.
I think it has been previously dictated, but likely under the
wrong code. This must be included in the dictation summary."
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
gentleman with a long history of end-stage renal disease
secondary to polycystic kidney disease. He also had
polycystic liver disease that was complicated by an infected
cyst involving the liver that ruptured into the pericardium
necessitating a prolonged hospitalization.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2196-6-29**], with congestive heart failure. He underwent
further evaluation and was found to have a pericardial
tamponade secondary to a rupture of infected hepatic cyst
into his pericardium. He had a pericardial window done in the
past with Dr. [**First Name (STitle) 4667**] [**Doctor Last Name **] and abdominal incision at that
point in time we removed the lateral segment of the liver to
include the cyst. His postoperative course from that episode
was long and prolonged and he eventually was able to recover,
but he presented on [**2196-7-2**] with sepsis. A tube was
placed into his pericardium and fluid demonstrated high white
count consistent with pericarditis.
He was taken to the operating room on [**7-2**], where he
underwent a pericardial window. Despite this, he continued to
remain septic with pressor requirements and acidosis. At that
point in time, we were concerned that he, in fact, had a
visceral perforation that had contaminated the communication
between his pericardium and his abdominal cavity and he was
taken emergently to the operating room on [**2196-7-4**],
where he was found to have a perforation of the sigmoid
colon. He underwent sigmoid colectomy and colostomy with a
long Hartmann pouch at that point in time. He developed
bilateral DVTs and a filter was placed on [**7-9**]. Despite
this, he continued to have problems with multisystem organ
failure with hyperbilirubinemia, elevated white count. He
underwent a number of CT scans that demonstrated no intra-
abdominal fluid collections, but findings suspicious for a
bilious/postoperative bowel obstruction. He underwent
exploratory laparotomy on [**2197-7-19**], that did not
demonstrate any intra-abdominal complications. There was no
evidence of bowel obstruction. On [**2196-7-22**], he
underwent a tracheostomy for prolonged mechanical
ventilation. Over the next 72 hours, his condition
deteriorated and on [**2196-7-24**], he expired.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern4) 3433**]
MEDQUIST36
D: [**2197-8-7**] 07:37:22
T: [**2197-8-7**] 08:34:52
Job#: [**Job Number 4668**]
|
[
"428.0",
"707.03",
"584.5",
"117.3",
"573.8",
"570",
"V58.65",
"569.83",
"707.8",
"427.31",
"276.52",
"420.99",
"038.42",
"286.7",
"577.1",
"785.51",
"567.21",
"560.1",
"518.5",
"518.0",
"753.12",
"995.92",
"423.0",
"484.6",
"562.11",
"996.81",
"569.5",
"285.29",
"453.40",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"96.04",
"31.1",
"96.6",
"39.95",
"99.15",
"38.7",
"38.95",
"33.24",
"54.91",
"99.05",
"99.04",
"45.76",
"99.07",
"96.72",
"46.11",
"00.14",
"37.12",
"54.12",
"99.06",
"38.93",
"89.64",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
688, 2937
|
367, 670
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,035
| 146,528
|
24376
|
Discharge summary
|
report
|
Admission Date: [**2191-4-19**] Discharge Date: [**2191-5-12**]
Date of Birth: [**2124-1-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
hypotension, pulmonary edema
Major Surgical or Invasive Procedure:
CVVHD, hemodialysis
History of Present Illness:
Pt is a 67 male well known to me, with h/o CAD s/p CABG, CHF (EF
30%) ESRD on HD, COPD, Chronic Afib who was transferred NH with
pulmonary edema and hypotension; also found to be in Atrial
fibrillation with rapid ventricular rate.
Mr. [**Known lastname 37564**] was noted to be dyspneic on the afternoon of
admission. O2 sats were found to be 76% on RA and 80% on a NRB.
On arrival to [**Hospital1 18**], he was noted to be in Afib in rvr to
140-160 and BP was in mid 70s/20s. CXR was consistant with
pulmonary edema. He was given diltiazem, lasix 100iv in the ED.
He was then attempted on BiPAP, however he was unable to
tolerate it. He was then admitted to the ICU for CVVH.
Additionally, he required pressor support of levophed and
dopamine which were weaned off. Pt had intermittent episodes of
rapid a fib which were controlled with IV beta blockers.
While in the ICU in the am of [**4-20**], pt had an episode of
coffee-ground emesis. NG lavage was negative. INR was noted to
be 10.8. His INR was reversed with FFP and vitamin K was given.
GI consulted and said that scoping at this point was not
recommended as pt had recent hypotension, a stable Hct, and no
frank blood on lavage.
Additionally, pt with rising WBC to 31.5 on [**2191-4-20**] from an
initial WBC of 14. ? of infiltrate on CXR. Initially started on
vanc/levo/flagyl ([**2191-4-19**]) for possible pneumonia. CVVH and
dopamine d/cd [**2191-4-21**].
Pt was on transferred to the floor and had signs and symptoms
consistant with stroke. MRI revealed a small ischemic stroke in
the corona radiata on the left. Pressures were kept ~100 as
there was a tight balance between rate control and pressure
control. On [**2191-4-25**] pt went to HD. Pressures were in the 80s
systolic and he did not tolerate it and was not stable to UF.
His pulse went to the 130s and it came down to ~100 with 5 IV
metoprolol. Cardiology was consulted and we loaded pt with
digoxin (1 gram). Pt was transferred to the MICU for possible
CVVH with pressor support. He was stable overnight in the unit,
received no intervention, and was transferred back to the
medicine team now.
Past Medical History:
1. DM2
2. HTN
3. COPD- on home COPD though pt unaware how much
4. PVD s/p L BKA and R TMA [**2180**]
5. CAD s/p CABG
6. CHF (EF %30)
7. ESRD on HD MWF at [**Location (un) 4265**] [**Location (un) 86**]
8. Chronic Afib
Social History:
Pt is a former bartender. He lives alone in NH. Usual care is at
[**Hospital1 2177**]. He is a former bartender, has never been married and has no
children. Quit smoking 15 years ago, with 30 year pack history.
No EtOH.
Family History:
Non-contributory
Physical Exam:
on admission to medical service
VS: T: 95.1; BP: 113/41; P: 71; RR: 26; O2: 94% on 2L
Gen: slightly tachypneic, able to speak for [**2-22**] words and then
getting short of breath. In NAD
Neck: Elevated JVD to jaw line.
CV: Irregularly irregular. S1S2.
Lungs: Crackles at bases b/l. Decent airflow.
Abd: soft, nt, nd.
Ext: Right above foot amputation; right bandage on (pt deferred
me looking until next dressing change). Left leg: BKA. No
edema.
Neuro: A&O x 3.
Pertinent Results:
Labs on admission:
[**2191-4-19**] 05:35PM BLOOD WBC-18.0*# RBC-4.73 Hgb-14.0# Hct-45.5#
MCV-96 MCH-29.6 MCHC-30.8* RDW-17.1* Plt Ct-316
[**2191-4-19**] 05:35PM BLOOD Neuts-91* Bands-0 Lymphs-6* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2191-4-19**] 05:35PM BLOOD Plt Smr-NORMAL Plt Ct-316 LPlt-2+
[**2191-4-19**] 06:10PM BLOOD Glucose-413* UreaN-18 Creat-2.9* Na-139
K-3.5 Cl-96 HCO3-24 AnGap-23*
[**2191-4-19**] 11:30PM BLOOD ALT-15 AST-15 LD(LDH)-308* CK(CPK)-35*
AlkPhos-106 TotBili-1.2
[**2191-4-19**] 11:30PM BLOOD Albumin-3.2* Calcium-7.9* Phos-4.1
Mg-1.4*
[**2191-4-19**] 10:08PM BLOOD Type-ART pO2-63* pCO2-40 pH-7.39
calHCO3-25 Base XS-0
[**2191-4-20**] 01:45PM BLOOD Lactate-2.1*
_________________________________
Other Labs:
[**2191-4-19**] 11:30PM BLOOD ALT-15 AST-15 LD(LDH)-308* CK(CPK)-35*
AlkPhos-106 TotBili-1.2
[**2191-4-19**] 11:30PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2191-4-25**] 05:05AM BLOOD Triglyc-72 HDL-52 CHOL/HD-2.3 LDLcalc-54
[**2191-4-19**] 11:30PM BLOOD Cortsol-51.3*
[**2191-4-19**] 11:46PM BLOOD Cortsol-57.9*
[**2191-4-20**] 05:31AM BLOOD Cortsol-79.1*
[**2191-4-20**] 01:45PM BLOOD Lactate-2.1*
_________________________________
Radiology:
Chest AP [**2191-4-19**]-IMPRESSION: Mild worsening of congestive heart
failure with small bilateral pleural effusions. No definite
underlying consolidation is identified; however, if pneumonia is
suspected, followup films may be helpful.
MR head [**2191-4-23**]-FINDINGS: On diffusion images, a small area of
hyperintense signal is seen within the left corona radiata,
which could represent an acute subcortical infarct. Moderate to
severe brain atrophy is noted. Increased signal is seen in the
periventricular white matter due to small vessel disease.
IMPRESSION: Somewhat limited study secondary to motion. Small
area of hyperintense signal seen on diffusion images in the left
corona radiata could represent a small acute infarct. Moderate
to severe changes of small vessel disease and brain atrophy.
Echo [**2191-4-26**]-The left atrium is elongated. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis. No definite left ventricular
thrombus is seen (images suboptimal). The right ventricular
cavity is mildly dilated with severe global free wall
hypokinesis. The aortic valve leaflets are moderately thickened.
There is minimal aortic stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Moderate (2+) mitral regurgitation is seen.
Brief Hospital Course:
67M DM2, HTN, COPD, PVD, CAD s/p CABG, CHF, ESRD on HD admitted
for hypoxia, and a. fib in rapid ventricular response with
resultant hypotension. Also found to have ? pneumonia and with
episode of hematemesis in MICU. Pt has CHF in the setting of
ESRD and and likely rapid a. fib as well. [**Date range (1) 61736**]/05- [**2191-4-27**] pt
with 18 s (49 beat run VT), Asx. [**2191-4-28**] pt febrile, tachypnic
without hypoxia. tachypnea was likely [**12-22**] fever. He did have a
resp alkalosis with increase of Aa gradient. Received tylenol PR
and Mg 2 g. Fever from likely line infection (started on zosyn
and vanc) with cultures.
1. CV
a. [**Name (NI) 4964**] Pt was in frank overload upon admission to the ICU. He
was on CVVH in the ICU as above. Echo done showed an EF of 20%
with RV and LV hypokinesis. Pt's CHF was handled by dialysis. He
initially did not tolerate it secondary to fluctuation of
pressures and hypotention. He improved when his rate improved
(See below) and he handled dialysis until he decided that he not
longer wished to have it (see below)
b. [**Name (NI) 2694**] Pt with CAD s/p CABG. We continued ASA, beta
blocker, and statin. His enzymes were negative here.
c. [**Name (NI) 9520**] Pt came in in rapid a. fib with rapid ventricular
response with possible flash. He remained in atrial
fibrillation. MR. [**Known lastname 37564**] was initially on metoprolol 50 tid
for rate control but BPs were tenous and lead to hypotension. He
was digoxin loaded IV but levels reached 3.4 on HD 9. He had a
49 beat run of Vtach during that time but no evidence of EKG
changes. His levels slowly drifted down. During the initial
loading of digoxin, his rate slowed down to the 90s-100 and BP
improved dramatically to 100-110 systolic.
2. Fever/Leukocytosis/Fungemia-
a. [**Name (NI) 25933**] Pt spiked 101.3 on HD #10 and had a leukocytosis. CXR
was clear. Pt was tender in suprapubic region, refusing straight
cath, and Ab CT. We started pt empirically on Vanc (dosed by
level <15) and Zosyn with negative cultures. We d/cd the zosyn
but were treating what we thought was a probably line infection.
b. Fungemia-Blood culture from [**2191-5-2**] (surveillance) grew out
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 29361**]. The plan was to treat pt for 2 weeks with
flucanazole, however, given his refusal and ultimate CMO, he was
unable to take the course. Opthamology came by initially but pt
refused dilated eye exam.
3. Stroke- The day after admission to the medicine service, pt
with slurred speech, altered mental status, and problems
swallowing. [**Name2 (NI) 430**] CT showed areas of old stroke and large
ventricles. MRI showed acute left corona radiata ischemic
stroke. We continued ASA, and INR was therapeutic though pt not
on coumadin at that time. We started a statin. Neurology was
initially following pt.
4. Hypoxia- Improved after pt went to medical floor. He was
stable on 2 L -->RA. In the unit previously he had aspiration
PNA which was treated with levo/flagyl 11 day course.
5. Hypotension- BPs went to the 100s-110 systolic with digoxin.
This was likely in the setting of better rate control, better
filling, and atrial kick.
6. Coffee ground emesis- Pt had an episode coffee ground emesis
in unit with INR 10.8. His INR was reversed and pt had no
episodes after that. GI workup was not initiated given his state
then and he was stable from that point of view afterwards.
7. ESRD on [**Name (NI) 4164**] Pt started dialysis 8 weeks prior to admission.
Had a right quintin catheter in place. Was getting CVVH in the
MICU and then tolerated dialysis once rate was under better
control.
8.DM- Tight glucose control post stroke. RISS that was
uptitrated
9.COPD- we continued nebs (ipratropium and albuterol). Pt was
stable.
10. PPX- was on subcutaneous heparin and we continued pt's PPI.
11. Access- Had a right quintin catheter for hemodialysis. PIV.
Would have needed access for dialysis to have changed given his
fungemia but pt was made CMO (see below)
12. Wound care- pt with left heel ulcer and left upper back
duoderm in place. Wound care nursing consultation saw pt and
recommended dressing changes.
13. F/E/N- Post stroke, pt failed his speech and swallow
evaluation. He was advanced to ground solids. He was not eating
and his nutritional status was quite poor; pt said that he has
no appetite. We started megace but pt refused.
a. hypernatremia- Pt hypernatremic to 150s; we gave him free
water through his IV as tolerated and at dialysis they did not
use sodium filter.
14. Code status- Pt was DNR/DNI. He made this clear throughout
his stay. Towards the end of his hospital stay, Mr. [**Known lastname 37564**]
would refuse medication and dialysis occasionally but then do
it. Ethics saw pt and agreed that he had capacity, though
delirius at times, was clear in his overall goals. Pt's refusal
became more and more and the team initiated discussions with him
regarding goals of care. It became clear to pt and team that
what he wanted was comfort measures only. He was sick of being
in his condition and knew that it was time for him to be
comfortable. He was made CMO on [**2191-5-11**]. Palliative care saw pt
and facilitated transition back to NH with hospice.
[**Name (NI) 1094**] HCP [**Name (NI) **] [**Name (NI) **] was involved in discussions with pt
regarding goals of care and agreed with pt and the team.
Medications on Admission:
N/A
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Morphine 10 mg/5 mL Solution Sig: [**11-21**] PO Q2-3H (every [**12-23**]
hours) as needed for SOB,Pain.
5. Morphine 2 mg/mL Syringe Sig: One (1) Injection Q3-4H () as
needed for SOB, PAIN.
6. Lorazepam 0.5 mg Tablet Sig: 1-4 Tablets PO Q2-3H (every [**12-23**]
hours) as needed for SOB, pain: alternatively could have SC.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
Congestive heart failure
Hypotension
Atrial fibrillation
Fungemia
Stroke
Aspiration pneumonia
Secondary diagnosis:
End stage renal disease
Diabetes Mellitus
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Pt has decided to be CMO. He is comfortable upon discharge.
Discharge Instructions:
Plan of care per hospice facility. Comfort measures only.
Followup Instructions:
Plan of care per hospice facility. Comfort measures only.
Completed by:[**2191-5-12**]
|
[
"112.5",
"578.9",
"496",
"414.00",
"V49.75",
"434.91",
"428.0",
"427.31",
"403.91",
"707.14",
"507.0",
"250.40",
"V45.81",
"996.62",
"276.0",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12190, 12266
|
6101, 11506
|
344, 365
|
12525, 12586
|
3532, 3537
|
12692, 12781
|
3014, 3032
|
11560, 12167
|
12287, 12287
|
11532, 11537
|
12610, 12669
|
3047, 3513
|
276, 306
|
393, 2520
|
12422, 12504
|
12306, 12401
|
3551, 4272
|
2542, 2761
|
2777, 2998
|
4285, 6078
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,344
| 195,040
|
45892
|
Discharge summary
|
report
|
Admission Date: [**2134-7-15**] Discharge Date: [**2134-7-30**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Nausea, bloating and early satiety
Major Surgical or Invasive Procedure:
[**2134-7-17**] Exploratory lap with multiple peritoneal biopsies and
gastrojejunostomy
History of Present Illness:
89 yo male presents with 5 day history of nausea but no
vomiting;
+ bloating and burping; early satiety. No abdominal pain.
Decreased amount of
bowel movements. No blood in stool. Present s to the ED at
[**Hospital1 18**] for further management.
Past Medical History:
Colon CA - s/p resection in [**2112**]
BPH - s/p TURP [**2114**]
Prostate CA
HTN
Social History:
Married; lives with wife.
Family History:
Noncontributory
Pertinent Results:
Upon admission:
[**2134-7-15**] 06:52AM GLUCOSE-83 UREA N-26* CREAT-0.9 SODIUM-140
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14
[**2134-7-15**] 06:52AM ALT(SGPT)-24 AST(SGOT)-31 ALK PHOS-67
AMYLASE-129* TOT BILI-0.7
[**2134-7-15**] 06:52AM ALBUMIN-3.3* CALCIUM-8.7 PHOSPHATE-3.7
MAGNESIUM-2.1
[**2134-7-15**] 06:52AM WBC-7.6 RBC-3.36* HGB-12.0* HCT-33.5*
MCV-100* MCH-35.8* MCHC-35.8* RDW-13.3
[**2134-7-15**] 06:52AM PLT COUNT-124*
[**2134-7-15**] 06:52AM PT-13.0 PTT-25.9 INR(PT)-1.1
Cardiology Report ECHO Study Date of [**2134-7-24**]
Conclusions:
The left atrium is normal in size. The left ventricular cavity
is unusually
small. Due to suboptimal technical quality, a focal wall motion
abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic
(EF>75%). There is a severe resting left ventricular outflow
tract
obstruction. Right ventricular chamber size is normal. Right
ventricular
systolic function is normal. The aortic valve is not well seen.
There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There
is systolic anterior motion of the mitral valve leaflets.
Moderate (2+) mitral
regurgitation is seen. The mitral regurgitation jet is
eccentric. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of
[**2130-3-2**], left ventricular outflow gradient is now higher and
left
ventricular systolic function is now hyperdynamic. Estimated
pulmonary artery
systolic pressure is now higher.
UGI SGL CONTRAST W/ KUB
Reason: contrast through NGT - does it pass anastomosis?
[**Hospital 93**] MEDICAL CONDITION:
89 year old man with gastric outlet syndrome repaired with
gastrojejunostomy with increasedd NGT output and recent
aspiration
REASON FOR THIS EXAMINATION:
contrast through NGT - does it pass anastomosis?
INDICATION: Gastric outlet syndrome with gastrojejunostomy and
increased NG tube output.
COMPARISON: Upper GI [**2134-7-22**].
FINDINGS: Supine scout image demonstrates an NG tube with its
tip within the fundus and multiple midline surgical skin
staples. Conray contrast was administered through the NG tube
which collected within the fundus. A repeat abdominal radiograph
20 minutes later demonstrated contrast passing through the
gastrojejunal anastomosis into loops of jejunum. Focused spot
images of the gastrojejunal anastomosis are limited because
contrast was not present at the anastomosis at the time of
spotting; however, there is no evidence of extravasation of
contrast.
IMPRESSION: Evidence of slow gastric emptying through the
anastomosis into jejunum after 20 minutes, improved from prior
study. No evidence of contrast extravasation.
Pathology Examination
SPECIMEN SUBMITTED: Abdominal wall mass
Procedure date Tissue received Report Date Diagnosed
by
[**2134-7-17**] [**2134-7-17**] [**2134-7-23**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/kg
Previous biopsies: [**-8/2153**] GASTRIC BX (1).
[**Numeric Identifier 97741**] SKIN EXCISION, RIGHT POSTERIOR SHOULDER (1).
[**-7/4475**] RIGHT: NASAL ALA & POST. SHOULDER.
[**Numeric Identifier 97742**] GI BX'S.
(and more)
DIAGNOSIS:
1. Abdominal wall implant (A):
Adenocarcinoma involving fibroadipose tissue. See note.
2. Portal implant (B):
Adenocarcinoma involving fibroadipose tissue. See note.
Note:
Morphologically, the tumor is favored to be of
pancreatico-biliary origin (or other gastrointestinal
carcinoma). However, immunohistochemical studies will be
performed and the results issued in an addendum.
Clinical: Gastric obstruction.
Gross: The specimen is received fresh intraoperatively in two
parts, labeled with the patient's name, "[**Known firstname **] [**Known lastname 349**]" and the
medical record number.
Part 1 is additionally labeled "abdominal wall implant" and
consists of a single piece of tan-yellow tissue measuring 1.7 x
0.7 x 0.4 cm. The entire specimen was given for frozen section
diagnosis performed by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] with a diagnosis which
reads as follows: "Moderately differentiated adenocarcinoma".
The entire frozen section remnant is submitted in cassette A.
Part 2 is additionally labeled "portal implant" and consists of
a single piece of tan-yellow tissue measuring 1.6 x 0.7 x 0.3
cm. The entire specimen given for frozen section diagnosis
performed by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] which reads as follows:
"Moderately differentiated adenocarcinoma". The entire frozen
section remnant is submitted in cassette B.
Brief Hospital Course:
He was admitted to the Surgical Service. Gastroenterology was
consulted, he underwent an EGD which revealed a gastric outlet
obstruction. He was taken to the operating room on [**7-17**] by Dr.
[**Last Name (STitle) **] for an exploratory laparotomy with multiple peritoneal
biopsies and gastrojejunostomy. There were no intraoperative
complications.
Postoperatively he was initially kept NPO with an NG tube in
place to suction. His diet was advanced slowly from sips to
clears and eventually to regular diet. He is currently
tolerating his regular diet.
Hematology/Oncology was consulted for mid epigastric mass,
ascites and peritoneal
carcinomatosis. Discussions took place with patient and family
regarding treatment options. It was decided to not proceed with
anything further at this time in order to allow him to heal. He
will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
Urology was consulted because of traumatic Foley removal; he
developed hematuria. He was started on continuous bladder
irrigation and intermittent hand irrigation. The hematuria
resolved and his Foley was removed. He is voiding without
difficulty.
There was some concern for DVT as he was noted with lower
extremity swelling; a DVT ultrasound was performed and was
negative for thrombus. He has been on Heparin SQ since
hospitalization for DVT prophylaxis.
Physical therapy was consulted because of his deconditioned
state. He did have complaints of left hip pain reportedly from a
fall that he sustained approximately 2 months ago. Hip and femur
films were taken and did not reveal any fractures or
dislocations; degenerative changes were noted. It is being
recommended that he go to a rehab facility after hospital
discharge.
Medications on Admission:
Lopressor 50 tid
Avapro 75 qd
Synthroid 50 qd
Lipitor 10 qd
Vit C 500 qd
Fish oil
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours):
Apply to back as directed.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb rx
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
ML Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): Apply to affected areas.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constiaption.
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged
Discharge Diagnosis:
Gastric outlet obstruction due to carcinomatosis, likely of
pancreaticobiliary origin.
Status post gastrojejunostomy for relief of gastric outlet
obstruction.
Discharge Condition:
improved
stable
Discharge Instructions:
Return to the Emergency room if you develop any fevers, chills,
increased shortness of breath, abdominal pain, nausea, vomiting,
diarrhea and/or any other symptoms that are concerning to you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] next week, call [**Telephone/Fax (1) 6429**] for an
appointment.
Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Hematology/Oncology by
calling [**Telephone/Fax (1) 6568**] for an appointment.
Follow up with your primary care doctor as directed; you will
need to call for an appointment.
Follow up with Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D., Urology.
Phone:[**Telephone/Fax (1) 277**] Date/Time:[**2134-10-7**] 10:00
Completed by:[**2134-7-30**]
|
[
"V10.46",
"425.1",
"599.7",
"507.0",
"E928.9",
"537.0",
"157.0",
"197.6",
"V10.05",
"867.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"54.11",
"54.23",
"99.15",
"44.39"
] |
icd9pcs
|
[
[
[]
]
] |
9405, 9464
|
5668, 7422
|
296, 386
|
9667, 9685
|
863, 865
|
9925, 10511
|
827, 844
|
7554, 9382
|
2652, 2778
|
9485, 9646
|
7448, 7531
|
9709, 9902
|
222, 258
|
2807, 5645
|
414, 663
|
879, 2615
|
685, 768
|
784, 811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,095
| 180,490
|
9949
|
Discharge summary
|
report
|
Admission Date: [**2197-2-7**] Discharge Date: [**2197-2-10**]
Date of Birth: [**2157-1-10**] Sex: M
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
40 yo man with Hx of Hepatitis B and hepatocellular carcinoma
that is admitted with respiratory failure. Pt currently
intubated and family present did not have any further history.
History taken from ED notes, Pt presented with increasing SOB
today & increased work of breathing, difficulty getting a full
breath.
+F/C but no N/V.
.
In ED, the pt got Vanco, Cefepime, and metronidazole, 10 liter
IVF, 2 U PRBC, 4 units of FFP, and was intubated after both
family and patient decided to pursue aggressive care (initially
did not want). Unable to place CVL - failed attempt at left
subclavian, left IJ, femoral line.
Past Medical History:
(Oncologic history obtained from previous records)
.
1. Past Oncology History: He was found to have an elevated AFP
on
routine screening in [**2196-4-20**] (normal in [**2193**]). At that time,
imaging revealed a large mass in his liver with smaller liver
masses. He was initially evaluated for a surgical ressection,
which he declined. In [**2196-6-20**], he decided to begin systemic
chemotherapy. Prior to starting chemotherapy, he became short of
breath and was found to have a pulmonary embolism as well as
portal, hepatic, and IVC thrombosis. He was tried on
doxorubicin/cisplatin/avastin. He was on Xelodia but recently
failed this therapy.
.
Other Medical History:
1. Hepatitis B
Social History:
He is married and lives with his mother, wife and two children,
ages 3 [**11-21**] and 1 [**11-21**]. He used to work in a restaurant, but he
is currently not working. He grew-up in [**Doctor Last Name **]-[**Doctor Last Name 6431**] and moved to
the United Stated in [**2171**]. He used to smoke 2.5 packs per day
and quit smoking approximately four years ago. He does not
drink alcohol.
Family History:
He has four siblings who all have hepatitis B. One brother died
recently secondary to hepatocellular carcinoma. He has another
brother that is currently undergoing evaluation for likely
diagnosis of hepatocellular carcinoma. His mother has some
intestinal cancer.
Physical Exam:
Vital Signs: T 99.2 BP 101/45 P 116 RR 22 O2 sat 100%
intubated
AC 500/20-->25. 100%.
Gen: NAD, AAOx3
HEENT: MMM, OP-ETT in place, mild icterus
Neck: No LAD,
Heart: Tachy unable to hear murmur
Lungs: coarse BS
Abd: Markedly distended, severe hepatomegaly, tympanic, +BS
Extr: 1+ LE edema
Neuro: sedated
Pertinent Results:
Imaging:
CT C/A/P [**2-6**] (the day prior to admission):
IMPRESSION: Increase in the size and extent of multiple
pulmonary nodules as well as liver masses. Tumor thrombus
invading the upper inferior vena cava as well as the right
portal vein. An increase in the amount of free fluid in the
abdomen and pelvis. Increase in the size of the right pleural
effusion. All of these findings are consistent with progression
of disease.
CXR [**2-7**]:
1. Right middle and lower lobe atelectasis with adjacent
predominantly
subpulmonic right pleural effusion.
2. Widespread pulmonary metastasis.
Brief Hospital Course:
40 yo with metastatic hepatocellular carcinoma metastatic to the
lung, complicated by PE, IVC, portal, and hepatic vein
thrombosis on lovenox, who presented to the ED with tachypnea
and hypotension.
.
# Sepsis/Respiratory distress:
His initial presentation with hypotension was concerning for
sepsis although no clear source was found. He was started on
vancomycin and zosyn for broad empiric coverage and his blood
pressure was supported with IV fluids and levophed. His
respiratory distress and increased work of breathing was thought
to be compensation for his acidosis and he eventually required
intubation. His elevated LFTs and renal function were thought
to be due to poor end-organ perfusion due to his hypotension and
improved somewhat with IV fluid resuscitation.
.
# Anemia:
He was noted to have coffee ground emesis in his NG tube and
required support with multiple transfusions of red blood cells
and FFP in an attempt to reverse his INR in the setting of
active bleeding.
.
# Dispo:
Due to his history of end-stage metastatic hepatocellular
carcinoma and his presentation to the ED with likely sepsis,
there was discussion in the ED about the appropriateness of
intubation and aggressive measures. After discussion with the
family and the primary oncology team the decision to intubate
and treat aggressively was made. After a day of aggressive
treatment in the ICU his labs showed minimal improvement and he
was requiring increasing amounts of IV fluid and red blood cells
to support his blood pressure and hematocrit. A family meeting
was again held with his primary oncology team present and the
decision to stop aggressive treatment and pursue comfort
measures was made. On [**2-8**] he was extubated and transferred to
the floor for comfort care. He was given Morphine gtt and
Ativan PRN anxiety, as well as Scopolamine and IV Benadryl to
decrease secretions. Family present at bedside. Pt. passed
away early in the morning on [**2-9**].
.
# Hepatocellular carcinoma:
His oncologist Dr. [**First Name (STitle) **] was contact[**Name (NI) **]. [**Name2 (NI) **] spoke to the family
and explained that pt was at the end of his treatment options.
.
# H/o PE, portal, hepatic, and IVC thrombosis:
-Continued lovenox until [**2-8**], when it was d'ced, as care was
transitioned to comfort measures only per family wishes
.
Medications on Admission:
1. Enoxaparin 40 mg [**Hospital1 **]
2. Oxycodone SR 50 mg [**Hospital1 **]
3. Colace
4. Senna
5. Simethicone
6. Oxycodone 5 mg prn
7. Simethicone 80 mg Tablet
8. Furosemide 40 mg ? one dose
9. Lorazepam 1 mg qd
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic Hepatocellular Carcinoma
Multiorgan system failure [**12-22**] above
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2197-2-10**]
|
[
"995.92",
"578.9",
"155.0",
"584.9",
"785.52",
"197.0",
"518.81",
"285.9",
"038.9",
"V66.7",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.04",
"96.71",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
5944, 5953
|
3303, 5652
|
277, 289
|
6076, 6086
|
2685, 3280
|
6139, 6174
|
2074, 2340
|
5915, 5921
|
5974, 6055
|
5678, 5892
|
6110, 6116
|
2355, 2666
|
230, 239
|
317, 935
|
957, 1647
|
1663, 2058
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,207
| 147,704
|
23034
|
Discharge summary
|
report
|
Admission Date: [**2152-12-31**] Discharge Date: [**2153-1-8**]
Date of Birth: [**2095-9-18**] Sex: M
Service: MEDICINE
Allergies:
Asparagus
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Transfer from [**Hospital1 **] for pericardiocentesis with pigtail
catheter placement.
Major Surgical or Invasive Procedure:
Right heart catheterization
Pericardiocentesis with pericardial drain placement [**2153-1-1**]
Right thoracentesis [**2153-1-3**]
Left thoracentesis [**2153-1-5**]
History of Present Illness:
Mr. [**Known lastname **] is a 57 year old male with history of hyperlipidemia
and GERD, who is transferred to [**Hospital1 18**] from [**Hospital1 **] for
urgent pericardiocentesis with drain placement. His symptoms
began 1 week prior to admission, when he awoke with malaise,
cough, and sore throat. His malaise became worse through the
week, and he complained of fevers/chills, as well as n/v/d the
day before presentation to [**Hospital1 **] on [**2152-12-30**]. + anorexia.
At [**Location (un) 620**] he was noted to be tachycardic to 110 bpm, and
hypoxic at 92% on RA, though afebrile. A CXR revealed RLL and
RUL infiltrates, and his wbc count was 13.2 with mild L shift.
Rapid influenza was negative, and he was started on levaquin,
later changed to ceftriaxone and zithromax. He was additionally
noted to be in ARF with creatinine 1.8. Clinically he worsened
rapidly; on the second day of admission he was noted to be
dyspneic, cyanotic, with ABG 7.45/19/65, and patient intubated
with serosanguinous secretions. An echo done later that night
showed a large pericardial effusion, and decision was made to
transfer patient to [**Hospital1 18**] for pericardiocentesis and pigtail
catheter placement.
On [**Last Name (LF) **], [**First Name3 (LF) **] patient's family, he was in his usual state of
health prior to this illness. They deny that he complained of
any previous cough, no previous n/v/d, no anorexia or weight
loss. He did have hematochezia approximately 3 weeks ago,
however attributed it to a hemorrhoid, and it resolved. Last
colonoscopy 1 year ago, normal per wife. Unsure if he has ever
had a PPD test. Smoked 2 PPD x 30 years, but quit 13 years ago.
Past Medical History:
Hyperlipidemia, on lipitor.
GERD, on a PPI or H2 blocker - unsure.
Social History:
"Heavy" smoker until 13 years ago - smoked 2 PPD x 30 years.
Also used to be an alcoholic, but quit 20 years ago. Uncertain
PPD status. Last colonoscopy 1 year ago, normal.
Married to his second wife, 2 children.
Family History:
Did not elicit.
Physical Exam:
VS: 97.5, 106/72, 98, RR 30 on AC 100%, 600/30. PAP 32/19. CO
4.6, CI 2.2.
Gen: Overweight caucasian male lying supine in bed, intubated,
sedated.
HEENT: Pupils pinpoint, reactive, edematous conjunctiva.
CVS: RR, normal rate, faint rub, S3 vs. split S2.
Lungs: Difficult to auscultate over ventilator, from anterior
chest. Loud upper airway sounds.
Chest: Pigtail catheter site clean/dry, dressings in place.
Abd: NABS, soft, obese, no dullness to percussion. No
hepatosplenomegaly.
Extr: No c/c/e. L great toe cyanotic, R great toe pale, DP/PT
non-palpable but present with doppler. Hands cold. Multiple
lines in R groin.
Pertinent Results:
[**2152-12-31**] WBC-13.6* Hgb-9.3* Hct-28.4* MCV-91 MCHC-32.8 RDW-14.2
Plt Ct-224
[**2153-1-7**] WBC-10.6 Hgb-12.0* Hct-36.9* MCV-90 MCHC-32.6 RDW-14.4
Plt Ct-313
[**2152-12-31**] Neuts-89.5* Bands-0 Lymphs-7.0* Monos-3.1 Eos-0.1
Baso-0.2
[**2153-1-5**] Neuts-88.5* Lymphs-6.4* Monos-4.7 Eos-0.4 Baso-0
[**2152-12-31**] PT-23.1* PTT-40.2* INR(PT)-3.4
[**2153-1-5**] PT-13.4 PTT-23.9 INR(PT)-1.1
[**2152-12-31**] Glucose-94 UreaN-69* Creat-2.1* Na-145 K-4.1 Cl-110*
HCO3-17*
[**2153-1-2**] Glucose-116* UreaN-55* Creat-1.0 Na-148* K-3.2* Cl-117*
HCO3-25
[**2153-1-7**] Glucose-98 UreaN-11 Creat-0.5 Na-141 K-3.6 Cl-107
HCO3-24
[**2152-12-31**] ALT-2911* AST-3424* LD(LDH)-6996* CK(CPK)-2782*
AlkPhos-71 TotBili-0.7
[**2153-1-2**] ALT-3119* AST-1643* LD(LDH)-2252* CK(CPK)-1316*
AlkPhos-90 TotBili-0.9
[**2153-1-5**] ALT-1069* AST-142* LD(LDH)-457* AlkPhos-177*
TotBili-1.6*
[**2153-1-6**] ALT-620* AST-68* LD(LDH)-306* AlkPhos-140* Amylase-80
TotBili-1.1
[**2152-12-31**] Albumin-2.9* Calcium-6.7* Phos-7.6* Mg-2.5
[**2153-1-7**] Calcium-8.0* Phos-2.2* Mg-1.8
[**2153-1-2**] Iron-35* calTIBC-191* Ferritn-GREATER TH TRF-147*
[**2152-12-31**] Cortsol-53.8*
05:33AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM HAV-NEGATIVE
[**2153-1-6**] BLOOD CEA-78*
FLUID STUDIES:
[**2152-12-31**] PERICARDIAL FLUID WBC-2700* HCT,fl-26* Polys-37*
Lymphs-8* Monos-5* Eos-1* Atyps-2* Macroph-31* Other-16*
TotPro-5.6 Glucose-29 LD(LDH)-831 Amylase-35 Albumin-3.3
[**2153-1-3**] PLEURAL WBC-2500* RBC-[**Numeric Identifier 59406**]* Polys-13* Lymphs-72*
Monos-1* NRBC-3* Meso-6* Macro-2* Other-3*
TotProt-2.6 Glucose-125 LD(LDH)-443
[**2153-1-5**] PLEURAL WBC-278* RBC-[**Numeric Identifier 59407**]* Polys-21* Lymphs-32*
Monos-0 Macro-4* Other-43*
TotProt-2.4 Glucose-106 LD(LDH)-423 Albumin-1.4
MICRO:
[**2153-1-1**] 12:44 am BLOOD CULTURE Site: A LINE
**FINAL REPORT [**2153-1-7**]**
AEROBIC BOTTLE (Final [**2153-1-7**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2153-1-7**]): NO GROWTH.
[**2153-1-3**] 9:37 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2153-1-5**]**
GRAM STAIN (Final [**2153-1-3**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2153-1-5**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
YEAST. SPARSE GROWTH. PREDOMINATING ORGANISM.
[**2153-1-3**] 3:49 pm PLEURAL FLUID
**FINAL REPORT [**2153-3-5**]**
GRAM STAIN (Final [**2153-1-3**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2153-1-6**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1 COLONY ON 1
PLATE.
ANAEROBIC CULTURE (Final [**2153-1-9**]): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final [**2153-1-4**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Final [**2153-3-5**]): NO MYCOBACTERIA
ISOLATED.
IMAGING:
Cardiac cath [**2152-12-31**]: COMMENTS:
1. Baseline right atrial pressure was markedly elevated with a
mean
pressure of 30 mmHg. Upon entry into the pericardial space, the
pericardial pressure was entrained with the RA pressure tracing
(mean of
30 mmHg). A promenent pulsus paradoxus was noted in the femoral
arterial tracing, all signs consistent with pericardial
tamponade.
2. Successful pericardiocentesis with drainage of
approximately 800 cc
of grossly bloody fluid. The last 200 cc of fluid were bright
red, with
a saturation of 95%.
3. Selective coronary angiography demonstrated minimal luminal
irregularities, with no obstructive lesions in the LMCA, LAD,
LCX, or
RCA.
4. Left ventriculography demonstrated normal ventricular
systolic
function.
5. Post-pericardiocentesis hemodynamics demonstrated marked
respiratory variation in the intracardiac pressure tracings,
with
pericardial pressure of 10mmHg, and RA pressure remaining
elevated. The
PCWP was elevated at 18mmHg, and the cardiac index was
low-normal. The
patient's blood pressure was markedly improved at the end of the
procedure.
FINAL DIAGNOSIS:
1. Coronary arteries are angiographically normal.
2. Normal LV wall motion
3. Cardiogenic shock
4. Severe pericardial tamponade, successfully
drained by pericardiocentesis
5. Effusive constrictive syndrome.
Chest Portable [**2153-1-1**]: IMPRESSION: Widened mediastinum and
rounded enlargement of the right hilar contours, concerning for
lymphadenopathy from a neoplastic process. TB is also a
possibility. Correlative contrast enhanced chest CT may be
helpful for better assessment if warranted clinically, as
communicated to the clinical house staff caring for the patient.
Multifocal pulmonary opacities most prominent in the right upper
lobe and retrocardiac portions of the lower lobes, which may be
due to the history of pneumonia.
TTE [**2153-1-2**]: Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is a
small echodense pericardial effusion located and anterior to the
left ventricle and extending around the left venticular apex
with minimal effusion anterior to the right ventricle. No
evidence for tamponade or constriction are seen. Compared with
the prior study (tape reviewed) of [**2153-1-1**], the findings are
similar.
CT TORSO w/wout contrast [**2153-1-2**]:
IMPRESSION:
1. Right upper lobe lung mass with extensive mediastinal and
hilar lymphadenopathy, suspicious for primary lung cancer with
extensive nodal spread. These would be amenable to bronchoscopic
biopsy.
2. No pulmonary embolism.
3. Small low attenuation lesion in the liver too small to
characterize.
4. No lymphadenopathy within the abdomen or pelvis.
5. Moderate-to-large bilateral pleural effusions with lower lobe
consolidation and collapse.
TTE [**2153-1-4**]: Conclusions:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen. There is no pericardial effusion.
CT head [**2153-1-6**]: IMPRESSION: No evidence of intracranial
metastases.
Bone Scan [**2153-1-8**]: IMPRESSION: No foci of osseous metastatic
disease.
PATHOLOGY:
Pericardial fluid [**2153-1-1**]:
DIAGNOSIS: Positive for malignant cells, consistent with poorly
differentiated non-small cell carcinoma.
Heme slide (173D) reviewed.
Note: Immunocytochemical studies were performed on cytospin
slides. The malignant cells are immunoreactive for
monoclonal CEA, cytokeratin 7, and focally TTF1 (nuclear
pattern). The tumor cells are non-reactive for CK20.
Calretinin stains background benign mesothelial cells. This
immunocytochemical profile supports a carcinoma of lung
origin. This diagnosis was discussed with Dr. [**Last Name (STitle) **] by A.
[**Doctor Last Name **] on [**2153-1-3**].
Endotracheal sputum [**2153-1-4**]: DIAGNOSIS: Atypical.
A few atypical but degenerated epithelial cells present in a
background of pulmonary macrophages, bronchial cells,
squamous cells and inflammatory cells.
Pleural fluid [**2153-1-4**]: DIAGNOSIS: SUSPICIOUS.
Suspicious for metastatic non-small carcinoma.
Rare highly atypical epithelial cells present, especially in
additionally prepared cytospin slide and Heme slide (1403D;
[**2153-1-3**]).
Note: Immunostains performed on cytospin slides including
monoclonal CEA, calretinin, CK7 and CK20 are not
contributory due to scant atypical cells and high background
staining.
Brief Hospital Course:
57 year old male ex-smoker with hyperlipidemia and GERD, who
presented to OSH with multilobar pneumonia, large pericardial
effusion, desaturation requiring extubation, transferred to
[**Hospital1 18**] for urgent pericardiocentesis with pericardial drain
placement.
1) Hypotension, shock: Thought to be cardiogenic in nature,
secondary to tamponade as demonstrated on echo and confirmed in
the cath lab. He received fluids and his hemodynamics markedly
improved after drainage of his pericardial effusion. He did not
require pressors.
2) Pericardial effusion: On arrival, 850 cc of hemorrhagic
fluid were drained in cath lab. Given the patient's bilobar
pneumonia, mildly elevated calcium at OSH, and heavy smoking
history, there was concern for bronchogenic carcinoma. The
pathology on the fluid returned with poorly differentiated
non-small cell carcinoma. He had a pericardial drain placed in
the cath lab that was left in for 2 days and subsequently
removed. His effusion was followed with serial echo and did not
reaccumulate during his stay.
3) Non-small cell lung cancer: A CT of his chest demonstrated a
3.5 x 3.5 cm mass within the right upper lobe medially; areas of
collapse/consolidation adjacent to this; extensive
lymphadenopathy within the prevascular, pretracheal, subcarinal,
and right hilar regions, the largest lymph node conglomerate
measuring 2.3 x 5.8 cm in the subcarinal region; no
pathologically enlarged axillary lymph nodes; 3.1 x 2.7 cm right
paratracheal lymph node as well as a 2.4 x 2.9 cm left
prevascular lymph node; right hilar lymph node measuring
approximately 2.8 x 2.7 cm. As above, the cytology from his
pericardial effusion was consistent with a poorly differentiated
non-small cell lung cancer, making bronchoscopic biopsy
unecessary. A staging workup was negative for brain or bone
metastases, and the remainder of his CT did not show
intra-abdominal metastases. He was discharged with follow up in
oncology clinic.
4) Post-obstructive pneumonia: He was treated with ceftriaxone
and azithromycin, later changed to levaquin for a total of 10
days. He was comfortably breathing room air on discharge, and
had been afebrile for days.
5) ARF: Pt. found to have elevated creatinine on presentation
to OSH - thought to be pre-renal from dehydration in the setting
of infxn, nausea and vomiting. On arrival his creatinine was
2.1, which trended down with fluids to 0.5 on discharge.
6) Anion gap metabolic acidosis: He had a gap acidosis on
arrival, thought secondary to his lactate of 14, which trended
down concurrent with gap closure.
7) Elevated LFTs: His transaminases were in the thousands on
arrival, with elevated PT, thought secondary to shock liver.
His transaminases trended down during the course of the
admission, bilirubin peaking at 1.6, ALT at 3119, AST at 3424.
8) CK elevation: Pt. with high CK to 1200 at OSH, up to 2700
here. His MB fraction and index were both normal. Troponin was
elevated at 0.13, however given his normal CK-MB, this was
attributed to impaired clearance with renal failure, and the
stress on the heart given his effusion and cardiogenic shock.
His CK peaked at 2809, and then trended down.
9) Ventilation: He was intubated at the OSH, and extubated
successfully on his 5th hospital day. To facilitate extubation
and improve oxygenation, the patient had bilateral thoracenteses
prior. Both taps yielded 1L of sanguinous fluid, positive for
atypical cells.
10) Anemia: His iron studies were consistent with anemia of
chronic inflammation.
Medications on Admission:
Ranitidine
Atorvastatin
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
2. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO at
bedtime.
3. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO at
bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Non-small cell lung cancer
Pericardial effusion
Pleural effusions bilaterally
Pneumonia
Acute renal failure, now resolved
Discharge Condition:
Good, stable.
Discharge Instructions:
Resume all of your previous medications (Lipitor and
Ranitidine).
You will need to follow up as an outpatient with pulmonary and
oncology as listed below. The doctors [**Name5 (PTitle) **] review your bone
scan and CAT scans.
Seek medical help if you become more short of breath, or develop
lightheadedness or chest pain.
Followup Instructions:
1. Oncology:
You have an appointment set up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] of
oncology, Thursday, [**1-11**] at 10:30 am, on the [**Hospital Ward Name 516**],
[**Hospital Ward Name 23**] [**Location (un) **]. [**Telephone/Fax (1) 6568**].
2. Pulmonary department:
Provider: [**Name10 (NameIs) 1571**] BREATHING TEST Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2153-1-18**]
7:45
Provider: [**Last Name (LF) **],[**First Name3 (LF) **] MULTI MULTI-SPECIALTY THORACIC
UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI Date/Time:[**2153-1-18**]
8:15
3. Please call Dr. [**Last Name (STitle) **] of cardiology for an appointment in
the next week or two at [**Telephone/Fax (1) 127**].
You may need to contact your primary care doctor to obtain a
referral for the oncology and pulmonary appointments.
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62,871
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39734
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Discharge summary
|
report
|
Admission Date: [**2144-9-9**] Discharge Date: [**2144-9-28**]
Date of Birth: [**2076-8-28**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline / Meclizine / Demerol / Thioridazine /
Opioids-Morphine & Related / Chlorpromazine
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Sepsis (presumed from a biliary source).
Major Surgical or Invasive Procedure:
ERCP with Biliary stent placement
Right Internal Jugular Central Venous Line Placement
Midline venous line placement
History of Present Illness:
Patient is a 68 year old female with (per OSH records) history
of HTN, bipolar disorder, ? ESRD on HD, CAD s/p PCI, and COPD
who was transferred from an OSH this morning for management of
septic shock, thought secondary to ascending cholangitis. Per
records, patient, who lives in nursing home, was found to have
episodes of nausea and vomiting at her nursing home with
associated fever. She was noted to be hypotensive, EMS was
called, and upon arriving at scene, found patient to be
"unconscious" with SBP in the 50s. Baseline mental status is
unable to be determined at this time. She received 1 liter NS
enroute to OSH ED. In the ED, patient remained unresponsive
with hemodynamic instability, and a right femoral line was
placed, and norepi was started.
.
Initial labs showed creatinine of 2.6, t. bil of 5, AST 470, ALT
227, alk phs 422. trop T 0.21. BNP > [**Numeric Identifier **]. WBC 17.5, 64%
polys, 19% bands. INR 1.4. U/A showed 21-30 WBCs and 1 blood
culture grew out GNRs. lipase 42.
.
Following admission, she received vancomycin and zosyn. She was
also started on pantoprazole IV. CT scan showed GB distention
with pericholecystic fluid, CBD dilated to 10 mm with 8 mm
high-density filling defect in distal CBD, with intrahepatic
bile ducts were also dilated. There was a question of portal
vein thrombosis. GI was consulted, and suggested stablizing
patient prior to MRCP or ERCP. Cardiology was also consulted ->
her cath films were reviewed, and she was noted to have ectatic,
dilated coronaries; stents were patent (unsure of anatomy).
Patient was improved hemodynamically, and transfer was arranged
directly to MICU to facilitate ERCP.
.
Upon arrival to the floor, patient was alert to name, not
following commands. She was unable to provide any history.
Attempt was made to contact next of [**Doctor First Name **].
.
Past Medical History:
HTN
CRI: History of hemodialysis over 15 years ago with R AV-fistula
in place; unclear recent baseline creatinine.
CAD s/p PCI
COPD
Mood disorder NOS s/p recent psychiatric admission for one month
Osteoporosis
Social History:
Lives in a nursing home. Denies history of tobacco, alcohol or
illicit drugs. Per nursing home she requires help with nearly
all ADLs. Has had psych decline over the last few months.
Recently admitted to psych inpatient facility.
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM:
Vitals: T: 98.8 BP: 125/69 P: 90s R: 16 18 O2: 97% 3.5
liters
General: Alert, oriented to name, not following commands
initially. Subsequent assessment showed patient was more
interactive, following commands, no 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, systolic murmurs,
rubs, gallops
Abdomen: soft, mildly tender to palpation in epigastrium and
RUQ, no rebound/guarding, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place from OSH
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE EXAM:
V T=98.6, BP 104/51, HR 68, RR 18, 98%RA
Gen: NAD, comfortable
Cardiac: systolic murmur at right sternal border, S1, S2
Pulm: CTAB, no crackles, no rhonchi, no rhales
Abd: soft, nt, nd, pos bs
Skin: erythematous rash on buttocks and medial thights
Ext: warm, has fistula in right arm. No pedal edema. No
anasarca.
Pertinent Results:
ADMISSION LABS:
.
[**2144-9-9**] 06:32PM TYPE-ART TEMP-36.7 O2 FLOW-6 PO2-104 PCO2-32*
PH-7.38 TOTAL CO2-20* BASE XS--4 INTUBATED-NOT INTUBA
[**2144-9-9**] 06:32PM LACTATE-2.2*
[**2144-9-9**] 06:32PM freeCa-1.09*
[**2144-9-9**] 06:05PM GLUCOSE-102* UREA N-50* CREAT-2.1* SODIUM-145
POTASSIUM-3.5 CHLORIDE-114* TOTAL CO2-21* ANION GAP-14
[**2144-9-9**] 06:05PM CALCIUM-7.6* PHOSPHATE-2.5* MAGNESIUM-2.4
[**2144-9-9**] 06:05PM WBC-23.9* RBC-4.03* HGB-11.9* HCT-35.7*
MCV-89 MCH-29.6 MCHC-33.5 RDW-15.4
[**2144-9-9**] 06:05PM PLT COUNT-65*
[**2144-9-9**] 06:05PM PT-14.6* PTT-31.5 INR(PT)-1.3*
[**2144-9-9**] 02:48PM TYPE-MIX PO2-53* PCO2-37 PH-7.36 TOTAL CO2-22
BASE XS--3
[**2144-9-9**] 02:48PM LACTATE-2.0
[**2144-9-9**] 02:48PM O2 SAT-86
[**2144-9-9**] 02:30PM GLUCOSE-84 UREA N-52* CREAT-2.3* SODIUM-147*
POTASSIUM-4.6 CHLORIDE-115* TOTAL CO2-21* ANION GAP-16
[**2144-9-9**] 02:30PM ALT(SGPT)-103* AST(SGOT)-92* ALK PHOS-228*
TOT BILI-1.8*
[**2144-9-9**] 02:30PM CALCIUM-7.5* PHOSPHATE-3.0 MAGNESIUM-2.8*
[**2144-9-9**] 02:30PM WBC-20.5* RBC-4.12* HGB-12.0 HCT-37.1 MCV-90
MCH-29.2 MCHC-32.4 RDW-16.2*
[**2144-9-9**] 02:30PM PLT COUNT-66*
[**2144-9-9**] 02:30PM PT-14.5* PTT-31.2 INR(PT)-1.3*
[**2144-9-9**] 06:32AM TYPE-MIX COMMENTS-GREEN TOP
[**2144-9-9**] 06:32AM LACTATE-2.7*
[**2144-9-9**] 06:22AM URINE RBC-1 WBC-23* BACTERIA-NONE YEAST-NONE
EPI-0
[**2144-9-9**] 06:21AM GLUCOSE-75 UREA N-53* CREAT-2.4* SODIUM-150*
POTASSIUM-3.5 CHLORIDE-116* TOTAL CO2-19* ANION GAP-19
[**2144-9-9**] 06:21AM ALT(SGPT)-116* AST(SGOT)-133* CK(CPK)-146 ALK
PHOS-246* TOT BILI-2.0* DIR BILI-1.5* INDIR BIL-0.5
[**2144-9-9**] 06:21AM LIPASE-12
[**2144-9-9**] 06:21AM CK-MB-6 cTropnT-0.11*
[**2144-9-9**] 06:21AM ALBUMIN-2.4* CALCIUM-5.9* PHOSPHATE-2.7
MAGNESIUM-1.5*
[**2144-9-9**] 06:21AM WBC-30.4* RBC-4.59 HGB-13.0 HCT-42.1 MCV-92
MCH-28.3 MCHC-30.9* RDW-16.2*
[**2144-9-9**] 06:21AM NEUTS-94.9* LYMPHS-3.9* MONOS-0.7* EOS-0.2
BASOS-0.4
[**2144-9-9**] 06:21AM PLT COUNT-82*
[**2144-9-9**] 06:21AM PT-15.6* PTT-33.1 INR(PT)-1.4*
DISCHARGE LABS:
[**2144-9-28**] 07:40
COMPLETE BLOOD COUNT
White Blood Cells 4.2 4.0 - 11.0 K/uL
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.19* 4.2 - 5.4 m/uL
PERFORMED AT WEST STAT LAB
Hemoglobin 9.4* 12.0 - 16.0 g/dL
PERFORMED AT WEST STAT LAB
Hematocrit 28.9* 36 - 48 %
PERFORMED AT WEST STAT LAB
MCV 91 82 - 98 fL
PERFORMED AT WEST STAT LAB
MCH 29.4 27 - 32 pg
PERFORMED AT WEST STAT LAB
MCHC 32.4 31 - 35 %
PERFORMED AT WEST STAT LAB
RDW 16.4* 10.5 - 15.5 %
PERFORMED AT WEST STAT LAB
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 139* 150 - 440 K/uL
PERFORMED AT WEST STAT LAB
[**2144-9-28**] 07:40
RENAL & GLUCOSE
Glucose 87 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
PERFORMED AT WEST STAT LAB
Urea Nitrogen 10 6 - 20 mg/dL
PERFORMED AT WEST STAT LAB
Creatinine 0.8 0.4 - 1.1 mg/dL
PERFORMED AT WEST STAT LAB
Sodium 139 133 - 145 mEq/L
PERFORMED AT WEST STAT LAB
Potassium 4.3 3.3 - 5.1 mEq/L
PERFORMED AT WEST STAT LAB
Chloride 106 96 - 108 mEq/L
PERFORMED AT WEST STAT LAB
Bicarbonate 26 22 - 32 mEq/L
PERFORMED AT WEST STAT LAB
Anion Gap 11 8 - 20 mEq/L
ENZYMES & BILIRUBIN
Alkaline Phosphatase 121* 35 - 105 IU/L
PERFORMED AT WEST STAT LAB
CHEMISTRY
Calcium, Total 7.9* 8.4 - 10.3 mg/dL
PERFORMED AT WEST STAT LAB
Phosphate 2.1* 2.7 - 4.5 mg/dL
PERFORMED AT WEST STAT LAB
Magnesium 1.7 1.6 - 2.6 mg/dL
PERFORMED AT WEST STAT LAB
Alkaline Phosphatase 121* 35 - 105 IU/L
PERFORMED AT WEST STAT LAB
CHEMISTRY
Calcium, Total 7.9* 8.4 - 10.3 mg/dL
PERFORMED AT WEST STAT LAB
Phosphate 2.1* 2.7 - 4.5 mg/dL
PERFORMED AT WEST STAT LAB
Magnesium 1.7 1.6 - 2.6 mg/dL
PERFORMED AT WEST STAT LAB
.
MICRO:
[**Date range (1) 87530**] Blood cx: NGTD
.
[**2144-9-10**] C. diff toxin: NEGATIVE
[**2144-9-27**] C. Diff Toxin: POSITIVE
.
[**2144-9-9**] Urine cx: contamination
.
[**2144-9-10**] Urine cx: contamination
.
IMAGES:
.
[**2144-9-9**] EKG: EKG: sinus rhythm, rate in 70s, normal axis,
intervals, inverted T waves in V2-V5 unchanged from two days
ago, no other ST-T wave changes. V2-V5 flipped Ts are new from
last year.
.
[**2144-9-9**] ERCP:
IMPRESSION:
1) Multiple duodenal erosions
2) Partial pancreatogram
3) Successful biliary cannulation
4) A moderate diffuse dilation was seen at the main duct with
the CBD measuring 12 mm.
5) A single 10 mm round stone that was causing partial
obstruction was seen at the middle third of the common bile
duct. There were a couple other small filling defects suggestive
of stones or stone fragments seen on the cholangiogram.
6) A 7cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed
Otherwise normal ercp to third part of the duodenum
.
[**2144-9-11**] ECHO: The left atrium is moderately dilated. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. 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
no pericardial effusion.
.
[**2144-9-11**] CT Head w/o contrast: No acute intracranial abnormality
[**2144-9-9**] Liver/Gallbladder U/S:
IMPRESSION: Dilated sludge-filled gallbladder with an irregular
wall, which is, in the appropriate clinical setting, consistent
with cholecystitis.
[**2144-9-12**] KUB:
REASON FOR EXAMINATION: Recent ERCP , new emesis, evaluation of
NG tube
placement.
Two AP views of the abdomen were reviewed.
There is coiled tube in the proximal stomach/lower portion of
the known hiatal
hernia. Small bowel loops are dilated up to 3.4 cm. There is
relative
paucity of the bowel gas in the abdomen.
Multiple vertebroplasties findings are present. Left lower lung
opacity most
likely representing area of atelectasis, partially imaged.
Tortuous aorta as
well as the abdominal aortic calcifications are present.
Brief Hospital Course:
Ms. [**Known lastname 75626**] is a 68 year old woman with h/o CAD s/p percutaneous
intervention, CKD (formerly on HD but no longer), depression and
bipolar disorders, admitted with septic shock from ascending
cholangitis, cholecystitis, and E. Coli bacteremia.
#. Septic shock/Ascending cholangitis/Bacteremia - Pt admitted
from OSH initially with septic shock secondary to ascending
cholangitis, cholecystitis, and Ecoli bacteremia. E. coli from
OSH sensitive to ceftriaxone and pt completed 10 days, completed
on [**2144-9-18**]. She had ERCP & CBD stenting [**2144-9-9**]. Large stone
was not removed as patient was too unstable during procedure. GI
placed temporary stent until infection resolves, and then follow
up 4 week stent and stone removal. Subsequent bacterial and
urine cultures were negative. Surgery team was consulted for
cholecystitis (no gallbladeder stones visualized) seen on
ultrasound, treated patient supportively with antibiotics. Pt
improved during hosptalization and remained afebrile, normal
WBC, normotensive.
**Plan to follow up with Dr.[**Name (NI) 2798**] office at [**Telephone/Fax (1) 2799**]
on [**2144-9-7**] for stent removal, sphincterotomy, and stone
extraction.
.
#. Mental Status Change/Catatonia?????? Patient had altered mental
status in hospital, likely secondary to acute toxic metabolic
encephalopathy as well as underlying psych disorder, possibly
schizophrenia with catatonic state. CT head negative. She was
very withdrawn, refused to eat or talk, had posturing. She was
responsive but would not cooperate. Psych was constuled and
reccomended haldol and ativan PRN as well as re-starting abilify
that was initially held on admission. Pt was unable to take
abilify until she started to eat food. Until she started to eat,
she was given PPN, IV haldol and lorazepam. As she started to
eat, abilify dose was increased to 15mg daily and she was
contiued on lorazpam 0.5 TID for treatment of catatonic state.
Pt's fentanyl patch was decreased to 100-->25 every 72 hours.
She is wearing her final 25mg patch which should be removed in 2
days. She will not need further fentanyl patches. Nursing home
and daughter [**Name (NI) 653**] - reported that pt has had significant
psych decline over the last month with a recent psych hospital
admission. She requires continued psych follow up to help her
recover from her catatonic state.
.
#C. diff: Pt developed diarrhea the last few days of
hospitalization, tested positive for stool C. diff. Started on
flagyl 500 TID on [**2144-9-28**]. Should continue for 14 days.
***
-continue Flagyl 500 TID for 14 days.
-Make sure patient drinks enough and matches her output. Needs
1:1 assistance to make sure she is drinking and eating.
.
#CKD: Cr 2.4 on admission and Cr trended down during
hospitalization. It was 0.8 on day of discharge. Has history of
renal failure with HD and fistula. No longer requiring HD.
Daughter reports that pt was on HD for alcohol induced renal
failure. Isopropyl alchohol? Unclear exact etiology of prior
renal insult.
.
#. Anasarca ?????? Pt noted to have edema of hands and feet that
improved with aggressive IV lasix. Was given Furosemide 40mg IV
BID. Anarsarca secondary to agressive volume resuscitation in
the setting of biliary sepsis as well as hypoabluminemia. Echo
without significant valvular disease or evidence of
decompensation. No respiratory or renal compromise from elevated
volume status. Pt's anarsarca resolved and IV furosemide was no
longer needed.
.
#. HTN, benign - Pts home BP med initially held when she was
acute septic and hypotensive. Meds were reintroduced in IV/Skin
patch form since pt's AMS prevented her from swallowing. She was
given Metoprolol IV, mitropaste, and clonidine patch. Clonidine
patch was decreaed to 0.2mg/q monday, metoprolol was decreased
from 50BID to 25 [**Hospital1 **]. and nitropaste was stopped. Hydralazine
caused pt to have tachycardia and was avoided. Lisinopril was
reintroduced as she started to eat food. Pt did not need her
home lasix or imdur at the time of discharge.
***
-[**Month (only) 116**] reconsider adding Lasix 40Am and 20Pm if pt has any edema.
She did not require this during the final 2 weeks of her
hosptialization
-[**Month (only) 116**] consider adding back her home Imdur 30mg daily if her BP
increases. She did not need this at the time of discharge.
.
#. Anemia/thrombocytopenia ?????? Found to have HCT drop on
admission, thought to be due to hypoproliferation due to sepsis.
HCT (range 28-30) and PLT (100-200s) stabalized during
hospitalization and daughter reported that Ms. [**Known lastname 75626**] has a
history of chronic anemia and thrombocytopena.
.
#. CAD, native ?????? Given home ASA and Metoprolol medications.
.
#. Nutrition - Feeding tube initially placed to provide
nutrition since pt's catatonic state prevented her from eating.
She eventually pulled out dopoff and feeds were held until pt
more alert to eat. She was given PPN until she was able to eat
food on her own. She then pulled out all of her lines and
refused peripheral line replacement. She gradually started to
eat food by the time of discharge. She was eating 1,000-2,000
calories a day by the time of discharge.
***
-Pt needs 1:1 assistance during mealtime to encourage eating
Medications on Admission:
Fosamax 70 mg weekly
allopurinol 200 mg daily
Abilify 5 mg daily
ASA 81 mg daily
Celexa 10 mg day
Clonidine 0.2 mg patch, two patches weekly
colace 100 mg daily
fentanyl patch 100 mcg Q72 hours
lasix 40 mg QAM, 20 mg QPM
imdur 30 mg daily
lisinopril 40 mg daily
ativan 0.5 mg TID
metoprolol 50 mg [**Hospital1 **]
omeprazole 20 mg daily
ditropan 10 mg daily
miralax 17 gm daily
trazadone 50 mg QHS, 12.5 mg at 14:00 daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash: Apply to buttocks, thighs.
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever/pain.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please give standing to clear catatonic state. [**Month (only) 116**]
titrate down and off when pt less withdrawn.
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 14 days: Day 1=[**2144-9-28**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 31006**] of [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
1)Ascending cholangitis
2)Psychological disorder
SECONDARY:
1)Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure providing care for you during your
hospitalization.
You were admitted for an infection of your bile duct system. A
gallbladder stone was stuck in one of the ducts causing an
infection and pain. Specialists put a stent in the duct to keep
it open. They were unable to remove the stone at the time of the
procedure because you were so sick. You were also started on
antibiotics that were targeted against the specific bacteria in
your duct and blood. The stent and antibiotics helped to clear
the infection and your symptoms improved, you stopped having
fevers. Within a couple of weeks, the stent will be removed
along with the stone that caused the initial plug. You will
follow up with the specialists outpatient on [**2144-10-7**]. You must
call them to coordinate a time.
As the infection cleared, your psychological state was a little
concerning. You did not talk or eat. We had psychiatrists help
us in treating your underlying psych disorder. We gave you
medicines that helped clear your mind and you gradually
improved.
For nutrition, we gave you food through your veins (called PPN)
until you were able to eat on your own.
You developed an infection in your gut called C.Diff which was
the cause of your diarrhea the last couple of days of your
admission. We started you on antibiotics for this. You must
continue a 14 day course.
The following changes were made to your medications:
Your home antihypertensive medications (metoprolol, imdur,
lisinopril) were briefly held. They were then gradually
restarted and titrated to your blood pressure. You will go home
on clonipine patch 0.2/Monday (you came in on 0.4mg which was
changed to 0.2mg), metprolol 25 [**Hospital1 **] (you came in on 50BID which
was changed to 25 [**Hospital1 **]), lisinopril 40mg. You did not require the
imdur at the time of your discharge.
Your lasix 40mg AM and 20mg in PM was held. You did not require
it at the time of discharge.
Your fentanyl patch was titrated down. You came in on 100mcg/hr
and it was titrated down, on the day of discharge you were
wearing your final patch (25 mcg/hr). It should be removed in 2
days and you no longer require any further fentanyl patches.
You completed 10 days of Ceftriaxone antibiotics, finished on
[**2144-9-18**].
Your abilify and celexa were held. You will go home on abilify
15mg and celexa 10mg as well as Lorazepam 0.5mg [**Hospital1 **] for
catatonia.
Your fosamaz 70mg weekly was held throughout admission.
Your trazadone 50mg qhs was held since you did not require it
during hospitalization.
Your ditropan 10mg daily was held.
Please resume all of your other home medications when you leave
the hospital.
Please make sure to follow up with the GI doctors to get the
stent and stone removed on [**2144-10-7**].
Followup Instructions:
You will need to meet with the specialists to get both the stone
and the stent removed on [**2144-10-7**], please call [**Telephone/Fax (1) 86464**] to
confirm the appointment and time.
Department: ENDO SUITES: Call: [**Telephone/Fax (1) 86464**] to confirm the time.
When: WEDNESDAY [**2144-10-7**] at 11:00 AM
Department: DIGESTIVE DISEASE CENTER
When: WEDNESDAY [**2144-10-7**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
|
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] |
icd9cm
|
[
[
[]
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] |
[
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icd9pcs
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[
[
[]
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17376, 17448
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|
2653, 2884
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,738
| 147,070
|
32355
|
Discharge summary
|
report
|
Admission Date: [**2124-11-8**] Discharge Date: [**2124-11-15**]
Date of Birth: [**2056-10-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest discomfort with exertion referred for cardiac
catheterization.
Major Surgical or Invasive Procedure:
[**11-9**] CABGx3(LIMA-LAD,SVG-OM,SVG-PDA)ASD closure/Ligation of [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 1916**]
History of Present Illness:
68 y.o male with chest discomfort on exertion, was referred for
cardiac catheterization. Catheterization report on [**2124-11-8**]
showed an EF of 60%, no MR LAD:40-50%, LCX: 90%, RCA 100%. He
was then referred to for cardiac surgery.
Past Medical History:
PMH: DM type 2, AF, DJD, anxiety, arthritis.
PSH:L TKR, Cervical fusion C2-4, Tonsillectomy, Rt hernia
repairx2, Lipoma removal rt chest
[**Last Name (un) 1724**]: Zetia 10', Celexa 20', Digoxin 0.25', Avodart 0.5',
Metformin 500", Gluburide 2.5", Verapamil 240 QA & 120 QP,
Lipitor 40', Doxasosin 4', Coumadin 10(3x/wk)15(4x/wk), ASA 81',
Social History:
Occupation: Financial
Tobacco: Quit [**2088**] [**12-15**] ppdX33yrs
ETOH: [**4-16**] drinks/week
Family History:
Family history:
Race: Caucasian
Brother died from MI at age 65
Father had an MI in his early 60s
Sister had a stroke at age 59.
Physical Exam:
Admission Physical Exam [**11-8**]
Pulse:64, Resp: 18, BP R: 143/77 L:132/91 Height: 5'9", Wgt:
240lbs
General: NAD
Skin: Unremarkable well healed scar R chest
HEENT: Unremarkable, glasses
Chest: Lungs CTA bilat
Heart: RRR
Abdomen: Obese, benign
Extremities: Well-perfused, no edema
Varicosities: None
Neuro: None focal
Pulses:
Femoral, BP, PT Radial equal bilaterally +2
Carotid bruit: none bilaterally
Discharge Physical Exam [**11-15**]
Neuro: None-focal
Pulmonary: Decreased air L base
Sternal incision: No drainage, no erythema
Abdomen: Soft, non-tender, bowel sound present
Extremities: Warm, no edema, 1+ pedal pulses
Leg incision: LLE, EVH dry and intact
Pertinent Results:
[**2124-11-8**] 01:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.037*
[**2124-11-8**] 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2124-11-8**] 11:30AM GLUCOSE-115* UREA N-19 CREAT-0.7 SODIUM-133
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-27 ANION GAP-11
[**2124-11-8**] 11:30AM ALT(SGPT)-18 AST(SGOT)-15 ALK PHOS-47 TOT
BILI-0.5
[**2124-11-8**] 11:30AM ALBUMIN-3.7
[**2124-11-8**] 11:30AM %HbA1c-6.6*
[**2124-11-8**] 11:30AM WBC-8.5 RBC-4.66 HGB-13.8* HCT-41.3 MCV-89
MCH-29.7 MCHC-33.5 RDW-14.2
[**2124-11-8**] 11:30AM PLT COUNT-285
[**2124-11-8**] 11:30AM PT-13.1 PTT-26.4 INR(PT)-1.1
[**2124-11-14**] 07:35AM BLOOD WBC-13.1* RBC-2.94* Hgb-8.9* Hct-25.8*
MCV-88 MCH-30.2 MCHC-34.3 RDW-14.4 Plt Ct-308#
[**2124-11-15**] 07:15AM BLOOD PT-15.3* INR(PT)-1.3*
[**2124-11-14**] 07:35AM BLOOD Plt Ct-308#
[**2124-11-14**] 07:35AM BLOOD Glucose-107* UreaN-36* Creat-0.9 Na-136
K-4.1 Cl-96 HCO3-32 AnGap-12
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2124-11-11**] 2:50 PM
CHEST (PORTABLE AP)
Reason: Evaluate for effusion
[**Hospital 93**] MEDICAL CONDITION:
68 year old man with
REASON FOR THIS EXAMINATION:
Evaluate for effusion
PORTABLE CHEST, [**2124-11-11**] AT 15:02
COMPARISON STUDY: [**2124-11-10**].
CLINICAL INFORMATION: Effusion.
FINDINGS:
Since the prior study, there is mild interval increase in the
left-sided pleural effusion, which is now moderate. There is
continued left lower lobe consolidation. The right lung is
relatively clear. Cardiomediastinal silhouette is within normal
limits. There is a median sternotomy.
IMPRESSION:
Interval increase in left pleural effusion. Left lower lobe
atelectasis.
DR. [**First Name11 (Name Pattern1) 3993**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3994**]
Approved: SUN [**2124-11-12**] 8:11 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75587**] (Complete)
Done [**2124-11-9**] at 9:30:40 AM PRELIMINARY
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: [**2056-10-19**]
Age (years): 68 M Hgt (in): 70
BP (mm Hg): 140/80 Wgt (lb): 240
HR (bpm): 65 BSA (m2): 2.26 m2
Indication: Intraoperative TEE for CABG, ASD closure, LAA
ligation
ICD-9 Codes: 745.5, 410.91, 427.31, 786.51, 440.0
Test Information
Date/Time: [**2124-11-9**] at 09:30 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) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW4-: Machine: 4
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.9 cm <= 2.5 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Moderate to severe spontaneous echo contrast in the
body of the LA. Depressed LAA emptying velocity (<0.2m/s) Cannot
exclude LAA thrombus.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Left-to-right shunt
across the interatrial septum at rest. Secundum ASD.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Mildly dilated ascending
aorta. Normal aortic arch diameter. Simple atheroma in aortic
arch. Mildly dilated descending aorta. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Torn
mitral chordae. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. 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-BYPASS:
1. Moderate spontaneous echo contrast is seen in the body of the
left atrium. The left atrial appendage emptying velocity is
depressed (<0.2m/s). A left atrial appendage thrombus cannot be
excluded. There is prominence of the pectinate muscles.
2. A left-to-right shunt across the interatrial septum is seen
at rest. A secundum type atrial septal defect is present.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). There is
hypokinesis of the inferior and inferior lateral walls from the
mid=papillary to apical levels.
4. Right ventricular chamber size and free wall motion are
normal.
5. The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. There are simple atheroma in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta.
6. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. A2 scallop is notable for a torn
chordae.
POST-BYPASS:
Pt removed from cardiopulmonary bypass on phenylephrine infusion
and AV paced.
1. Biventricular function is maintained, regional wall
abnormalites as noted pre-bypass.
2. ASD is closed; there is no flow across the intra-atrial
septum.
3. The left atrial appendage has been obliterated.
4. Aortic contours are intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
Brief Hospital Course:
Mr [**Known lastname 3077**] was admitted on [**11-8**] for cardiac catheterization which
revealed 3VDs and was then referred to for cardiac surgery. He
was brought to the operating room on [**11-9**] and underwent a
CABGX3 LIMA-LAD, SVG-OM, SVG-PDA, ASD closure and Ligation of L
Atrial Appendage without any immediate complication. He was then
transferred to the intensive care in stable condition. He
received Vancomycin in during his perioperative period because
he was inpatient prior to his surgery. He did well in the
immediate period, he anesthesia was reversed and he was weaned
off the ventilator and extubated. On POD1 he was weaned off of
his vasoactive infusions and his CTs were removed followed by a
CXR that showed no pneumothorax. On POD2, he had and episode of
rapid AF and was treated with beta-blockers and anticoagulation.
On POD3 he was transferred to F6 for further post-operative care
management. Over the last couple of days, he has advance his
activity level with the help of physical therapy. On POD6 it was
decided that he was stable and ready to transfer out to a
rehabilitation center for further management of his physical
activity. His INR will be followed by [**Hospital1 **] TCU at discharge
and then by Dr [**First Name (STitle) **] when discharge from the rehabilitation
center.
Medications on Admission:
Zetia 10mg daily
Celexa 20mg daily
Digoxin 0.25mg daily
Metformin 500mg [**Hospital1 **]
Avodart 0.5mg daily
Glyburide 2.5mg [**Hospital1 **]
Verapamil 120mg QPM
Lipitor 40mg bedtime
Doxazosin 4mg daily
Coumadin 10mg 3X/wk
Coumadin 15mg 4X/wk
ASA 81mg daily
SL Nitro PRN
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. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-17**]
hours as needed.
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 2
weeks.
Disp:*qs Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
6. Warfarin 10 mg Tablet Sig: 10mg alt w/15mg Tablets PO once a
day: target INR 2-2.5
Previously 10mg alt with 15mg
Pt to receive 10mg on [**11-15**].
Disp:*qs Tablet(s)* Refills:*0*
7. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*qs Tablet(s)* Refills:*2*
8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
9. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*qs Tablet(s)* Refills:*2*
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*qs Tablet(s)* Refills:*2*
11. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*qs Capsule(s)* Refills:*2*
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*0*
13. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*0*
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*qs Tablet(s)* Refills:*2*
15. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
Disp:*qs Tablet Sustained Release(s)* Refills:*2*
16. Verapamil 120 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*qs Tablet(s)* Refills:*2*
17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks.
Disp:*qs Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
CAD now s/p CABG
DM2, Afib, DJD, Anxiety, arthritis,
L TKR, Cervical fusion C2-4, Tonsillectomy, Rt hernia repairx2,
Lipoma removal rt chest
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) 1295**] 2 weeks
Dr. [**First Name (STitle) **] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2124-11-15**]
|
[
"401.9",
"V58.67",
"427.31",
"413.9",
"V58.61",
"745.5",
"272.4",
"414.01",
"V58.66",
"300.00",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"88.56",
"88.53",
"88.72",
"37.33",
"37.22",
"36.15",
"35.71"
] |
icd9pcs
|
[
[
[]
]
] |
12483, 12628
|
8907, 10223
|
348, 478
|
12813, 12821
|
2068, 3200
|
13121, 13364
|
1254, 1368
|
10545, 12460
|
3237, 3258
|
12649, 12792
|
10249, 10522
|
12845, 13098
|
7075, 8884
|
1383, 2049
|
240, 310
|
3287, 7026
|
506, 742
|
764, 1107
|
1123, 1222
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,778
| 197,782
|
26357
|
Discharge summary
|
report
|
Admission Date: [**2156-1-9**] Discharge Date: [**2156-1-14**]
Date of Birth: [**2083-11-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Murmur with recent CHF
Major Surgical or Invasive Procedure:
[**2156-1-9**] Aortic Valve Replacement (#[**Street Address(2) 65216**]. [**Male First Name (un) 923**])
History of Present Illness:
72 y/o male with h/o murmur x 20 yrs. Recent Echo showed
mod-severe Aortic Stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.7 cm2. Cath fd pt to
have clean coronaries and confirmed the aortic stenosis.
Past Medical History:
Aortic Stenosis s/p Aortic Valve Replacement [**2156-1-9**]
End Stage Renal Disease - on Hemodialysis
Hypertension
Hypercholesterolemia
s/p AAA repair
R knee surgery
R aorti iliac bypass
Peripheral Vascular Disease
Anxiety/depression
s/p R quad repair
Benign Prostatic Hypertrophy
s/p L lung biopsy
Social History:
Quit smoking 15 yrs ago after 2ppd prior. Several glasses of
wine/day
Family History:
Non-contributory
Physical Exam:
VS: 53 130/54 13
General: NAD
HEENT: NC/AT, EOMI, PERRL
Neck: Supple, FROM, Murmur radiates to carotids
Heart: RRR 3/6 SEM at base and apex
Lungs: CTAB -w/r/r
Abd: Soft, NT/ND, +BS
Ext: Warm, +pp, -edema
Neuro: A&O x 3, non-focal, MAE
Pertinent Results:
[**2156-1-9**] 10:21AM BLOOD WBC-9.5 RBC-2.79*# Hgb-8.8*# Hct-26.1*
MCV-94# MCH-31.4 MCHC-33.5 RDW-15.3 Plt Ct-181
[**2156-1-14**] 06:50AM BLOOD WBC-8.5 RBC-3.02* Hgb-9.9* Hct-27.6*
MCV-91 MCH-32.6* MCHC-35.7* RDW-15.3 Plt Ct-309
[**2156-1-10**] 02:32AM BLOOD PT-12.6 PTT-28.3 INR(PT)-1.1
[**2156-1-14**] 06:50AM BLOOD Glucose-90 UreaN-29* Creat-4.3*# Na-139
K-4.4 Cl-105 HCO3-27 AnGap-11
[**2156-1-13**] 01:30PM BLOOD Calcium-8.7 Phos-2.0* Mg-1.8
Brief Hospital Course:
Patient was a same day admit and on [**2156-1-9**] he was taken to the
operating room where he underwent a aortic valve replacement
with a tissue valve. Please see op not for surgical details.
Patient was then brought to the CSRU in stable condition. Later
on op day pt was weaned from mechanical ventilation and sedation
and extubated. He was neurologically intact. Renal was
immediately consulted and saw pt throughout his hospital course
for his ESRD and hemodialysis. His chest tubes were removed post
op day two and all drips were off by post op day three.
Diuretics and b blockers were started per protocol and he was
transferred to the telemetry floor. On post op day four his
epicardial pacing wires were removed and he had HD for the
second time following surgery. Patient was encouraged to
increase ambulation and was at level 5 on post op day five. He
had one final CXR (see results) and was discharged home with VNA
services and the appropriate follow up appointments.
Medications on Admission:
ASA 325mg qd, Quinapril 20mg qd, Lipitor 10mg qd, Norvasc 10mg
qd, Flomax 0.4mg qd, Nephrocaps 1mg qd, Renagel, Colace prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
8. Quinapril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement [**2156-1-9**]
End Stage Renal Disease - on Hemodialysis
Hypertension
Hypercholesterolemia
Peripheral Vascular Disease
Anxiety/depression
Benign Prostatic Hypertrophy
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, no baths. No lotions, creams or powders to incision.
No driving or lifting more than 10 pounds.
Call with fever, redness or drainage from incision.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 65217**] 2 weeks
Dr. [**Last Name (STitle) 31187**] 2 weeks
Completed by:[**2156-1-14**]
|
[
"300.4",
"424.1",
"428.30",
"428.0",
"600.00",
"V70.7",
"443.9",
"585.6",
"427.41",
"272.4",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"99.04",
"35.21",
"99.62",
"39.95",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
3985, 4044
|
1894, 2876
|
344, 450
|
4299, 4305
|
1422, 1871
|
4532, 4686
|
1134, 1152
|
3049, 3962
|
4065, 4278
|
2902, 3026
|
4329, 4509
|
1167, 1403
|
282, 306
|
478, 709
|
731, 1031
|
1047, 1118
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,368
| 140,398
|
8164
|
Discharge summary
|
report
|
Admission Date: [**2112-8-2**] Discharge Date: [**2112-8-5**]
Date of Birth: [**2034-6-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
dyspnea on exertion, lower extremity edema
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Ms. [**Known lastname 487**] is a 78yo woman with h/o AFib on coumadin and CHF
with unknown EF who presents with dyspnea and LE edema.
.
She presented to her cardiologist on [**8-1**] for regular follow-up
visit. She reported a several month history of worsening
dyspnea on exertion. She used to be able to mow her lawn and
run the snow-blower. This winter, she felt she wasn't getting
enough air and so stopped running the snow-blower. Now she has
to stop 3 times when she walks up the incline from her driveway.
Her cardiologist ordered a chest CT and called her the next day
to return to his office for an echocardiogram. Per report from
the ED, the TTE demonstrated pericardial effusion without
evidence of tamponade. There was concern that tamponade
physiology might be masked by her pulmonary hypertension. He
sent her to [**Hospital1 18**] for further evaluation.
.
In the ED, initial VS were 99.4 76 159/74 18 98% RA.
She was noted to have elevated JVD. Because of INR elevated to
4.5, she received Vitamin K 10mg PO x 1. FFP was ordered but
she did not receive it prior to admission to CCU.
.
Upon presentation to the CCU, she was comfortable without
complaint other than feeling somewhat tired.
.
ROS as discussed above. Of note, she presented to OSH ED about
3 weeks ago (around the time of a root canal) with feeling as
though "someone was sitting on my chest." They kept her there
for a few hours and sent her home. She did not receive any
antibiotics around the time of the procedure. She denies any
h/o GI bleed; she has not had any bloody or black BMs.
.
She denies any known TB contacts. [**Name (NI) **] exposure to homeless
people, no foreign travel. Has chronic cough x 2 years for
which she was recently given Z-pack without any help. No other
symptoms of URI.
Past Medical History:
Atrial fibrillation on coumadin
CHF
HTN
Pulmonary HTN
3+ Mitral regurgitation
[**2-21**]+ Tricuspid regurgitation
COPD
s/p hip surgery
OA
Osteoporosis
Recurrent bronchitis
Claustrophobia
Root canal 2 weeks ago.
Social History:
She is widowed, currently living alone. She does not work. She
does not smoke cigarettes. She does not drink much alcohol or
follow a particular diet.
Family History:
No family history of premature coronary artery disease or sudden
death.
Physical Exam:
Gen: Elderly woman in no acute distress. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP at angle of jaw when sitting up; no
respiratory variation.
CV: PMI located in 5th intercostal space, midclavicular line.
Irreg irreg with III/VI systolic murmur in the sub xiphoid area.
No S4, no S3. Heart sounds are crisp.
Chest: +scoliosis and kyphosis. Resp were unlabored, no
accessory muscle use. +b/l crackles at bases.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: +++pitting LE edema b/l. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
TTE [**2112-8-3**]:
Overall left ventricular systolic function is normal (LVEF>55%).
Mild to moderate ([**1-20**]+) mitral regurgitation is seen. Moderate
to severe [3+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
moderate sized pericardial effusion. No right atrial or right
ventricular diastolic collapse is seen. Echocardiographic signs
of tamponade may be absent in the presence of elevated right
sided pressures.
Cardiac catheterization [**2112-8-4**]:
-LMCA, LAD, LCX, and RCA were without angiographically apparent
flow-limiting disease
-Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP of 17 mm Hg and LVEDP of 20 mm Hg. There
was
moderate pulmonary arterial hypertension of 50/10 mm Hg. There
was
moderate systemic arterial hypertension of 151/72 mm Hg. The
cardiac
index was preserved at 2.4 l/min/m2. There was no gradient upon
pullback of the catheter from LV to the aorta.
-Left ventriculography revealed mild mitral regurgitation with a
normal left ventricular ejection fraction of 65%. There were no
wall
motion abnormalities.
[**2112-8-4**] 04:20AM BLOOD WBC-9.2 RBC-3.79*# Hgb-11.5*# Hct-35.6*
MCV-94 MCH-30.3 MCHC-32.3 RDW-14.6 Plt Ct-284
[**2112-8-2**] 08:25PM BLOOD PT-41.3* PTT-35.0 INR(PT)-4.5*
[**2112-8-4**] 04:20AM BLOOD PT-15.2* PTT-25.3 INR(PT)-1.3*
[**2112-8-4**] 04:20AM BLOOD Glucose-114* UreaN-13 Creat-0.6 Na-145
K-3.8 Cl-107 HCO3-31 AnGap-11
[**2112-8-3**] 05:07AM BLOOD ALT-22 AST-22 AlkPhos-79 TotBili-0.7
[**2112-8-3**] 05:07AM BLOOD TSH-3.4
[**2112-8-3**] 04:55PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2112-8-3**] 05:07AM BLOOD RheuFac-9
[**2112-8-3**] 08:18AM BLOOD Type-ART Temp-36.7 O2 Flow-2 pO2-86
pCO2-40 pH-7.49* calTCO2-31* Base XS-6 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
Brief Hospital Course:
78yo woman with h/o diastolic heart failure, pulmonary HTN, and
longstanding dyspnea on exertion found to have pericardial
effusion. No echocardiographic evidence of tamponade and pulsus
of 12, yet does not have respiratory variation of her elevated
neck veins. She is hemodynamically stable at present. Note that
evidence of tamponade could be masked by elevated right-sided
pressures secondary to her pulmonary HTN.
.
# Pericardial effusion:
Pt did not have any echocardiographic evidence of tamponade. Her
pericardial effusion had an unclear chronicity and etiology. She
denied recent viral prodromes or TB risk factors. No recent
trauma or procedure. TSH normal, Rheum. Factor also normal, [**Doctor First Name **]
negative. Outside hospital chest CT showed "large pericardial
effusion," "coronary artery calcification," left and right
atrial enlargement, and a possible "diverticulum" or
"pericardial lymph node" adjacent to the right pericardium.
Pericardiocentesis was planned, but on TTE at [**Hospital1 18**] a moderate
sized circumferential pericardial effusion most prominent
inferior and inferolateral to the left ventricle was found that
was determined to be too inferior for pericardiocentesis. On
cardiac catheterization there was no evidence of hemodynamic
compromise due to tamponade physiology.
.
# CAD: Selective coronary angiography of this right dominant
system
revealed no angiographically apparent coronary artery disease.
The
LMCA, LAD, LCX, and RCA were without angiographically apparent
flow-limiting disease.
.
# Valves: On TTE the mitral leaflets appeared structurally
normal. There was no mitral valve prolapse. Moderate (2+)
mitral regurgitation was seen. Moderate [2+] tricuspid
regurgitation was seen.
.
# Pump: On cardiac catheterization, left ventriculography
revealed mild mitral regurgitation with anormal left ventricular
ejection fraction of 65%. There were no wall motion
abnormalities.
.
# Pulmonary hypertension: On cardiac catheterization resting
hemodynamics revealed elevated right and left sided filling
pressures with RVEDP of 17 mm Hg and LVEDP of 20 mm Hg. There
was moderate pulmonary arterial hypertension of 50/10 mm Hg. A
nutrition consult was requested to assist patient with following
a low-salt diet. The patient was restarted on Lasix. Patient
will have outpatient PFTs.
.
# Atrial fibrillation: Coumadin was held initially given the
patient's elevated INR and the plan for pericardiocentesis.
Following the TTE and cardiac catheterization the patient was
restarted on coumadin and diltiazem for rate control. The
patient was monitored on telemetry.
.
# Hypertension: The patient's blood pressure tolerated
restarting [**First Name8 (NamePattern2) **] [**Last Name (un) **] and diltiazem.
.
# Low hematocrit: In setting of INR of 4.5, this was concerning
for bleeding, however the patient's hematocrit remained stable
during admission.
.
# Abdominal distention on exam: Thought to be due to volume
overload. LFT's were within normal ranges.
.
# Osteoarthritis: The patient was restarted on her arthritis
medications upon discharge.
Medications on Admission:
Coumadin 4mg daily except Sundays, when she takes 2mg; last dose
was Sunday
Lasix 20 mg daily
Cartia XT (Diltiazem) 180 mg daily
Diovan (Valsartan) 160 mg daily (?recently stopped given low BP)
Celebrex 200 mg daily
Digoxin 0.25 mg daily
Metformin ER 500 mg daily
Aciphex (Rabeprazole) 20 mg daily prn
Xopenex inhaler
Percocet 5-325 0.5-1 tab qhs
Vitamin D
Discharge Medications:
1. Xopenex 1.25 mg/0.5 mL Solution for Nebulization Sig: One (1)
Inhalation twice a day.
2. Percocet 5-325 mg Tablet Sig: [**1-20**] to one Tablet PO at bedtime
as needed for pain.
3. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Outpatient Lab Work
Please have your INR, BUN, creatinine and potassium checked on
Monday [**8-8**] with results sent to Dr. [**Last Name (STitle) 15131**] at [**Telephone/Fax (1) 18203**].
You can go to Dr.[**Name (NI) 29049**] office to have this done.
5. Celebrex 200 mg Capsule Sig: One (1) Capsule PO once a day.
6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: Take
2 mg on Sunday only.
7. Diltiazem HCl 180 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Pericardial effusion
Secondary Diagnoses: Diastolic heart failure, Atrial
fibrillation on coumadin, hypertension, mitral regurgitation,
tricuspid regurgitation
Discharge Condition:
Vital signs stable with appropriate follow-up
Discharge Instructions:
You were admitted with fluid around your heart known as a
pericardial effusion. The fluid is behind your heart, so we
were unable to drain it with a needle. We did a heart
catheterization, which showed no evidence that the fluid was
making it difficult for your heart to pump. The heart
catheterization also showed no evidence of coronary artery
disease, which is what causes heart attacks.
1. Please take all medications as prescribed. The only
medication change we made was stopping your digoxin.
2. Please attend all follow-up appointments listed below.
3. Please call your doctor or return to the hospital if you
develop chest pain, worsening shortness of breath,
lightheadedness, fevers, or any other concerning symptom.
4. You were found to have diastolic heart failure. This happens
when your heart becomes stiff. It is important to keep track of
your weight. Weigh yourself every morning and call your doctor
if you gain 3 pounds in a day or 6 pounds in a week. Adhere to
2 gm low salt diet.
Followup Instructions:
Primary care:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15131**], MD Phone: [**Telephone/Fax (1) 18203**]. Date/Time: Tuesday [**8-9**]
at 4:30pm
Cardiology:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/time: [**8-22**]
at 1:20pm
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2112-9-23**] 3:20
|
[
"401.9",
"416.8",
"715.90",
"782.3",
"428.0",
"427.31",
"397.0",
"424.0",
"V58.61",
"428.30",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9938, 9944
|
5477, 8577
|
355, 380
|
10169, 10217
|
3604, 5454
|
11277, 11747
|
2639, 2713
|
8984, 9915
|
9965, 9965
|
8603, 8961
|
10241, 11254
|
2728, 3585
|
10028, 10148
|
273, 317
|
408, 2217
|
9985, 10006
|
2239, 2451
|
2467, 2623
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,556
| 184,798
|
4683+4684
|
Discharge summary
|
report+report
|
Admission Date: [**2113-8-9**] Discharge Date: [**2113-9-6**]
Service: Cardiothoracic Service
IDENTIFICATION/REASON FOR ADMISSION: Mr. [**Known lastname 19388**] is an
80-year-old gentleman who has complained of shortness of
breath and fatigue over the past four years; worsening over
the past year.
He is postoperative admission scheduled for a redo mitral
valve replacement with a tricuspid valve replacement via a
right thoracotomy.
HISTORY OF PRESENT ILLNESS: This is an 80-year-old gentleman
status post coronary artery bypass graft in [**2097**] and a
percutaneous transluminal coronary angioplasty in [**2109**] with
complaints of shortness of breath on exertion and fatigue
over the past four years which has worsened over the past
year, prompting the patient to finally consent to surgery
which he has been refusing for at least one year prior to
this surgical date.
The patient had a cardiac catheterization done on [**7-11**]
that showed left main disease with a patent right coronary
artery stent a left internal mammary artery to the left
anterior descending artery, saphenous vein graft to the left
circumflex; both patent. Severe mitral regurgitation and an
ejection fraction of 67%. His echocardiogram done on [**7-6**]
showed right ventricular enlargement with moderate-to-severe
tricuspid regurgitation and moderate mitral regurgitation.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Atrial fibrillation.
3. Prostate cancer.
4. Colon cancer.
5. Pancytopenia.
PAST SURGICAL HISTORY:
1. Status post coronary artery bypass graft times two
in [**2097**].
2. Status post colonoscopy in [**2109**].
3. Status post colectomy in [**2107**].
4. Status post radical prostatectomy in [**2108**].
5. Status post penile implant.
6. Status post right urethral stent.
7. Status post bone marrow biopsy to diagnose pancytopenia
in [**2113-7-13**].
MEDICATIONS ON ADMISSION: Medications prior to admission
included atenolol 50 mg p.o. q.d., aspirin 81 mg p.o. q.d.,
Coumadin 2 mg p.o. q.d., Lasix 20 mg p.o. q.d., and
Vasotec 5 mg p.o. q.d.
ALLERGIES: He has no known drug allergies.
FAMILY HISTORY: The patient's family history revealed father
died of a myocardial infarction at the age of 59. Mother
died of breast cancer at 48.
SOCIAL HISTORY: He lives alone in Lundinary, [**Location (un) 3844**].
Positive tobacco use; four packs per day times 35 years; quit
about 35 years ago. Social alcohol use; about 10 beers per
month. He denies any other drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
prior to admission revealed height was 5 feet 10 inches,
weight was 185 pounds, heart rate was 85 and irregular, blood
pressure was 106/62, respiratory rate was 24. In general, a
pleasant male who appeared his stated age, in no acute
distress. Skin was well hydrated. Left cheek with a
half-dollar size lesion, purplish in color. Head, eyes,
ears, nose, and throat revealed pupils were equally round and
reactive to light with extraocular movements intact.
Positive glasses. Positive hearing aid. Positive upper and
lower dentures. Normal buccal mucosa. The neck was supple.
No jugular venous distention. No thyromegaly. No
lymphadenopathy. No carotid bruits. Chest with positive
crackles at the right base. A sternal incision was
well-healed. The sternum was stable. Heart was irregular,
second heart sound and second heart sound, with a positive
[**2-15**] murmur heard best at the apex. Slightly distant heart
sounds. The abdomen was soft, nontender, and nondistended.
Normal active bowel sounds with a median abdominal incision
that was well-healed. A colostomy bag and the ileostomy bag
were both intact. Diffuse bilateral varicosities; right
greater than left. Neurologically, cranial nerves II through
XII were grossly intact. A nonfocal examination. Femoral
pulses were 2+ bilaterally. Dorsalis pedis pulses were 2+ on
the right and 1+ on the left. Posterior tibialis pulses were
not palpated. Radial pulses were 2+ bilaterally.
HOSPITAL COURSE: On [**8-9**], the patient was a direct
admission to the operating room at which time he underwent a
beating heart mitral valve replacement with a #27 Mosaic
valve and a tricuspid valve repair with a 32-mm ring.
The patient tolerated the operation and was transferred from
the operating room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient was in atrial
fibrillation at a rate of 100 with a central venous pressure
of 13, a mean arterial pressure was 67. He had propofol at
30 mcg/kg per minute, and epinephrine at 0.3 mcg/kg per
minute.
The patient had an extended postoperative recovery in the
Cardiothoracic Intensive Care Unit. He received large
amounts of volume during his surgical repair. The first
several days of his Intensive Care Unit admission were spent
diuresing the patient in an attempt to get him successfully
extubated. During that time, he remained hemodynamically
stable. He was weaned from all cardioactive drugs. He did,
however, have frequent episodes of rapid atrial fibrillation;
for which he was initially loaded with amiodarone and later
switched to digoxin for rate control.
During the surgical repair of the patient's mitral valve and
tricuspid valve repair, he received large amounts of fluid,
and the first several days of the Intensive Care Unit were
spent with the patient undergoing vigorous diuresis in an
attempt to successfully extubate him.
On postoperative day eight, an attempt was made to extubate
the patient. He rapidly failed the attempted extubation a
reintubated within 60 minutes of his initial extubation. The
patient again weaned to CPAP following reintubation and
remained in the Intensive Care Unit ventilatory dependent.
On [**8-23**], the patient underwent a percutaneous
tracheostomy and percutaneous gastric tube placement. He had
a #8 percutaneous tracheostomy placed at the bedside. The
patient tolerated that procedure well and remained in the
Intensive Care Unit for the next several days; again,
undergoing ventilatory wean and ramping up of the patient's
tube feeds. He was noted to have a large right loculated
pleural effusion.
On [**8-29**], he underwent a right videoscopic
thoracoscopy for removal of his loculated right pleural
effusion. From that time forward, the patient remained in
the Intensive Care Unit with attempts being made to wean the
patient from the ventilator and get him to tracheostomy
collar. The patient did tolerate ventilatory wean to a
pressure support of 5 and 5 during the day, resting at night,
with increased amounts of pressure support (up to 15) or
intermittent mandatory volumes with a rate of 8 to 10 breaths
per minute. During this period of time, the patient was also
restarted on his anticoagulation given his history of atrial
fibrillation.
The patient is now postoperative day 27 from his valvular
surgery and on postoperative day seven from his tracheostomy
and percutaneous endoscopic gastrostomy tube, and it was felt
that he was stable and ready to be transferred to
rehabilitation for continuing weaning from his ventilator.
PHYSICAL EXAMINATION ON DISCHARGE: A review of the patient's
physical examination at this time is as follows; temperature
was 99.8, heart rate was 100 in atrial fibrillation, blood
pressure was 129/50, respiratory rate was 20, oxygen
saturation was 100% (that was with pressure support of 10,
positive end-expiratory pressure of 5, and 40% FIO2). His
tidal volume with those settings was a tidal volume of
between 450 and 500, and his respiratory ranges 20 to 25.
Neurologically, the patient was alert and oriented. He
followed commands and moved all extremities. He does have
periods of agitation, and he felt frustrated that he could
not eat or talk. Cardiovascularly, he had a heart rate from
80 to 100, in atrial fibrillation. Second heart sound and
second heart sound with no murmurs. The patient had a
well-healed old sternal incision. Respiratory revealed he
had a #8 Portex tracheostomy. He remained on CPAP 40%, 5 of
positive end-expiratory pressure, 10 of pressure support,
oxygen saturations were 96% to 100%. He had scattered
rhonchi throughout, and no rales. Suctioned for thick tan
secretions. The abdomen was soft, nontender, and
nondistended, with positive bowel sounds. Tube feeds via his
gastrectomy tube at a goal rate. He also had an intact
colostomy drainage bag. He had an ileal loop that had a
collection bag that was intact, draining yellow urine with
some sediment in it. Endocrine wise, the patient was
receiving sliding-scale insulin to cover blood sugars of
greater than 150. He had a right thoracotomy with clean
margins, a small amount of sanguinous drainage from the upper
portion of that incision.
PERTINENT LABORATORY DATA ON DISCHARGE: The patient's
laboratories on discharge were white blood cell count of 15,
hematocrit was 25, platelets were 240. PT was 16, INR
was 1.8. Sodium was 149, potassium was 4.7, chloride
was 115, bicarbonate was 31, blood urea nitrogen was 48,
creatinine was 1, blood glucose was 151. Magnesium was 1.8,
phosphate was 3, and calcium was 8.7.
MEDICATIONS ON DISCHARGE: (The patient's discharge
medications included).
1. Vancomycin 1000 mg q.24h. (therapy to be terminated on
[**9-8**]).
2. Fluoxetine 20 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Digoxin 0.25 mg p.o. q.d.
5. Xanax 0.25 mg p.o. t.i.d. as needed.
6. Prevacid oral solution 30 mg p.o. b.i.d.
7. Combivent 4 puffs q.6h. and as needed.
8. Tolnaftate powder topically t.i.d.
9. Regular insulin sliding-scale; less than 150 use
0 units, 150 to 200 use 4 units, 201 to 250 use 7 units, 251
to 300 use 10 units, 301 to 351 use 13 units, greater than
350 use 16 units.
10. Coumadin 5 mg p.o. q.d. (titrate to achieve a goal INR
of 2.5).
11. Tube feeds via his percutaneous endoscopic gastrostomy
tube; Impact with fiber at 75 cc per hour. At this time, he
continues to receive free water 250 cc q.i.d.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; status post coronary artery
bypass graft times two.
2. Atrial fibrillation.
3. Prostate cancer; status post radical prostatectomy and
ileal conduit.
4. Colon cancer; status post colectomy and status post
colonoscopy.
5. Status post mitral valve replacement with a #27 Mosaic
valve.
6. Status post tricuspid valve repair with a #32
annuloplasty ring.
7. Status post percutaneous tracheostomy and percutaneous
endoscopic gastrostomy tube placement on [**8-23**].
8. Status post right videoscopic thoracoscopy on
[**8-29**] for evacuation of a loculated pleural effusion.
9. Also, the patient was noted to have a positive screen
during this admission, and he was treated for
methicillin-resistant Staphylococcus aureus in his sputum.
DISCHARGE STATUS: The patient was to be discharged to
rehabilitation.
DI[**Last Name (STitle) 408**]E FOLLOWUP: He was to have follow up with
Dr. [**Last Name (Prefixes) **] in three weeks from the time of his discharge
from rehabilitation.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2113-9-5**] 17:38
T: [**2113-9-5**] 17:51
JOB#: [**Job Number 11443**]
Admission Date: [**2113-8-9**] Discharge Date: [**2113-9-6**]
Service: Cardiothoracic Service
IDENTIFICATION/REASON FOR ADMISSION: Mr. [**Known lastname 19388**] is an
80-year-old gentleman who has complained of shortness of
breath and fatigue over the past four years; worsening over
the past year.
He is postoperative admission scheduled for a redo mitral
valve replacement with a tricuspid valve replacement via a
right thoracotomy.
HISTORY OF PRESENT ILLNESS: This is an 80-year-old gentleman
status post coronary artery bypass graft in [**2097**] and a
percutaneous transluminal coronary angioplasty in [**2109**] with
complaints of shortness of breath on exertion and fatigue
over the past four years which has worsened over the past
year, prompting the patient to finally consent to surgery
which he has been refusing for at least one year prior to
this surgical date.
The patient had a cardiac catheterization done on [**7-11**]
that showed left main disease with a patent right coronary
artery stent a left internal mammary artery to the left
anterior descending artery, saphenous vein graft to the left
circumflex; both patent. Severe mitral regurgitation and an
ejection fraction of 67%. His echocardiogram done on [**7-6**]
showed right ventricular enlargement with moderate-to-severe
tricuspid regurgitation and moderate mitral regurgitation.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Atrial fibrillation.
3. Prostate cancer.
4. Colon cancer.
5. Pancytopenia.
PAST SURGICAL HISTORY:
1. Status post coronary artery bypass graft times two
in [**2097**].
2. Status post colonoscopy in [**2109**].
3. Status post colectomy in [**2107**].
4. Status post radical prostatectomy in [**2108**].
5. Status post penile implant.
6. Status post right urethral stent.
7. Status post bone marrow biopsy to diagnose pancytopenia
in [**2113-7-13**].
MEDICATIONS ON ADMISSION: Medications prior to admission
included atenolol 50 mg p.o. q.d., aspirin 81 mg p.o. q.d.,
Coumadin 2 mg p.o. q.d., Lasix 20 mg p.o. q.d., and
Vasotec 5 mg p.o. q.d.
ALLERGIES: He has no known drug allergies.
FAMILY HISTORY: The patient's family history revealed father
died of a myocardial infarction at the age of 59. Mother
died of breast cancer at 48.
SOCIAL HISTORY: He lives alone in Lundinary, [**Location (un) 3844**].
Positive tobacco use; four packs per day times 35 years; quit
about 35 years ago. Social alcohol use; about 10 beers per
month. He denies any other drug use.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
prior to admission revealed height was 5 feet 10 inches,
weight was 185 pounds, heart rate was 85 and irregular, blood
pressure was 106/62, respiratory rate was 24. In general, a
pleasant male who appeared his stated age, in no acute
distress. Skin was well hydrated. Left cheek with a
half-dollar size lesion, purplish in color. Head, eyes,
ears, nose, and throat revealed pupils were equally round and
reactive to light with extraocular movements intact.
Positive glasses. Positive hearing aid. Positive upper and
lower dentures. Normal buccal mucosa. The neck was supple.
No jugular venous distention. No thyromegaly. No
lymphadenopathy. No carotid bruits. Chest with positive
crackles at the right base. A sternal incision was
well-healed. The sternum was stable. Heart was irregular,
second heart sound and second heart sound, with a positive
[**2-15**] murmur heard best at the apex. Slightly distant heart
sounds. The abdomen was soft, nontender, and nondistended.
Normal active bowel sounds with a median abdominal incision
that was well-healed. A colostomy bag and the ileostomy bag
were both intact. Diffuse bilateral varicosities; right
greater than left. Neurologically, cranial nerves II through
XII were grossly intact. A nonfocal examination. Femoral
pulses were 2+ bilaterally. Dorsalis pedis pulses were 2+ on
the right and 1+ on the left. Posterior tibialis pulses were
not palpated. Radial pulses were 2+ bilaterally.
HOSPITAL COURSE: On [**8-9**], the patient was a direct
admission to the operating room at which time he underwent a
beating heart mitral valve replacement with a #27 Mosaic
valve and a tricuspid valve repair with a 32-mm ring.
The patient tolerated the operation and was transferred from
the operating room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient was in atrial
fibrillation at a rate of 100 with a central venous pressure
of 13, a mean arterial pressure was 67. He had propofol at
30 mcg/kg per minute, and epinephrine at 0.3 mcg/kg per
minute.
The patient had an extended postoperative recovery in the
Cardiothoracic Intensive Care Unit. He received large
amounts of volume during his surgical repair. The first
several days of his Intensive Care Unit admission were spent
diuresing the patient in an attempt to get him successfully
extubated. During that time, he remained hemodynamically
stable. He was weaned from all cardioactive drugs. He did,
however, have frequent episodes of rapid atrial fibrillation;
for which he was initially loaded with amiodarone and later
switched to digoxin for rate control.
During the surgical repair of the patient's mitral valve and
tricuspid valve repair, he received large amounts of fluid,
and the first several days of the Intensive Care Unit were
spent with the patient undergoing vigorous diuresis in an
attempt to successfully extubate him.
On postoperative day eight, an attempt was made to extubate
the patient. He rapidly failed the attempted extubation a
reintubated within 60 minutes of his initial extubation. The
patient again weaned to CPAP following reintubation and
remained in the Intensive Care Unit ventilatory dependent.
On [**8-23**], the patient underwent a percutaneous
tracheostomy and percutaneous gastric tube placement. He had
a #8 percutaneous tracheostomy placed at the bedside. The
patient tolerated that procedure well and remained in the
Intensive Care Unit for the next several days; again,
undergoing ventilatory wean and ramping up of the patient's
tube feeds. He was noted to have a large right loculated
pleural effusion.
On [**8-29**], he underwent a right videoscopic
thoracoscopy for removal of his loculated right pleural
effusion. From that time forward, the patient remained in
the Intensive Care Unit with attempts being made to wean the
patient from the ventilator and get him to tracheostomy
collar. The patient did tolerate ventilatory wean to a
pressure support of 5 and 5 during the day, resting at night,
with increased amounts of pressure support (up to 15) or
intermittent mandatory volumes with a rate of 8 to 10 breaths
per minute. During this period of time, the patient was also
restarted on his anticoagulation given his history of atrial
fibrillation.
The patient is now postoperative day 27 from his valvular
surgery and on postoperative day seven from his tracheostomy
and percutaneous endoscopic gastrostomy tube, and it was felt
that he was stable and ready to be transferred to
rehabilitation for continuing weaning from his ventilator.
PHYSICAL EXAMINATION ON DISCHARGE: A review of the patient's
physical examination at this time is as follows; temperature
was 99.8, heart rate was 100 in atrial fibrillation, blood
pressure was 129/50, respiratory rate was 20, oxygen
saturation was 100% (that was with pressure support of 10,
positive end-expiratory pressure of 5, and 40% FIO2). His
tidal volume with those settings was a tidal volume of
between 450 and 500, and his respiratory ranges 20 to 25.
Neurologically, the patient was alert and oriented. He
followed commands and moved all extremities. He does have
periods of agitation, and he felt frustrated that he could
not eat or talk. Cardiovascularly, he had a heart rate from
80 to 100, in atrial fibrillation. Second heart sound and
second heart sound with no murmurs. The patient had a
well-healed old sternal incision. Respiratory revealed he
had a #8 Portex tracheostomy. He remained on CPAP 40%, 5 of
positive end-expiratory pressure, 10 of pressure support,
oxygen saturations were 96% to 100%. He had scattered
rhonchi throughout, and no rales. Suctioned for thick tan
secretions. The abdomen was soft, nontender, and
nondistended, with positive bowel sounds. Tube feeds via his
gastrectomy tube at a goal rate. He also had an intact
colostomy drainage bag. He had an ileal loop that had a
collection bag that was intact, draining yellow urine with
some sediment in it. Endocrine wise, the patient was
receiving sliding-scale insulin to cover blood sugars of
greater than 150. He had a right thoracotomy with clean
margins, a small amount of sanguinous drainage from the upper
portion of that incision.
PERTINENT LABORATORY DATA ON DISCHARGE: The patient's
laboratories on discharge were white blood cell count of 15,
hematocrit was 25, platelets were 240. PT was 16, INR
was 1.8. Sodium was 149, potassium was 4.7, chloride
was 115, bicarbonate was 31, blood urea nitrogen was 48,
creatinine was 1, blood glucose was 151. Magnesium was 1.8,
phosphate was 3, and calcium was 8.7.
MEDICATIONS ON DISCHARGE: (The patient's discharge
medications included).
1. Vancomycin 1000 mg q.24h. (therapy to be terminated on
[**9-8**]).
2. Fluoxetine 20 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Digoxin 0.25 mg p.o. q.d.
5. Xanax 0.25 mg p.o. t.i.d. as needed.
6. Prevacid oral solution 30 mg p.o. b.i.d.
7. Combivent 4 puffs q.6h. and as needed.
8. Tolnaftate powder topically t.i.d.
9. Regular insulin sliding-scale; less than 150 use
0 units, 150 to 200 use 4 units, 201 to 250 use 7 units, 251
to 300 use 10 units, 301 to 351 use 13 units, greater than
350 use 16 units.
10. Coumadin 5 mg p.o. q.d. (titrate to achieve a goal INR
of 2.5).
11. Tube feeds via his percutaneous endoscopic gastrostomy
tube; Impact with fiber at 75 cc per hour. At this time, he
continues to receive free water 250 cc q.i.d.
DISCHARGE DIAGNOSES:
1. Coronary artery disease; status post coronary artery
bypass graft times two.
2. Atrial fibrillation.
3. Prostate cancer; status post radical prostatectomy and
ileal conduit.
4. Colon cancer; status post colectomy and status post
colonoscopy.
5. Status post mitral valve replacement with a #27 Mosaic
valve.
6. Status post tricuspid valve repair with a #32
annuloplasty ring.
7. Status post percutaneous tracheostomy and percutaneous
endoscopic gastrostomy tube placement on [**8-23**].
8. Status post right videoscopic thoracoscopy on
[**8-29**] for evacuation of a loculated pleural effusion.
9. Also, the patient was noted to have a positive screen
during this admission, and he was treated for
methicillin-resistant Staphylococcus aureus in his sputum.
DISCHARGE STATUS: The patient was to be discharged to
rehabilitation.
DI[**Last Name (STitle) 408**]E FOLLOWUP: He was to have follow up with
Dr. [**Last Name (Prefixes) **] in three weeks from the time of his discharge
from rehabilitation.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2113-9-5**] 17:38
T: [**2113-9-5**] 17:51
JOB#: [**Job Number 19773**]
|
[
"V10.05",
"V45.81",
"518.81",
"427.31",
"V10.46",
"424.0",
"511.9",
"397.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"35.14",
"35.24",
"31.1",
"96.72",
"43.11",
"34.04",
"39.61",
"34.51"
] |
icd9pcs
|
[
[
[]
]
] |
13446, 13579
|
21334, 22597
|
20498, 21313
|
13217, 13429
|
15355, 18461
|
12832, 13190
|
20130, 20471
|
11779, 12675
|
12697, 12809
|
13596, 15336
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,730
| 153,992
|
6711
|
Discharge summary
|
report
|
Admission Date: [**2196-1-7**] Discharge Date: [**2196-1-8**]
Date of Birth: Sex:
Service:
The patient is a 29-year-old female with excessive history of
gastrointestinal dysmotility problems, gastroesophageal
reflux disease, failure to thrive, Lyme disease who had
previously undergone a laparoscopic Nissen fundoplication and
feeding jejunostomy at [**Hospital6 1129**]. The
patient presented to the [**Hospital1 69**]
emergency department complaining of one day history of
nausea, abdominal distension and pain. The patient described
the abdominal pain beginning one day prior to admission post
prandially. The patient described the pain as being diffuse,
crampy abdominal pain of severe intensity without any
radiation. There were no aggravating nor alleviating
factors. The patient denies having fevers, dysuria, hematuria
and had a last bowel movement one day prior to admission.
PAST MEDICAL HISTORY: Gastrointestinal dysmotility disorder,
Lyme disease, gastroesophageal reflux disease, failure to
thrive.
PAST SURGICAL HISTORY: Status post laparoscopic Nissen
Fundoplication and feeding jejunostomy tube at [**Hospital1 2025**].
The patient takes no medicines at home. The patient reports
a questionable history of allergy to Penicillin.
SOCIAL HISTORY: Not significant for alcohol or tobacco abuse.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Afebrile, vital signs stable,
temperature of 96.8, heart rate 54, blood pressure 105/60,
respiratory rate 16, breathing 100% on room air. Awake,
alert, times three in no apparent distress. Cardiac exam:
Rate and rhythm regularly, slightly bradycardiac without
murmurs or rubs. Respiratory exam: Clear to auscultation
bilaterally. Abdominal exam: Distended and tympanitic,
diffusely tender without evidence of guarding or rebound.
Well healed incision without evidence of hernia.
Extremities: Were well profused. Rectal exam was guaiac
negative.
LABORATORY: White count of 9.3, with 83% PMN's and 3% bands.
Hematocrit of 39.8, platelet of 210. Chemistries: Sodium 142,
potassium 3.8, chloride 100, CO2 34, BUN 5, creatinine 0.7,
glucose of 158. AST 41, ALT l62, amylase 110 and lipase 48.
Abdominal x-ray shows a very large gastric bubble with air
fluid level. Otherwise positive gas within the abdomen.
There was no evidence of pneumatosis or free air.
CT of the abdomen and pelvis shows massive gastric
distension, marked dilatation at the duodenum an the proximal
few cm of the jejunum. Otherwise a remainder of the small
bowel was collapsed. There was stool within the colon.
There was a small amount of abdominal ascites. The liver
demonstrated altered enhancement of the left lobe relative to
the right. Spleen, adrenal glands, pancreas and kidneys were
unremarkable. The area was of normal caliber. There was no
pneumatosis or portal venous gas appreciated. The lung basis
are clear and there was no pleural effusion. Impression of
the CT exam was consistent with high grade mechanical small
bowel obstruction and a proximal jejunum.
The patient was admitted to the Gold Surgery Service with a
diagnosis of high grade small bowel obstruction. The patient
was made NPO, nasogastric tube was placed on medium cutaneous
wall suction. The patient was resuscitated with intravenous
fluid.
The patient arrived on the floor between 5:30 and 6 PM on the
night of [**2196-1-7**]. The resident on call was called to see the
patient approximately 8 PM in the evening, notified by the
nurse that the patient was in distress. The patient was
found to have temperature of 100.2, heart rate of 58, blood
pressure 120/88 breathing 18 with 100% on room air. The
patient at that examination was in distress with the abdomen,
diffusely tender and rigid. The patient was found to have
rectal prolapse at the time as well. The chief resident was
immediately notified as well as the attending surgeon Dr.
[**Last Name (STitle) **]. The patient was brought emergently to the O.R. for
exploratory laparotomy and was examined by the Attending
Surgeon prior to operation.
The patient was found to have a small bowel obstruction at
the proximal jejunum with a necrosis of the first 30 cm of
the bowel due to adhesions formed at the former jejunostomy
site. She was also found to have perforated lesser curvature
of the stomach. The patient received a bowel resection of
the proximal 30 cm of the jejunum with gastrotomy with
exploration of the stomach and a manual reduction of the
rectal prolapse. Please see the operative report for
details. Intraoperatively the patient received 10 liters of
crystalloid as well as 9 units of packed red blood cells and
one unit of FFP. The patient recorded ascites 3 liters was
taken out and estimated blood loss 1 liter and urine output
of 50 cc's.
Immediately postoperatively the patient was brought to the
Trauma Surgical Intensive Care Unit for further care. On
arrival to the Intensive Care Unit the patient was
hypothermic with temperature of 89.2. Heart rate 98 in sinus
rhythm, blood pressure 100/30 on Epinephrine drip. Sating
99% on CMV rate of 12, 500 cc's, 100% oxygen. The patient
was ascidotic with pH of 7.16 and base deficit of -12.
Hematocrit was 18.9, with platelets of 20. The patient was
also coagulopathic with prothrombin time of 15.4, PTT of 137,
INR 1.6. The patient was aggressively resuscitated receiving
multiple units of packed red blood cells, platelets, FP and
cryoprecipitate, Vitamin K Intravenous and subcutaneously as
well s calcium. The patient initially responded with
increase in blood pressure but remained on Levophed and
Epinephrine drip. The patient continued to have nasogastric
output that was bloody and oozing from the incision. The
patient was also having labile blood pressure, continued to
require Prednisone. All in all the patient had a total
nasogastric output of 12.5 liters.
Approximately 2 AM on [**2196-1-8**] the patient was becoming
unstable, having bradycardia and hypotensive. Soon
afterwards the patient was asystolic. CPR was administered
according to the ACLS protocol. The patient was given
Epinephrine, Atropine, bicarbonate and calcium. The patient
responded initially and had a sinus rhythm at a rate of 86,
20 seconds after return of the sinus rhythm the patient was
asystolic again. The patient was again coded per ACLS
protocol and then had a PEA rhythm. The patient was shocked
with 360 Joules times three and again underwent 360 Joules
shock times three. During this resuscitation a sinus rhythm
was briefly attained with blood pressure of 56/30. The
patient again went into asystole and the patient was
pronounced deceased at 2:28 AM.
In all the patient received a total of 28 units of packed red
blood cells, 5 units of platelets, 3 units of cryoprecipitate
and 21 units of FFP during this resuscitation.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**]
Dictated By:[**Last Name (NamePattern1) 10201**]
MEDQUIST36
D: [**2196-5-2**] 21:28
T: [**2196-5-2**] 19:32
JOB#: [**Job Number 25577**]
|
[
"789.5",
"560.2",
"569.1",
"997.4",
"286.6",
"569.83",
"998.11",
"557.0",
"261"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.49",
"54.59",
"96.07",
"38.93",
"45.62",
"38.91",
"99.04",
"96.26",
"99.05",
"99.62",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
1366, 1384
|
1073, 1286
|
1407, 7135
|
943, 1049
|
1302, 1349
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,674
| 195,302
|
35119
|
Discharge summary
|
report
|
Admission Date: [**2182-6-11**] Discharge Date: [**2182-6-14**]
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Septic shock
Major Surgical or Invasive Procedure:
Central line placement [**2182-6-12**]
History of Present Illness:
[**Age over 90 **]F h/o CAD s/p fall found to be anemic and in septic shock at
OSH. Patient seen at [**Hospital1 **] after fall complaining of left knee
pain. Per her report, she heard the phone ringing in the other
room and does not remember anything else. She is unclear if she
tripped, denies any chest pain, palpitations. EMS was called
and at OSH patient became hypotensive and concern for shock.
Given 1U PRBC for a 10 unit crit drop. Femoral line placed and
she was started on vancomycin and levophed. CT head and C-spine
were reportedly negative, but there was a question of C2
fracture and patient was placed in collar. Patient reports
chronic dysuria for the past year, denies any changes in her
bowel habits (cannot see stools) and denies any trouble eating
and drinking. Per report, patient had one episode of emisis
earlier today.
In the ED, initial Vitals/Trigger: 98.2 125 81/53 18 98% 15L
nrb. Mentating well. Norepiniphrine drip was initially held
while patient went to the CT scanner. She was given 4 L fluids.
CT head - no acute intracranial process. CT C-spine - no
fracture. FAST negative, pulmonary u/s negative. CT torso w/o
contrast - aspiration pneumonitis with likely PNA. L knee film -
no evidence of fracture/dislocation. CBC - significantly
elevated WBC. chem 7 - elevated CR. Broadened to zosyn for PNA.
Admission Vitals: T 97.6, HR 102, BP 90/71, RR 26, O2 sat 100%
on NRB
On arrival to the MICU, patient is in pain and agitated with any
movement.
Review of systems:
(+) Per HPI including intermittant diarrhea and constipation
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, abdominal pain, or changes in bowel habits.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
CAD status post stent, MI,
IBS
GERD
sciatica s/p recent epidural injections.
syncope
status post right Colles fracture
The patient is legally blind.
Social History:
Born in [**Location (un) 686**], lived in MA her whole life, widowed, has 3
children, worked as a sewing teacher before being married.
Never smoker, drinker, drugs
Family History:
Non contributory
Physical Exam:
General: Alert, oriented, in pain
HEENT: Dried blood on left side of forehead. Sclera anicteric,
dry mucus membranes, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic
murmur, no rubs, gallops
Lungs: Clear to auscultation bilaterally, trace crackles at
bases, no wheezes, ronchi
Abdomen: soft, non-tender, obese, bowel sounds present, no
organomegaly, no suprapubic tenderness
GU: foley
Left knee warm to touch, patella non-ballotable, no erythema.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
[**2182-6-12**] 12:00AM URINE HOURS-RANDOM
[**2182-6-12**] 12:00AM URINE GR HOLD-HOLD
[**2182-6-12**] 12:00AM URINE COLOR-DKYELLOW APPEAR-Cloudy SP
[**Last Name (un) 155**]-1.016
[**2182-6-12**] 12:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2182-6-12**] 12:00AM URINE RBC-15* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
[**2182-6-12**] 12:00AM URINE MUCOUS-RARE
[**2182-6-11**] 11:19PM LACTATE-3.5*
[**2182-6-11**] 10:55PM GLUCOSE-75 UREA N-34* CREAT-1.9* SODIUM-141
POTASSIUM-5.2* CHLORIDE-111* TOTAL CO2-18* ANION GAP-17
[**2182-6-11**] 10:55PM estGFR-Using this
[**2182-6-11**] 10:55PM ALT(SGPT)-23 AST(SGOT)-27 ALK PHOS-96 TOT
BILI-0.9
[**2182-6-11**] 10:55PM LIPASE-9
[**2182-6-11**] 10:55PM cTropnT-<0.01
[**2182-6-11**] 10:55PM ALBUMIN-2.8*
[**2182-6-11**] 10:55PM WBC-20.4* RBC-3.46* HGB-10.6* HCT-33.9*
MCV-98 MCH-30.6 MCHC-31.2 RDW-14.9
[**2182-6-11**] 10:55PM NEUTS-77* BANDS-17* LYMPHS-3* MONOS-2 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2182-6-11**] 10:55PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2182-6-11**] 10:55PM PLT SMR-NORMAL PLT COUNT-213
[**2182-6-11**] 10:55PM PT-13.8* PTT-28.7 INR(PT)-1.3*
Brief Hospital Course:
[**Age over 90 **]F CAD s/p fall found to be in septic shock at OSH.
# Septic shock from multiple sources: pulmonary, urinary, and c
diff colitis. On presentation 17% bands on diff. Patient
initially treated with Vancomycin and Zosyn, switched to
cefepime. Patient also started on norepinephrine drip
initially, switched to phenyelphrine when having episodes of
SVT. Patient initially resuscitated with 5L NS.
Over the three days, she had continued leukocytosis and pressor
requirements and worsening oxygenation. Patient and family
understood that patient was not critically ill and decision was
made to transition to comfort measures. Patient was transitioned
to a morphine drip, titrated to pain control and air hunger. On
[**2182-6-14**], patient passed peacefully with family at bedside.
Medications on Admission:
vitamin D 1000 international units p.o. daily,
Multivitamin 1 p.o. daily,
aspirin 81 mg p.o. daily,
Tylenol 500mg daily
Floragen 3 460mg each
ferrous sulfate 325 mg b.i.d.,
Neurontin 300 mg p.o. every morning,
Requip 1 mg p.o. q.h.s.,
Ultram 50 mg p.o. every 8 hours p.r.n. pain,
Zantac 300 mg p.o. daily.
ceterizine unknown dose
Aleve
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Septic shock from urinary and pulmonary sources
Secondary: coronary artery disease
Discharge Condition:
NA
Discharge Instructions:
Dear Mrs. [**Known lastname **],
It was our pleasure to care for you at [**Hospital1 18**]. You were admitted
for a serious infection in your bladder and lungs which caused
you to have a low blood pressure. We treated you with
antibiotics, however your infection was overwhelming. You
passed away peacefully with your family at bedside.
Followup Instructions:
Please follow up with the doctors [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] to have another
epidural injection/ manage your pain.
|
[
"369.4",
"564.1",
"507.0",
"599.0",
"995.92",
"530.81",
"276.7",
"593.9",
"414.01",
"V49.86",
"785.52",
"038.9",
"251.2",
"724.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
5917, 5926
|
4729, 5531
|
246, 286
|
6061, 6065
|
3416, 4706
|
6454, 6604
|
2617, 2636
|
5947, 6040
|
5557, 5894
|
6089, 6431
|
2651, 3397
|
1823, 2246
|
193, 208
|
314, 1804
|
2268, 2419
|
2435, 2601
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,181
| 173,258
|
33298
|
Discharge summary
|
report
|
Admission Date: [**2191-4-8**] Discharge Date: [**2191-4-21**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
failure to extubate s/p hemicolectomy
Major Surgical or Invasive Procedure:
hemicolectomy with primary anastomosis
History of Present Illness:
**NOTE - this discharge summary reflects only the medical care
that this pt. recieved while under the care of the Hospitalist
Attending, Dr. [**Last Name (STitle) **] from [**4-19**] through discharge on [**4-21**]**
The review of the history up to this point is obtained from
review of the medical record.
For further detail of the hospital course from admission [**4-8**]
through [**4-19**], please contact the Attending Physician of [**Name9 (PRE) **],
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**].
85 F h/o HTN, dCHF (EF=55-60%), [**Hospital **] transferred to [**Hospital1 18**] for
surgical treatment of mass at splenic flexure discovered on
sigmoidoscopy after small LGIB, likely adenoca. Upon arrival,
pt underwent colonoscopy [**4-11**], biopsy showed adenocarcinoma.
Plan made for resection, pt seen by med/[**Female First Name (un) **] service pre-op, who
noted rales bilaterally, 2L O2 requirement, treated with
perioperative BB, taken to OR on [**3-/2112**] for hemicolectomy which
was completed succesfully (EBL= , pt received 600cc IVF). Pt
also seen by heme-onc for leukopenia, felt [**3-19**] infection and
likely malignancy.
.
Post-operatively, she was extubated, however, ABG=6.84/193/157,
c/w hypercarbic respiratory failure, felt [**3-19**] sedation. She was
reintubated, and transferred to [**Hospital Unit Name 153**] after failing to extubate.
Upon arrival to the [**Hospital Unit Name 153**] she was awake and alert, and was
extubated.
.
.
Of note, pt recently hospitalized at OSH [**Date range (1) 56895**] for UTI, PNA,
course c/b hypotension, bradycardia thought to be due to
dehydration/sepsis. Pt's diuretics and BB were d/c'd due to
hypotension/bradycardia, which resolved. She also developed
pancytopenia which was presumed related to medication
related(zosyn/levoflox) vs. myelosuprression from her underlying
infection. She was switched to azithromycin, completed 6 day
course. Her counts improved. She received 1UPRBC for anemia,
HCT 32 at time of discharge, her Aspirin was held and was placed
on lovenox for DVT ppx. Pt was also noted to be significantly
malnourished, albumin 2.2 and was started on TPN.
.
Pt was subsequently sent to rehab where she had an episode of
bloody BM, readmitted to OSH where simoidoscopy noted
circumferential mass, bx was c/w Adenoca as detailed above. pt
therefore transferred to [**Hospital1 18**].
.
Past Medical History:
-CHF, diastolic dysfunction, EF 55-60%, [**2-16**]+AR, 1+MR [**3-25**].
-HTN
-TIAs
-dementia
-osteoporosis
-recurrent UTIs
Social History:
-Pt lives alone with home health aides. Has 3 children, involved
in medical care.
-Quit TOB 25 years ago, smoked [**2-16**] cigs/day x10 years. No ETOH
use or other drug use
Family History:
non contributory
Physical Exam:
VS: 150/70, Afebrile, HR 70s, RR 26 94% on 2L
GEN: using accessory muscles
HEENT: sclera anicteric, OP clear, MMM, no LAD, unable to see
JVP
CV: regular, nl s1, s2, no m/r/g, HS distant
PULM: coarse upper airway noise, + rales throughout ant-lat
ABD: soft, NT, ND, + BS, mildline surgical wound, c/d/i.
EXT: warm, 2+ dp/radial pulses BL, no edema
NEURO: pleasant, oriented to the hospital, [**Hospital1 18**], [**2190-3-18**],
follows commands
.
Brief Hospital Course:
**NOTE - this discharge summary reflects only the medical care
that this pt. recieved while under the care of the Hospitalist
Attending, Dr. [**Last Name (STitle) **] from [**4-19**] through discharge on [**4-21**]**
The review of the history up to this point is obtained from
review of the medical record.
For further detail of the hospital course from admission [**4-8**]
through [**4-19**], please contact the Attending Physician of [**Name9 (PRE) **],
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**].
Hospital course
Complicated eldelry woman with a history of underlying
hypertension, cognitive impairment and newly diagnosed colonic
adenocarcinoma, s/p hemicoloectomy with primary anastamosis on
[**3-/2112**]. Her post-op course was complicated initially by
hypercarbic respiratory failure attributed to
hypoventilation/CO2 narcosis, necessitating a short ICU course
where she was successfully extubated and sent to 12 [**Hospital Ward Name 1827**].
Since arrival to the floor, there have been problems with her
urine output bringing about some isotonic volume boluses
resulting in total body overload.
Medicine was consulted for oligouria and found the patient to
clinically have significant left-sided heart failure with use of
her accessory muscles and hypoxemia (low 90's on 2L). Chest
X-ray confirms this. Upon review of her EKGs, it appears she has
also had paroxysmal atrial fibrillation likely accounting in
part for her decompensation.
She is thus transferred to the Medicine service for ongoing
treatment and evaluation.
## Diastolic Heart Failure with Paroxysmal Atrial Fibrillation
--Rate controlled with beta blockade
--12 lead EKG and troponin without evidence of ischemia or
atrial fibrillation
--diuresed approximately 3 litres [**Date range (1) 9238**] with clinical
improvement (RR down, wheezing diminished, pt. no longer
complaining of sob)
--hydralazine 10 mg IV q6 hrs and isordil 10 mg po tid
--discussed anticoagulation with pt.s daughter, re: atrial
fibrillation. Decided jointly to resume aspirin only and not to
anticoagulate given fall risk and risk of bleeding given recent
surgery. 81 mg asa re-initiated after discussing with surgery
team, who agreed this was safe.
# Colonic Adenocarcinoma s/p succesful distal-transverse
colectomy - lymph nodes negative for involvement in pathology.
In discussion with Dr. [**Last Name (STitle) 1120**], she will see pt. in follow up to
discuss with pt. and family if they want to pursue surveillance
for recurrence, which is unclear given pt.s age.
.
-- Dr. [**Last Name (STitle) 1120**] would like to see pt. in follow up within one
month.
.
# UTI -s/p treatment with ampicillin for enterococcal UTI [**4-9**]
--repeat UA negative. Foley d/c'd and pt. voided.
.
# h/o TIA
--ASA resumed as above
.
# dementia - mental status at baseline at time of d/c
Medications on Admission:
Aricept
Ptotonix
Risondronate
Aspirin
Albuterol and Atrovent nebulizers
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection [**Hospital1 **] (2 times a day).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Risedronate 35 mg Tablet Sig: One (1) Tablet PO QSun ().
6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours) as needed for
wheezing.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
8. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
12. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
13. Erythromycin 5 mg/g Ointment Sig: One (1) inch Ophthalmic
[**Hospital1 **] (2 times a day) for 2 days.
14. Nitrofurantoin Macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Colon cancer s/p resection
Acute on chronic diastolic heart failure
Urinary tract infection
Dementia
Discharge Condition:
Stable.
Discharge Instructions:
Take all medications as prescribed. Return to the [**Hospital1 18**]
Emergency Department for:
Shortness of breath
Fever
Rectal bleeding
Followup Instructions:
PCP: [**Name10 (NameIs) 15072**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 15073**] - call and schedule
appointment for within a month of leaving the hospital.
Dr. [**Last Name (STitle) 1120**] - ([**Telephone/Fax (1) 3378**]. Call to schedule a follow up
appointment for within 3-4 weeks from leaving the hospital.
|
[
"372.30",
"153.7",
"428.33",
"733.00",
"427.31",
"599.0",
"578.9",
"997.5",
"294.8",
"428.0",
"788.5",
"V15.82",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"96.71",
"96.04",
"45.74"
] |
icd9pcs
|
[
[
[]
]
] |
7949, 8021
|
3604, 6471
|
265, 305
|
8166, 8176
|
8364, 8716
|
3098, 3116
|
6593, 7926
|
8042, 8145
|
6497, 6570
|
8200, 8341
|
3131, 3581
|
188, 227
|
333, 2743
|
2765, 2890
|
2906, 3082
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,531
| 130,424
|
24187
|
Discharge summary
|
report
|
Admission Date: [**2194-2-6**] Discharge Date: [**2194-2-7**]
Date of Birth: [**2128-7-5**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8480**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is 65F with h/o CAD s/p CABG, DM, HTN, hyperlipidemia,
tracheomalacia with tracheal stenosis and permanent trach, s/p
PEA arrest on [**2193-12-17**], who presents after respiratory and
cardiac arrest today. Pt went to see Dr. [**First Name (STitle) **] (ENT) as an
outpatient today, who did CO2 laser for stenosis and downsized
her trach. Pt reportedly did well during the outpatient
procedure and went home. While at home, pt was able to climb
stairs by herself, then shortly afterwards she sat in a chair
and suddenly had a resp arrest. EMS was called, and pt's trach
was taken out due to occlusion, and ETT was placed in trach site
(she could not be intubated by mouth due to vocal cord
adhesions). While en route to [**Hospital6 302**], pt had
asystolic arrest. She was resuscitated with epi, and then
received dopamine for low BP while in the [**Hospital3 **] ED. She was
reportedly "down" for approx 15 min. She was stabilized on a
ventilator. She was then transferred to [**Hospital1 18**] on a dopamine gtt.
On arrival to the ICU at [**Hospital1 18**], pt was unresponsive and had
intermittent myoclonic jerks. Neurology service was consulted.
She then had a tonic-clonic seizure, and was given 1.5g Dilantin
and 2mg Ativan. Of note, pt's seizure and myoclonic jerks ceased
prior to receiving Dilantin or Ativan.
.
Pt's family reportedly said that pt was "not feeling well for
the past several weeks".
Past Medical History:
- s/p PEA arrest on [**2193-12-17**]
- CAD s/p 3V CABG in [**2191**]
- CHF w/ previous report of EF 30% (no echo in system)
- HTN
- hyperlipidemia
- DMII
- hpothyroidism
- tracheostenosis/tracheomalacia from prolonged intubation at
time of CABG in [**2191**]. s/p tracheal resection and reconstruction
in [**6-/2192**] and multiple revisions. T-tube removed in [**11-6**]
following near complete occlusion and supraglottic, glottic,
subglottic edema/granulation tissue. s/p outpatient procedure
for tracheal stenosis today by Dr. [**First Name (STitle) **].
- Depression
- h/o MRSA PNA
Social History:
Son and daughter live in [**Name (NI) 5503**] area. Very supportive
family
Family History:
non-contributory
Physical Exam:
On admission:
VS: T 96.9, P 64, BP 135/36, RR 14, SaO2 100% on AC/400x14/40%/5
GEN: pt unresponsive, intermittent myoclonic jerks with eye
opening
HEENT: pupils fixed and dilated, no corneal reflex
NECK: ETT in place through trach site
PULM: coarse BS bilaterally
CV: exam limited by breath sounds; RRR, nl S1/S2,no murmur
appreciated
ABD: +BS, soft, nontender, nondistended
EXT: 1+ distal pulses, no edema
NEURO: A&Ox0. Intermittent myoclonic jerks. Babinski equivocal.
2+ reflexes on L, reflexes on R trigger myoclonic jerks.
Pertinent Results:
[**2194-2-6**] 08:04PM BLOOD WBC-14.6*# RBC-4.33# Hgb-12.7# Hct-37.2
MCV-86 MCH-29.3 MCHC-34.0 RDW-15.0 Plt Ct-199
[**2194-2-6**] 08:04PM BLOOD Plt Ct-199
[**2194-2-6**] 08:04PM BLOOD Glucose-303* UreaN-44* Creat-1.3* Na-137
K-4.6 Cl-99 HCO3-25 AnGap-18
[**2194-2-6**] 08:04PM BLOOD estGFR-Using this
[**2194-2-6**] 08:04PM BLOOD CK(CPK)-196*
[**2194-2-6**] 08:04PM BLOOD CK-MB-14* MB Indx-7.1* cTropnT-<0.01
[**2194-2-6**] 08:04PM BLOOD Calcium-9.2 Phos-4.5 Mg-1.9
Brief Hospital Course:
Several hours after arriving in the ICU, the pt went into
asystolic arrest. She was pulseless. Chest compressions were
initiatied. She was given 1mg epinephrine, and her pulse
returned. She then was hypertensive to the 200's. A family
meeting was then convened, and after a discussion with the
treating team and the family, it was decided by the family that
she be made CMO. She was given morphine PRN for comfort, and
ativan PRN for seizures. She expired at 12:45 AM on [**2194-2-7**].
Medications on Admission:
Albuterol 2 puffs q4h prn
Atrovent 4 puffs qid
Diovan 160mg qd
Colace 100mg [**Hospital1 **]
Flovent 2 puffs [**Hospital1 **]
Lasix 20mg [**Hospital1 **]
Lantus 18 U qhs
Humalog SS
Synthroid 150mcg qd
Metoprolol (? dose)
Mucinex 1200mg [**Hospital1 **]
Protonix 40mg qd
Sertraline 100mg qd
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p cardiopulmonary arrest
anoxic brain injury
tracheal stenosis
CAD
Discharge Condition:
expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2194-2-7**]
|
[
"250.00",
"244.9",
"V45.81",
"428.0",
"519.19",
"401.9",
"348.1",
"333.2",
"518.84",
"427.5",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"96.71",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
4436, 4445
|
3577, 4067
|
337, 343
|
4557, 4566
|
3087, 3554
|
4618, 4651
|
2504, 2522
|
4408, 4413
|
4466, 4536
|
4093, 4385
|
4590, 4595
|
2537, 2537
|
279, 299
|
371, 1785
|
2551, 3068
|
1807, 2395
|
2411, 2488
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,422
| 152,584
|
5506+55679
|
Discharge summary
|
report+addendum
|
Admission Date: [**2156-6-13**] Discharge Date: [**2156-6-20**]
Date of Birth: [**2079-8-6**] Sex: F
Service: VSU
HISTORY OF PRESENT ILLNESS: Chronic renal failure requiring
hemodialysis, atrial fibrillation, history of left renal cell
cancer, gout, history of viral myocarditis, and
spondylolisthesis of L5. She is status post left nephrectomy
in [**12-19**], AV fistula, status post recanalization and
angioplasty of her right brachiocephalic occlusion, status
post thoracentesis for right-sided pleural effusion, and
status post stenting.
The patient is a 75-year-old female who came into the
hospital complaining of right upper extremity edema,
numbness, and cyanosis. She has an AV fistula in her right
arm for her hemodialysis secondary to chronic renal failure.
It was shown that she had a right brachiocephalic occlusion.
On [**2156-6-15**], she underwent a right brachiocephalic
recanalization and angioplasty. She developed a right-sided
pleural effusion at which time a thoracentesis was performed
on [**2156-6-16**] complicated by pneumothorax. She was followed by
serial chest x-rays, which showed improvement of her
pneumothorax. On [**2156-6-17**], she received stenting without
event. She did have 24-hour mental status changes, believed
to be secondary to oversedation. Pulmonary was consulted and
agreed with our diagnosis.
DISCHARGE DIAGNOSES: Right brachiocephalic vein occlusion.
Right-sided pleural effusion.
Right-sided pneumothorax.
Chronic renal failure requiring hemodialysis.
Atrial fibrillation.
Gout.
L5 spondylolisthesis.
DISCHARGE MEDICATIONS:
1. Levothyroxine 25 mcg p.o. q.d.
2. Docusate sodium 100 mg p.o. b.i.d.
3. Pyridoxine HCl 100 mg p.o. q.d.
4. Cyanocobalamin 500 mcg p.o. q.d.
5. Bisacodyl 5 mg p.o. q.d.
6. Aspirin 325 mg p.o. q.d.
7. Warfarin 1 mg p.o. q.d.
8. Diltiazem 90 mg p.o. q.i.d.
9. Diphenhydramine 25 mg p.o. q.d.
Other discharge medications, which the patient was taking,
her own supply while in the hospital include:
1. Sevelamer 2400 mg p.o. with lunch, 800 mg p.o. with
breakfast and supper, 800 mg p.o. before snack p.r.n.
2. Tocopheryl 400 units p.o. q.d.
3. Coenzyme Q10 30 mg q.d.
4. Glucose sulfate 1 g p.o. q.d.
5. Nephro-Vite 1 tablet p.o. q.d.
6. Vitamin C 1 tablet q.d.
7. Folic acid 800 mcg p.o. q.d.
RECOMMENDED FOLLOW UP: Follow up with provider [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) **]. Appointment should be made within the next 7 to 10
days; appointment can be made at [**Telephone/Fax (1) 1784**]. She should
also follow up her INR levels in [**Hospital 197**] Clinic or with
primary care physician as before her hospitalization.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7258**], [**MD Number(1) 7263**]
Dictated By:[**Last Name (NamePattern1) 22242**]
MEDQUIST36
D: [**2156-6-20**] 09:22:04
T: [**2156-6-20**] 11:12:21
Job#: [**Job Number 22243**]
Name: [**Known lastname 3715**],[**Known firstname 194**] Unit No: [**Numeric Identifier 3716**]
Admission Date: [**2156-6-13**] Discharge Date: [**2156-7-10**]
Date of Birth: [**2079-8-6**] Sex: F
Service: VSURG
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 3717**]
Chief Complaint:
Several months of massively increase R arm, R face and R chest
wall edema.
Major Surgical or Invasive Procedure:
1. Recanalization and angioplasty of right brachiocephalic vein.
2. Thoracentesis
3. stenting
4. Insertion of chest tube
5. VATS Pleurodesis
History of Present Illness:
As in primary summary
Past Medical History:
As in primary summary
Social History:
Tobacco +
Professor
Family History:
N/A
Physical Exam:
Intake Exam:
Tm=100, Tc=98.3 120/60 hr=103 rr=22 O2sat=94%@RA
NAD
HEENT: PEERLA, mildly edematous R face/neck
CHEST: suggestion of distant BS on R
HEART: Tachy, irregular rythm, no MMR
ABD: soft, NT/ND
EXT: R AV fistula w/ bruit/thrill. Marked edema, bruising of R
arm. Radial pulse palp B
Pertinent Results:
[**2156-6-28**] 11:00AM PLEURAL WBC-167* RBC-[**Numeric Identifier 3718**]* Polys-21*
Lymphs-13* Monos-0 Macro-66*
[**2156-6-16**] 04:53PM PLEURAL WBC-197* RBC-[**Numeric Identifier 3719**]* Polys-12*
Lymphs-22* Monos-41* NRBC-1* Meso-5* Macro-19*
[**2156-6-28**] 11:00AM PLEURAL TotProt-3.6 Glucose-118 LD(LDH)-127
Amylase-70 Albumin-2.2
[**2156-6-16**] 04:53PM PLEURAL TotProt-2.8 Glucose-120 LD(LDH)-75
Amylase-83 Albumin-1.9
[**2156-6-29**] 02:30PM OTHER BODY FLUID WBC-25* RBC-5800* Polys-62*
Lymphs-13* Monos-7* Mesothe-6* Macro-12*
[**2156-6-29**] 02:30PM OTHER BODY FLUID TotProt-3.5 Glucose-96
LD(LDH)-1493 Amylase-75
[**2156-7-10**] 05:32AM BLOOD WBC-9.1 RBC-3.00* Hgb-9.2* Hct-29.6*
MCV-99* MCH-30.6 MCHC-31.1 RDW-15.9* Plt Ct-363
[**2156-7-10**] 05:32AM BLOOD PT-19.3* PTT-76.8* INR(PT)-2.5
[**2156-7-10**] 05:32AM BLOOD Plt Ct-363
[**2156-6-13**] 08:20PM BLOOD PT-13.1 PTT-28.5 INR(PT)-1.1
[**2156-6-13**] 08:20PM BLOOD Plt Ct-263
[**2156-7-10**] 05:32AM BLOOD Glucose-103 UreaN-23* Creat-4.5*# Na-142
K-3.6 Cl-103 HCO3-27 AnGap-16
[**2156-6-13**] 08:20PM BLOOD Glucose-88 UreaN-56* Creat-8.3*# Na-138
K-5.0 Cl-93* HCO3-29 AnGap-21*
[**2156-7-10**] 05:32AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0
[**2156-6-13**] 08:20PM BLOOD Calcium-10.6* Phos-4.8* Mg-2.9*
All blood cultures NEG for growth
Brief Hospital Course:
The prior discharge summary leaves off at [**2156-6-17**] s/p stenting of
the R brachiocephalic vein.
Following the [**6-16**] thoracentesis, the R pleural effusion was
monitored by serial CXR, and was seen to reaccumulate within 5
days, during which time, her 02 demand increased. Pulmonary was
consulted and was unable to help determine a medical etiology
for the effusion. At this time, she was transfered to the VICU
setting, and thoracentesis via ultrasound was repeated on [**6-28**];
it productive of less fluid then the original tap but without
complication. Neither tap was suggestive of a frank bleed (see
lab results). She was then intubated, brought to the ICU. A
chest CT on [**6-28**] suggested a patent stent with a large,
freely-layering right pleural effusion as well as associated
compressive atelectasis without evidence of large mass. Since
the effusion was felt to be refractory to thoracentesis,
Thorsasic Surgery was consulted to place and manage a chest tube
([**6-29**]). Tube drainage was not felt to provide therapuetic
improvement in her lung function, and on [**7-5**], Thorasic surgery
took her for a VATS pleurodesis. Since that time, she has
continued to improve both in her clinical demands for
supplementary oxygen and in her serial CXRs. On [**7-10**], her CXR
was significant for a marked reduction in the right pleural
effusion, and she was maintaining an O2 sat of 92% on room air,
at rest.
Medications on Admission:
Same as below, with the exception of Diltiazem 90 qid
Discharge Medications:
1. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Pyridoxine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO QD (once
a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QD (once a day) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
8. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
ONCE (once) for 1 doses.
Disp:*30 Capsule(s)* Refills:*0*
10. Sevelamer HCl 800 mg Tablet Sig: Four (4) Tablet PO Q
BREAKFAST AND SUPPER ().
11. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO Q LUNCH
().
12. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO BEFORE
SNACK PRN ().
13. Albuterol Sulfate 0.083 % Solution Sig: [**12-19**] Inhalation Q6H
(every 6 hours) as needed.
14. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO QD (once a day).
15. Nephrovite 1 tab po qd
Discharge Disposition:
Extended Care
Facility:
Eagle [**Hospital **] Rehabilitation Center - [**Location 3720**]
Discharge Diagnosis:
Primary: Right brachiocephalic vein occlusion
Right-sided pleural effusion
Secondary: Right-sided Pneumothorax
Chronic renal failure requiring hemodialysis
Atrial fibrillation
Gout
L5 spondylothisthesis
Discharge Condition:
Fair-good
Discharge Instructions:
If you experience any chest pain, shortness of breath, or
fevers/chills, please seek immediate medical attention.
Please call go to the ER if you experience worsening shortness
of breath.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) 798**] D. [**Telephone/Fax (1) 3721**] Appointment should be
in [**6-26**] days
Please call Dr.[**Name (NI) 3722**] (Thoracic Surgery) office at
([**Telephone/Fax (1) 2125**] and set up follow up appointment for [**7-6**].
Please follow up INR levels in [**Hospital 1209**] clinic or Primary Care
Physician as before.
Please follow up lab results with [**Hospital 3723**] clinic.
[**First Name11 (Name Pattern1) 798**] [**Last Name (NamePattern4) 3683**] MD [**MD Number(1) 3724**]
Completed by:[**2156-7-10**]
|
[
"585",
"518.5",
"285.9",
"427.31",
"512.1",
"511.9",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"39.50",
"39.90",
"99.04",
"34.21",
"34.92",
"34.91",
"96.04",
"34.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8488, 8580
|
5434, 6875
|
3476, 3619
|
8882, 8893
|
4109, 5411
|
9129, 9728
|
3768, 3773
|
1395, 1585
|
6979, 8465
|
8601, 8861
|
6901, 6956
|
8917, 9106
|
3788, 4090
|
2331, 3345
|
3362, 3438
|
3647, 3670
|
3692, 3715
|
3731, 3752
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,558
| 121,748
|
13029
|
Discharge summary
|
report
|
Admission Date: [**2155-8-14**] Date of Death: [**2155-9-5**]
Service: MED-CCU
EXPIRATION DATE: [**2155-9-5**].
HISTORY OF PRESENT ILLNESS: The patient is an 89 year old
female, Caucasian, recently admitted on [**6-1**] until [**2155-6-18**], for inferior wall myocardial infarction. A
catheterization at that time showed a 50% mid left anterior
descending and 40% left circumflex, obtuse marginal
occlusions as well as 50% proximal right coronary artery and
40 to 50% diagonal and 80% of distal posterior PDA
occlusions. The right coronary artery was thought to be the
culprit but at the time of catheterization, no arteries
needed intervention. The distal PDA lesion underwent
percutaneous transluminal coronary angioplasty.
Post-catheterization, the patient had bradycardia and
hypotension and a re-look catheterization was without any
significant changes. Her hospital course was also
significant for intubation for lactic acidosis. The patient
was re-admitted in early [**Month (only) 205**] for shortness of breath and
mental status changes. She was found to have stable pleural
effusions secondary to congestive heart failure and was
medically stabilized.
At that time, she opted for comfort care, however, when she
came from rehabilitation at this time, her code status was
changed to Full Code in the interim.
On [**8-14**], she complained of substernal chest pain,
shortness of breath and diaphoresis. The Emergency Medical
System was activated and found the patient to be hypotensive
with altered mental status. Per report, the patient was
lying semi-recumbent, nonresponsive except when verbally
stimulated. She was placed on two liters of nasal cannula
oxygen and was noted to have cold and clammy extremities.
She received three sublingual Nitroglycerin tablets earlier.
At [**Hospital1 **], she was hypotensive with blood pressure
68/38 and pulse 60. She was started on Dobutamine and
heparin. Lytics were also started at that time. EKG was
notable for diffuse ST elevations in weeks II, III and AVF as
well as V1 through V5. She was intubated for airway
protection on the way to [**Hospital1 69**]
for emergent catheterization.
The catheterization was notable for right coronary artery
tapering occlusion without changes in other vessels. She was
given Nitroglycerin with resolution of occlusion, suggestive
of a spasm. The stent was deployed to the site of the spasm.
She was given Dobutamine with resultant hypotension and
started on Levophed.
PHYSICAL EXAMINATION: On admission, vital signs were heart
rate 70; blood pressure 80/58; intubated with arterial blood
gas 7.27, 49, 300, lactate 5. Sodium 133, potassium 5.0. In
general, a thin, Caucasian female, intubated and sedated.
HEENT: Jugular venous distention not measurable. Pupils
small and equal. Positive S1, S2. No other sounds could be
appreciated. Lungs were decreased breath sounds bilaterally
at the bases. Mild wheezing. Abdomen quiet, nontender,
nondistended, no masses palpable. Extremities cool and
clammy, one plus dorsalis pedis and posterior tibial pulses
bilaterally. Right femoral sheath in place. No signs of
bleeding.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Care Unit with the diagnosis of right ventricular infarction.
Her mental status continued to be unchanged since admission
until her death with the patient not being able to respond to
any stimuli except for pain.
During the course of the hospital stay, she developed
Klebsiella pneumonia treated with Cefepime. She also
developed a large deep venous thrombosis of the right lower
extremity and was started on heparin.
Her renal function, which was decreased at baseline,
continued to deteriorate during the hospital stay and
required hemodialysis to the end of her stay.
The patient's respiratory function required ventilatory
support during this stay and extubation attempt was made two
weeks after admission and was unsuccessful. By the end of
her stay, she required tracheostomy tube placement.
Her cardiac function, despite all the interventions,
continued to deteriorate and the patient was unable to
maintain blood pressures without pressor support, despite
aggressive fluid resuscitation. At the end of her stay, she
also developed large necrotic sacral ulcer.
Despite aggressive measures [**First Name8 (NamePattern2) **] [**Known lastname **] continued to have
multiple system failure and was made comfort measures only by
her family. On [**9-4**], she was taken off the ventilator
the same day and expired the next day from congestive heart
failure and respiratory arrest.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-222
Dictated By:[**Name8 (MD) 4562**]
MEDQUIST36
D: [**2155-9-18**] 08:47
T: [**2155-9-24**] 15:36
JOB#: [**Job Number 39894**]
|
[
"427.31",
"584.5",
"707.0",
"410.41",
"785.51",
"276.2",
"482.0",
"518.5",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.01",
"31.1",
"39.95",
"36.06",
"38.93",
"96.72",
"37.23",
"38.95",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
3178, 4825
|
2519, 3160
|
153, 2496
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,620
| 183,777
|
49843
|
Discharge summary
|
report
|
Admission Date: [**2168-5-10**] Discharge Date: [**2168-5-19**]
Date of Birth: [**2120-9-25**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Benzodiazepines / Percocet
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
fevers, UTI, bacteremia
Major Surgical or Invasive Procedure:
CVL placement
History of Present Illness:
47 yo female with pmhx sig for developmental delay, renal
transplant x 2, IDDM, and multiple UTIs who was brought to the
ED from her NH today for low grade temp, 2/2 blood cultures
drawn on the 21st positive for GPC.
.
On arrival to the [**Name (NI) **], pt febrile to 101.4, hypotensive to 70's
systolic. UA suggestive of UTI, urine culture and blood
cultures sent. The patient was given dose of Vanc/Levo for
empiric coverage. R 18 guage was placed, LIJ was attempted x3
without success due to inability to pass the wire. RSC CVL also
attempted x3 without success. The patient received 3 liters
IVF, with improvement of BP to systolic of 95-110. In addition,
the patient's oxygen saturation dropped from 100% to 86%,
increased to 93-94% on NRB.
.
On arrival to ICU the patient is awake, complaining of "pain all
over". 100% on NRB, remains 100% on 3L NC. Agitated, but able
to answer questions, requesting vicodin for headache.
Past Medical History:
1. s/p LRT- ESRD [**1-22**] DM, failed 1st tx ([**2150**], lasted [**12-2**] yrs,
donor was sister), 2nd transplant from unrelated donor in [**10-22**],
postop course c/b Klebsiella UTI and ureteral necrosis requiring
stent and percutaneous nephrostomy tube in [**11-21**]
2. Type I DM- dx at age 10; c/b ESRD, severe neuropathy, chronic
heel ulcers, DKA, autonomic dysfunction; on Lantus as outpatient
3. Hypertension
4. Hypercholesterolemia
5. Hypothyroidism
6. s/p multiple AV access surgeries - hx. of AV fistula
infection
7. Squamous cell carcinoma of the vulva
8. Legally blind- impaired visually guided reaching, inability
to see the whole but only pieces at a time (simultanagnosia),
and impaired volitional saccades (optic apraxia) as evaulated by
Dr. [**First Name (STitle) 2523**] of neuroophthalmology likely related to her
tacrolimus toxicity
9. Osteoporosis
10. Posterior leukoencephalopathy [**1-22**] tacrolimus toxicity- found
by MRI during a prolonged hospital course in [**3-23**] c/b coma
requiring intubation, aspiration pneumonitis with methicillin
resistant Staphylococcus aureus and Aspergillus in her sputum
11. Psych- Narcotic and benzodiazepine dependence, eating
disorder, Depression, Personality disorder
12. Chronic constipation/diarrhea since her second transplant.
13. Shingles
Social History:
Currently at Hunt NH, since [**Month (only) 547**] after long hospital
stay. Sister [**Name (NI) 7798**] [**Name (NI) 5586**] [**Telephone/Fax (1) 104109**] is very involved in her
care and is HCP.
Physical Exam:
98.6/ 108/40/ 84/ 12/ 100% on 3L NC
GEN: Agitated, four point restraints in place. Responsive
HEENT: normocephalic, anicteric, EOMI, dry mucosa
NECK: no JVD, no LAD
CV: RRR, nml s1/s2, no murmurs appreciated
LUNGS: rhonchi B/L, no wheeze or crackles, no accessory muscle
use or tachypnea
ABD: soft, nt, nd, NABS. L-sided surgical scar.
EXT: warm, dry. No [**Location (un) **], faint DP and radial pulses B/L
NEURO: A/O x2, not to date. Moves all extremities
spontaneously, follows commands
SKIN: rash suggestive of yeast on groin, no areas of breakdown
or ulcerations
Pertinent Results:
CXR (Preliminary result): No pneumothorax is identified.
Compared to prior exam from [**2167-10-22**], there are markedly
diminished lung volumes with secondary bronchovascular crowding.
Allowing for this, the heart size and pulmonary vascularity are
probably within normal limits. No pleural effusion is detected.
Again identified are old rib fractures involving the right
fifth rib.
IMPRESSION: Compared to prior exam, there are markedly
diminished lung volumes. No pneumothorax is detected.
Brief Hospital Course:
# Sepsis - Patient was found to have MRSA bacteremia and was
treated with Vancomycin intravenously for this. The source was
thought to be a cellulitis. She also had ESBL E. coli urinary
tract infection and was treated with meropenem. She developed
hypotension due to the sepsis, but responded well to fluids, and
did not require vasopressors while in the ICU. She was
subsequently transferred out to the floor. While on the floor,
patient continued to receive antibiotics and was stable.
However, on [**2168-5-19**], she was found pulseless while morning
vitals were being obtained. Given that she was DNR, patient was
not resuscitated. Mode of death unclear. ? Myocardial
infarction/arrhythmia versus pulmonary embolism.
.
# Renal failure - Most likely pre-renal due to sepsis and
resultant hypotension. Creatinine returned to baseline.
Rejection was entertained given history of transplants, but was
felt to be unlikely, given resolution of creatinine. She was
continued on immunosuppressive medications.
.
# Diabetes- type I, 35 + years. Glycemic control achieved with
glargine and regular insulin sliding scale.
.
# Anemia- Anemia of chronic disease secondary to renal disease,
remained stable through hospital course.
.
# Psych- depression, personality disorder NOS, outpatient
treatment regimen of risperdal, buspirone was continued.
.
# Hypothyroidism- Continued levothyroxine
.
# GERD- Continued outpatient PPI
.
# Access- Right fem line placed from [**Date range (1) 104143**], as IR unable to
place PICC
.
# Prophyalxis- DVT prophylaxis with heparin SC.
.
# Code- DNR, but intubation OK
.
# [**Name (NI) 2638**] sister is HCP [**Name (NI) 7798**] [**Name (NI) 5586**]. [**Telephone/Fax (1) 104109**] (h),
[**Telephone/Fax (1) 104142**] (c); other sister [**Name (NI) **] [**Name (NI) 104144**] [**Telephone/Fax (1) 104145**] (w),
[**Telephone/Fax (1) 104146**] (h)
Medications on Admission:
Lantus 14 qam/ 12 units q pm
Humalog sliding scale
azathioprine
buspirone
cyclosporine
colace
lasix 80 mg
levothyroxine
metoprolol
omeprazole
risperdal
ambien
tylenol
bisacodyl
vicodin
loperamide
lorazepam
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2168-5-22**]
|
[
"285.21",
"041.4",
"682.6",
"599.0",
"V58.67",
"995.92",
"276.52",
"584.5",
"530.81",
"403.91",
"250.41",
"V10.44",
"244.9",
"276.1",
"996.81",
"585.4",
"369.4",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6171, 6180
|
4000, 5886
|
327, 342
|
6227, 6232
|
3476, 3977
|
6284, 6318
|
6143, 6148
|
6201, 6206
|
5912, 6120
|
6256, 6261
|
2883, 3457
|
264, 289
|
370, 1310
|
1332, 2651
|
2667, 2868
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,867
| 129,498
|
29055
|
Discharge summary
|
report
|
Admission Date: [**2189-2-26**] Discharge Date: [**2189-2-27**]
Date of Birth: [**2141-8-19**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Penicillins / Bactrim / Augmentin / Ceftin
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
transphenoidal brain biopsy
Major Surgical or Invasive Procedure:
brain mass biopsy via sphenoidal sinus
History of Present Illness:
47F DM2, recently diagnosed metastatic adenoCA presents for
elective bx of brain mass. The mass is a "mass arising in the
center of the clivus and extending into the adjacent sphenoid
bones and petrous apices bilaterally" She underwent the surgery
today without post-operative complications. The procedure was a
trans-sphenoidal approach to the mass with muslitple biopsies
taken. The lesion was noted to erode through the sphenoid sinus
and into the nasoopharynx.
Per anesthesia resident, there was concern that the pt would be
a diffficult intubation given body habitus. The intubation was
able to be performed without fiberoptic guidance, although a
special blade was used and the resident commented that he pulled
"harder than I have ever had to pull before". He was concerned
that an urgent intubation would present difficulties. She was
intubated in the OR and was breathing comfortably looking well,
fully awake, alert, and oriented after arriving to the floor.
Past Medical History:
Onc Hx:
Pt presented for GI evaluation in [**12-24**] when liver mass was
noted incidentally during an abdominal ultrasound for
investigation of gallstones. While undergoing outpt work-up for
the liver mass, the pt developed severe constant headaches
distinctly different from her previous migraines in [**Month (only) 404**].
Head imaging revealed a Clivus mass. She was noted to have L
abducens palsy, neurologically otherwise intact. She was
admitted [**Date range (1) 69996**] for headaches, dizzinesss, vomiting. CT torso
which showed multiple enhancing liver
masses. Liver performed [**2189-2-14**] at [**Hospital1 18**] during her last
hospitalization which showed poorly differentiated
adenocarcinoma of the liver.
.
Past Medical History:
1. Liver mass (4.7 cm mass L lobe liver) incidentally discovered
[**7-24**] by u/s for gallstones - had initial w/u at [**Hospital3 3583**],
then transferred care to [**Hospital1 18**], for high res MRI liver next
week, and biopsy/ccy to be scheduled with Dr. [**First Name (STitle) **] after this
2. DM-II with retinopathy
3. Gallstones
4. Asthma: rarely uses inhalers
5. Seasonal allergies
-Migraines/"sinus HA" x ">20 yrs"
-Hx recurrent sinusitis
-PCOS
-Hernia repair
-Repair of deviated nasal septum
-Depression
Social History:
Social History:
Lives with husband, on disability for DM and other health
problems. [**Name (NI) **] hx tob, etoh, drugs.
Family History:
Family History:
Mother and maternal uncle had strokes, HTN, DM; maternal uncle
also had throat ca and mother had kidney tumor. Another uncle
also had throat cancer. Father with glaucoma and alzheimer's
dz.
Physical Exam:
VS: Temp: 97.2 BP: 148/73 HR: 59 RR: 18 O2sat: 96 2L
GEN: pleasant, comfortable, NAD
HEENT: MMM, bandage over nose, mild bleeding,
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
NEURO: AAOx3. perrl, L eye abducens palsy, cranial nerves
otherwise intact. 5/5 strength throughout. No sensory deficits
to light touch appreciated. 2+DTR's-patellar and biceps
Pertinent Results:
Admission labs;
135 97 21
--------------< 274
4.2 28 0.7
Ca: 8.6 Mg: 1.8 P: 4.4 D
ALT: 137 AP: 110 Tbili: 0.5 Alb:
AST: 98 LDH: 389 Dbili: TProt:
.
14.4
15.6 >----< 300
42.1
PT: 13.1 PTT: 32.2 INR: 1.1
.
[**2189-2-26**]: CXR: Left subclavian central venous catheter, tip in
upper SVC. No pneumothorax
.
[**2189-2-26**]: CT sinus: Again noted is the expansile destructive
lesion involving the center of the clivus and extending into the
adjacent sphenoid bones and petrous apices is unchanged.
This si demonstrated with VTI set in-situ for pre-operative
planning.
Brief Hospital Course:
47F DM2, recently diagnosed metastatic adenoCA presents for
elective bx of brain mass. Hosp course by problem:
.
#. Transphenoidal clival mass biopsy: Pt initially tolerated
biopsy well. Please see OP report for details. Per anesthesia,
there was concern to monitor pt overnight in case of sedation
and she has a difficult airway. She was monitored in the ICU
overnight. There were no events and she did well. She ate
prior to discharge. we continued her outpatient meds, including
decadron
.
# Pain/Nausea: we treated with tramadol and compazine.
.
#. DM2:
-lantus, SSI.
-held metformin overnight
.
#. HTN: rx with home nifedipine
.
FEN: diabetic diet
Access: LSC, difficult access
PPx: P-boots, PPI
Medications on Admission:
Allergies: Erythromycin, Penicillins, Bactrim, Cefuroxime. The
pt states that these abx make her feel itchy, no rash, no hives.
.
Medications:
Dexamethasone 4mg [**Hospital1 **]
Lantus 26 u qam
Humalog sliding scale at home
Glucophage 1000 mg [**Hospital1 **]
Verapamil 240 mg qd
Claritin 10 mg qd
Astelin ii puffs each nostril [**Hospital1 **]
Singulair 10 mg qd
Zoloft 12.5 mg qd
Albuterol prn rarely uses
Lisinopril 40 mg qd
Prilosec i tab qd unknown dose]
Discharge Medications:
1. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
2. Lantus 100 unit/mL Solution Sig: Twenty Six (26) units
Subcutaneous once a day.
3. Humalog 100 unit/mL Solution Sig: variable Subcutaneous four
times a day: use sliding scale as previously instructed.
4. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
5. Verapamil 240 mg Cap, 24HR Sust Release Pellets Sig: One (1)
Cap, 24HR Sust Release Pellets PO once a day.
6. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Astelin 137 mcg Aerosol, Spray Sig: Two (2) Nasal twice a
day.
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Sertraline 50 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily).
10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea for 1 weeks.
Disp:*20 Tablet(s)* Refills:*0*
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- s/p brain biopsy
- unknown primary met adenoca
- DMII
Secondary:
- liver mass
- asthma
- migraines
- sinusiis
- depression
Discharge Condition:
well
Discharge Instructions:
You were admitted for a brain biopsy. You tolerated this
procedure well. Thereafter, we were concerned about your
breathing so monitored you overnight in the intensive care unit.
.
Please followup with Dr. [**Last Name (STitle) 69997**] as below. please contact his
office with any concerns about the procedure.
.
Pleaes resume your medications as previously prescribed.
.
Please do only light activity for the next week. This means: no
nose blowing, no heavy lifting, and no bending down.
Followup Instructions:
Please followup with Dr. [**Last Name (STitle) 69997**] on [**3-4**] at 12:45pm.
Please followup with your PCP in the next month.Provider: [**Name10 (NameIs) 5005**]
[**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2189-3-2**] 3:00
|
[
"250.50",
"197.3",
"198.89",
"493.90",
"199.1",
"362.01",
"327.23",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"22.11",
"22.52"
] |
icd9pcs
|
[
[
[]
]
] |
6547, 6553
|
4150, 4860
|
351, 392
|
6731, 6738
|
3542, 4127
|
7280, 7552
|
2854, 3047
|
5372, 6524
|
6574, 6710
|
4886, 5349
|
6762, 7257
|
3062, 3523
|
284, 313
|
420, 1391
|
2160, 2681
|
2713, 2822
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,860
| 105,510
|
14999+56590
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-9-23**] Discharge Date: [**2200-9-28**]
Date of Birth: [**2141-2-13**] Sex: F
Service: CCU
CHIEF COMPLAINT: Chest pain with nausea and vomiting.
HISTORY OF PRESENT ILLNESS: This is a 59 year old woman with
a history of hypertension and borderline hypercholesterolemia
who presents complaining of shoulder and arm pain that
nausea and vomiting. She was noted to awake from sleep with
ten out of ten substernal chest pain described as heavy
pressure with shortness of breath radiating to her left
shoulder and arm and she went to [**Hospital3 **], given two
sublingual Nitroglycerin and started on Aspirin, Aggrestat,
Heparin and oxygen with a decrease in her symptoms with her
pain rated as a two out of ten. She was noted to be
[**Hospital1 69**] for emergent
catheterization.
She was noted to have similar symptoms of left sided chest
pain and shortness of breath, nausea and vomiting
approximately one week ago rated two to three out of ten
while at work. She felt better after vomiting and left work
while feeling fatigued. These episodes of chest pain are now
new for her and seemingly unrelated to exertion. She is
currently chest pain free, denies shortness of breath or
palpitations, but continues with nausea.
Initial cardiac catheterization revealed cardiac output of
6.14, cardiac index of 3.77, wedge of 17, right atrial
pressure of seven, right ventricular pressure of 29/4,
pulmonary artery pressure of 26/15. Left ventriculogram
revealed mitral regurgitation with low normal ejection
fraction with inferobasal hypokinesis. Right dominant
system, 85% proximal lesion in the left anterior descending,
40% lesion in the left circumflex at the origin. The right
common artery was tortuous with a distal occlusion and distal
vessel comprised of two small diffuse diseased vessels that
were unable to stent.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypothyroidism.
3. Increased lipids.
MEDICATIONS ON ADMISSION:
1. Avapro 150 mg p.o. once daily.
2. Synthroid 112 mcg p.o. once daily.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient smokes approximately for twenty
plus pack years, currently smoking one pack every other day.
She denies any alcohol or intravenous drug abuse. She is
divorced and has five kids and lives in [**Location 43901**] and works at
[**Company 39532**].
FAMILY HISTORY: Significant for colon cancer and Alzheimer's
disease. No coronary artery disease.
REVIEW OF SYSTEMS: She denies currently fever, chills,
headaches, eye pain, ear pain, dysphagia and abdominal pain,
melena, hematochezia or myalgias.
PHYSICAL EXAMINATION: On admission, temperature was 98.4,
blood pressure 99/42, heart rate 67, respiratory rate 20, 98%
oxygen saturation on two liters nasal cannula. In general,
she appears comfortable, sleeping on the stretcher. Head,
eyes, ears, nose and throat - The pupils are equal, round,
and reactive to light and accommodation. Extraocular
movements are intact. Normocephalic and atraumatic. Mucous
membranes are moist. She has dentures. Her oropharynx is
pink and moist. The neck revealed no lymphadenopathy, flat
neck veins, no carotid bruits and 2+ carotid pulses
bilaterally. The lung examination was clear to auscultation
bilaterally, no wheezes, rales or rhonchi. Cardiovascular
examination reveals S1 and S2, regular rate, II/VI systolic
murmur at the right upper sternal border which is
nonradiating, no rubs or gallops. Abdominal examination -
bowel sounds present, soft, nontender, nondistended, no
guarding, tenderness or rebound, no masses palpated, no
hepatosplenomegaly. Groin revealed no hematoma and no
femoral bruit. Extremity examination revealed warm
extremities, no cyanosis, clubbing or edema, 2+ dorsalis
pedis pulses bilaterally.
LABORATORY DATA: White blood cell count 7.2, hematocrit
32.5, platelets 298,000. Sodium 138, potassium 4.3, chloride
104, CO2 22, blood urea nitrogen 21, creatinine 0.7, glucose
185. CPK at outside hospital was 348; at 8:00 p.m. on
arrival to hospital was 386 with a MB fraction of 36.
Electrocardiogram on admission revealed normal sinus rhythm,
rate 54 beats per minute, normal QRS axis, borderline left
ventricular hypertrophy, good R wave progression, PR interval
of 0.15, QRS 0.09, Q waves found in leads II, III and aVF,
flipped T waves in II, III, aVF, V5 and V6, approximately 1.[**Street Address(2) 27948**] elevations in II and aVF.
HOSPITAL COURSE:
1. Cardiovascular - The patient was taken to emergent
cardiac catheterization but was unable to stent the right
coronary artery. The proximal lesion found in the left
anterior descending was initially left alone. She was
started on an Aspirin and Lipitor as well as a low dose ace
inhibitor and beta blocker. However, the patient continued
to experience mild to moderate episodes of nausea and
vomiting as well as recurrent chest and shoulder pain. She
was brought back to the cardiac catheterization laboratory
and the proximal left anterior descending lesion was stented
and her symptoms of nausea and shoulder pain resolved. An
echocardiogram after her second catheterization revealed an
ejection fraction of 55%, mildly dilated left atrium, mild
regional left ventricular systolic dysfunction with focal
akinesis of the basal third of the inferior wall, mild aortic
regurgitation, trivial mitral regurgitation and no
pericardial effusion was present. Her ace inhibitor and beta
blocker were titrated upwards. She did continue to experience
mild left shoulder pain usually present in the morning that
was alleviated with a combination of Tylenol and sublingual
Nitroglycerin. Imdur 30 mg was started for long acting
anginal control. Her ace inhibitor and beta blocker were
changed to once daily dosing. These episodes of shoulder
pain and mild nausea were not accompanied by
electrocardiographic changes. Her CPK peaked at 633 with a
MB fraction of 55 and a troponin greater than 50. These
cardiac enzymes down trended throughout the remainder of her
hospital admission and she appeared stable for discharge on
hospital day number five. She is to follow-up with her
primary care physician in regards to choosing a cardiologist
as well as pursuing an outpatient cardiac rehabilitation
program.
2. Hematology - The patient was noted to have a baseline
hematocrit of 32.0 which down trended after her cardiac
catheterization. She was transfused two units throughout her
hospital admission and her hematocrit remained stable
thereafter and she had no transfusion complications.
3. Pulmonary/Infectious Disease - The patient was noted to
have low grade temperature after her second cardiac
catheterization. Blood cultures, urine cultures, chest x-ray
were sent in regards to finding a possible infectious
etiology of her temperatures. Her blood cultures were no
growth to date at the time of this dictation. Her urine
cultures were no growth to date at the time of dictation.
Her urinalysis was normal with slight leukocyte esterase, [**3-25**]
white blood cells and occasional bacteria. She was not
complaining of dysuria at this time. Chest x-ray revealed no
infiltrates. It was felt that this low grade temperature was
secondary to atelectasis, and her fever grade remained low
grade and incentive spirometry was encouraged. She will be
afebrile for approximately 24 hours prior to discharge.
CONDITION ON DISCHARGE: Deceased.
DISCHARGE STATUS: Deceased.
Addendum: The patient on the day prior to discharge became
unresponsive with code called. The patient was attempted to be
resuscitated but all attempts failed. Initial rhythm was
pulseless electrical activity and despite maximal measures
including temporary ventricular pacing, ACLS protocols and urgent
echocardiography (to rule out pericardial effusion) the patient
could not be resuscitated.
MEDICATIONS ON DISCHARGE:
1. Atenolol 12.5 mg p.o. once daily.
2. Lisinopril 20 mg p.o. once daily.
3. Atorvastatin 20 mg p.o. once daily.
4. Levoxyl 112 mcg p.o. once daily.
5. Plavix 75 mg p.o. once daily for thirty days.
6. Aspirin 325 mg p.o. once daily.
7. Imdur 30 mg p.o. once daily.
DISCHARGE DIAGNOSES:
1. Acute inferior myocardial infarction, status post left
anterior descending stent. s/p cardiac arrest without ability
to resuscitate.
2. Anemia requiring transfusion.
3. Atelectasis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2200-9-27**] 10:53
T: [**2200-10-5**] 10:19
JOB#: [**Job Number 43902**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 7973**]
Admission Date: [**2200-9-23**] Discharge Date: [**2200-9-28**]
Date of Birth: [**2141-2-13**] Sex: F
Service: CCU
ADDENDUM: On hospital day #6, the patient was found to be
unresponsive. Cardiac arrest code was called. The patient
was found to be in pulseless electrical activity.
Cardiopulmonary resuscitation was initiated with
electrocardiogram changes showing acute ST elevations in II,
III, and aVF, which progressed to third degree heart block.
A transvenous pacer was utilized in attempts to control her
rhythm. Cardiac arrest code was performed for approximately
45 minutes without benefit. The patient expired on [**2200-9-28**]. Family was notified and a postmortem examination
was declined at this time.
[**First Name11 (Name Pattern1) 448**] [**Last Name (NamePattern4) 2130**], M.D. [**MD Number(1) 4055**]
Dictated By:[**Name8 (MD) 1554**]
MEDQUIST36
D: [**2200-9-29**] 19:21
T: [**2200-10-6**] 07:36
JOB#: [**Job Number **]
|
[
"998.2",
"305.1",
"410.41",
"414.01",
"518.0",
"997.3",
"427.5",
"401.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"36.06",
"37.23",
"36.01",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
2401, 2485
|
8185, 9757
|
7891, 8164
|
1979, 2108
|
4479, 7400
|
2661, 4462
|
2505, 2637
|
149, 187
|
216, 1870
|
1892, 1953
|
2125, 2384
|
7425, 7865
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,242
| 104,456
|
21718
|
Discharge summary
|
report
|
Admission Date: [**2138-8-29**] Discharge Date: [**2138-9-11**]
Date of Birth: [**2089-4-2**] Sex: M
Service: [**Doctor First Name 147**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 57094**]-renal shunt
History of Present Illness:
49 yo man with h/o binge drinking and remote intravenous drug
use who has not seen a physician in over 30 years initially
presented to an OSH ED [**8-28**] with nausea, hematemesis,
lightheadedness, and diaphoresis. The pt was never
hemodynamically unstable in the OSH ED (HR 81-96, BP
111-150/67-80). In the ED there he received PPI IV, ondansetron,
and lorazepam, and he was started on an octreotide gtt. An EGD
done on the day of admission there showed blood with clots in
the stomach but no active bleed; a 3-4 cm submucosal mass was
seen in the fundus of the stomach with overlying clot consistent
with a recent bleed. The duodenum was normal. These findings
were thought to be consistent with varices vs. leiomyoma vs.
submucosal tumor. A CT scan of the abdomen showed splenomegaly
and prominent varices clustered in the area of the fundus and GE
junction. Given these findings, the pt was transferred here for
further evaluation and treatment for portal hypertension.
Past Medical History:
1. tobacco abuse
2. binge EtOH use
3. remote intravenous and intranasal drug abuse
4. excision of benign cyst on L anterior chest wall
Social History:
The patient lives with his family in an apartment in [**Location (un) **]. He
has six children. He works as a landscaper and general
handyman. He has no pets.
Family History:
The patient's father died at age 72 from complications of
Alzheimer's disease. There is a history of diabetes on his
father's side of the family. His mother is in her 70s and is
well. He has four brothers and three sisters, all of whom are
well. The patient has six children, the youngest of whom has
asthma.
Physical Exam:
Temp 98.0 BP 131/64 HR 77 RR 12 SpO2 97% room air
Gen: Pleasant man lying flat in bed, appearing his stated age
and in no acute distress
HEENT: NCAT, no sinus tenderness, conjunctivae pink and
non-icteric, OP clear, MMM, no sublingual jaundice, poor
dentition
Neck: Soft, supple, no LAD
CV: RRR, normal S1 and S2, no m/r/g.
Pulm: CTA bilaterally
Abd: Soft, non-tender, non-distended, active bowel sounds, no
palpable hepatosplenomegaly, liver span 6 cm on scratch test
Back: No CVA or paraspinal tenderness
Ext: 2+ DP pulses, no edema, no teres nails
Neuro: Alert, oriented, appropriate, no focal deficits
Skin: No rashes, no lesions, no telangiectasias, normal skin
tone without jaundice, no caput medusae
Pertinent Results:
[**2138-8-29**] 04:11AM BLOOD WBC-7.0 RBC-3.46* Hgb-11.6* Hct-31.4*
MCV-91 MCH-33.4* MCHC-36.8* RDW-14.0 Plt Ct-68*
[**2138-8-30**] 06:07AM BLOOD WBC-4.6 RBC-3.26* Hgb-10.7* Hct-29.6*
MCV-91 MCH-32.9* MCHC-36.3* RDW-14.3 Plt Ct-67*
[**2138-8-31**] 05:04AM BLOOD WBC-4.5 RBC-3.32* Hgb-11.2* Hct-29.8*
MCV-90 MCH-33.7* MCHC-37.5* RDW-14.1 Plt Ct-87*
[**2138-9-1**] 08:50AM BLOOD WBC-5.2 RBC-3.60* Hgb-12.0* Hct-32.5*
MCV-90 MCH-33.3* MCHC-36.9* RDW-14.7 Plt Ct-101*
[**2138-9-2**] 08:55AM BLOOD WBC-4.5 RBC-3.38* Hgb-11.6* Hct-30.8*
MCV-91 MCH-34.2* MCHC-37.5* RDW-14.8 Plt Ct-97*
[**2138-9-3**] 05:10AM BLOOD WBC-4.3 RBC-3.27* Hgb-11.1* Hct-30.6*
MCV-94 MCH-34.1* MCHC-36.4* RDW-15.1 Plt Ct-83*
[**2138-9-5**] 03:50AM BLOOD WBC-3.6* RBC-3.07* Hgb-10.3* Hct-28.2*
MCV-92 MCH-33.6* MCHC-36.6* RDW-15.0 Plt Ct-88*
[**2138-9-5**] 12:51PM BLOOD WBC-8.7# RBC-3.39* Hgb-11.5* Hct-31.4*
MCV-93 MCH-33.9* MCHC-36.6* RDW-15.3 Plt Ct-125*
[**2138-9-6**] 05:30AM BLOOD WBC-13.0* RBC-3.60* Hgb-12.4* Hct-33.3*
MCV-92 MCH-34.5* MCHC-37.3* RDW-15.4 Plt Ct-107*
[**2138-9-8**] 04:58AM BLOOD WBC-10.3 RBC-3.05* Hgb-10.2* Hct-27.9*
MCV-92 MCH-33.5* MCHC-36.6* RDW-15.2 Plt Ct-98*
[**2138-8-29**] 04:11AM BLOOD PT-13.9* PTT-28.9 INR(PT)-1.2
[**2138-8-29**] 11:15AM BLOOD PT-13.8* PTT-29.1 INR(PT)-1.2
[**2138-8-31**] 05:04AM BLOOD PT-13.6 PTT-27.8 INR(PT)-1.2
[**2138-9-5**] 03:50AM BLOOD PT-14.4* PTT-30.7 INR(PT)-1.3
[**2138-9-7**] 04:39AM BLOOD PT-14.1* PTT-34.8 INR(PT)-1.3
[**2138-8-29**] 04:11AM BLOOD Glucose-132* UreaN-19 Creat-0.9 Na-138
K-4.2 Cl-106 HCO3-25 AnGap-11
[**2138-8-31**] 05:04AM BLOOD Glucose-119* UreaN-13 Creat-0.9 Na-139
K-4.0 Cl-106 HCO3-26 AnGap-11
[**2138-9-3**] 05:10AM BLOOD Glucose-95 UreaN-11 Creat-0.9 Na-137
K-3.8 Cl-103 HCO3-24 AnGap-14
[**2138-9-6**] 05:30AM BLOOD Glucose-124* UreaN-12 Creat-1.3* Na-138
K-4.1 Cl-105 HCO3-27 AnGap-10
[**2138-9-8**] 04:58AM BLOOD Glucose-95 UreaN-13 Creat-0.9 Na-136
K-3.8 Cl-102 HCO3-26 AnGap-12
[**2138-8-29**] 04:11AM BLOOD ALT-88* AST-80* LD(LDH)-192 AlkPhos-79
Amylase-55 TotBili-1.7*
[**2138-9-1**] 08:50AM BLOOD ALT-81* AST-69* AlkPhos-85 TotBili-1.7*
[**2138-9-3**] 05:10AM BLOOD ALT-66* AST-54* AlkPhos-77 TotBili-1.4
[**2138-9-5**] 03:50AM BLOOD ALT-49* AST-43* AlkPhos-70 TotBili-1.3
[**2138-9-5**] 12:51PM BLOOD ALT-52* AST-54* AlkPhos-68 Amylase-76
TotBili-2.0*
[**2138-9-7**] 04:39AM BLOOD ALT-47* AST-60* AlkPhos-67 Amylase-58
TotBili-2.5*
[**2138-9-8**] 04:58AM BLOOD ALT-42* AST-52* AlkPhos-67 TotBili-2.6*
[**2138-9-9**]: Alkphos 115, T Bili 1.4, ALT 39, AST 50
[**2138-8-29**] 04:11AM BLOOD calTIBC-263 VitB12-540 Folate-13.1
Ferritn-509* TRF-202 Iron-246*
[**2138-8-29**] 04:11AM BLOOD Albumin-3.5 Calcium-8.4 Phos-2.8 Mg-1.9
[**2138-8-31**] 05:04AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.6
[**2138-9-5**] 12:51PM BLOOD Albumin-3.1* Calcium-8.6 Phos-5.1*
Mg-1.4*
[**2138-9-7**] 04:39AM BLOOD Calcium-8.1* Phos-2.4*# Mg-1.8
[**2138-9-8**] 04:58AM BLOOD Albumin-2.7* Calcium-8.0* Phos-2.2*
Mg-1.6
[**2138-8-29**] 04:11AM BLOOD AFP-17.1*
[**2138-8-29**] 04:11AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-POSITIVE
[**2138-8-29**] 04:11AM BLOOD HCV Ab-POSITIVE
[**2138-8-29**] 04:11AM BLOOD TSH-0.44
RADIOLOGY:
[**8-29**] U/S abdomen:
1) Coarsely echogenic liver texture without evidence of focal
lesions.
2) Small amount of sludge without evidence of acute
cholecystitis.
3) Splenomegaly.
4) No evidence of ascites. Normal Doppler flow.
[**8-30**] CT abdomen:
1. Splenomegaly and large gastric varices, consistent with
portal
hypertension.
2. Conventional liver anatomy and blood flow with patent
hepatic veins and
portal vein.
[**9-2**] Celiac angiogram:
1) Enlarged left-sided renal vein with possible small
splenorenal shunt.
However, this shunt is not seen on the splenic venogram.
2) Widely patent portal vein, splenic vein, and superior
mesenteric vein.
Varices identified off of the splenic vein.
3) PRESSURES: Left renal vein 9 mmHg, IVC 6 mmHg, hepatic vein 7
mmHg, wedged
hepatic 20 mmHg.
[**9-10**] venogram study:
No shunt stenosis, with pressures of 31 mmHg in the splenic
vein, 25 mmHg in the renal vein, and 15 mmHg in the IVC.
Brief Hospital Course:
This patient was a 49 yo man with remote history of alcohol
abuse, ongoing binge alcohol use, and remote intravenous and
intranasal drug abuse who has not seen a physician in over
thirty years was transferred to the [**Hospital1 18**] from an OSH for
further evaluation of hematemesis and gastric varices.
The patient had an abdominal ultrasound and CT scan, as well as
celiac angiogram as part of a workup of portal hypertension. He
also had Hepatitis C serologies drawn which showed a positive
Hep-C antibody and Hep C viral load of >700,000 by PCR;
Hepatitis B serologies were only remarkable for positive core
antibody. He had an abdominal ultrasound on [**8-29**] which
demonstrated a coarsely echogenic liver texture without evidence
of focal lesions, a small amount of sludge in the gall bladder,
and splenomegaly. A CT scan on [**8-30**] demonstrated similar
findings as well as conventional liver anatomy. His celiac
angiogram on [**9-2**] demonstrated an enlarged left-sided renal vein
with possible small splenorenal shunt, as well as idely patent
portal vein, splenic vein, and superior mesenteric veins.
[Pressures of : Left renal vein 9 mmHg, IVC 6 mmHg, hepatic vein
7 mmHg, wedged hepatic 20 mmHg]. Varices were identified off of
the splenic vein.
With regards to his hematemesis, the patient was noted to be
hemodynamically stable throughout his hospital course and did
not have any episodes of hematemesis during his hospital stay.
He had an anemia workup which was unremarkable with a normal
serum Folate, B12, TIBC, and transferrin on [**8-29**]. His hematocrit
remained stable in the 27 to 33 range throughout his
hospitalization.
After thorough discussion of risks and benefits, the patient
underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) 57094**]-renal shunt for treatment of severe
portal hypertension on [**2138-9-5**]. The patient was noted to do
remarkably well in his post-operative course, with good pain
control and tolerating a regular diet by POD 4. He had a
venogram study on post-operative day 5 which demonstrated no
shunt stenosis, with pressures of 31 mmHg in the splenic vein,
25 mmHg in the renal vein, and 15 mmHg in the IVC.
Medications on Admission:
1. octreotide gtt
2. pantoprazole 40 mg IV BID
Discharge Medications:
1. 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*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*10 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Portal Hypertension
Discharge Condition:
Fair
Discharge Instructions:
Please call the office or come to the emergency room with any
worsening of abdominal pain, new-onset jaundice, or fever. You
may shower but no baths/swimming for 2 weeks. No heavy lifting
for 5 weeks.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in on [**2138-9-17**], 9:20 am.
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER (NHB) Where: LM
[**Hospital 5628**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2138-9-17**] 9:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2138-9-11**]
|
[
"287.5",
"572.3",
"571.2",
"305.02",
"578.0",
"285.1",
"456.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"39.1",
"99.05",
"88.65",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9780, 9786
|
6977, 9200
|
344, 429
|
9850, 9856
|
2837, 6954
|
10105, 10586
|
1785, 2095
|
9297, 9757
|
9807, 9829
|
9226, 9274
|
9880, 10082
|
2110, 2818
|
293, 306
|
457, 1433
|
1455, 1591
|
1607, 1769
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,504
| 180,365
|
17373
|
Discharge summary
|
report
|
Admission Date: [**2173-7-12**] Discharge Date: [**2173-8-2**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2173-7-12**] Cardiac Catheterization. Placement of IABP.
[**2173-7-16**] CABGx2, MV Repair with 26mm [**Last Name (un) 3843**] [**Doctor Last Name **] Ring.
History of Present Illness:
81 year old woman with known CAD (last cath [**2171-8-15**] demonstrated
prox LCx in-stent restonosis tx w/angioplasty and
B-brachytherapy, mid LAD w/50% stenosis, OM with diffuse dz up
to 70% and RCA, R-PDA and R-PL filling via L-->R collaterals),
3+MR on last echo ([**2171-5-28**]), HTN, hyperlipidemia, and former
smoker. She was in her USOH until Sat (2d pta) when @ 7:30 she
experienced heartburn while watching TV, not associated with
SOB, diaphoresis, N/V, or other sx.
Sunday she presented to [**Hospital 1474**] hospital. ECG was read as wide
paced QRS to 80 w/lateral ST elevations 2-4mm. CK667, MB47.8,
Trop20.8. Pt was transferred to [**Hospital1 18**].
Cath @ [**Hospital1 18**] revealed 3VD w/LMCA w/mid vessel haziness, LAD with
90% mid vessel stenosis, LCx filling via L-->L collaterals and
RCA chronically occluded. IABP placed. CO/CI 2.33/1.62, RA 14,
RV 60/12, PA 59/26, PCWP 27.
Past Medical History:
Arrhythmia status post pacemaker implantation.
Valvular disease.
History of for hypertension.
PVD s/p L fem-peroneal bypass
s/p TAH/BSO
hyperlipidemia
s/p appy
hx anemia
glaucoma
TTE [**5-25**]: normal LVEF, mod to severe MR, mild PA htn (TR
gradient = 32)
Left common fem-mid peroneal bypass
CRI
Social History:
X-smoker. No EtOH, IVDA. Lives w/husband and [**Name2 (NI) 12496**]
Family History:
grandparents with CAD
Physical Exam:
GEN: lying in bed in no acute distress
NEURO: Alert and oriented, no focal deficits
LUNGS: Scattered rhonchi
HEART: RRR, normal S1-S2, II/VI systolic murmur
ABD: Soft, nontender, nondistended.
EXT: Warm, no edema. Pulses intact
Pertinent Results:
[**2173-7-12**] 06:25PM PT-12.8 PTT-53.0* INR(PT)-1.1
[**2173-7-12**] 06:17PM GLUCOSE-126* UREA N-36* CREAT-1.2*
SODIUM-130* POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-20* ANION GAP-16
[**2173-7-12**] 06:17PM CK(CPK)-428*
[**2173-7-12**] 06:17PM CK-MB-24* MB INDX-5.6 cTropnT-2.06*
[**2173-7-12**] 06:17PM CALCIUM-8.4 PHOSPHATE-3.5 MAGNESIUM-1.6
[**2173-7-12**] 06:17PM WBC-12.3* RBC-2.90* HGB-8.6* HCT-24.8* MCV-86
MCH-29.8 MCHC-34.7 RDW-13.3
[**2173-7-12**] 06:17PM PLT COUNT-234
[**2173-7-12**] 04:39PM O2 SAT-55
[**2173-7-12**] 04:39PM TYPE-MIX
[**2173-7-30**] 06:10AM BLOOD WBC-16.6*
[**2173-7-28**] 07:03AM BLOOD WBC-17.9* RBC-3.62* Hgb-10.6* Hct-31.9*
MCV-88 MCH-29.2 MCHC-33.2 RDW-14.8 Plt Ct-281
[**2173-7-28**] 07:03AM BLOOD Plt Ct-281
[**2173-7-30**] 06:10AM BLOOD UreaN-60* Creat-1.8* K-4.3
[**2173-7-30**] 06:10AM BLOOD ALT-33 AST-33 AlkPhos-218* Amylase-97
TotBili-2.8*
[**2173-8-2**] WBC 18.6, HCT 26.5, PLT 365, Na 131, K+4.9, Cl 96, HCO3
27, BUN 60, Creat 1.7.
[**2173-7-12**] Cardiac Cath
1. Coronary angiography of this right dominant circulation
revealed
severe LMCA and additional two vessel coronary artery disease.
The LMCA
had a 60% distal narrowing with haziness surrounding the lesion.
The LAD
had a 90% mid vessel stenosis and supplied two moderate sized
diagonal
branches that were free of obstructive disease. The LCX was
occluded at
its ostium at the proximal edge of the prior stent. Small OM
branches
filled faintly via L->L collaterals from the LAD. The RCA was
diffusely
diseased and subtotally occluded throughout its course.
2. Resting hemodynamics revealed markedly elevated left and
right heart
filling pressures with an LVEDP of 30 mmHg and an RVEDP of 20
mmHg in
the setting of relative hypotension with a SBP of 93 mmHg. The
mean PCWP
was 27 mmHg with V-waves up to 41 mmHg. There was evidence of
moderate
to severe pulmonary hypertension with PA pressures of 60/26/39
mmHg. The
cardiac index was severely depressed at 1.6 L/min/m2. No
gradient across
the aortic valve was detected.
3. Due to the presence of cardiogenic shock associated with a
hazy LMCA
lesion, an intra-aortic balloon pump was placed through the
right
femoral arteriotomy after angiography of the right lower
extremity
revealed an acceptable amount of peripheral vascular disease.
4. Left ventriculography was not performed due to the markedly
elevated
left ventricular filling pressures.
[**2173-7-12**] ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is moderately depressed.
[Intrinsic left ventricular systolic function may be more
depressed given the severity of valvular regurgitation.] Resting
regional wall motion abnormalities include inferior and
inferolateral hypokinesis. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate to severe (3+) mitral regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
[**2173-7-13**] Carotid Ultrasound
1. 60-69 right ICA stenosis.
2. No significant left ICA stenosis.
3. High-grade right external carotid artery stenosis.
[**2173-7-27**] CXR
Findings consistent with CHF. There is probably slight interval
improvement when compared to the prior study.
[**2173-7-29**] CXR
Multiple loculated right pleural effusion, with slight decrease
in size following thoracentesis but no evidence of pneumothorax.
Stable widening of the mediastinum consistent with known fluid
collection on recent CT.
[**2173-7-29**] Abdominal Ultrasound
Cholelithiasis, without cholecystitis. Bilateral pleural
effusions.
[**2173-7-29**] Chest CT
1) Large amount of retrosternal/mediastinal fluid, and bilateral
pleural effusions, including loculated right pleural effusion.
While some amount of retrosternal fluid can be visualized up to
15 days post-median sternotomy, the amount of fluid in the
mediastinum and right pleural space is unusual, and infection
within these collections should be considered in the appropriate
clinical setting.
2) Congestive heart failure and anasarca.
3) Severe tracheomalacia demonstrated within the mid trachea,
with near complete collapse of the tracheal lumen. Once the
patient is clinically stable, a dedicated CT examination of the
trachea may be helpful in delineating the full extent of
tracheomalacia.
4) Large hiatal hernia.
5) Moderate pericardial effusion.
6) Cholelithiasis
Brief Hospital Course:
Ms. [**Known lastname 48604**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2173-7-12**] via transfer from [**Hospital 1474**] Hospital. She
underwent a cardiac catheterization which revealed a 90%
stenosed left anterior descending artery, an occluded right
coronary artery and an occluded circumflex artery. An
intra-aortic balloon pump was placed for coronary perfusion. An
echocardiogram was obtained which revealed an ejection fraction
of 45-50%, 3+ mitral regurgitation and inferior/inferolateral
hypokinesis. Due to the severity of her disease, Ms. [**Known lastname 48604**] was
worked-up in the usual preoperative manner. A carotid duplex
ultrasound was performed which revealed a 60-69% stenosed right
internal carotid artery and a less then 40% stenosed left
internal carotid artery. A dental consult was obtained for oral
clearance for valve surgery. Ms. [**Known lastname 48604**] was transfused for
anemia. As she had a pacemaker, the electrophysiology service
was consulted who interoggated and reprogrammed her pacemaker.
On [**2173-7-17**], Ms. [**Known lastname 48604**] was taken to the operating room where
she underwent two vessel coronary artery bypass grafting and a
mitral valve repair utilizing a 26mm [**Last Name (un) **] [**Doctor Last Name **]
annuloplasty band. Postoperatively she was taken to the cardiac
surgical intensive care unit for monitoring. The
elctrophysiology service reprogrammed her pacemaker
psotoperatively. On postoperative day one, her intra-aortic
balloon pump was weaned and removed without complication. She
was transfused with red blood cells for postoperative anemia. As
her urine output was low and her creatinine was elevated, the
renal service was consulted. Her mean arterial pressure was
maintained at a higher pressure for perfusion as she likely had
acute tubular necrosis post bypass. On postoperative day two,
Ms. [**Known lastname 48604**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Ms.
[**Known lastname 48604**] was noted to have an elevated white blood cell count. A
chest x-ray revealed bilateral pleural effusions for which she
underwent thoracentesis. Her liver enzymes were elevated and an
abdominal ultrasound was obtained. This revealed cholithiasis
without other notable abnormalities. A chest CT scan was
obtained for sternal drainage which showed Large amount of
retrosternal/mediastinal fluid, and bilateral pleural effusions,
including loculated right pleural effusion, congestive heart
failure and anasarca, severe tracheomalacia demonstrated within
the mid trachea, with near complete collapse of the tracheal
lumen, large hiatal hernia, moderate pericardial effusion and
cholelithiasis. Vancomycin was started prophylactically. She
underwent bilateral thoracentesis with complete resolution of
sternal drainage, but continued to have and elevated WBC without
evidence of fever or infectious source. The vancomycin was d/c.
She underwent US of abdomen due to elevated WBC which showed
cholelithiasis without evidence of cholecystitis. Her CXR [**8-2**]
showed ?new RLL infiltrate and she was started on levofloxacin.
It was determined that she did not have an acute process causing
her elevated WBC and was cleared for discharge to rehab.
Medications on Admission:
atenolol 100 qd, lipitor 40qd, hctz 50qd, zestril 40qd, plavix
75qd, eye drops
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Alphagan P 0.15 % Drops Sig: One (1) gtt Ophthalmic three
times a day.
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 2 weeks.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
Coronary artery disease
s/p CABG/MV repair
PVD
s/p L fem-peroneal bypass
h/o PPM insertion
glaucoma
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage and increased pain.
2) Report any fever greater then 100.5
3) No swimming or bathing for 4 weeks.
4) Do not apply lotions, creams or powders to wound.
5) No lifting more then 10 pounds or driving for 4 weeks.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks.
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
Follow-up with Dr. [**First Name8 (NamePattern2) 20069**] [**Last Name (NamePattern1) **] in 2 weeks.
Please call for appointments.
Completed by:[**2173-8-2**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"89.60",
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icd9pcs
|
[
[
[]
]
] |
11455, 11514
|
6818, 10169
|
278, 440
|
11658, 11664
|
2088, 6795
|
1801, 1824
|
10299, 11432
|
11535, 11637
|
10195, 10276
|
11688, 11972
|
12023, 12301
|
1839, 2069
|
228, 240
|
468, 1377
|
1399, 1698
|
1714, 1785
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,434
| 192,274
|
35298
|
Discharge summary
|
report
|
Admission Date: [**2178-11-22**] Discharge Date: [**2178-11-27**]
Date of Birth: [**2124-7-3**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Dilantin / Tegretol / Iodine; Iodine Containing /
Latex
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
unresponsiveness, dysuria, chills
Major Surgical or Invasive Procedure:
intubation
central line placement
PICC line placement
History of Present Illness:
54 yr old quadraplegic from MVA with suprapubic catheter, CRI,
recurrent UTI's, hx of seizures. Presenting from NH after
episode of unresponsiveness x three minutes. Documented as non
responsive to tactile stimuli or command. At that time VS 98%
RA, 118/64. Was two days into Macrobid treatment for UTI.
Brought to [**Hospital1 18**] though receives most of care at [**Hospital1 59561**].
In ED AOx 3, denies episode or mental status change. Initially
120/60, 93% then to 89% RA- 98% 5L (patient and brother reports
NC 2 liters at baseline for COPD), 99.8 axillary. AO x 3 on
arrival. Audible breath sounds and upper respitory sounds.
Erythema, swelling right thigh. EKG NSR 73, ST depressions v1-v2
no comparison, but in ED reported as no change from prior. WBC
9.1, Cr 1.5, Hct 35 unknown baseline. CXR with no evidence of
infiltrate. 3L NS given, vancomycin 1 gram, Zosyn 4.5 grams
given. Right IJ placed. Admitted for further work up. Patient
reported feeling fine, no worsening SOB from baseline, and
alert. No diarrhea, no BM x 2 days. Reportedly denied abdominal
pain, fevers, chest pain, SOB. + chills. Given patient with
waxing MS, admitting resident obtained an ABG PH 7.26/86/81.
lactate to 3.4.
.
Stat MICU consult for transfer, concern for impending
hypercarbic respiratory failure. Mixed disturbance perhaps in
the setting of lactic acidosis from sepsis of several sources,
urine, abdomen, lung. Did not receive any narcotics, benzos.
When arrived in room patient unresponsive. Abdomen increasingly
distended. Code called stat. Patient with pulse but
respirations to [**4-7**]/minute. BP stable, 85% on 6L. Non
rebreather, labs with ABG repeat at 7.27/86/50. Lytes stable.
Crit to 30 (down 5pts from prior). Immediately prior to
intubation patient intermittently awoke and was conversant but
then would quickly become somnolent. EKG unchanged. Decision
made with anesthesia to intubate given waxing and waining mental
status. Patient intubated and transferred to the unit. Discussed
with brother via phone. Patient is full code.
.
Upon arrival to the MICU, VS 96.1, 113/56, 70, 17 on 100% on CMV
ventilation, FIO2 100%. Patient is intubated and sedated.
Bloody mucous is being suctioned from airway. No obvious pain
Past Medical History:
: from patient and brother, no clear records of pmhx.
C6 Quadraplegia with suprapubic catheter
Hx of UTI frequent
Hx of seizure, not on antiseizure medications ?pseudoseizures
neurogenic bowel
?CRI
urinary incontinence
GERD
Gingivitis
Osteopenia
Neuropathic pain
Abdominal aortic aneurysm
Paranoid schizophrenia
Chronic pressure ulcers
R BKA
Social History:
Was living at home with wife and daughter. Nursing home [**Doctor Last Name **] on
the Commons x 2 weeks as wife away on business. 1 pack per 4 day
smoker x several years. Veteran. Social support good.
Family History:
NC
Physical Exam:
Gen: chronically ill appearing male, intubated
HEENT: MM dry, EOMI, no vertical nystagmus. Reactive pupils
Neck: No JVD, no thyromegaly, no LAD, IJ in place on right
Cor: RRR no m/r/g
Pulm: rhoncorous sounds apically.
Abd: distended, no shifting dullness, +BS
Extrem: Amputee right LE, Right thigh with marked erythema
swelling. warm to the touch. Area demarcated previously. No
palpable cords.
Neuro: Unable to assess [**3-7**] sedation. Contracted hands.
Pertinent Results:
[**2178-11-22**] 06:10PM PT-12.8 PTT-26.2 INR(PT)-1.1
[**2178-11-22**] 06:10PM NEUTS-78.2* LYMPHS-15.5* MONOS-4.7 EOS-1.4
BASOS-0.2
[**2178-11-22**] 06:10PM WBC-9.1 RBC-3.90* HGB-11.4* HCT-35.2* MCV-90
MCH-29.2 MCHC-32.4 RDW-14.0
[**2178-11-22**] 06:10PM GLUCOSE-102 UREA N-40* CREAT-1.5* SODIUM-137
POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-41* ANION GAP-8
[**2178-11-22**] 06:18PM HGB-12.5* calcHCT-38
[**2178-11-22**] 06:18PM GLUCOSE-100 LACTATE-0.8 K+-5.0
[**2178-11-22**] 06:40PM URINE RBC->50 WBC->50 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2178-11-22**] 06:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2178-11-22**] 06:40PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.005
[**2178-11-27**] 06:08AM BLOOD WBC-4.5 RBC-3.25* Hgb-9.7* Hct-29.2*
MCV-90 MCH-29.9 MCHC-33.3 RDW-13.9 Plt Ct-173
[**2178-11-27**] 06:08AM BLOOD Glucose-80 UreaN-15 Creat-0.9 Na-145
K-4.1 Cl-107 HCO3-31 AnGap-11
[**2178-11-27**] 06:08AM BLOOD Calcium-7.9* Phos-2.6* Mg-2.1
CT abdomen/pelvis
1. Increasing abdominal distention likely related to severe
constipation and possible fecal impaction. No CT findings on
this non-contrast study to
suggest ischemia.
2. Small bilateral pleural effusions and left greater than right
airspace
consolidation, likely atelectasis.
3. Medullary and caliceal calcifications involving atrophic and
scarred
kidneys bilaterally, suggestive of underlying medullary
nephrocalcinosis.
Bilateral hypoattenuating renal lesions are not fully
characterized on this non-contrast study but likely represent
benign cysts.
4. Gluteal, pelvic, and psoas musculature wasting as well as
multiple
decubital ulcerations extending to the bony surfaces. Regions of
sclerosis
are noted within the adjacent upper sacrum and right ischial
tuberosity which likely reflect changes from subacute or chronic
osteomyelitis. Acute
osteomyelitis cannot be completely excluded and should be
correlated with
clinical exam.
LENI negative for DVTin R leg
culture data: no growth do date other than [**2-6**] blood cultures
positive for staph epi (thought ot be contaminant)
video swallow negative.
Brief Hospital Course:
54yoM C6 quadraplegic with suprapubic catheter, recurrent UTIs
(h/o ESBL EColi), pseudoseizures, CRI, schizophrenia, and COPD
admitted for hypercarbic respiratory failure and sepsis.
# Acute Hypoxic Hypercarbic Respiratory Failure: Patient
intubated on the floor for hypercarbic/hypoxic respiratory
failure thought to be due to a combination of COPD exacerbation,
pneumonia, and poor pulmonary reserve from quadriplegia.
patient was started on steroids & nebs & antibiotics. extubated
shortly thereafter with mental status much improved. His
steroids were tapered and he should complete a 14-day course of
meropenem & vancomycin for health-care associated pneumonia.
started albuterol & atrovent with improvement in wheezing.
# Pneumonia: improving on vancomycin & meropenem. should finish
14-day course with last day of admit [**12-6**].
# atrial fibrillation: developed combination of atrial fib, a
flutter, ? a tach in setting of frequent nebulizer treatments.
this responded to diltiazem boluses and he was maintained in
sinus rhythm for 18 hours prior to d/c. He should continue
diltiazem 60mg qid until PCP or medical director decides to
taper.
# Altered mental status: probably from hypercarbic/hypoxic
respiratory failure. Resolved in the hospital. He was somewhat
sleepy (although very oriented and appropriate). His providers
could consider tapering his sedating psychiatric medications in
the future.
#h/o sacral decubitus ulcer: Chronic, 6mo long issue. Denied
pain during admission although sensation questionable
considering quadraplegia. CT showed multiple decubital ulcers
extending to bony surfaces with ?subacute/chronic OM. wound
looks clean and pt has had recent MRI. PCP to decide [**Name9 (PRE) 80494**]
further work-up for osteomyelitis.
# C6 quad: Restarted spasticity meds, baclofen 10mg PO QID,
after patient was extubated.
# Renal failure: Resolved wtih IVF
# Psychiatric history: ?Paranoid Schizophrenia. After patient
was extubated, began to have paranoid ideation of "people
looking at him" Continued home doses of Risperdal, trazadone,
and Amitriptyline.
Ppx: Bowel Regimen
Access: RIJ, placed [**2178-11-23**] & removed [**11-27**] PICC line placed
on [**11-27**].
CODE: FULL CODE (confirmed with family on admission)
# Communication: With patient, brother [**Name (NI) **] [**Telephone/Fax (1) 80495**]
Medications on Admission:
taken from documents brought with patient
Docusate 100 mg [**Hospital1 **]
Gabapentin 100 mg TID
Baclofen 10 mg QID
Trazodone 25 mg PO QHS PRN
Lorazepam 0.5 mg TID PRN
Acetaminophen 1 gram Q6 hrs prn
Albuterol/Ipratropium nebs q4 hrs prn
Oxycodone 10 mg PO Q4
Risperdal 4 mg daily
Omeprazole 40 mg daily
Bisacodyl supp
MVI
Amitriptyline 100 mg at bedtime
Lactulose 30 mg PO BID
Senna one tab [**Hospital1 **]
Ascorbic acid 500 mg [**Hospital1 **]
Guiafenisin 10 mg Q6 prn
Proair 90 mcg inh
Discharge Medications:
1. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime). Tablet(s)
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
3. Baclofen 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Risperidone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2
times a day).
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for severe pain.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q4H (every 4
hours) as needed for shortness of breath or wheezing.
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO x1 () for 3
days: last day [**11-30**].
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
3 days: [**Date range (1) 45408**].
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
14. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
16. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
17. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every
6 hours) as needed for cough.
19. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): may consider decreasing dose if remains in sinus
rhythm.
20. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 9 days: last dose
[**12-6**].
21. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 9 days: last day = [**12-6**].
22. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day).
Discharge Disposition:
Extended Care
Facility:
Roscommon
Discharge Diagnosis:
pneumonia
COPD flare
atrial fibrillation with rapid ventricular response
respiratory arrest
quadriplegia
Discharge Condition:
good. AFVSS. On 2L n/c oxygen
Discharge Instructions:
You were admitted to the haspital with altered mental status.
You were found to have a COPD flaire and pneumonia. After a
short stay on the ventilator you improved and will need to
finish a 2 week course of antibiotics along with a taper of
steroids. As you know, you need to stop smoking. Also, in the
hospital you had a heart arrhythmia called atrial fibrillation.
This was probably because of your pneumonia and your nebulizer
treatments. We have started you on a medication called
diltiazem to help prevent this rhythm from happening again.
Your PCP will help decide when to stop this medication. please
Followup Instructions:
with your PCP [**Last Name (NamePattern4) **] [**2-4**] weeks
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"285.9",
"491.21",
"V02.54",
"038.9",
"518.81",
"518.0",
"707.03",
"995.91",
"344.00",
"486",
"441.4",
"295.30",
"560.39",
"707.20",
"799.02",
"511.9",
"590.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10936, 10972
|
5976, 7145
|
360, 416
|
11121, 11154
|
3781, 5953
|
11815, 11974
|
3284, 3288
|
8875, 10913
|
10993, 11100
|
8361, 8852
|
11178, 11792
|
3303, 3762
|
287, 322
|
444, 2683
|
7160, 8335
|
2706, 3048
|
3064, 3268
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,033
| 161,468
|
43043
|
Discharge summary
|
report
|
Admission Date: [**2187-4-5**] Discharge Date: [**2187-4-13**]
Date of Birth: [**2148-4-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Hypertensive emergency
Major Surgical or Invasive Procedure:
Right Femoral Triple Lumen Catheter
Right subclavian tunnelled hemodialysis catheter exchange
Hemodialysis
History of Present Illness:
Mr. [**Known lastname **] is a 38yo male with PMH significant for CAD with
recent STEMI in [**12-21**], DM1 with severe gastroparesis, and ESRD
on HD. He was recently hospitalized at [**Hospital1 18**] from [**Date range (1) 35342**] for
severe gastroparesis and hypertensive urgency. Of note, his
blood cultures grew coag negative staph and he was started on
Vancomycin. Surveillance blood cultures grew coag negative
staph. Per discharge summary, patient left AMA on [**4-2**].
.
Mr. [**Known lastname **] presented to the ED this morning with N/V, abdominal
pain, and high BPs. Initial vitals were T 96.5 BP 229/56 AR 97
RR 12 O2 sat 97% RA. He received Ativan 9mg IV, Dilaudid 8mg IV,
and labetolol 60mg IV. Given poor BP control he was started on a
labetolol gtt. Femoral line was placed and patient is being
transferred to the MICU for blood pressure management.
Past Medical History:
1)Type 1 DM complicated by gastroparesis
2)CAD s/p STEMI on [**2186-12-17**] in setting of cocaine use with bare
metal stent placement to the LAD
3)ESRD on HD since [**2-/2184**]
4)Line sepsis, coag negative staph, prior
klebsiella/enterobacteremia
5)Autonomic dysfunction wtih hypertensive emergency and
orthostatic hypotension
6)History of substance abuse (cocaine and marijuana)
7)History of esophageal erosion, [**Doctor First Name **]-[**Doctor Last Name **] tear
8)History of AV fistula clot
9)CVA?
Social History:
Patient has a prior history of tobacco and marijauna use, but he
does not currently smoke. He has a prior history of alcohol
abuse and has been sober for 9 years. He has a past history of
cocaine use. He currently denies illicit drugs.
Family History:
Father deceased of ESRD and DM. Mother aged 50's with
hypertension. 2 sisters, one with diabetes. 6 brother, one with
diabetes. There is no family history of premature coronary
artery disease or sudden death
Physical Exam:
vitals T 96.8 BP 187/123 AR 75 RR 30 O2 sat 99% on 2L
Gen: Patient sedated but arousable, appears acutely ill
HEENT: MMM
Heart: RR, II/VI systolic murmur best heard at LUSB, no
rubs/gallops
Lungs: CTAB, no wheezes, rhonchi, rales
Abdomen: soft, diffusely tender to palpation
Extremities: No LE edema, pulses difficult to palpate, well
perfused
Pertinent Results:
LABS:
[**2187-4-5**] 09:30AM BLOOD WBC-10.7# RBC-3.99* Hgb-9.8* Hct-32.4*
MCV-81* MCH-24.5* MCHC-30.2* RDW-19.3* Plt Ct-287
[**2187-4-12**] 01:45PM BLOOD WBC-6.8 RBC-3.87* Hgb-9.5* Hct-32.2*
MCV-83 MCH-24.5* MCHC-29.4* RDW-19.4* Plt Ct-255
[**2187-4-5**] 09:30AM BLOOD Neuts-79.5* Lymphs-11.2* Monos-4.4
Eos-4.7* Baso-0.3
[**2187-4-6**] 03:07AM BLOOD PT-13.1 PTT-28.6 INR(PT)-1.1
[**2187-4-5**] 09:30AM BLOOD Glucose-258* UreaN-55* Creat-9.6* Na-137
K-4.8 Cl-90* HCO3-29 AnGap-23*
[**2187-4-12**] 01:45PM BLOOD Glucose-246* UreaN-53* Creat-11.0*#
Na-135 K-4.3 Cl-91* HCO3-26 AnGap-22*
[**2187-4-12**] 01:45PM BLOOD ALT-10 AST-9 LD(LDH)-138 AlkPhos-69
TotBili-0.1
[**2187-4-5**] 09:30AM BLOOD CK(CPK)-239*
[**2187-4-6**] 03:07AM BLOOD CK(CPK)-166
[**2187-4-5**] 09:30AM BLOOD CK-MB-8
[**2187-4-5**] 09:30AM BLOOD cTropnT-0.33*
[**2187-4-6**] 03:07AM BLOOD CK-MB-5 cTropnT-0.34*
[**2187-4-5**] 09:30AM BLOOD Calcium-10.0 Phos-6.9*# Mg-2.2
[**2187-4-12**] 01:45PM BLOOD Albumin-3.9 Calcium-9.7 Phos-7.7* Mg-2.4
[**2187-4-12**] 01:45PM BLOOD Ammonia-8*
[**2187-4-5**] 09:30AM BLOOD Vanco-20.3*
[**2187-4-12**] 01:30PM BLOOD Vanco-17.1
[**2187-4-5**] 09:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2187-4-12**] 09:46AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
MICRO:
[**2187-4-6**] 3:53 pm CATHETER TIP-IV Source: HD catheter line.
**FINAL REPORT [**2187-4-9**]**
WOUND CULTURE (Final [**2187-4-9**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
COAG NEG STAPH does NOT require contact precautions,
regardless of resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
______________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
.
[**2187-4-6**] 6:51 pm CATHETER TIP-IV Source: right triple
lumen.
**FINAL REPORT [**2187-4-9**]**
WOUND CULTURE (Final [**2187-4-9**]):
Mixed bacterial types (>= 3 colony morphologies) isolated.
Abbreviated work-up performed Isolate(s) identified and
susceptibility testing performed because of concomitant
positive
blood culture(s) Comparison of the susceptibility patterns
may be
helpful to assess clinical significance.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
COAG NEG STAPH does NOT require contact precautions,
regardless of resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
______________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
.
Blood Cx ([**4-8**]): No growth x2
.
Blood Cx ([**4-10**]): NGTD
.
Blood Cx ([**4-12**]): NGTD
.
IMAGING:
ECG ([**4-5**]): Sinus rhythm at upper limits of normal rate, rate
94. RSR' pattern in lead V1 and QR complex in lead V2 with Q
waves across the precordium. Probable anteroseptal myocardial
infarction, age undetermined. Compared to the previous tracing
of [**2187-3-31**] the limb lead voltage is less and lateral precordial
voltage is increased, perhaps related to lead position.
.
TUNNELED HEMODIALYSIS CATHETER EXCHANGE ([**4-6**]):
PROCEDURE AND FINDINGS: After explaining the risks and benefits
of the procedure, an informed consent was obtained from the
patient. The patient was placed supine on the angiographic table
and the patient's right neck and right upper chest were prepped
and draped in standard sterile fashion. A preprocedure timeout
was performed.
After injection of local anesthesia at subcutaneous tunnel the
existing tunneled hemodialysis catheter was released from the
tunnel. A 0.035 Amplatz guidewire was advanced through each
lumens of the indwelling hemodialysis catheter into the IVC
under fluoroscopic guidance. The indwelling hemodialysis
catheter was removed and a new 15.5 French tunneled hemodialysis
catheter with 19 cm tip-to-cuff length was advanced over the
wire. However, it was not possible to advance the catheter
across the venotomy site. The Amplatz guidewires were exchanged
for two stiff glidewires, which were advanced into the IVC under
fluoroscopic guidance, one through each catheter lumen. However
the catheter could not be advanced into the SVC. A 16 French
peel- away sheath catheter was therefore advanced over the
guidewire into the SVC under fluoroscopic guidance and the inner
dilator and guidewire were then removed and the tunneled
hemodialysis catheter was advanced through the peel- away sheath
with its tip positioned at the right atrium.
The catheter was flushed, heplocked and a sterile dressing was
applied. The catheter was secured to the skin with 0 silk
sutures. The patient tolerated the procedure well and there were
no immediate complications.
IMPRESSION: Successful replacement of tunneled dialysis catheter
with a new 15.5 French tunneled hemodialysis catheter, 19 cm
tip-to-cuff in length via right internal jugular vein, its tip
is positioned at the right atrium. The catheter is ready to use.
.
TTE ([**4-6**]):
The left atrium is normal in size. There is severe symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. No masses or thrombi are seen in the left
ventricle. Overall left ventricular systolic function is low
normal (LVEF 50%) secondary to hypokinesis of the apical third
of the left ventricle with focal dyskinesis of the apex. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Impression: no definite vegetations seen
.
LUE U/S ([**4-11**]): Focused scanning in the left upper extremity in
the region of the patient's known AV graft demonstrates no focal
fluid collection or secondary signs of abscess. Color and pulsed
wave Doppler analysis of the graft demonstrates no evidence for
flow. Echogenic thrombus is seen throughout the graft on
grayscale son[**Name (NI) 1417**].
IMPRESSION:
1. Complete thrombosis of the left upper extremity AV graft.
2. No evidence of fluid collection/abscess in the surrounding
soft tissues.
Brief Hospital Course:
# Hypertensive urgency: The patient presented with a blood
pressure of 229/56 and EKG showing old ST elevations in V1-V4,
ST elevations more significantly in II, and decreased more
significantly in aVR. However, a repeat EKG was back to
baseline. Cardiology was consulted in the ED, and determined
that the EKG changes were most likely secondary to his
uncontrolled hypertension, as the patient did not complain of
chest pain. His serum tox was negative. He was initially placed
on a Labetolol gtt, and transferred to the MICU for blood
pressure management. He had a brief episode of hypotension after
hemodialysis, but his pressures then normalized. He was
transitioned back to PO blood pressure medications, which were
added back as his pressure tolerated. He was discharged on
Labetolol 300 PO bid and Lisinopril 20 mg daily (which can be
titrated back up to his home dose of 40 mg daily). We continued
to hold his home doses of Clonidine 0.1 PO bid and Clonidine 0.2
mg/24 hr qSat, but these can be added back as his blood pressure
tolerates.
.
# Gastroparesis: The patient's symptoms of nausea/vomiting and
abdominal pain are consistent with underlying gastroparesis. He
has presented with similar symptoms during his recent
admissions. He has been seen previously by Dr. [**Last Name (STitle) **] in GI
(most recently in [**5-20**]), who indicated that he has had multiple
past gastric emptying studies which have shown severe delay in
emptying. He has been on Reglan, Erythromycin, Zelnorm, and
Domperidone without significant improvement. He has found some
symptomatic improvement with dietary modifications such as
frequent small meals, liquid nutrients and avoiding [**Doctor First Name **] foods
and those containing high fiber. The patient's nausea/vomiting
and pain were controlled with Ativan, Dilaudid, and Zofran. He
was continued on Reglan 5 mg PO qidachs and Omeprazole 40 mg
daily, and encouraged to eat small, frequent meals. He was
scheduled an outpatient GI appointment to follow up with Dr.
[**Last Name (STitle) **] to address his gastroparesis and for consideration of G
tube and J tube.
.
# Coag negative Staph bacteremia: The patient has had
intermittent blood and catheter cultures positive for Coag
negative Staph since [**2186-11-30**]. Blood culture from [**2187-4-3**] showed
no growth, but his HD catheter and right triple lumen both grew
Staph coag negative. He had an exchange of his right IJ tunneled
dialysis catheter in IR on [**4-6**] due to persistent bacteremia. He
was continued on Vancomycin per HD protocol. Surveillance blood
cultures from [**4-8**], [**4-10**], and [**4-12**] showed no growth. In order to
work up the potential nidus of his bacteremia, he had a LUE
ultrasound to evaluate his old HD graft, which showed complete
thrombosis of the left upper extremity AV graft and no evidence
of fluid collection/abscess in the surrounding soft tissues. He
should be followed up by transplant surgery to determine if the
old graft should be removed prior to possible transplant. A TTE
on this admission showed no vegetations. ID was consulted and
recommended obtaining a [**Month/Year (2) **] to rule out abscess or vegetation.
However, since the patient has a reported history of esophageal
erosion and [**Doctor First Name **]-[**Doctor Last Name **] tear, Cardiology requested GI
clearance prior to the [**Doctor Last Name **]. The patient did not want to stay
over the weekend to wait for the EGD and [**Last Name (LF) **], [**First Name3 (LF) **] he left AMA
prior to these procedures.
****PLEASE REVIEW "VANCO SCHEDULE" ONLINE FOR HIS HISTORY OF
VANCO ADMINISTRATION****
.
# ESRD on HD: Renal followed the patient for HD while he was
hospitized. The patient's HD catheter grew Staph coag negative,
so it was changed over a wire in IR on [**4-6**]. His Vancomycin was
dosed per HD protocol. He was continued on Lanthanum 500 PO tid
with meals. He went to his outpatient renal transplant
appointment while hospitalized. He is a high risk transplant
candidate given his gastroparesis, but they do recommend
proceeding with transplantation given his previous difficulties
with HD access. He will need a toxicology screen and cardiology
clearance prior to the operation. His status will be changed
from TU to active. Cardiology was consulted, but will not
comment on clearance until his gastroparesis and hypertension
are under better control. Once these issues are ressolved,
Cardiology will re-evaluate him for clearance as an outpatient.
.
# CAD: The patient is s/p STEMI in [**12-21**] in the setting of
cocaine use. He underwent PCI with bare metal stent placement to
the LAD. ECG in ED was concerning for persistent ST elevations.
Cardiology was consulted and felt that the ECG was not
concerning for a new cardiac event. CEs 0.33->0.34, CK 239->166,
CK-MB 8->5. TTE showed severe symmetric LVH, LVEF 50% secondary
to hypokinesis of the apical third of the left ventricle with
focal dyskinesis of the apex, and no definite vegetations seen.
He was continued on ASA 325 mg daily, [**Date Range **] 75 mg daily, and
Atorvastatin 80 mg daily. He was continued on Labetalol 300 mg
[**Hospital1 **] and Lisinopril 20 daily (to titrate back up to home dose of
40 daily). He missed an outpatient cardiology appointment while
hospitalized, so this was rescheduled. The renal transplant
outpatient team had asked Cardiology to give clearance prior to
transplant, however Cardiology will not comment on clearance
until his gastroparesis and hypertension are under better
control. Once these issues are ressolved, Cardiology will
re-evaluate him for clearance as an outpatient. Cardiology did
say that the patient likely needs 1 month of [**Hospital1 **] s/p STEMI,
so can consider discontinuing [**Hospital1 **].
.
# Type 1 DM: Continued Glargine 5 U qhs and RISS.
.
# Mental status changes: The patient triggered for somnolence on
[**4-11**]. His mental status cleared, and he was alert and oriented
x3. His AMS was thought to be secondary to the Ativan/Dilaudid
that he has been getting for his gastroparesis. Urine tox was
negative except for opiates (which he is receiving in house),
ammonia 8. The next day, the patient was found to be sniffing
the stethoscope wipes, and had a bottle of cleaning solution by
his bed.
.
# Prophylaxis: MRSA precautions (sputum positive for MRSA in
[**2-18**])
Medications on Admission:
Aspirin 325mg PO daily
Clopidogrel 75mg PO daily
Atorvastatin 80mg PO daily
Lanthanum 500mg PO TID W/MEALS
Omeprazole 40mg PO daily
Clonidine 0.1mg PO BID
Clonidine 0.2 mg/24hr QSAT
Lisinopril 40mg PO daily
Hydromorphone 2mg 1-2 Tablets PO Q6H PRN
Glargine 5 units QHS
Labetalol 300mg PO BID
Reglan 5mg PO QIDACHS.
Gabapentin 200mg PO QSun, Mon, Wed, Fri
Gabapentin 100mg PO QTues, Thurs, Sat
Ativan 1mg PO Q4H
Vancomycin 1gm at HD
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. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
4. Vancomycin 1000 mg IV HD PROTOCOL
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain (do not give for nausea/vomiting).
10. Insulin Glargine 100 unit/mL Solution Sig: Five (5) U
Subcutaneous at bedtime.
11. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
12. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO 4X/WEEK
([**Doctor First Name **],MO,WE,FR).
13. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO 3X/WEEK
(TU,TH,SA).
14. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Hypertensive Urgency
Coagulase negative Staph Bacteremia
End-stage Renal Disease on HD
Diabetes mellitus Type 1
Gastroparesis
.
SECONDARY:
CAD s/p STEMI
Discharge Condition:
Left AMA
Discharge Instructions:
The patient left AMA. He was given a printed list of his current
medication regimen, and instructed to return to the ED if he had
any symptoms that concerned him
Followup Instructions:
You missed a Cardiology appointment while you were hospitalized.
This appointment with Dr. [**Last Name (STitle) **] is rescheduled for [**2187-5-14**]
at 3:20p in the [**Hospital Ward Name **] CENTER, [**Location (un) **] CC7 CARDIOLOGY.
.
You have an appointment with Dr. [**Last Name (STitle) **] in Gastroenterology
([**Telephone/Fax (1) 463**]) on [**2187-5-15**] at 8:30 am in the [**Hospital Unit Name 1825**] [**Location (un) 859**]. At that appointment you should discuss if you should have
a G tube placed.
.
You have a follow up appointment with Dr. [**Known lastname **] in Transplant
on [**2187-5-25**] at 1:40p in the [**Hospital Unit Name **], [**Location (un) **] TRANSPLANT
CENTER.
.
You have a follow up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
your primary care physician) on [**2187-5-30**] at 4:00 in the [**Location (un) **]
of the [**Hospital Ward Name 23**] Building ([**Telephone/Fax (1) 250**]).
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64,514
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40434
|
Discharge summary
|
report
|
Admission Date: [**2163-5-5**] Discharge Date: [**2163-5-17**]
Date of Birth: [**2131-9-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
Upper endoscopy
TIPS procedure
Central Venous Line Placement
Endotracheal intubation
History of Present Illness:
Mr. [**Known lastname **] is a 31 yo man with alcohol abuse and new diagnosis
of cirrhosis who was transferred from the [**Location (un) **] ICU for
management of upper GI bleed. The patient was in his USOH until
10pm last night when he had >30 bouts of bright red hematemesis
about 15 minutes apart with an estimated total amount of 2 L. He
also had a large, black, tarry bowel movement. He called his PCP
who referred him to the [**Location (un) **] ED.
.
Presenting vs were: T 98.7, P 148, BP 108/55, RR 20, O2sat 100%
RA. Labs showed Hct 14.9, Plts 126, INR 2.7. He was admitted to
the ICU and then taken shortly thereafter to the endoscopy
suite. He was found to have an actively bleeding lesion, thought
to be a Dieulafoy's lesion and less likely a gastric varix. GI
was able to place a clip but felt it was tenuous. They also
noted an esophageal mass and a question of grade I esophageal
varices. They recommended transfer to [**Hospital1 18**] via [**Location (un) **] for
higher level of care. The patient was transfused a total of 5
units pRBC and 4 units FFP at [**Location (un) **] and was given 3.5 L of IVF
and a banana bag. He also was given octreotide, zofran, and
ativan 1mg. Repeat labs prior to transfer showed Hct of 17. He
reportedly has not been hypotensive. At the time of sign-out, he
was still recovering from conscious sedation in the endoscopy
suite with the following VS: BP 91/30, P 111, O2sat 100% RA. Per
[**Location (un) **], his BPs remained stable en route but he was
tachycardic to the 120s throughout.
.
On arrival, pt had another melanic bowel movement. He reports
feeling mildly nauseated and during his exam, had two small
bouts of bilious emesis with a few dark clots. He denies any
abdominal pain, chest pain, lightheadedness.
.
He reports having felt nauseated several times in the past week
but had never had any previous episodes of hematemesis, melana,
or hematochezia. He denies pruritis but has noticed jaundice of
his eyes and skin for several weeks as well as yellow stools and
occasionally dark urine. He has also noted increased abdominal
girth for months. He denies any NSAID or tylenol use. He reports
drinking alcohol socially since he was a teenager, then more
heavily since age 22, with regular intake of [**12-26**] pints of vodka
daily in the past 1-2 years. He admits to prior cocaine and
heroine use; denies IVDU. He has multiple tattoos done by a
friend but reports testing negative for HIV and hepatitis after
his most recent one. His birth mother also has a history of
alcohol abuse but there is no known family history of liver
disease.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies dysphagia, early satiety, or bloated sensation.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes.
Past Medical History:
Alcohol abuse, likely cirrhosis
H/o general tonic-clonic seizure thought to be alcohol-provoked
H/o minor concussion in [**2146**]
Lone v. paroxysmal atrial fibrillation, attributed to stress
S/p appendectomy
S/p cholecystectomy in [**2156**]
Right club foot s/p surgery
Congenital presbyopia
Social History:
Works as a deli manager. Lives with his [**Last Name (LF) 18933**], [**First Name3 (LF) **].
- Tobacco: Smoking 1/2-1 ppd for at least 15 years.
- Alcohol: As above, drinks [**12-26**] pints of vodka daily.
- Illicits: Previous cocaine and heroin abuse but denies IVDU;
reports being clean for 6 years.
Family History:
Adopted. As above, birth mother with likely alcohol abuse but no
liver disease. Birth father died of diabetes. Biological brother
and sister without known medical illnesses. No history of CAD or
cancers.
Physical Exam:
On Admission:
Vitals: T 98.9, BP 138/74, P 90, RR 23, O2sat 94% 2L NC
General: Alert, oriented, appears uncomfortable but in no acute
distress
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular but tachycardic, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, hepatomegaly and splenomegaly
present, fluid wave with shifting dullness present
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAO x 3, mild tremor
Skin: Mildly jaundiced with scattered spider angioma across
chest. Multiple tattoos.
On Discharge:
***
Pertinent Results:
Admission labs:
[**2163-5-5**] 05:09PM BLOOD WBC-11.1* RBC-2.65* Hgb-7.9* Hct-23.2*
MCV-88 MCH-29.9 MCHC-34.0 RDW-20.0* Plt Ct-88*
[**2163-5-5**] 05:09PM BLOOD PT-18.8* PTT-43.2* INR(PT)-1.7*
[**2163-5-5**] 05:09PM BLOOD Fibrino-133*
[**2163-5-5**] 05:09PM BLOOD Glucose-234* UreaN-13 Creat-0.8 Na-138
K-4.0 Cl-106 HCO3-23 AnGap-13
[**2163-5-5**] 05:09PM BLOOD ALT-34 AST-131* AlkPhos-99 Amylase-22
TotBili-8.0*
[**2163-5-5**] 05:09PM BLOOD Albumin-3.0* Calcium-6.8* Phos-3.1 Mg-1.6
Iron-182*
.
Discharge Labs:
[**2163-5-17**] 04:40AM BLOOD WBC-16.8* RBC-3.05* Hgb-10.0* Hct-30.0*
MCV-98 MCH-32.9* MCHC-33.4 RDW-22.0* Plt Ct-174
[**2163-5-17**] 04:40AM BLOOD PT-21.5* PTT-45.8* INR(PT)-2.0*
[**2163-5-17**] 04:40AM BLOOD Glucose-153* UreaN-8 Creat-0.7 Na-135
K-3.8 Cl-101 HCO3-24 AnGap-14
[**2163-5-15**] 05:45AM BLOOD ALT-54* AST-166* AlkPhos-95 TotBili-9.1*
[**2163-5-17**] 04:40AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.6
[**2163-5-15**] 05:45AM BLOOD VitB12-1484*
[**2163-5-5**] 05:09PM BLOOD calTIBC-200* Ferritn-50 TRF-154*
[**2163-5-5**] 05:09PM BLOOD TSH-0.59
[**2163-5-5**] 05:09PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2163-5-5**] 05:09PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2163-5-5**] 05:09PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2163-5-5**] 07:55PM BLOOD HIV Ab-NEGATIVE
.
Peritoneal Fluid:
[**2163-5-8**] 02:20PM ASCITES WBC-833* HCT,fl-9* Polys-89* Lymphs-8*
Monos-3*
[**2163-5-8**] 02:20PM ASCITES TotPro-2.0 Glucose-109 LD(LDH)-235
Albumin-LESS THAN
[**2163-5-13**] 01:46PM ASCITES WBC-1500* RBC-[**Numeric Identifier 88615**]* Polys-1*
Lymphs-15* Monos-1* Mesothe-13* Macroph-70*
[**2163-5-13**] 01:46PM ASCITES TotPro-2.5 Glucose-121 LD(LDH)-418
TotBili-7.0
.
[**5-5**] Chest X-Ray:
AP chest reviewed in the absence of prior chest radiographs:
Tip of the endotracheal tube is just above the level of the
sternal notch, no less than 5.5 cm above the carina. With the
chin elevated this is standard placement. Lung volumes are low
exaggerating mild interstitial abnormality and vascular
congestion as well as heart size which is probably top normal.
No pneumonia, pneumothorax or appreciable pleural effusion.
.
Abdominal Ultrasound:
The findings are consistent with cirrhosis, splenomegaly,
ascites and portal hypertension. Portal venous system is patent
but flow is hepatofugal throughout the portal and splenic veins.
ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
.
CT Head:
No acute intracranial abnormality.
.
Microbiology:
Urine Culture: No growth
Blood culture: No growth
Peritoneal Culture: No growth
C.Diff: Negative
Brief Hospital Course:
The patient is a 31 year-old male with history of ETOH abuse who
presents with massive hematemesis and melena (thought to be
secondary to a bleeding gastric varix, banded at OSH) and
alcoholic hepatitis; his course was complicated by respiratory
failure, alcohol withdrawal, and encephalopathy.
.
# Upper GI bleed: Prior to transfer to [**Hospital1 18**], the patient had an
EGD at OSH, which revealed an actively bleeding Dieulafoy's
lesion versus gastric varix, which was clipped. Upon arrival to
[**Hospital1 18**], EGD revealed non-bleeding gastric varices with no
esophageal varices. Patient presented with an HCT of 23.2, and
required a total of 10 units of PRBC while in the ICU to
maintain HCT. He was started on protonix and octreotide gtts.
Following EGD, his protonix was changed to 40 mg IV BID and
octreotide was continued for three days. Patient was
administered prophylactic dose of 1g ceftriaxone daily for five
days.
.
The day following the EGD, the patient underwent TIPS procedure
by interventional radiology. This proceeded without
complication, and follow-up ultrasound showing patent vessels.
His HCT remained stable following TIPS procedure ranging between
25 - 27. During his hospital course, he had no further episodes
of GI bleeding. He was discharged home with PO PPI.
.
# Alcoholic Hepatitis/Cirrhosis: The patient presented without a
previous diagnosis, however his elevated INR, bilirubin,
ascites, and spider angioma were consistent with cirrhosis
complicated by portal hypertension. Ultrasound confirmed
findings consistent with cirrhosis, splenomegaly, ascites, and
portal hypertension. The etiology of his liver disease was
believed to be EtOH given the clear history, however given the
patient's young age, he was ruled out for viral etiologies and
autoimmune hepatits. The patient's acute clinical picture and
laboratory findings was consistent with alcoholic hepatitis.
Discriminant Function was approximately 40. This was believed to
be the cause of his persistent leukocytosis and low-grade fevers
throughout hospital course. At the time of discharge, his
bilirubin was 9.1.
He underwent TIPS procedure sucessfully, pressures improved from
16 to 12. He was started on lasix and aldactone following his
ICU course. He was discharged with lasix 40 mg and
spironolactone 100 mg, to be further titrated with outpatient
follow-up. He was also prescribed rifaximin to be taken as an
outpatient.
.
# Altered mental status/encephalopathy: Believed to be
multifactorial; contributions included hepatic encephalopathy,
delirium (ICU) and EtOH withdrawal. Patient's hepatic
encephalopathy was treated with lactulose and rifaxamin. He was
frequently reoriented and had tethering minimized. For evidence
of alcohol withdrawal, he was administered ativan as necessary.
Patient remained A&Ox1 when discharged from ICU, though improved
to A+Ox3 over subsequent days with above interventions. As the
patient's acute encephalopathy improved, he was observed to
display underlying cognitive impairment, characterized by
extensive confabulation despite good attention and orientation.
There was suspicion of underlying Wernicke's
encephalopathy/Korsakoff's due to patient's long-term alcohol
intake. Psychiatry evalauted the patient, but did not find
evidence of Wernicke's/Korsakoff towards the end of his hospital
course. He was discharged with MVI/thiamine/folate
supplementation. He will follow-up with outpatient Neurology.
.
# Seizure: Believed to represent withdrawal seizure, as
patient's family provided history of prior seizures in setting
of alcohol use. Seizure occurred approximately 9-10 days
following last alcoholic drink. No clear medications or
electrolyte abnormalitites were implicated as cause. He was
placed in restraints temporarily, though these were removed the
following morning. He was continued on low-dose Ativan for
alcohol withdrawal with no further seizures. He will follow-up
with outpatient Neurology.
# Hypoxic Respiratory Failure: On hospital day 4 of admission,
patient became acutely hypoxic and a respiratory code was
called. There was concern for aspiration event in the setting
of benzodiazepine use. Patient was intubated. Patient
sucessfully extubated the next day when his condition improved.
He completed a seven day course of vancomycin/zosyn as below.
.
# Fever/Leukocytosis: Patient spiked fever to 100.4 on [**5-8**] with
cough and increased abdominal distension; aspiration PNA and SBP
were both on differential. Patient underwent paracentesis, which
was was grossly bloody and showed Hgb of 9 with elevated WBC and
polys. Patient was started on vancomycin and zosyn for HCAP and
SBP coverage (though he did not strictly meet criteria for SBP
when ascites sample corrected for HCT) and recived 75 g of
albumin on days one and three of treatment. After seven days of
treatment, antibiotics were discontinued. Subsequent fevers were
attributed to ongoing alcoholic hepatitis. All urine, blood, and
peritoneal cultures showed no growth.
.
# Disposition: Goal of disposition was inpatient alcohol
treatment facility. This was unable to be coordinated given
patient's insurance status. He was discharged home under his
parents' supervision, and will initiate an intensive outpatient
alcohol treatment program at the beginning of [**Month (only) **].
Medications on Admission:
None
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for anxiety.
Disp:*15 Tablet(s)* Refills:*0*
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Alcoholic Hepatitis
- Gastric varix status-post clip
- Respiratory Failure secondary to aspiration
- Withdrawal seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital after vomiting
blood, and spent time in the intensive care unit. During your
stay in the ICU, your blood counts remained stable. You were on
a breathing machine for a period of time, and then this was
removed after your condition improved. All of the medical
problems that were treated during your hospital stay were
related to alcohol use. The alcohol has caused extensive damage
to your liver. Consumption of alcohol after leaving the hospital
could lead to even more severe consequences, including death.
You will be discharged home to live under your parents'
supervision until your intensive alcohol program begins at the
beginning of [**Month (only) **].
.
Please START the following medications after leaving the
hospital.
LASIX
SPIRONOLACTONE
PROTONIX
RIFAXIMIN
THIAMINE
FOLIC ACID
ATIVAN (LORAZEPAM)
.
Should you experience any symptoms that concern you after
leaving the hospital, please call your liver doctor or return to
the emergency room.
Followup Instructions:
Please follow-up at these times/places:
.
Department: LIVER CENTER
When: THURSDAY [**2163-5-26**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
NOTE: Currently you have no insurance listed with us. If you
are unable to pay out of pocket for this appt, please look into
Masshealth for insurance options.
.
Department: NEUROLOGY
When: MONDAY [**2163-5-30**] at 1 PM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 3294**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
NOTE: Currently you have no insurance listed with us. If you
are unable to pay out of pocket for this appt, please look into
Masshealth for insurance options.
|
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icd9cm
|
[
[
[]
]
] |
[
"88.64",
"38.93",
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icd9pcs
|
[
[
[]
]
] |
14565, 14571
|
8320, 13645
|
319, 405
|
14756, 14756
|
5110, 5110
|
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|
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|
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|
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|
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|
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|
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|
3781, 4089
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,175
| 119,795
|
25345
|
Discharge summary
|
report
|
Admission Date: [**2197-6-15**] Discharge Date: [**2197-6-21**]
Date of Birth: [**2143-8-10**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
??deep wound infection around the hardware
Major Surgical or Invasive Procedure:
[**2197-6-15**]
1. Exploration of neck wound.
2. Removal of previous cranioplasty hardware.
3. Evacuation of epidural abscess with debridement and
extensive incision and drainage.
History of Present Illness:
The patient is a 53-year-old male who is well
known to Dr [**Last Name (STitle) **] from previous surgeries including resection
of posterior cranial fossa tumor two years ago. He was recently
seen in
his office as an outpatient. He had approximately 8 weeks ago
presented with an abscess of his skin at the level of his
neck wound from his brain surgery approximately 2 years ago.
The patient at that time had a neck exploration, washout, and
primary closure. The patient was placed on IV antibiotics.
After the antibiotic course had been finished and re-imaging
showed stable contrast enhancing signal changes in the
posterior fascia, we followed the patient with serial labs
showing a rebound elevation of CRP and ESR. Since Dr [**Last Name (STitle) **] was
concerned of a deep wound infection around the hardware, we
decided to bring the patient back for elective surgery for
exploration as well as a shunt tap.
Past Medical History:
Spina bifada occulta
Seasonal allergies
Cerebellar Ependymoma S/P Cerebellar and posterior resection
S/P PEG, S/P VP shunt, trach removed at [**Hospital1 **]
Social History:
Married with children
Works as a Service Technician for a mechanical firm
30 pack year history of tobacco abuse
No alcohol use
Family History:
Father deceased of Lymphoma in 50's
Mother healthy with "heart valve replacement"
Physical Exam:
His overall neurological condition remains stable. He has no
new
neurological deficit. The wound is clean, dry, and intact. He
has no erythema.
Pertinent Results:
[**2197-6-15**] 11:41AM TYPE-ART TEMP-35.6 RATES-14/ TIDAL VOL-560
PEEP-5 O2-50 PO2-188* PCO2-44 PH-7.42 TOTAL CO2-30 BASE XS-4
INTUBATED-INTUBATED VENT-CONTROLLED
[**2197-6-15**] 11:27AM GLUCOSE-100 UREA N-14 CREAT-0.8 SODIUM-143
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-28 ANION GAP-12
[**2197-6-15**] 11:27AM estGFR-Using this
[**2197-6-15**] 11:27AM CALCIUM-8.2* PHOSPHATE-3.1 MAGNESIUM-2.0
[**2197-6-15**] 11:27AM WBC-7.9 RBC-4.01* HGB-11.5* HCT-34.3* MCV-86
MCH-28.5 MCHC-33.4 RDW-14.2
[**2197-6-15**] 11:27AM PLT COUNT-291
[**2197-6-15**] 11:27AM PT-13.3* PTT-27.7 INR(PT)-1.2*
[**2197-6-15**] 10:21AM TYPE-ART O2-100 PO2-411* PCO2-43 PH-7.44
TOTAL CO2-30 BASE XS-5 AADO2-281 REQ O2-52 INTUBATED-INTUBATED
[**2197-6-15**] 10:21AM GLUCOSE-105 LACTATE-2.5* NA+-139 K+-3.9
CL--106
[**2197-6-15**] 10:21AM HGB-12.8* calcHCT-38 O2 SAT-99
[**2197-6-15**] 10:21AM freeCa-1.11*
[**2197-6-15**] 09:11AM TYPE-ART O2-100 PO2-387* PCO2-37 PH-7.46*
TOTAL CO2-27 BASE XS-3 AADO2-311 REQ O2-56 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2197-6-15**] 09:11AM GLUCOSE-105 LACTATE-2.5* NA+-139 K+-3.9
CL--107
[**2197-6-15**] 09:11AM HGB-13.0* calcHCT-39 O2 SAT-99
[**2197-6-15**] 09:11AM freeCa-1.12
[**2197-6-15**] 08:25AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0
LYMPHS-65 MONOS-35
MICRO
[**6-15**] SUPERFICIAL CX . **FINAL REPORT [**2197-6-15**]**
GRAM STAIN (Final [**2197-6-15**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
Brief Hospital Course:
Pt was admitted to the neurosurgery service and brought to the
OR where under general anesthesia he underwent exploration of
neck wound with removal of previous cranioplasty hardware and
evacuation of epidural abscess with debridement and extensive
incision and drainage. He tolerated this procedure well and was
transferred to ICU for close monitoring. Drain placed intra op
was dc'd on POD#1. He was transferred to the floor. His
incision was clean and dry with sutures intact. He was followed
by ID who made recommendations for antibiotics based on
cultures. A PICC line was placed. Pt was doing well on the
floor and ready for discharge home on [**6-21**]. Home services were
put in place for antibiotics, lab draws and appropriate follow
up was made with infectious disease.
Discharge Medications:
1. Vancomycin 500 mg Recon Soln [**Month/Year (2) **]: Three (3) Intravenous
twice a day for 5 weeks: continue through [**2197-7-24**].
Disp:*210 vial* Refills:*0*
2. PICC line
Care per NEHT protocol
3. Ciprofloxacin 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO twice a
day for 5 weeks: continue through [**2197-7-24**].
Disp:*70 Tablet(s)* Refills:*0*
4. Outpatient Lab Work
needs vancomycin trough level drawn prior to afternoon dose on
[**6-22**].
Fax results to [**Telephone/Fax (1) 432**] - Dr. [**First Name (STitle) **]
5. Oxycodone-Acetaminophen 5-325 mg Tablet [**First Name (STitle) **]: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule [**First Name (STitle) **]: One (1) Capsule PO BID (2
times a day): take while using narcotics.
Disp:*60 Capsule(s)* Refills:*0*
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0*
8. Outpatient Lab Work
Please have following labs done weekly:
CBC w/ diff,ESR,CRP,BUN,creatine,LFTs, vancomycin trough
Fax results to Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 432**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Epidural Abscess
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 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.
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:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 1 WEEK for suture removal.
Follow up with ID - Dr. [**First Name (STitle) **] [**2197-7-24**] at 9am basement of [**Hospital Unit Name **].
You also need to have labs weekly and fax to [**Telephone/Fax (1) 432**] - CBC
w/ diff,ESR,CRP,BUN,creatine,LFTs.
Completed by:[**2197-6-27**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"01.24",
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icd9pcs
|
[
[
[]
]
] |
5819, 5888
|
3722, 4509
|
362, 552
|
5949, 5973
|
2105, 3699
|
7094, 7491
|
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|
4532, 5796
|
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|
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|
1938, 2086
|
280, 324
|
580, 1497
|
1519, 1678
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,322
| 163,177
|
6351+6352
|
Discharge summary
|
report+report
|
Admission Date: [**2103-6-30**] Discharge Date: [**2103-7-4**]
Date of Birth: [**2055-11-14**] Sex: F
Service:
ADDENDUM: This discharge summary addendum is the colonoscopy
results.
The patient underwent a colonoscopy on the date of discharge
where a single sessile 7 mm bleeding polyp of benign
appearance was found in the rectum. A single
polypectomy was performed. The polyp was completely
retrieved. After a polypectomy, active bleeding was noted.
This was controlled with 4 cc of 1:10,000 dilution
epinephrine and BICAP. The patient was recommended to
follow-up with the referring physician as needed. Follow-up
postbiopsy results. If the patient rebleeds, consider
clipping with reinjection of epi or surgical oversew. The
patient tolerated the procedure well and was hemodynamically
stable for the rest of her hospital course.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Name8 (MD) 6867**]
MEDQUIST36
D: [**2103-7-4**] 01:34
T: [**2103-7-4**] 13:44
JOB#: [**Job Number 24568**]
Admission Date: [**2103-6-30**] Discharge Date: [**2103-7-4**]
Date of Birth: [**2055-11-14**] Sex: F
Service: MICU
CHIEF COMPLAINT: Rectal bleeding.
HISTORY OF PRESENT ILLNESS: The patient is a 47 year-old
female with chronic obstructive pulmonary disease, asthma,
chronic constipation who was discharged to [**Hospital **] Rehab on
[**2103-6-26**] from [**Hospital1 69**]. Last
hospital course at [**Hospital1 69**]
notable for back surgery that was complicated by a
gastrointestinal bleeding and a chronic obstructive pulmonary
disease flare that required intubation. Further workup of
her gastrointestinal bleeding was deferred until resolution
of her chronic obstructive pulmonary disease flare. The
patient reports no bowel movements for the past five days
prior to admission. On the night prior to admission she took
Milk of Magnesia. On the morning of admission she had a bed
pan and had watery red stool. She felt very tired and
fatigued since then and was slightly dizzy. The patient
denies fevers or chills, only chronic pain at the site of her
back surgery. On arriving to [**Hospital1 188**] her blood pressure was 140/80. Pulse 126. O2 sat 98%
on 2 liters. Frank blood clots were seen in the perirectal
area on admission. No bowel movements since admission.
Hematocrit upon admission was 33.8, subsequently went down to
28.4 at which point she was transfused 2 units of packed red
blood cells. The patient had no complaints of chest pain or
shortness of breath. At baseline she has a bowel movement
every three to four days with a fair amount of straining
required. She had a lower gastrointestinal bleed on [**6-13**]
in house after a TA vertebrectomy and T7-9 stabilization
after a fall injury. At that time she had a hematocrit drop
from 34 to 24, transfused 4 units of packed red blood cells
and 4 units of fresh frozen platelets. Afterwards she was
hemodynamically stable. Given the patient's recent surgery
and that the bleeding had stopped a colonoscopy was planned
as an outpatient.
PAST MEDICAL HISTORY:
1. Schizoaffective disorder.
2. Chronic obstructive pulmonary disease 100 pack year
history of smoking.
3. Asthma.
4. Hypercholesterolemia.
5. Hypothyroidism.
MEDICATIONS ON ADMISSION:
1. Percocets two tabs po q.i.d.
2. Lasix 20 mg po q.d.
3. Cardizem 60 mg po b.i.d.
4. Colace 100 mg b.i.d.
5. Nicotine patch 21 micrograms q.d. transdermally.
6. K-Dur 20 milliequivalents po q.d.
7. Clonazepam 250 mg po q.h.s.
8. Cliropamine 150 mg po q.d.
9. Thiothixene 20 mg po q.a.m., 10 mg po q.p.m.
10. Doxepin 50 mg po q.d.
11. Combivent three puffs inhaled q.i.d.
12. Fluticasone four puffs inhaled q.i.d.
13. Heparin 5000 units subQ b.i.d.
14. Prevacid 30 mg po q.d.
15. Multivitamin one tab po q.d.
16. Ativan 0.5 mg po t.i.d.
SOCIAL HISTORY: Lives alone with her sister in area. Smokes
two to three packs a day. Currently not drinking alcohol.
Questionable history of prior alcohol abuse.
PHYSICAL EXAMINATION: Temperature on admission 96.4. Blood
pressure 118/60. Pulse 90. Respiratory rate 13 after 2
units of packed red blood cells. The patient initially upon
arrival to the Emergency Department temperature 96.4. Blood
pressure 81/52. Respiratory rate 24. O2 sat 97% on room
air. General obese, pleasant, tired appearing young woman in
no acute distress lying comfortably in bed. HEENT pupils are
equal, round and reactive to light. Oropharynx is slightly
dry. Chest crackles at the left base, otherwise clear to
auscultation bilaterally. Cardiovascular tachycardic, normal
S1 and S2. No murmurs. Abdomen obese, soft, nontender,
nondistended. Positive bowel sounds. Rectal area small
clots seen in the perirectal area. No hemorrhoids seen. No
fresh blood seen. Internal rectal examination was not
performed. Extremities no edema.
LABORATORIES ON ADMISSION: White blood cell count 18.4,
hematocrit 31.1, platelets 226, neutrophils 24, bands 1,
lymphocytes 14, monocytes 3, eosinophils 2, PT/PTT was
12.8/21.1, INR 1.1. Urinalysis specific gravity was 1.025,
moderate blood, trace protein, trace ketone, trace leukocyte
esterase, 6 to 10 red blood cells, 6 to 10 white blood cells,
few bacteria, moderate yeast. Chem 7 was sodium 140,
potassium 4.0, chloride 101, bicarb 28, BUN 23, creatinine
7.9, glucose 104, calcium 8.8, phos 2.7, magnesium 1.8. TSH
was 3.1.
INITIAL ASSESSMENT: The patient is a 47 year-old female with
gastrointestinal bleeding three weeks ago now presenting with
five days of constipation, bright red blood per rectum on
admission. The patient with a prior history of chronic
obstructive pulmonary disease and recent back surgery.
HOSPITAL COURSE: 1. Gastrointestinal bleeding: The patient
remained hemodynamically stable at all times throughout the
hospital course without any further episodes of hypotension
or tachycardia. The patient did have an episode of about 500
cc of bright red blood per rectum on the day after admission
with a hematocrit drop of approximately 6 points. She
received 2 units of packed red blood cells to bring her
hematocrit from 26 up to 33. Thereafter her hematocrit
slowly rose on its own without requiring any further packed
red blood cell transfusions. The plan was for colonoscopy
with a 500 cc of bright red blood per rectum she did have a
bleeding scan, which was negative. The patient was then
vigorously prepped for a colonoscopy with attempts to clear
her stool requiring 4 gallons of GoLYTELY and 4 Dulcolax. An
attempted colonoscopy after the bright red blood per rectum
was aborted after 75 cm of insertion due to a poor prep and
black out from blood. The patient was prepped for two more
days until clearing of stool until a good colonoscopy could
be performed. Results of the colonoscopy will be dictated as
a discharge summary addendum.
2. Chronic obstructive pulmonary disease: The patient was
oxygenated and ventilated adequately. The patient was
continued on inhaler therapy and was sating 100% on room air
at all times throughout admission with no desaturations. The
patient had her Flovent decreased to two puffs inhaled b.i.d.
and her Combivent increased to four puffs inhaled q 6 hours
and was stable on this regimen.
3. Schizoaffective disorder: The patient was continued on
her outpatient antipsychotic regimen with no further
problems.
4. Recent back surgery: Neurosurgery service was contact[**Name (NI) **]
as to the safety of performing a colonoscopy prep and
colonoscopy procedure since she had recent back surgery.
They informed us that it would be safe as long as she was
lying either flat in bed at all times or wearing her back
brace while not in bed. These precautions were maintained.
The patient had significant back pain, which was treated with
Oxycodone and Percocet and a one time dose of Toradol.
Overall the patient was watched carefully in the MICU after
the episode of hypotension. She had one episode of bleeding,
which required packed red blood cells, however, no further
episode of bleeding and stable hematocrit by the time of
discharge. Colonoscopy results will be dictated as a
discharge summary addendum.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleeding.
2. Chronic obstructive pulmonary disease.
3. Schizoaffective disorder.
DISCHARGE MEDICATIONS:q
1. Doxepin 50 mg po q.d.
2. Thiothixene 20 mg po q.d.
3. Cliropamine 150 mg po q..d
4. Klonopin .25 mg po h.s.
5. Protonix 40 mg po q.d.
6. Prednisone 20 mg po q.d. on [**7-5**] and [**2110-7-6**] mg po
q.d. on [**7-7**] and 15 and then stop.
7. Combivent four puffs inhaled q 6 hours.
8. Flovent two puffs inhaled b.i.d.
9. Nicotine 21 microgram patch transdermally q.d.
10. Ativan 1 mg po t.i.d.
11. Percocet two tabs po q.o.d. prn.
DISCHARGE LABORATORIES: Hematocrit 32.3. Sodium 140,
potassium 3.4, chloride 100, bicarb 27, BUN 8, creatinine .8,
glucose 71. The patient was given 50 mg of potassium po
prior to discharge. Calcium 8.7, phos 3.9, magnesium 1.5.
The patient was given 800 mg of magnesium oxide prior to
discharge.
DISCHARGE STATUS: To [**Hospital6 310**] to
complete her rehabilitation program. The patient is to
follow up as an outpatient with her primary care physician.
DISCHARGE CONDITION: Good.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Name8 (MD) 6867**]
MEDQUIST36
D: [**2103-7-4**] 11:53
T: [**2103-7-4**] 12:07
JOB#: [**Job Number 24569**]
|
[
"496",
"211.4",
"295.70",
"578.1",
"564.00",
"724.5",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"48.36",
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
9350, 9602
|
8288, 8393
|
8415, 9328
|
3368, 3922
|
5804, 8267
|
4112, 4969
|
1262, 1280
|
1309, 3155
|
4984, 5786
|
3177, 3342
|
3939, 4089
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,824
| 181,413
|
28039+57572
|
Discharge summary
|
report+addendum
|
Admission Date: [**2184-9-28**] Discharge Date: [**2184-10-18**]
Date of Birth: [**2124-9-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
s/p fall with femur fracture
Major Surgical or Invasive Procedure:
1) Right femur ORIF
History of Present Illness:
Mr. [**Name13 (STitle) **] is a 60 y/o male with PMH significant for CHF (EF 15%
per outside report), hepatitis C, dementia [**2-26**] ETOH abuse, and
known CAD who presents from his rehab facility today following
an unwitnessed fall. The patient is not a reliable historian.
Basically, it appears as though he fell sometime yesterday.
There is no clear neurologic or cardiac etiology of this fall.
This morning, he could not bear weight, and the NP[**MD Number(3) 31663**]
facility sent him to the ED. In the ED, he was found to have a
mildly displaced intertrochanteric proximal right femur fracture
as well as questionable fractures of the left superior and
inferior pubic rami. He was seen by orthopedics in the ED whose
recommendations are in the chart. He is being admitted to
medicine for pre-op cardiac evaluation as well as monitoring for
alcohol withdrawal.
.
At the present time, the patient is not complaining of pain. He
does not know what happened yesterday and cannot give coherent
answers to most questions. In the ED, he admitted to recent
cocaine use, but per his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5762**], the patient is totally
unreliable due to his underlying dementia due to alcohol. He has
been at rehab for greater than one month so it is unlikely that
he has been using alcohol or drugs at this facility.
.
Past Medical History:
* 3V CAD per outside cath ([**Hospital2 **] [**Hospital3 6783**], [**2184-7-24**]): 75%
mid-shaft LAD stenosis, dominant RCA with 50-70% stenosis in
mid-segment, diffuse hypokinesis on ventriculogram with
estimated EF 15%
* Chronic renal insufficiency (Cr ~ 1.9 at outside facility)
* Diabetes requiring insulin
* Hepatitis C
* Hypertension
* Seizure disorder, on dilantin
* Alcohol abuse, with history of withdrawal issues
* Prior cocaine abuse
Social History:
Was previously living with sister prior to hospitalization in
[**2184-7-24**]. Since then, has been at rehab center. The patient's
POA is [**Name (NI) 1785**] [**Name (NI) 21822**] - ([**Telephone/Fax (1) 68256**].
Family History:
Noncontributory
Physical Exam:
Vitals T 98, HR 96, BP 160/100, RR 20 with O2 sats 98% on RA
Gen Pleasant gentleman in no acute distress.
HEENT Normocephalic. No signs of trauma. PERRL, EOMI. Poor
dentition.
Neck No JVD. No lymphadenopathy or thyromegaly.
Chest Clear to auscultation bilaterally.
CV RRR with 2/6 systolic murmur
Abd Soft, nontender, nondistended. Positive bowel sounds.
Ext RLE externally rotated and shortened compared to LLE. DP
pulses 2+ bilaterally. No peripheral edema.
Skin Sclera injected bilaterally.
Neuro Not oriented to time or place. At times pauses prior to
answering questions. Moving both upper extremities without
problem.
Pertinent Results:
[**2184-9-28**] 03:30PM K+-5.2
[**2184-9-28**] 01:30PM GLUCOSE-203* UREA N-42* CREAT-1.4*
SODIUM-130* POTASSIUM-5.3* CHLORIDE-97 TOTAL CO2-23 ANION GAP-15
[**2184-9-28**] 01:30PM PHENYTOIN-3.2*
[**2184-9-28**] 01:30PM WBC-8.9 RBC-3.53* HGB-11.0* HCT-31.7* MCV-90
MCH-31.1 MCHC-34.7 RDW-14.0
[**2184-9-28**] 01:30PM PT-12.1 PTT-26.4 INR(PT)-1.0
.
RADIOLOGY Final Report
CHEST (SINGLE VIEW) [**2184-9-28**] 2:02 PM
CHEST (SINGLE VIEW)
Reason: eval for cardiopulmonary process
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p fall
REASON FOR THIS EXAMINATION:
eval for cardiopulmonary process
CHEST, AP SINGLE VIEW
INDICATION: Status post fall, evaluate for cardiopulmonary
abnormalities.
FINDINGS: AP single view of the chest obtained with patient in
semi-upright position demonstrates normal heart size without
typical configurational abnormality. Thoracic aorta mildly
widened and slightly elongated, but not excessive for age. No
suspicious local aortic contour abnormalities identified. Upper
mediastinum unremarkable. No pneumothorax seen. The pulmonary
vasculature is normal. No signs of acute or chronic parenchymal
infiltrates are present, and the lateral pleural sinuses are
free. Skeletal structures grossly within normal limits, but mild
asymmetric appearance of vertebral body Th12 being slightly
lower on the left than on the right.
Our records do not include a previous chest examination
available for comparison.
IMPRESSION: No evidence of CHF, pneumothorax, or acute
infiltrates. Chest examination is limited to AP single view.
Telephone report delivered to referring physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2270**]
[**Last Name (NamePattern1) 68257**].
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: WED [**2184-9-29**] 9:25 AM
.
RADIOLOGY Final Report
HIP UNILAT MIN 2 VIEWS RIGHT [**2184-9-28**] 2:02 PM
HIP UNILAT MIN 2 VIEWS RIGHT
Reason: eval for fx
[**Hospital 93**] MEDICAL CONDITION:
60 year old man s/p fall, right hip pain, shortening on exam
REASON FOR THIS EXAMINATION:
eval for fx
PELVIS AND RIGHT HIP, THREE VIEWS:
INDICATION: 60-year-old man status post fall with right hip
pain. Evaluate for fracture.
FINDINGS: No comparisons. There is a displaced intertrochanteric
fracture of the proximal right femur. Mild displacement of the
distal fracture fragment with respect to the proximal fracture
fragment is seen. There is moderate degenerative change of the
right hip. There is also a suggestion of fractures of the left
superior and inferior pubic rami; this could be better evaluated
with CT. The left hip is intact. Degenerative changes of the
left hip are also noted. Evaluation of the sacrum is obscured by
overlying bowel gas. The soft tissues are otherwise
unremarkable.
IMPRESSION:
1) Mildly displaced intertrochanteric proximal right femur
fracture.
2) Possible additional fractures of the left superior and
inferior pubic rami. These would be better evaluated with CT if
clinically necessary.
Findings discussed with Dr. [**Last Name (STitle) 68257**] at the time of this
dictation.
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: TUE [**2184-9-28**] 5:00 PM
Brief Hospital Course:
A/P: 60 y/o M with history of CAD, CHF, and dementia secondary
to EtOH presents to the floor from the MICU s/p extubation from
aspiration event.
.
1. Right Femur Fracture
Patient was admitted s/p an unwitnessed fall at his nursing
home. He was found to have a right femur fracture and was
admitted for right femur fracture repair by orthopedic surgery.
While awaiting surgery, patient was found to have vital signs of
HO was called to evaluate and found the pt as described with
fever to 104, BP 180/90, HR 120s, rr 50s-60s and had aspirated
on chicken. He was intubated and transferred to the MICU. After
extubation in the MICU, patient underwent right femur ORIF
without complication. His wound was healing without any signs of
inflammation and patient is to have follow-up with orthopedic
surgery. Patient was maintained on lovenox after ORIF. Pt should
receive 4 weeks total of lovenox after surgery. Therefore, the
patient should have an additional 1-2 weeks. Therewas some
concern that the patient may have had bleeding after PEG tube
placement, but based on ortho recommendations, the patient
should remain on the lovenox as the risk of PE is high after
ORIF.
.
2. Altered Mental Status
While awaiting right femur ORIF by orthopedic surgery, the
patient was found to have a fever to 104, BP 180/90, HR 120s, rr
50s-60s and had aspirated on chicken.
Unclear what precipitated this event. Differential diagnosis
included a seizure given patient's history of a seizure
disorder, infection, or stroke. To help treat possible seizure,
patient was given 2mg ativan with no improvement in mental
status. As for infectious etiology, patient found to have
pneumonia on CXR and exam and was started on vancomycin and
zosyn to cover hospital-acquired pneumonia since patient had
been living in nursing home. CT head was not suggestive of
stroke. Patient's mental status slowly returned to baseline.
Altered mental status somewhat difficult to assess given
patient's baseline dementia secondary to alcohol use.
.
3. Anemia
Stable. Goal Hct of 28 given patient's cardiac disease.
However, the patient had hct drop after PEG placement. The
patient was given transfusion of PRBCs that improved hct and was
stable x 48 hours after. The anticoagulation meds were held,
but based on ortho recommendations should be continued for a
total of 4 weeks after surgery.
.
4. HTN
BP meds converted to PO hydral 25 q6h, isosorbide dinitrate 20mg
tid, metoprolol 75 mg PO tid
- increase metoprolol
.
5. Coronary Artery Disease
Patient was continued on home doses of aspirin, beta blocker,
and nitroglycerine.
.
6. Diabetes mellitus
Home regimen of lantus 10U, but will give 1/2 dose while NPO and
cover with insulin sliding scale.
.
7. Nutrition
Given patient's aspiration on chicken while awaiting ORIF,
patient was made NPO and failed subsequent speech and swallow
evaluations. A nasogastric tube was placed temporarily for tube
feedings, but the patient could not tolerate the NG tube and
pulled the tube out. Surgery was consulted for J tube placement,
consent was obtained from patient's daughter, and the patient
has successful placement of the PEG. Should continue tube
feeds.
Medications on Admission:
Lantus 10 U QHS
SSI
Spironolactone 12.5 daily
lasix 80 mg daily
lisinopril 20 mg daily
metoprolol 75 mg [**Hospital1 **]
dilantin 200 mg [**Hospital1 **]
reglan 10 mg TID
NTG 2.5 mg daily
omeprazole 20 mg daily
ASA 81 daily
folic acid 1 mg daily
Colace 100 mg [**Hospital1 **]
Glucerna 240 mL TID
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-26**]
Drops Ophthalmic PRN (as needed).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO QID (4
times a day).
6. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
7. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
8. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO BID (2 times a day).
9. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO DAILY (Daily).
10. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily).
11. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous once a day for 2 weeks: DVT prophylaxis after ORIF.
12. Morphine Sulfate 1-2 mg IV Q4H:PRN pain
PLEASE NOTE THAT THE LOVENOX WAS HELD FOR CONCERN THAT THE PEG
SITE WAS BLEEDING, HOWEVER THE HCT WAS STABLE X 48 HOURS AND THE
LOVENOX SHOULD BE RESTARTED PER RECOMMENDATIONS OF ORTHOPAEDICS
AND CONTINUED FOR 1-2 WEEKS (RISK OF DVT AFTER ORIF)
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1) Right Femur Fracture
2) Altered Mental Status
3) Aspiration Pneumonia
.
SECONDARY DIAGNOSIS:
1) Coronary Artery Disease
2) Chronic Renal Insufficiency
3) Diabetes Mellitus
4) Hepatitis C
5) Hypertension
6) Seizure disorder, on dilantin
7) Alcohol abuse, with history of withdrawal issues
8) Prior cocaine abuse
Discharge Condition:
Fair - Patient is tolerating intake via his PEG tube.
Discharge Instructions:
- Please take all medications as prescribed.
- If you have any symptoms of fevers, chills, night sweats,
drainage or tenderness at site of right femur repair, increased
confusion, abdominal pain or drainage at the site of the J tube
site, please seek immediate medical attention.
Followup Instructions:
Please call Dr.[**Name (NI) 14038**] office at [**Telephone/Fax (1) 608**] for an
appointment in the next 2-3 weeks or sooner if needed.
Please follow up with Dr. [**First Name (STitle) **] [**10-26**] at 9:05 PM. [**Hospital Ward Name 23**] bld
[**Location (un) **].
Name: [**Known lastname 1937**],[**Known firstname **] Unit No: [**Numeric Identifier 11737**]
Admission Date: [**2184-9-28**] Discharge Date: [**2184-10-18**]
Date of Birth: [**2124-9-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4709**]
Addendum:
On Friday prior to discharge, the patient had an acute hct drop
from 28 to 22. This was concerning for bleeding into the PEG
site. Therefore the patient had a CT scan that showed no signs
of bleeding. Given that the patient was on lovenox and there
was some blood at the time of the PEG placement, it was thought
that there was a small amount of bleeding into the site caused
by anticoagulation. Therefore the hct was closely monitored and
the patient was given a transfusion of PRBCs. Following the
transfusion, the patient had increased hct that remained stable
for 24 hours. Therefore the patient was thought to be stable to
be transferred to the outside hospital. The lovenox was held
after hct decrease, but should be restarted as the patient is at
significant risk for DVT after hip fracture.
See CT results below:
CT Abdomen/Pelvis [**10-16**]
IMPRESSION:
1. No evidence of intra-abdominal hemorrhage, as clinically
questioned.
2. Bilateral lower lobe pulmonary opacities, suspicious for
aspiration.
3. Mesenteric and subcutaneous edema, likely secondary to
anasarca in this patient with cirrhosis.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 419**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 164**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4710**] MD [**MD Number(1) 4274**]
Completed by:[**2184-10-18**]
|
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icd9cm
|
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,966
| 141,032
|
39440
|
Discharge summary
|
report
|
Admission Date: [**2131-11-30**] Discharge Date: [**2131-12-5**]
Date of Birth: [**2067-1-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 922**]
Chief Complaint:
Fatigue/Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2131-11-30**] Redo sternotomy, redo mitral valve replacement with a
25/33-mm Conformex mechanical valve
History of Present Illness:
64 year old gentleman with a history of bileaflet mitral
regurgitation who underwent a mitral valve repair in [**Month (only) 404**]
[**2131**] at [**Hospital3 **] Hospital. This spring, he noted tea colored
urine, some jaundice and was found to have hemolytic anemic.
Hematology work-up was negative and suggested that his mitral
valve repair may be the cause of his hemolytic anemia. An echo
in [**2131-5-26**] was reportedly okay however his anemia progressed
along with symptoms of fatigue and dyspnea on exertion. Repeat
echocardiogram in [**Month (only) 462**] showed severe mitral valve
regurgitation. Given the severity of his mitral regurgitation
and persistent hemolytic anemia, he has been referred to Dr.
[**Last Name (STitle) 914**] for redo mitral valve surgery.
Past Medical History:
Mitral regurgitation s/p MV Repair [**2131-3-1**]
Hypertension
Hyperlipidemia
Hemolytic anemia
Degenerative joint disease
Malaria [**2091**]'s
Nephrolithiasis
h/o depression
Ventricular ectopy
Past Surgical History:
s/p bone marrow biopsy: negative
s/p liver biopsy negative
knee surgery
hernia repair
appendectomy
Social History:
Race: caucasian
Last Dental Exam: last month
Lives with: wife
Occupation: retired
Tobacco: Past smoker
ETOH: Occassional use
Family History:
denies
Physical Exam:
Pulse: 66 Resp:16 O2 sat:100%
B/P Right: 130/92 Left:
Height: 72" Weight:183lb
General: WDWN in NAD
Skin: Warm[X] Dry [X] intact [X]. Well healed sternotomy.
HEENT: NCAT[X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, III/VI systolic murmur best heard over mid left
sternal border.
Abdomen: Soft [X] non-distended [] non-tender [] bowel sounds +
[]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right: None Left: None
Pertinent Results:
[**2131-11-30**] Echo: Pre-CPB: No spontaneous echo contrast is seen in
the left atrial appendage. Overall left ventricular systolic
function is mildly depressed (LVEF= 45 - 50%). with moderate
global free wall hypokinesis. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. A mitral valve annuloplasty ring is
present. Moderate to severe (3+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is no
pericardial effusion.
Post-CPB: The patient is A-Paced on no inotropes. There is a
bileaflet mitral prosthesis which is well-seated and functioning
well with no MR, and normal small upstream jets. Preserved
biventricular systolic fxn. EF remains 45 - 50%. TR is now mild.
No AI. Aorta intact.
[**2131-11-30**] 12:07PM BLOOD WBC-12.3*# RBC-3.01* Hgb-9.7* Hct-28.5*
MCV-95 MCH-32.2* MCHC-34.0 RDW-16.2* Plt Ct-100*
[**2131-12-4**] 09:30AM BLOOD WBC-6.4 RBC-3.42* Hgb-10.6* Hct-32.5*
MCV-95 MCH-30.9 MCHC-32.6 RDW-15.0 Plt Ct-205
[**2131-11-30**] 12:07PM BLOOD PT-19.3* PTT-43.2* INR(PT)-1.8*
[**2131-12-2**] 06:40AM BLOOD PT-18.2* PTT-28.9 INR(PT)-1.6*
[**2131-12-3**] 06:40AM BLOOD PT-26.2* INR(PT)-2.5*
[**2131-12-3**] 10:10AM BLOOD PT-27.8* PTT-30.8 INR(PT)-2.7*
[**2131-12-4**] 09:30AM BLOOD PT-21.0* PTT-29.2 INR(PT)-2.0*
[**2131-12-5**] 05:20AM BLOOD PT-23.5* INR(PT)-2.2*
[**2131-11-30**] 02:17PM BLOOD UreaN-22* Creat-1.0 Na-142 K-4.0 Cl-111*
HCO3-24 AnGap-11
[**2131-12-4**] 09:30AM BLOOD Glucose-130* UreaN-18 Creat-0.8 Na-139
K-3.8 Cl-102 HCO3-29 AnGap-12
[**2131-12-3**] 10:10AM BLOOD ALT-17 AST-32 LD(LDH)-524* AlkPhos-72
Amylase-30 TotBili-2.4*
Brief Hospital Course:
Mr. [**Known lastname 15068**] was a same day admit after undergoing pre-operative
work-up as an outpatient. On [**11-30**] he was brought directly to the
operating room where he underwent a redo-sternotomy, Mitral
valve replacement. Please see operative report for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
Beta blockers and diuretics were started on post-op day one and
he was diuresed towards his pre-op weight. On this day he was
transferred to the step-down unit for further care. Coumadin was
initiated and titrated for a goal INR 2.5-3.5. Chest tubes were
removed on post-op day two and epicardial pacing wires on day
three. He continued to make progress while working with physical
therapy for strength and mobility. He was discharged on a week
of Keflex for erythematous chest tube sites without drainage.
On post-op day five he appeared to be doing well and was
discharged home with VNA services by Dr. [**Last Name (STitle) 914**]. All follow-up
appointments were advised. His Coumadin for his mitral valve
will be followed by his Cardiologist Dr. [**Last Name (STitle) 20948**]. The goal INR
will be 2.5-3.5 it will be drawn every Monday, Wednesday and
Friday.
Medications on Admission:
Iron 100mg daily
Metoprolol XL 100mg in the am, 50mg in the PM
lasix 20mg daily
Aspirin 81mg daily
Celexa 20mg daily
Lisinopril 10mg daily
Bacterial prophylaxis
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
11. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
Coumadin to be adjusted by Dr. [**Last Name (STitle) 73562**] with a goal INR of
2.5-3.5.
Disp:*60 Tablet(s)* Refills:*2*
12. Outpatient [**Name (NI) **] Work
PT/INR for Coumadin ?????? indication: Mechanical Mitral Valve
Goal INR 2.5-3.5
First draw on Friday, [**2131-12-7**]. And then every Monday, Wednesday
and Friday.
Results to the office of Dr. [**Last Name (STitle) 20948**], fax ([**Telephone/Fax (1) 87144**] or
phone ([**Telephone/Fax (1) 87145**]. Plan confirmed with [**Doctor First Name 19267**]
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital3 **]
Discharge Diagnosis:
Mitral Valve regurgitation following Mitral Valve repair [**2131-3-1**]
s/p Redo-sternotomy, Mitral Valve Replacement
Past Medical History:
Hypertension
Hyperlipidemia
Hemolytic anemia
Degenerative joint disease
Malaria [**2091**]'s
Nephrolithiasis
h/o depression
Ventricular ectopy
Past Surgical History:
s/p bone marrow biopsy: negative
s/p liver biopsy negative
s/p knee surgery
s/p hernia repair
s/p appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage. Mild erythema
at chest tube incision sites.
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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**Known firstname **] [**Last Name (NamePattern1) 914**] [**2131-12-25**] at 2:30PM
Cardiologist: [**Doctor Last Name 20948**] [**12-11**] at 1130AM
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 73562**] in [**4-30**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: Mechanical Mitral Valve
Goal INR 2.5-3.5
First draw on Friday, [**2131-12-7**]. And then every Monday, Wednesday
and Friday.
Results to the office of Dr. [**Last Name (STitle) 20948**], fax ([**Telephone/Fax (1) 87144**] or
phone ([**Telephone/Fax (1) 87145**]
Completed by:[**2131-12-5**]
|
[
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"E878.2",
"401.9",
"272.4",
"428.22",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.49",
"35.24"
] |
icd9pcs
|
[
[
[]
]
] |
7600, 7654
|
4243, 5578
|
348, 456
|
8114, 8316
|
2499, 4220
|
9239, 10104
|
1758, 1766
|
5789, 7577
|
7675, 7793
|
5604, 5766
|
8340, 9216
|
7981, 8093
|
1781, 2480
|
281, 310
|
484, 1262
|
7815, 7958
|
1616, 1742
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,817
| 162,936
|
18763
|
Discharge summary
|
report
|
Admission Date: [**2111-8-11**] Discharge Date: [**2111-8-18**]
Date of Birth: [**2061-8-2**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Latex / Optiray 320
Attending:[**Doctor First Name 5911**]
Chief Complaint:
Menorrhagia
Endometriosis
Major Surgical or Invasive Procedure:
Total laparoscopic hysterectomy converted to open abdominal
hysterectomy.
Attempted uterine artery embolization
Exploratory laparotomy for re-exploration
Right salpingoophrectomy.
Cystoscopy
Bilateral ureteral stenting
History of Present Illness:
49-year-old G5, P3-0-2-3, perimenopausal Caucasian
female, employee at [**Hospital1 18**] [**Location (un) 620**], who recently underwent a
hysteroscopy and endometrial ablation, D&C ([**2111-4-22**]) with
for complaints of menorrhagia posterior submucosal
fibroid noted intraoperatively. Preoperatively, she complained
of menorrhagia with regular menses every 28 days with 6 days of
very heavy vaginal bleeding. Since the ablation, she complains
of irregular vaginal bleeding throughout the month with
prolonged
episodes of bleeding lasting 2 weeks to 26 days, ranging from
light to heavy bleeding. Preoperative office endometrial
biopsy,
and intraoperative Pap results revealed endometriosis for which
she underwent 2 courses of doxycycline treatment. She believes
that her endometriosis was noted to still be persistent with
most
recent pathology results of her D&C.
PUS ([**2111-3-3**]) at [**Hospital1 18**], [**Location (un) 620**], reveals an enlarged uterus,
11.8 cm, with multiple fibroids.
The patient presened to discuss more definitive surgical
options regarding her menometrorrhagia since her ablation. She
has no other specific gynecologic complaints. She has not had
repeat endometrial sampling since her D&C for [**2110**].
Past Medical History:
OB History: G5, P3-0-2-3, the patient reports 3 full-term
vaginal deliveries in [**2082**], [**2085**], and [**2090**], and 1 first
trimester
termination of pregnancy in [**2078**] and a first trimester pregnancy
loss in [**2078**] requiring a D&C.
.GYN History: Menarche at age 13. LMP continuous abnormal
bleeding since endometrial ablation. Prior to her ablation
regular, but very heavy flow consistent with menorrhagia every
28
days. The patient denies dyspareunia. Does complain of
discomfort with a full bladder or bowel movement. Denies a
history of abnormal Pap smears. Last Pap smear [**11/2110**],
reported
within normal limits. The patient is reportedly up-to-date with
mammogram. The patient is sexually active, prefers opposite sex,
does not currently use any birth control. Denies a history of
any STDs.
- GYN Problems:
1. Fibroids.
2. Menometrorrhagia after ablation.
.
Medical Problems:
1. [**Name2 (NI) **] apnea.
2. GERD.
3. Fibroids and menometrorrhagia.
4. Angioedema.
.
Past Surgical History:
1. [**2078**], D&C for first trimester TAB.
2. [**2078**], D&C for first trimester SAB.
3. Right heel open reduction surgery, [**2110-7-3**] at [**Hospital1 18**],
[**Location (un) 620**].
4. [**2111-4-22**], hysteroscopy and endometrial ablation, D&C for
menorrhagia at [**Hospital1 18**], [**Location (un) 620**], by Dr. [**First Name (STitle) **]. Denies any
abdominal surgeries.
Social History:
Quit smoking 29 years ago, but reportedly smoked
for 7 years in the past. The patient admits to drinking
socially. Denies any recreational or IV drug use. She is
currently employed at [**Hospital1 18**], [**Location (un) 620**], in medical assisting.
The patient is divorced, living with her son.
Family History:
Reports a mother with breast cancer, now
deceased. Denies a family history of ovarian, uterine,
cervical,
or vaginal cancer. Reports grandmother with [**Name2 (NI) 499**] cancer and
family history of skin cancer. Reports a strong family history
of diabetes, heart disease, and hypercholesterolemia
Physical Exam:
Pleasant, somewhat overweight Caucasian
female in no acute distress. BP is 160/100. Weight 183 pounds,
height 5 feet 8 inches. HEENT: Normocephalic, atraumatic.
Neck: Supple, full range of motion, no thyromegaly. Lungs:
Clear to auscultation bilaterally. CV: Regular rate and
rhythm.
Abdomen: Soft, nontender, nondistended, positive bowel sounds.
No rebound or guarding. Extremities: No clubbing, cyanosis, or
edema. On pelvic exam, there are grossly normal external female
genitalia. On speculum exam, there is a normal-appearing cervix
with no unusual bleeding, lesions, or discharge. On bimanual
exam, the uterine tilt and total size is somewhat difficult to
palpate due to the patient's body habitus, but roughly feels to
be slightly retroverted with a [**12-13**] week size, nontender,
multifibroid uterus with no palpable adnexal masses. No CMT
Pertinent Results:
[**2111-8-11**] 11:26PM GLUCOSE-198* UREA N-14 CREAT-1.1 SODIUM-138
POTASSIUM-5.5* CHLORIDE-108 TOTAL CO2-16* ANION GAP-20
[**2111-8-11**] 11:26PM estGFR-Using this
[**2111-8-11**] 11:26PM CALCIUM-6.9* PHOSPHATE-5.6* MAGNESIUM-1.7
[**2111-8-11**] 11:26PM WBC-32.3*# RBC-4.01* HGB-12.5 HCT-35.2*
MCV-88 MCH-31.2# MCHC-35.5* RDW-13.6
[**2111-8-11**] 11:26PM PLT COUNT-242
[**2111-8-11**] 11:26PM PT-13.3 PTT-25.0 INR(PT)-1.1
[**2111-8-11**] 07:27PM PH-7.27*
[**2111-8-11**] 07:27PM GLUCOSE-85 LACTATE-2.1* NA+-140 K+-2.0*
CL--127* TCO2-12*
[**2111-8-11**] 07:27PM HGB-5.5* calcHCT-17
[**2111-8-11**] 07:27PM freeCa-0.70*
[**2111-8-11**] 06:55PM VoidSpec-UNABLE TO
[**2111-8-12**] 02:27AM BLOOD WBC-30.0* RBC-3.77* Hgb-11.6* Hct-33.2*
MCV-88 MCH-30.9 MCHC-35.1* RDW-13.9 Plt Ct-205
[**2111-8-12**] 06:35AM BLOOD WBC-23.6* RBC-3.65* Hgb-11.2* Hct-31.8*
MCV-87 MCH-30.8 MCHC-35.4* RDW-14.1 Plt Ct-204
[**2111-8-12**] 03:15PM BLOOD Hct-29.3*
[**2111-8-12**] 07:50PM BLOOD Hct-25.3*
[**2111-8-13**] 07:10AM BLOOD WBC-16.3* RBC-3.08* Hgb-9.6* Hct-26.7*
MCV-87 MCH-31.3 MCHC-36.1* RDW-14.4 Plt Ct-131*
[**2111-8-13**] 01:00PM BLOOD WBC-14.5* RBC-3.15* Hgb-9.6* Hct-27.1*
MCV-86 MCH-30.5 MCHC-35.3* RDW-14.4 Plt Ct-109*
[**2111-8-13**] 06:45PM BLOOD WBC-15.2* RBC-3.47* Hgb-10.7* Hct-29.9*
MCV-86 MCH-30.8 MCHC-35.6* RDW-14.5 Plt Ct-114*
[**2111-8-14**] 12:38AM BLOOD Hct-28.9*
[**2111-8-14**] 04:14AM BLOOD WBC-15.9* RBC-3.02* Hgb-9.6* Hct-25.9*
MCV-86 MCH-31.9 MCHC-37.2* RDW-14.4 Plt Ct-109*
[**2111-8-14**] 09:10AM BLOOD Hct-27.1*
[**2111-8-14**] 01:44PM BLOOD Hct-30.3*
[**2111-8-14**] 07:53PM BLOOD Hct-32.4*
[**2111-8-15**] 04:45AM BLOOD WBC-17.7* RBC-3.59* Hgb-10.9* Hct-31.3*
MCV-87 MCH-30.3 MCHC-34.7 RDW-14.7 Plt Ct-172#
[**2111-8-15**] 06:50PM BLOOD WBC-13.9* RBC-3.51* Hgb-10.7* Hct-30.7*
MCV-88 MCH-30.6 MCHC-35.0 RDW-14.5 Plt Ct-164
[**2111-8-16**] 05:40AM BLOOD WBC-12.0* RBC-3.41* Hgb-10.2* Hct-29.6*
MCV-87 MCH-29.8 MCHC-34.2 RDW-14.5 Plt Ct-170
[**2111-8-17**] 09:00AM BLOOD WBC-10.7 RBC-3.46* Hgb-10.5* Hct-30.0*
MCV-87 MCH-30.3 MCHC-35.0 RDW-14.3 Plt Ct-204
[**2111-8-17**] 09:00AM BLOOD WBC-10.7 RBC-3.46* Hgb-10.5* Hct-30.0*
MCV-87 MCH-30.3 MCHC-35.0 RDW-14.3 Plt Ct-204
[**2111-8-11**] 11:26PM BLOOD Glucose-198* UreaN-14 Creat-1.1 Na-138
K-5.5* Cl-108 HCO3-16* AnGap-20
[**2111-8-12**] 12:51AM BLOOD K-5.6*
[**2111-8-12**] 06:35AM BLOOD Glucose-139* UreaN-20 Creat-1.5* Na-140
K-5.5* Cl-109* HCO3-20* AnGap-17
[**2111-8-12**] 03:15PM BLOOD Glucose-135* UreaN-20 Creat-1.2* Na-139
K-4.7 Cl-108 HCO3-24 AnGap-12
[**2111-8-13**] 07:10AM BLOOD Glucose-125* UreaN-13 Creat-0.7 Na-137
K-3.9 Cl-104 HCO3-28 AnGap-9
[**2111-8-13**] 01:00PM BLOOD Glucose-121* UreaN-9 Creat-0.5 Na-139
K-3.8 Cl-108 HCO3-27 AnGap-8
[**2111-8-13**] 06:45PM BLOOD Glucose-160* UreaN-7 Creat-0.5 Na-138
K-4.1 Cl-106 HCO3-26 AnGap-10
[**2111-8-14**] 04:14AM BLOOD Glucose-136* UreaN-6 Creat-0.5 Na-141
K-3.6 Cl-108 HCO3-28 AnGap-9
[**2111-8-15**] 04:45AM BLOOD Glucose-105 UreaN-10 Creat-0.5 Na-142
K-3.5 Cl-107 HCO3-27 AnGap-12
[**2111-8-15**] 06:50PM BLOOD Glucose-92 UreaN-8 Creat-0.4 Na-139 K-3.5
Cl-105 HCO3-24 AnGap-14
[**2111-8-16**] 05:40AM BLOOD Glucose-112* UreaN-7 Creat-0.4 Na-137
K-3.1* Cl-103 HCO3-25 AnGap-12
[**2111-8-17**] 09:00AM BLOOD Glucose-163* UreaN-5* Creat-0.6 Na-138
K-3.1* Cl-104 HCO3-24 AnGap-13
[**2111-8-13**] 07:10AM BLOOD Albumin-2.9* Calcium-7.6* Phos-2.0*
Mg-1.8
[**2111-8-17**] 09:00AM BLOOD Calcium-7.6* Phos-3.0 Mg-2.1
Brief Hospital Course:
Ms. [**Known lastname 4135**] was admitted after her attempted laparoscopic
hysterectomy was converted to an open supracervical hysterectomy
because of extensive endometriosis and adhesions. Bilateral
ureteral stents were placed and right rertoperitoneal dissection
was performed. She had an estimated blood loss of 3L
intraoperatively and received a transfusion of 4 units of packed
red blood cells. Please see the operative report for full
details of the procedure. Her hospital course was complicated
by:
*) Blood loss anemia -
An intraoperative HCT was 17 and after 4 units HCT was 35.
Postoperatively her HCT began to trend down to a nadir of 25.3
on postoperative day 1. Patient was persistently tachycardic
between 110 and 120 bpm. Patient was also oliguric. She received
another 2 units of PRBC on postoperative day 2. She also had a
downward trend of her platelets due to her acute blood loss. On
post operative day 2 the decision was made to proceed with
imaging for vessel embolization for presumed ongoing
post-operative blood loss. Prior to the IR procedure, anesthesia
intubated the patient for a difficult airway. At the onset of
the procedure the patient had a severe anaphylactic reaction to
contrast dye. Therefore, while intubated the patient was
transfered to the operating room for exploratory laparotomy
with re-exploration to identify the site of presumed bleeding.
No obvious source of bleeding was identified. There was a small
amount of serosanguinous ascites, but no hemoperitoneum or
active bleeding. At that time, she also had a right
salpingoophrectomy (given endometriosis involving her right
ovary, left ovary was not removed due to extensive bowel
adhesions & risk of bowel injury) restenting of ureters, and
cystoscopy. Please see the operative report for details of this
procedure.
.
*) [**Hospital Unit Name 153**] admission -
After exploratory laparotomy and reexploration for ongoing
bleeding the patient was admitted to the [**Hospital Unit Name 153**] for close
postoperative monitoring given her extensive blood loss. She was
intubated and remained in the [**Hospital Unit Name 153**] until postoperative day 5.
.
*) Postoperative Ileus-
Patient was noted to have an ileus that was clnically diagnosed.
During her stay in the [**Hospital Unit Name 153**], a nasogastric tube was placed on
postoperative day 4 for sympotmatic relief (it was removed by
the patient overnight). An abdominal flat plate was performed
suggesting a SBO. CLinically, the patient clearly had an ileus
and was advanced to regular diet within 2 days, on postoperative
day 6.
.
*) Tachycardia -
Presumed to be due to acute blood loss anemia. Patient received
a total of 8 units of PRBC during admission. Tachycardia
resolved finally on post operative day 5.
.
*) Acute renal failure -
This was believed to be secondary to prerenal intravascular
depletion due to acute blood loss. Patient was oliguric on
postoperative day 1 and received IV hydration support.
Creatinine increased up to 1.5 and then gradually trended down
[**Hospital 33970**] hospital day to normal levels by discharge.
*) Urinary tract infection -
On postoperative day 5 patient complained of dysuria and
dribbling. Her UA suggested a urinary tract infection and the
patient was started on Cipro antibiotics on postoperative day 6.
The final urine culture was contaminated with fecal contents (pt
was suffering from lose stools at the time of clean catch).
Patient was finally discharged home on postoperative day 6. She
was tolerating a regular diet, voiding spontaneously, ambulating
without difficulty and pain was well controlled on oral pain
medication.
Medications on Admission:
1. Nexium 40 mg daily.
2. Ambien for insomnia.
3. CPAP.
4. Vitamin C.
5. Florastor (homeopathic treatment for GI symptoms).
6. Biotin.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q3-4H () as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: Two (2) Capsule, Delayed Release(E.C.) PO daily ().
3. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*13 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Endometriosis
Abdominal adhesions
Urinary tract infection
Contrast dye induced anaphylaxis
Blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficult urinating
* vaginal bleeding requiring >1 pad/hr
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* No strenuous activity, nothing in the vagina (no tampons, no
douching, no sex), no heavy lifting of objects >10lbs for 6
weeks.
* You may eat a regular diet.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit .
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51396**], MD Phone:[**Telephone/Fax (1) 17200**]
Date/Time:[**2111-8-27**] 9:00
Provider: [**Name6 (MD) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 8246**] Date/Time:[**2111-9-14**]
8:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 5913**]
Completed by:[**2111-9-2**]
|
[
"997.5",
"997.4",
"285.1",
"584.9",
"998.11",
"E947.8",
"617.2",
"626.2",
"753.4",
"599.0",
"V64.41",
"218.1",
"218.2",
"560.1",
"617.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.98",
"96.04",
"65.49",
"59.8",
"57.32",
"59.02",
"68.39",
"59.00"
] |
icd9pcs
|
[
[
[]
]
] |
12645, 12651
|
8286, 11942
|
319, 540
|
12804, 12811
|
4800, 8263
|
13611, 14008
|
3594, 3896
|
12134, 12622
|
12672, 12783
|
11968, 12111
|
12835, 13339
|
13354, 13588
|
2869, 3259
|
3911, 4781
|
254, 281
|
568, 1818
|
1840, 2846
|
3275, 3578
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,611
| 101,732
|
2764
|
Discharge summary
|
report
|
Admission Date: [**2130-7-16**] Discharge Date: [**2130-7-18**]
Date of Birth: [**2043-4-12**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**Last Name (un) 11220**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
R IJ central line placement and removal
History of Present Illness:
History of Present Illness: Mr. [**Known lastname 13639**] is 87M with history of
dementia, diastolic CHF (EF%60), HTN who presented s/p fall.
The patient was taking a shower at 3AM this morning when her son
her a pounding sound. The patient's son found the patient
laying on the floor of the shower; unsure if there was LOC. The
patient reports that he was in the shower this morning when he
slipped and fell; denies hitting his head. Denies any chest
pain, denies any shortness of breath. Denies having any light
headedness or dizziness.
In the ED, initial VS were 91/68 90 RR 34. While in the ED, the
patient's only complaint was back pain, which moved after he was
transferred off stretcher. The patient was noted to be
tachycardic to the 160s by EMS. Of note, as per report, the
patient was given Dilt by EMS during transit to [**Hospital1 18**].
The patient was intermittently tachycardic while in the ED with
heart rates to the 110s. His pressures dropped as low as the 60s
systolic; the patient responded to IVF with pressures recovering
to the 90-100s. However, his pressures soon dropped again into
the 70s and a R IJ was placed and the patient was started on
Levophed. The patient was also initially 86% on RA, and
maintained his sats on face mask. The patient also had multiple
imaging studies done, with no e/o acute source of infection, or
any acute intracranial pathology. Labs notable for white count
of 14, lactate of 5.8. EKG with e/o LBBB c/w priors, Scarbossa
criteria negative. In total the patient received 3L IVF, and
was given Vanc/Cefepime, in addition to being started on
Levophed.
On ROS, the patient denies having any fevers/chills. Denies any
shortness of breath, no trouble breathing. Denies any chest
pain. Denies any nausea/vomiting, no abdominal pain. Denies
any coughing. Denies any pain or burning with urination.
On arrival to the MICU, patient's VS 94.5 124/59 62 24 100% on
50% high flow mask. The patient reports feeling well, without
any current complaints.
Past Medical History:
Patient without regular medical follow up, and self prescribes
his own medications.
Hypothyroidism
Bilateral hypoacusis, s/p bilateral hearing aids
Right eye retinal detachment
Severe myopia s/p surgery with residual exotropia
Atrial flutter
Diastolic CHF
Dementia
HTN
Anemia
Ezcema
Social History:
Patient is a retired primary care physician. [**Name10 (NameIs) **] for
activities of daily living. He takes care of his wife, who has
developed dementia. Lives with his son, who is 57 years old and
has dyslexia. Has not smoked for many years. Denies any alcohol
consumption or other illicit drug use.
Family History:
Noncontributory. There is no family history of premature
coronary artery disease or sudden death.
Physical Exam:
ADMISSION EXAM:
91/68 90 RR 34
General: elderly gentleman, NAD, laying comfortably in bed,
alert and appropriately answering questions, alert and oriented
to person, place, time
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, + R sided
surgical pupil
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, soft SEM loudest at RUSB, S1 + S2
Lungs: crackles throughout lung fields, good air movement, no
audible wheezes appreciated
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: + foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: dry areas of skin with flaking prominently on head/scalp
and lower extremities; 2cm skin abrasion on coccyx, area clean
with no e/o drainage
Neuro: CNII-XII intact, muscle strength and sensation grossly
intact, noted to have resting tremor at baseline, worse with
movement
Pertinent Results:
ADMISSION LABS:
[**2130-7-16**] 04:45AM BLOOD WBC-14.5* RBC-4.46* Hgb-13.9* Hct-43.4
MCV-97 MCH-31.2 MCHC-32.1 RDW-14.5 Plt Ct-295
[**2130-7-16**] 04:45AM BLOOD Neuts-87.5* Lymphs-7.3* Monos-1.4*
Eos-3.5 Baso-0.3
[**2130-7-16**] 04:45AM BLOOD PT-11.9 PTT-24.8* INR(PT)-1.1
[**2130-7-16**] 04:45AM BLOOD Glucose-291* UreaN-33* Creat-1.7* Na-141
K-3.2* Cl-101 HCO3-19* AnGap-24*
[**2130-7-16**] 04:45AM BLOOD ALT-26 AST-35 CK(CPK)-164 AlkPhos-101
TotBili-0.6
[**2130-7-16**] 04:45AM BLOOD cTropnT-0.07*
[**2130-7-16**] 04:45AM BLOOD Albumin-4.0 Calcium-9.7 Phos-2.6* Mg-1.8
[**2130-7-16**] 04:49AM BLOOD Lactate-5.8*
INTERVAL LABS:
[**2130-7-16**] 04:45AM BLOOD CK-MB-3
[**2130-7-16**] 10:19AM BLOOD CK-MB-9 cTropnT-0.17*
[**2130-7-17**] 03:28AM BLOOD CK-MB-8 cTropnT-0.09*
[**2130-7-16**] 10:19AM BLOOD WBC-14.2* RBC-3.76* Hgb-11.7* Hct-35.6*
MCV-95 MCH-31.2 MCHC-32.9 RDW-14.3 Plt Ct-277
[**2130-7-17**] 03:28AM BLOOD WBC-9.5 RBC-3.52* Hgb-10.9* Hct-33.7*
MCV-96 MCH-31.0 MCHC-32.3 RDW-14.4 Plt Ct-230
[**2130-7-16**] 10:19AM BLOOD Glucose-176* UreaN-28* Creat-1.1 Na-143
K-3.0* Cl-108 HCO3-24 AnGap-14
[**2130-7-17**] 03:28AM BLOOD Glucose-98 UreaN-23* Creat-0.8 Na-140
K-3.7 Cl-109* HCO3-19* AnGap-16
[**2130-7-16**] 10:19AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.5*
[**2130-7-17**] 03:28AM BLOOD Calcium-8.3* Phos-1.9* Mg-2.2
[**2130-7-16**] 04:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2130-7-16**] 10:45AM BLOOD Lactate-1.6
[**2130-7-16**] 10:45AM BLOOD freeCa-1.13
[**2130-7-16**] 05:40AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2130-7-16**] 05:40AM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE Epi-1
[**2130-7-16**] 05:40AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2130-7-16**] 05:40AM URINE Hours-RANDOM UreaN-645 Creat-163 Na-24
K-94 Cl-33
IMAGING:
-----------
CT C SPINE:
1. No evidence of acute fracture.
2. Extensive degenerative changes in the cervical spine, worse
from C2 through C7 levels, with multilevel moderate spinal canal
stenosis and neural foraminal narrowing.
3. A 2.3 cm calcified right thyroid lobe nodule.
-----------
NCHCT:
No evidence of hemorrhage or recent infarction. Old right
parietal and frontal infarctions. Severe involutional changes.
-----------
CT TORSO:
1. No acute traumatic injury identified in the chest, abdomen
and pelvis.
2. Extensive atherosclerotic disease of the thoracoabdominal
aorta, with
ectasia of the infrarenal aorta measuring 2.7 cm. High-grade
stenosis at the right renal artery origin. Extensive coronary
arterial calcification.
3. A 4 mm right upper lobe pulmonary nodule. If the patient
does not have risk factors for lung cancer, no further followup
is required. In the presence of risk factors, followup chest
CT in a year is recommended.
4. Mild small airways wall thickening especially in the left
lower lobe,
suggestive of bronchitis.
5. Cholelithiasis.
----------
ECHO:
The left atrium is dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is mildly depressed
(LVEF= XX %). The right ventricular cavity is mildly dilated
with borderline normal free wall function. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild biventricular dilation with mild biventricular
global hypokinesis. Moderate mitral regurgitation. Moderate
tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension.
Compared with the prior study (images reviewed) of [**2128-4-27**], the
severity of tricuspid regurgitation has increased. Estimated
pulmonary artery systolic pressures are slightly higher. The
right ventricle was probably mildly dilated with borderline
systolic function on the prior echo also.
Brief Hospital Course:
Assessment and Plan: Mr. [**Known lastname 13639**] is 87M with history of dementia,
diastolic CHF (EF%60), HTN who presented s/p fall found to have
elevated white count and lactate in the ED, as well as some
hypotension who was started on Levophed.
# Hypotension: The patient was found to be hypotensive in the ED
in the settting of elevated lactate and white count. He had
been afebrile, as per report, with no clear evidence of source
of infection. CXR negative for any acute pulmonary process, UA
negative for nitrite/leuks; cultures NGTD at discharge. The
patient also had e/o skin abrasion on lower back -- not
infected. Lactate initially elevated to 5.8 with acute rise in
creatinine as below. Patient initially required levophed which
was quickly weaned once in the MICU. He was started on levoquin
out of concern for possible respiratory process seen on CT
chest, but this was stopped after further review. LENIs were
performed for evalaution of possible pulmonary embolism causing
his symptoms and were negative. All of the patient's lab
abnormalities corrected with IV fluid arguing for hypovolemia
rather than sepsis as no source of infection could be
identified.
.
# Acute renal failure: The patient had a baseline creat of 0.9;
1.7 on presentation. Urine lytes suggestive of prerenal,
corrected with volume resusitation.
.
# Troponin leak with atrial flutter and RVR: The patient was
noted to have troponin of 0.07; baseline 0.02. No chest pain,
peaked at 0.17, cardiology consulted felt related to demand,
ECHO unchanged from prior. The patient has previously refused
treatment of his tachy-brady syndrome, so no changes were made
to his medications. He had no further issues during this
hospitalization.
.
# Elevated CK: likely from small amount of rhabdo due to fall.
Was resolving at discharge.
.
# Hypoxia: The patient was initially noted to be hypoxic in the
ED satting 86% on RA. He was transferred to the unit on 50%
high flow mask. He was easily weaned to room air.
.
# S/p fall: The patient fell while in the shower; as per OMR
documentation, he apparently has fallen the shower before.
Based on history, it seems like this was a mechanical fall.
Trauma work up negative. Physical therapy cleared the patient
to go home with home PT, home nursing and home safety eval.
This plan was discussed extensively with the patient and his son
[**Name (NI) **] and both felt it was reasonable and safe.
.
# Dementia: The patient has history of dementia, independent
with his ADLs, but needs assistance with cooking, cleaning, etc.
There were no issues with this during the hospitalization.
# Diastolic CHF: no evidence of acute failure despite 4 L of
fluid resusitation. ECHO unchanged from prior.
.
# HTN: Stopped his HCTZ at discharge given that it likely
caused/exacerbated his dehydration that led to the fall.
# Other: A calcified thyroid nodule was seen on his CT spine,
and may require outpatient follow-up.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver Admission
note.
1. Aspirin 325 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Calcitriol 0.25 mcg PO 1X/WEEK (MO)
5. Thyroid 90 mg PO DAILY
6. potassium citrate *NF* 10 mEq Oral DAILY
Aka "Klyte"
7. famciclovir *NF* 500 mg Oral TID
8. Vitamin A Dose is Unknown PO DAILY
9. Thiamine 100 mg PO DAILY
10. Triamcinolone Acetonide 0.1% Cream Dose is Unknown TP
Frequency is Unknown
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Thyroid 90 mg PO DAILY
4. Calcitriol 0.25 mcg PO 1X/WEEK (MO)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Dehydration leading to a fall
Dementia
Diastolic heart failure, ejection fraction 60%
Atrial flutter
Hypertension
Anemia not otherwise specified
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 after a serious fall at home, and were found
to have low blood pressure, fast heart rate and dehydration.
You were given intravenous fluids, and these problems resolved.
I suspect you fell due to dehydration -- you need to stay better
hydrated. You should be urinating several times a day, clear to
light yellow in color. If it's darker, you're dehydrated and
need to drink more. You are at risk for future falls and as a
result need home nursing, home physical therapy and a home
safety evaluation.
Followup Instructions:
2.3 cm calcified thyroid nodule seen on CT spine. [**Month (only) 116**] require
outpatient follow-up.
Department: GERONTOLOGY
When: WEDNESDAY [**2130-7-26**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]
Completed by:[**2130-7-18**]
|
[
"692.9",
"728.88",
"707.21",
"E885.9",
"276.51",
"411.89",
"401.9",
"414.01",
"707.03",
"244.9",
"428.0",
"428.32",
"294.20",
"584.9",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
12002, 12059
|
8322, 11273
|
272, 314
|
12247, 12247
|
4059, 4059
|
12975, 13504
|
3003, 3102
|
11853, 11979
|
12080, 12226
|
11299, 11830
|
12430, 12952
|
3117, 4040
|
228, 234
|
370, 2361
|
4075, 8299
|
12262, 12406
|
2383, 2668
|
2684, 2987
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,595
| 110,363
|
7342
|
Discharge summary
|
report
|
Admission Date: [**2105-1-13**] Discharge Date: [**2105-1-16**]
Date of Birth: [**2034-7-2**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Intermittent claudication
Major Surgical or Invasive Procedure:
Right femoral to above-knee popliteal artery
bypass with an 8-mm PTFE graft
History of Present Illness:
This 70-year-old gentleman is status post an
aortobifemoral bypass in the distant past for aneurysm with
occlusive disease. He has developed bilateral superficial
femoral artery occlusions with severe disabling claudication.
The left side was treated with an angioplasty. The right side
is not amenable to catheter-based intervention. Arteriography
showed reconstitution of an above-knee popliteal artery with
3-vessel runoff below the knee.
Past Medical History:
AAA with illiac artery aneurysms treated with an aortobifemoral
graft [**2089**].
Bilat carotid endarterectomies
CAD - coronary angioplasty and stenting [**2103**]
CABG (LIMA to LAD, SVG to diagonal, SVG to OM, sequential
SVG to AM/PDA)[**2089**]
Hyperlipidemia
HTN
AODM
Cerebral hemorrhage mid [**2085**]??????s
Prior CVA
Social History:
Patient is married with 8 children.
Lives with: Wife
Occupation: [**Name2 (NI) **] fitter - retired
ETOH: Rare
Tobacco: denies
Family History:
non contributory
Physical Exam:
Please See H&P
Pertinent Results:
[**2105-1-13**] 06:51PM GLUCOSE-153* UREA N-19 CREAT-1.1 SODIUM-137
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-21* ANION GAP-14
[**2105-1-13**] 06:51PM estGFR-Using this
[**2105-1-13**] 06:51PM ALT(SGPT)-32 AST(SGOT)-50* ALK PHOS-40
[**2105-1-13**] 06:51PM CK-MB-2 cTropnT-<0.01
[**2105-1-13**] 06:51PM CALCIUM-8.6 PHOSPHATE-4.1 MAGNESIUM-1.9
[**2105-1-13**] 06:51PM HGB-11.9* HCT-35.4*
[**2105-1-13**] 06:51PM PLT SMR-VERY LOW PLT COUNT-50*
[**2105-1-13**] 06:51PM PT-14.3* PTT-30.9 INR(PT)-1.2*
[**2105-1-13**] 05:25PM TYPE-ART PO2-203* PCO2-43 PH-7.34* TOTAL
CO2-24 BASE XS--2
[**2105-1-13**] 05:25PM GLUCOSE-137* LACTATE-1.9 NA+-136 K+-4.1
CL--105
[**2105-1-13**] 05:25PM HGB-12.8* calcHCT-38
[**2105-1-13**] 05:25PM freeCa-1.15
[**2105-1-13**] 03:46PM TYPE-ART PO2-101 PCO2-32* PH-7.45 TOTAL
CO2-23 BASE XS-0
[**2105-1-13**] 03:46PM GLUCOSE-143* LACTATE-1.6 NA+-138 K+-3.9
CL--107
[**2105-1-13**] 03:46PM HGB-14.2 calcHCT-43
[**2105-1-13**] 03:46PM freeCa-1.23
Brief Hospital Course:
This 70-year-old gentleman is status post an aortobifemoral
bypass in the distant past for aneurysm with occlusive disease.
He has developed bilateral superficial
femoral artery occlusions with severe disabling claudication.
The left side was treated with an angioplasty. The right side is
not amenable to catheter-based intervention. Arteriography
showed reconstitution of an above-knee popliteal artery with
3-vessel runoff below the knee. Patient was admitted for Right
femoral to above-knee popliteal artery bypass with an 8-mm PTFE
graft.
Post-op patient was noted to be doing well with minimal pain and
stable hct.
POD1: Patient continued to do well had a small hematoma at his
groin site. DP and PT pulsed were dopplerable bilat.
POD 2: Foley was removed. Patient voided appropriately. Patient
was started on Plavix and tolerated a regular diet.
POD 3: Patient was seen by PT and cleared for home without
services.
Medications on Admission:
[**Last Name (un) 1724**]: Plavix 75', Folate-B6-B12, Gabapentin 1200', Glimepiride 1
mg', Lopressor 50', Simvastatin 80', Sitagliptin 100', ASA 81,
Niacin, Omega FA, Vit E 400'.
Discharge Medications:
1. Oxycodone 5 mg Capsule Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: otc - while on pain medication.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO at
bedtime: home med.
6. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime): home med.
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
home med.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO at bedtime:
home med.
9. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day: home
med.
Discharge Disposition:
Home
Discharge Diagnosis:
Intermittent claudication with right
superficial femoral artery occlusion.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-26**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2105-1-29**] 12:40
|
[
"V45.82",
"V12.54",
"401.9",
"V45.81",
"250.00",
"440.4",
"414.01",
"440.21",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
4567, 4573
|
2438, 3367
|
296, 374
|
4692, 4692
|
1422, 2415
|
7657, 7817
|
1354, 1372
|
3596, 4544
|
4594, 4671
|
3393, 3573
|
4837, 7224
|
7250, 7634
|
1387, 1403
|
231, 258
|
402, 846
|
4706, 4813
|
868, 1193
|
1209, 1338
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,344
| 176,974
|
19776
|
Discharge summary
|
report
|
Admission Date: [**2122-2-4**] Discharge Date: [**2122-2-26**]
Date of Birth: [**2047-8-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Cirrhosis, ESLD, fatigue and malnutrition now s/p liver
transplant
Major Surgical or Invasive Procedure:
[**2122-2-7**]: Paracentesis
[**2122-2-8**]: Paracentesis
[**2122-2-10**]: Paracentesis
[**2122-2-14**]: Liver transplant
History of Present Illness:
74-year-old male from [**Country 4194**] with h/o cirrhosis [**2-9**] to
schistosomiasis treated many years ago with episodes of
encephalopathy, esopageal varices, who has decompensated over
last 6 months currently listed for liver transplant with the
most recent MELD score of 39. He p/w ascites and sob on [**2-4**] to
[**Hospital1 18**].
Paracentesis was performed on [**2-8**] and [**2-8**]. Fluid has been
negative. Dyspnea has improved after para's and diuretics, but
renal function has worsened with creat up to 1.5 from 1.2.
Receiving octreotide/midodrine for HRS. Levaquin and Flagyl were
started for possible aspiration pna as crackles noted on LLL
[**2-9**].
CXR on admit did not show evidence of pna. Rpt cxr [**2-9**] again was
negative for pna. Sputum culture was contaminated. Lactulose and
rifaximin continued for encephalopathy. He has had multiple
BMs/day attributed to lactulose, but a c.diff was sent on [**2-11**]
which was negative. A urine culture was sent on [**2-11**] showing
>100,000 colonies of enterococcus sensitive to vanco.
Past Medical History:
- Cirrhosis h/o variceal bleed in [**10/2116**] s/p banding, thought
[**2-9**] schistosomiasis. Last EGD in [**1-14**] with ligated varices and
gastropathy
- Schistosomiasis on serology IgG, not confirmed on liver
biopsy.
- "Hepatitis" at age 18 characterized by jaundice, abdominal
pain, nausea and vomiting. HAV Ab positive, HBV immunized, HCV
not tested.
- s/p Splenectomy in [**4-14**]
- Pancreatitis
- Benign prostatic hypertrophy
- Aplastic Anemia
- Status post cholecystectomy
Social History:
Patient emigrated from [**Country 4194**] in [**2101**]. Patient lives in MA. He
is married with 4 children. Works as a dishwasher and
maintenance worker. Denies tobacco and drugs. Rare EtOH.
Family History:
Patient had two sisters who died with "cirrhosis" of unknown
etiology. Aunt - diabetes [**Name2 (NI) **]
Physical Exam:
98.1 63 118/66 20 96%RA WT: Gluc 114am.310 at 3pm
(received 6 units humalog)
wife translated for husband
alert, [**Name2 (NI) 27723**]. wife present. very jaundiced. Frail appearing
mmm dry. feeding tube in R nares
neck no jvd, no lad
lungs rales bibasilar (R>L)
cor RRR, no murmurs
Abd very disteneded (ascites, tense). well healed midline scar.
dull on R side. tympanitic over gastric area/LUQ. NT. faint BS
ext 2+ DPs. pitting edema to upper shins bilat.
skin: dry, icteric, warm
M/S: no joint swelling. spine NT. No CVAT
Neuro: A&O, toes down.
Pertinent Results:
Upon Admission: [**2122-2-4**]
WBC-12.0* RBC-3.48* Hgb-12.0* Hct-35.0* MCV-100* MCH-34.4*
MCHC-34.3 RDW-18.4* Plt Ct-198
PT-32.0* PTT-51.5* INR(PT)-3.3*
Glucose-116* UreaN-44* Creat-1.2 Na-137 K-4.6 Cl-111* HCO3-16*
AnGap-15
ALT-110* AST-199* LD(LDH)-345* AlkPhos-324* TotBili-22.8*
Albumin-2.6* Calcium-8.9 Phos-3.1 Mg-2.4
At Dischat=rge: [**2122-2-26**]
WBC-14.6* RBC-2.98* Hgb-9.5* Hct-27.3* MCV-92 MCH-32.0 MCHC-34.9
RDW-16.8* Plt Ct-300
PT-13.3 PTT-24.1 INR(PT)-1.1
Glucose-50* UreaN-22* Creat-0.8 Na-134 K-4.8 Cl-104 HCO3-24
AnGap-11
ALT-32 AST-19 AlkPhos-112 TotBili-1.2
Calcium-7.9* Phos-2.9 Mg-1.4*
Brief Hospital Course:
74 y/o male initially admitted to the hepatology service with
increasing ascites and shortness of breath. He required
paracentesis x 3 and a Dobhoff feeding tube was placed due to
concerns for malnutrition. On [**2122-2-14**]: a liver became available
and he was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for an
orthotopic liver transplant. The surgery was unremarkable, he
received 11 units of FFP, 11 units of packed cells and 2
platelets with an EBL of 1500 cc. The liver made bile on the
table, he was transferred intubated to the SICU.
He received routine induction immunosuppression and was treated
for a recently discovered Vanco sensitive enterococcus in the
urine at the time of transplant. This was subsequently treated
with IV ampicillin for an 8 day course. Subsequent urine culture
was negative.
He was extubated on POD 1 and he was transferred to the regular
surgical floor on POD 3.
He made excellent post op progress, was ambulating with walker
and was tolerating diet with calorie counts being adequete
enough to d/c the Dobhoff and tube feeds as previously ordered.
Both JP drains were removed prior to discharge. He had no
difficulty with voiding once Foley was removed.
He was followed by [**Last Name (un) **], and was initially on insulin, but
they felt for discharge home he could be managed with PO Prandin
and follow-up as an outpatient.
His WBC trended up and he had low grade fever around POD 8. All
cultures were negative, his chest xray was clear and the WBC
started to trend back down.
Liver function improved daily with enzymes WNL by day of
discharge.
Medications on Admission:
cholestyramine 4", lactulose 30qid, nadolol 40', rifaximin
400'", Iron 325', hydrocortisone cr 1% tp qid, clotrimazole 1
troche 5x/day, octreotide 100"', midodrine 5"', flagyl
500"'(started [**2-9**]-Dr. [**Last Name (STitle) 497**] rec stopping [**2-13**]), levofloxacin
250'(started [**2-9**]), bicitra 30ml tid, Nutren 2.0 at 35cc/hr,
insulin ss, lasix 20' (hold per Dr. [**Last Name (STitle) 497**], spironolactone 50mg
qd (stop per Dr.[**Last Name (STitle) 497**])
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p orthotopic liver transplant [**2122-2-14**]
h/o schistosomiasis
cirrhosis
DM
Malnutrition
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medication,
abdominal distension, incision redness/bleeding/drainage,
jaundice, blood sugars over 200s, or any concerns
Labs every Monday and Thursday, fax results to the transplant
clinic at [**Telephone/Fax (1) 697**]
Please check your blood sugars at least twice daily (Fasting and
4PM). Record values and bring to clinic and [**Last Name (un) **] visits
No heavy lifting
No driving if taking narcotic pain medication
You may shower, allow water to run over incision, pat dry, leave
open to air. No tub baths or swimming until notified otherwise
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-3-5**] 1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51535**], M.D. Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2122-3-5**] 3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-3-10**] 10:00
[**Hospital **] Clinic for blood sugars: Call for appointment
[**Telephone/Fax (1) 2384**]
Completed by:[**2122-3-3**]
|
[
"041.04",
"571.5",
"E932.0",
"572.8",
"599.0",
"572.2",
"584.9",
"263.9",
"249.00",
"120.9",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"45.13",
"00.93",
"96.6",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
5807, 5865
|
3652, 5286
|
378, 502
|
6003, 6010
|
3020, 3022
|
6736, 7283
|
2321, 2427
|
5886, 5982
|
5312, 5784
|
6034, 6713
|
2442, 3001
|
272, 340
|
530, 1588
|
3036, 3629
|
1610, 2095
|
2111, 2305
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,992
| 115,338
|
52756
|
Discharge summary
|
report
|
Admission Date: [**2135-1-17**] Discharge Date: [**2135-1-19**]
Date of Birth: [**2099-9-11**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old
woman, who is a current smoker, with family history of early
coronary artery disease, who developed acute, severe chest
pressure while at work as an emergency medical technician.
The patient initially thought this was musculoskeletal;
however, she became diaphoretic, and the chest discomfort
persisted. So, she was brought to an outside hospital in
[**Hospital1 8**], [**State 350**].
At the outside hospital, the patient received 3 sublingual
Nitroglycerin, as well as aspirin, without relief of pain.
The patient was then given Nitroglycerin drip, as well as
started on heparin drip. The patient had a cardiac arrest at
the outside hospital. It was unclear whether it was
ventricular tachycardia versus ventricular fibrillation, as
the outside hospital did not send any ECG strips. The
cardiac arrest responded to 3 shocks with the defibrillator
with return to normal sinus rhythm. The patient was also
started on lidocaine at the outside hospital. ECG at the
outside hospital showed inferior lead ST elevation with
reciprocal changes throughout. The patient was emergently
transferred to [**Hospital1 18**] for coronary catheterization.
At arrival to the cath lab, the patient reportedly had mild
residual discomfort. In the coronary cath lab at [**Hospital1 18**], the
patient was found to have 95% distal right coronary artery
occlusion which received angioplasty, as well as a stent.
The patient developed bradycardia during catheterization and
hypotension which responded to dopamine which was started, as
well as IV fluids and atropine. Dopamine and lidocaine were
discontinued in the catheterization lab. The patient was
started on Neo-Synephrine; however, in the cardiac
catheterization lab for hypotension just prior to transfer to
the coronary care unit.
Upon arrival to the coronary care unit, the patient
complained of right groin pain at the site of
catheterization, but otherwise denied any shortness of
breath, chest pain, chest pressure, nausea, vomiting,
diaphoresis, or any other symptoms. The patient also denied
palpitations.
PAST MEDICAL HISTORY: The patient is obese, otherwise
without significant past medical history.
SOCIAL HISTORY: The patient is a current cigarette smoker.
FAMILY HISTORY: The patient with an uncle who had a
myocardial infarction in his 30s, as well as a grandfather
with a myocardial infarction in his 50s. The patient's
parents both passed away from pulmonary emboli when they were
elderly and bed bound. The patient works as an EMT in
[**Hospital1 8**].
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: None.
PHYSICAL EXAM ON ADMISSION: An obese, young Caucasian woman
lying in bed, mildly agitated, but in no apparent distress.
Physical exam was within normal limits. The patient was
afebrile, heart rate 90, regular rate, blood pressure 127/80.
Heart exam within normal limits with normal S1, S2, no
murmurs appreciated, no S3 or S4. Lungs were clear to
auscultation bilaterally. Patient with mild chest tenderness
to palpation in the sternal area. The remainder of the
physical exam was within normal limits. Right groin site of
catheterization with some mild oozing of blood, as well as a
small, stable hematoma. The patient's pulses were 2+
throughout.
DIAGNOSTICS ON ADMISSION: ECG upon arrival to the coronary
care unit showed normal sinus rhythm at 68, normal intervals,
axis within normal limits. It showed ST elevations in II,
III and AVF, 1 mm in II, 2 mm in III and AVF with reciprocal
ST depressions in I and AVL with T wave inversions, as well
as [**Street Address(2) 4793**] depression in V2. The patient's chemistries were
within normal limits except for potassium of 3.4 from the
outside hospital.
CARDIAC CATHETERIZATION: Please refer to the full report for
further details. It was notable for a 95% distal right
coronary artery stenosis which was stented, but with good
TIMI to distal flow even prior to stent. It also showed a
diffuse 40% proximal LAD stenosis. The left main was normal.
The patient's filling pressures were slightly elevated in the
cath lab with a right atrial pressure of 15, right
ventricular pressure of 38/20, PA pressure of 38/28, and
wedge pressure of 28.
CONCISE SUMMARY OF HOSPITAL COURSE: This 35-year-old female,
a smoker, brought in from an outside hospital with substernal
chest pain, as well as inferior lead ST elevation, status
post coronary catheterization at [**Hospital1 18**] with stent placement.
The patient notably had cardiac arrest at the outside
hospital which responded to defibrillation. The patient
transferred to coronary care unit after coronary
catheterization for further monitoring.
1) CORONARY ARTERY DISEASE: Patient with inferior myocardial
infarction status post right coronary artery stent. The
patient was started on aspirin, Plavix, Lipitor 20 qd, as
well as Integrilin for 18 hours. The patient was started on
low dose beta blocker which was titrated up the day after
admission. The patient also was adamant that she will quit
smoking, as well as maintain a cardiac diet and exercise
regimen.
The patient's early myocardial infarction was concerning for
possible abnormal coagulation underlying problem. The
patient's family history also concerning, as well as parents
who both had pulmonary emboli, although both were reportedly
bed bound at the time. Recommend outpatient work-up of
coagulation studies. This was passed on to the primary care
physician via [**Name Initial (PRE) **] telephone conversation prior to discharge.
The patient had no further symptoms of coronary artery
disease throughout her hospital stay. The patient's ECG
normalized; however, she did develop inferior Q waves by the
day after her myocardial infarction. The patient's creatine
kinase also trended up to a max of approximately 1,500 and
then trended down again. The patient's lipid profile was
obtained and showed a total cholesterol of 140, triglycerides
198, HDL 33, LDL 67.
2) HEMODYNAMICS: The patient arrived from the
catheterization lab on Neo-Synephrine which was titrated off
overnight. The patient's blood pressure tolerated this well,
did not require pressors, and also tolerated the beta blocker
well.
3) RHYTHM: The patient remained in normal sinus rhythm
throughout the remainder of her hospital stay. The patient
did have a short run of 10 beats of ventricular tachycardia
on her first night in the coronary care unit. Other than
this, the patient's rhythm was normal sinus rhythm with very
occasional premature ventricular complexes seen on telemetry.
4) PUMP: The patient's echocardiogram showed an ejection
fraction of 45-50%, as well as focal, severe hypokinesis of
the basal half of the inferior wall. The remainder of the
echocardiogram was within normal limits with 1+ mitral
regurgitation seen. Please refer to the full report for
further details.
5) FLUID, ELECTROLYTES AND NUTRITION: The patient maintained
on a cardiac diet throughout her hospital stay which she
tolerated well.
6) PROPHYLAXIS: The patient was on Integrilin initially and
then ambulated well. The patient also on a bowel regimen as
needed.
7) CODE STATUS: Full code. Communication was daily with the
patient.
8) ACCESS: The patient initially with a Swan-Ganz catheter
that was placed in the catheterization lab which was
discontinued. The patient did have a small femoral artery
hematoma that was stabilized with direct pressure and was
stable x 48 hours at discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Inferior wall myocardial infarction.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg qd.
2. Plavix 75 mg qd.
3. Lipitor 20 mg qd.
4. Toprol XL 50 mg qd.
FOLLOW-UP PLANS:
1. The patient to follow-up with her primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 26773**], within the next 2 weeks. I spoke to Dr. [**Last Name (STitle) 26773**]
over the phone with a brief update of the hospital course and
the importance of close follow-up with PCP, [**Name10 (NameIs) 3**] well as
cardiologist.
2. The patient has an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17437**] who
is a cardiologist who the patient's primary care physician
referred to.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 16731**]
MEDQUIST36
D: [**2135-1-19**] 12:18
T: [**2135-1-19**] 12:26
JOB#: [**Job Number 108811**]
|
[
"997.1",
"458.29",
"427.89",
"E879.0",
"414.01",
"427.1",
"305.1",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"36.01",
"88.52",
"89.64",
"36.06",
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
2434, 2760
|
7740, 7778
|
7801, 7888
|
2782, 2803
|
4433, 7655
|
7905, 8727
|
165, 2258
|
3473, 4404
|
2281, 2356
|
2373, 2417
|
7680, 7718
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,729
| 183,220
|
22181
|
Discharge summary
|
report
|
Admission Date: [**2106-2-9**] Discharge Date: [**2106-2-13**]
Date of Birth: [**2052-6-19**] Sex: M
Service: MEDICINE
Allergies:
Antidepressants O.U. Classifier
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
intubation in ICU
History of Present Illness:
53 y/o M with hx of COPD, OSA, OCD, ADD, bipolar disease and DM
presents today with worsening congestion. Reported to ED that he
has about a month of sinus congestion and then 2-3 days of
worsening symptoms, including cough and dyspnea. Had run out of
his combivent at home. Initially seen in the ED this morning
with SOB and congestion. Was treated for COPD flare with azithro
and solumedrol. Refused admission and left AMA with PO meds. He
denied fevers, chills, nausea, vomiting, headache, fainting,
falls, chest pain or other complaints (per ED report).
.
He returned later this evening with continued symptoms of SOB.
In the ED, initial vs were T 97.1, p 77, bp 145/78, r 20, 96% on
unknown O2 sat. Patient was given methylprednisone 125 mg IV x1,
levofloxacin 750 mg IV x1 and albuterol nebs. At that time, was
satting appropriately until he started to have a depressed
mental status. He was placed on bipap and his CO2 was
7.38/60/81. He remained on bipap for an hour but his mental
status did not improve. His repeat gas was 7.31/69/90. He was
intubated easily and place on a fentanyl and versed gtt for
sedation.
.
In the MICU, the patient was intubated and aggitated despite
being on fentanyl and versed. He was extubated the next day and
did well. He had one episode of desaturation and his ABG at that
time was worse than prior to extubation, but he was likely
hyperventilated on the vent. Pt. continued to be talkative, no
SOB. He was weaned to 3L NC and placed on BiPap ([**10-25**])
overnight. ICU team spoke with [**Last Name (un) 34793**] [**Last Name (un) 57907**] - program director
for his apartment building, obtained med list. According to
[**Last Name (un) 34793**], he takes the clonazepam 4 times per day. He does not have
a HCP, mother is still involved, but pt. asked to contact [**Name (NI) 34793**]
as opposed to his mother.
.
Past Medical History:
PSYCHIATRIC HISTORY:
Dx: per pt and his mother: [**Name (NI) 8372**], ADD, OCD since teenage years.
Hosps: first age 15, last 3 years ago, for bipolar symptoms.
Says
total of "three dozen."
Previous treatments; ECT x 3, last 7 years ago.
Reports becoming manic on "all the antidepressants."
Outpt: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for psychopharm and therapy, in
[**Location (un) **] [**Telephone/Fax (1) 57903**].
Denies h/o SAs/SIb or violence to others.
Lives in [**Location 57904**] independent housing, attends [**Location (un) 15852**] house.
.
PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS):
urinary incontinence, wears "diapers"
HTN
COPD
OSA
LBP
type II diabetes
.
ALLERGIES (INCLUDE REACTION, IF KNOWN): nkda
Social History:
Lives alone in [**Hospital1 **] Family and Social Services Apartment in
Brooline ([**First Name4 (NamePattern1) 6107**] [**Last Name (NamePattern1) **]). Says that he has a undergrad degree
from SUNY [**Location (un) **] and took some master's level courses in Pol
science and history. Mother lives in [**Name (NI) **], [**Name (NI) 531**]. He
speaks to her by phone several times per day and she provides
him some financial support. On SSDI. No arrest history. Has not
worked since being a social studies and English teacher in the
[**2065**]-80s.
- Tobacco: 1 ppd x many years
- Alcohol: denies
- Illicits: denies
Family History:
father, sister, [**Name2 (NI) **]. aunt with bipolar.
Physical Exam:
Vitals: T: 95.8, BP: 142/70, P: 120, R: 18, O2: 93% 2L
General: NAD, cooperative
Neck: supple, JVP not elevated, no LAD
Lungs: b/l mild wheeze otherwise CTAB
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, ND, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2106-2-9**] 04:30PM BLOOD WBC-8.1 RBC-4.97 Hgb-14.4 Hct-43.9 MCV-88
MCH-29.1 MCHC-32.9 RDW-13.2 Plt Ct-309
[**2106-2-9**] 10:10PM BLOOD WBC-9.0 RBC-5.08 Hgb-13.9* Hct-43.3
MCV-85 MCH-27.4 MCHC-32.1 RDW-13.1 Plt Ct-270
[**2106-2-12**] 05:35AM BLOOD WBC-13.4* RBC-4.80 Hgb-14.0 Hct-42.4
MCV-88 MCH-29.1 MCHC-33.0 RDW-13.3 Plt Ct-279
[**2106-2-9**] 04:30PM BLOOD Neuts-57.4 Lymphs-31.8 Monos-7.0 Eos-2.7
Baso-1.2
[**2106-2-10**] 04:40AM BLOOD Neuts-80.6* Lymphs-13.9* Monos-4.1
Eos-1.0 Baso-0.4
[**2106-2-10**] 04:40AM BLOOD PT-13.4 PTT-26.0 INR(PT)-1.1
[**2106-2-9**] 04:30PM BLOOD Glucose-62* UreaN-13 Creat-0.8 Na-143
K-4.7 Cl-101 HCO3-35* AnGap-12
[**2106-2-12**] 05:35AM BLOOD Glucose-95 UreaN-21* Creat-0.7 Na-143
K-4.4 Cl-102 HCO3-38* AnGap-7*
[**2106-2-10**] 04:40AM BLOOD ALT-11 AST-15 AlkPhos-63 TotBili-0.2
[**2106-2-12**] 05:35AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.0
[**2106-2-9**] 10:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2106-2-10**] 02:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2106-2-10**] 02:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2106-2-10**] 02:00AM URINE
.
.
.
[**2106-2-12**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT - negative
[**2106-2-10**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2106-2-10**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2106-2-10**] URINE Legionella Urinary Antigen -FINAL INPATIENT -
negative
[**2106-2-10**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2106-2-9**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
.
.
Brief Hospital Course:
53 y/o M with complicated past psychological history, COPD, OSA
and DM who presents with worsening congestion, SOB and potential
COPD flare vs. pneumonia.
.
# Respiratory Distress: likely from a COPD flare (not on home
O2) with superimposed LLL collapsed and likely PNA. initially
needed intubation for 1 day due to hypoxia and respiratory
failure. received solumedrol 125 mg IV q8 hrs in ICU, then
stopped, no need for taper. initially had swallowing difficulty
when extubated but S+S has since cleared pt. we started
fluticasone inhaler and sent him home to finish levoquin for a
total 10 days.
.
# Diarrhea: new onset overnight when pt came to the floor.
unclear etiology. reported to be guiaic pos but HCT stable. pt
was C diff neg and diarrhea resolved.
.
# Leukocytosis: WBC trending up. likely secondary to solumedrol.
No other signs of infx.
.
# OSA: has hx of severe OSA on bipap at home. pt should continue
his home BIPAP ([**10-25**]).
.
# Bipolar: has hx of bipolar disease. On clonazepam 1 mg [**Month/Day (4) **],
clozapine 250 mg daily, depakote 1500 mg [**Hospital1 **], and thiothixene 10
mg daily. Spoke with outpt psychiatrist and program director who
both said pt was safe to go home and had enough supports.
.
# Urinary Incontinence: apparently chronic due to BPH. cont
terazosin
.
.
# Communication: patient intubated; [**Name (NI) 34793**] [**Name (NI) 57907**] (pt's program
director)[**Telephone/Fax (1) 57908**] (w) [**Telephone/Fax (1) 57909**] (c) , Psychiatrist Dr.
[**First Name (STitle) **] [**Telephone/Fax (1) 57903**]
# Code: Full (presumed)
.
Medications on Admission:
# Clonazepam 1 mg [**Name (NI) **] PRN - pt. takes [**Name (NI) **] on a regular basis
# Clozapine 200 mg daily
# Depakote 1000 mg [**Hospital1 **]
# Terazosin 2 mg daily
# Combivent inhaler
# Thiothixene 10 mg daily
# Xalatan Eye Drop 0.005% 1 drop each eye qhs
Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO [**Hospital1 **] (4 times a
day).
2. Thiothixene 5 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Combivent 18-103 mcg/Actuation Aerosol Sig: [**11-21**] puff
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Clozapine 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
8. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
9. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Nicotine (Polacrilex) 2 mg Gum Sig: One (1) Gum Buccal Q1H
(every hour) as needed for craving.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
COPD exacerbation
PNA
.
Secondary:
OSA
DM
BPH
ADD
bipolar
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted due to pneumonia and COPD exacerbation. You
were intubated and in the ICU for one day. You improved with
antibiotics and steroids and were transferred to the medical
floor. You are to finish your antibiotic course as prescribed.
You are to also start taking fluticasone inhaler. There were no
other changes to your medications.
.
Please take all medications as prescribed.
Please follow up with all appointments.
Please do not hesitate to return to the hospital if you have any
concerning symptoms at all
.
Followup Instructions:
Please follow up with your primary care provider and
psychiatrist in the next 14-21 days.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
|
[
"787.91",
"305.1",
"296.89",
"491.21",
"600.01",
"486",
"401.9",
"518.0",
"314.00",
"327.23",
"250.00",
"518.81",
"788.30",
"300.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
8824, 8830
|
5868, 7447
|
295, 315
|
8941, 8941
|
4160, 5845
|
9638, 9853
|
3679, 3734
|
7760, 8801
|
8851, 8920
|
7473, 7737
|
9089, 9615
|
3749, 4141
|
252, 257
|
343, 2200
|
8956, 9065
|
2222, 3029
|
3045, 3663
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,132
| 199,113
|
38033
|
Discharge summary
|
report
|
Admission Date: [**2189-8-12**] Discharge Date: [**2189-8-17**]
Date of Birth: [**2151-4-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
clindamycin / Nafcillin / amoxacillin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
epigastric pain and + blood cultures
Major Surgical or Invasive Procedure:
[**2189-8-12**] Aortic valve replacement with a 21 mm On-X mechanical
valve, serial number [**Serial Number 84951**], reference number [**Serial Number 42227**]
History of Present Illness:
38 year old female 8 weeks pregnant transferred from [**Hospital1 **] on [**2189-7-18**] with epigastric pain, +IVDU, found to have
Staph auerus bacteremia (oxacillin sensitive) and started on IV
vanco. Admitted to [**Hospital1 18**] : blood cultures positive staph coag
positive 3/4 bottles. ID was consulted and recommended
continuing IV vanco and cultures (see OMR note). HIV neg and Hep
C positive (new diagnosis). A TEE was performed and showed
perforation of non-coronary aortic valve leaflet without a
discerete vegetation and severe (4+) aortic regurgitation. She
is now being referred to cardiac surgery for an aortic valve
replacement.
Past Medical History:
Endocarditis
OB/GYN: G5P3A2
Morbid Obesity
s/p cholecystectomy in [**2186**]
Iron Deficiency Anemia
PCOD
GERD
Depression
Polysubstance use
Social History:
Race:caucasian
Last Dental Exam: one month ago- needs root canal and teeth in
general poor condition
Lives with: is a single mother, currently lives alone
Contact:[**Name (NI) 6480**] [**Name (NI) 80966**] (mother) Phone #[**Telephone/Fax (1) 84952**]
Occupation: has not worked for over a year- prior medical
secretary
Cigarettes: Smoked no [] yes [x] current smoker, smokes [**Date range (1) 8642**]
ppd
Other Tobacco use: -
ETOH: < 1 drink/week [x] [**2-24**] drinks/week [] >8 drinks/week []
Illicit drug use: last use of heroin 3 days prior to
presentation in early [**Month (only) 205**], uses adderal 90-120mg IV/day.
History of cocaine (has not used for 1 year).
Mother also is an IVDA
Family History:
Non-contributory
Physical Exam:
Pulse:91 Resp:18 O2 sat:100/RA
B/P 100/65
Height:5'6" Weight:91 kgs
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 [x] grade II/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities [x-none]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right:+2 Left:+2
Carotid Bruit Right: none Left:none
Pertinent Results:
Echo [**2189-8-12**]: 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. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricle displays normal free wall contractility. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. There is no aortic valve stenosis. There is a
perforation of the non-coronary cusp. Moderate to severe (3+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**1-19**]+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results in the operating room at the time of
the study.
POST BYPASS The patient is in sinus rhythm. There is normal
biventricular systolic function. There is a bileaflet prosthesis
in the aortic position. It appears well seated and in limited
views it appears the leaflets are moving normally. There is
trace-mild valvular regurgitation seen as is expected from this
valve. Poor imaging windows prevent complete exclusion of a
small paravalvular regurgitant jet. The peak gradient was around
20 mmHg with a mean near 10 mmHg at a cardiac output of around 7
liters/minute. The effective aortic valve area was around 1.8
cm2. The mitral regurgitation is still in the mild to moderate
range. The rest of the exam is unchanged from the pre-bypass
study. The thoracic aorta appears intact after decannulation.
.
[**2189-8-17**] 09:38AM BLOOD WBC-7.8 RBC-3.01* Hgb-8.5* Hct-26.1*
MCV-87 MCH-28.1 MCHC-32.4 RDW-16.7* Plt Ct-388
[**2189-8-15**] 04:48AM BLOOD WBC-9.1 RBC-2.74* Hgb-7.7* Hct-24.3*
MCV-89 MCH-28.0 MCHC-31.7 RDW-17.5* Plt Ct-259
[**2189-8-17**] 05:35AM BLOOD PT-28.4* INR(PT)-2.7*
[**2189-8-16**] 06:03AM BLOOD PT-26.5* INR(PT)-2.5*
[**2189-8-15**] 01:56PM BLOOD PT-26.6* INR(PT)-2.6*
[**2189-8-15**] 04:48AM BLOOD PT-28.8* INR(PT)-2.8*
[**2189-8-14**] 03:26AM BLOOD PT-15.3* INR(PT)-1.4*
[**2189-8-12**] 01:16PM BLOOD PT-11.7 PTT-28.9 INR(PT)-1.1
[**2189-8-16**] 06:03AM BLOOD UreaN-19 Creat-0.8 Na-141 K-4.6 Cl-103
[**2189-8-15**] 04:48AM BLOOD Glucose-119* UreaN-19 Creat-0.7 Na-139
K-3.7 Cl-103 HCO3-27 AnGap-13
[**2189-8-14**] 03:26AM BLOOD Glucose-121* UreaN-13 Creat-0.8 Na-138
K-4.2 Cl-101 HCO3-27 AnGap-14
Brief Hospital Course:
Mrs. [**Known lastname 84950**] 38 yr old with h/o IVDU recently diagnosed Staph
auerus bacteremia endocarditis newly intolerant to nafacillin.
Pregnancy terminated and pt was tranferred back to the [**Hospital1 **]
to recover from D&C. She was transferred back from the [**Hospital **]
hospital on [**8-12**] and was brought directly to the operating room
where she underwent an aortic valve replacement (21mm On-X
Mechanical). Please see operative note for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. Later that day she was weaned
from sedation, awoke neurologically intact and extubated. She
had a high tolerance to pain meds and required high doses of
dilaudid. The acute pain service was consulted and she was
started on Dilaudid PCA. She transferred to the floor in stable
condition. Pacing wires and chest tubes removed without
difficulty.
She was weaned from the PCA to PO Dilaudid. She has remained
afebrile and will remain on IV Kefzol until [**9-1**]. OR cultures
revealed no growth. PICC line was placed. Beta blocker and
lasix were started and she was diuresed towards her preoperative
weight. Anti-coagulation was pursued with Warfarin. INR was
therapeutic at 2.7 on the day of discharge. She was seen by the
physical therapy department. By the time of discharge on POD# 5
she was in stable condition. Pain adequately controlled with
oral dilaudid,sternal wound healing well. She was discharged to
the [**Hospital6 2222**], appointments and follow-ups
arragnged.
Medications on Admission:
1. ALPRAZolam *NF* 1 mg Oral [**Hospital1 **]
2. Escitalopram Oxalate 20 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. Ranitidine 150 mg PO BID
5. Ferrous Sulfate 325 mg PO BID
6. Heparin 5000 UNIT SC TID
7. HYDROmorphone (Dilaudid) 0.5 mg IV Q4H:PRN pain hold for
sedation or RR<10
8. Ibuprofen 600 mg PO Q8H:PRN headache
9. Nafcillin 2 g IV Q4H
10. Nicotine Lozenge 2 mg PO Q1H:PRN craving
11. Nicotine Patch 14 mg TD DAILY
12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC,
non-heparin dependent: Flush with 10 mL Normal Saline daily and
PRN per lumen.
13. MetFORMIN XR (Glucophage XR) 500 mg PO QPM Do Not Crush
14. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. ALPRAZolam 2 mg PO TID:PRN anxiety
2. Aspirin EC 81 mg PO DAILY
3. Bisacodyl 10 mg PR DAILY:PRN constipation
4. CefazoLIN 2 g IV Q8H MSSA Endocarditis
Stop date [**2189-9-1**]
*Endocarditis
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 800 mg PO TID
7. 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.
8. HYDROmorphone (Dilaudid) 6-8 mg PO Q4H:PRN pain
9. Ibuprofen 600 mg PO Q8H
10. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
11. Milk of Magnesia 30 ml PO HS:PRN constipation
12. Nicotine Patch 21 mg TD DAILY
13. Ranitidine 150 mg PO BID
14. Warfarin 5 mg PO DAILY16
Dose to change daily for goal INR 2.5-3.5 for Mechanical Aortic
Valve
15. Furosemide 40 mg PO DAILY Duration: 7 Days
16. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
Hold for K+ > 4.5
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Aortic valve endocarditis s/p Aortic valve replacement
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with PO dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Edema: trace lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**], [**2189-9-17**] 1:00 in
the [**Hospital **] medical office building , [**Doctor First Name **], [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 28334**] [**2189-9-7**] at 1:00p
[**Location (un) **] [**Apartment Address(1) 32773**]
[**Location (un) 936**] [**Numeric Identifier 2876**]
[**Telephone/Fax (1) 84953**]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **], [**First Name3 (LF) 5320**] [**Telephone/Fax (1) 57304**] in [**4-23**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Mech AVR
Goal INR 2.5-3.5
First draw [**2189-8-18**]
Completed by:[**2189-8-17**]
|
[
"305.50",
"070.70",
"421.0",
"424.1",
"V85.30",
"250.00",
"041.11",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
8749, 8822
|
5533, 7084
|
341, 503
|
8920, 9116
|
2745, 5510
|
10039, 11044
|
2068, 2086
|
7801, 8726
|
8843, 8899
|
7110, 7778
|
9140, 10016
|
2101, 2726
|
265, 303
|
531, 1178
|
1200, 1340
|
1356, 2052
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,228
| 198,053
|
17864
|
Discharge summary
|
report
|
Admission Date: [**2159-6-11**] Discharge Date: [**2159-6-21**]
Date of Birth: [**2120-2-4**] Sex: M
Service: Thoracic Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 19672**] is a
39-year-old male with a history of tracheomalacia who
recently had stents placed and then removed approximately two
days prior to admission. The patient presented with several
hours of worsening dyspnea and described a sensation of being
filled up, which he described as worse than usual. He was
admitted to the intensive care unit at this time for
bronchoscopy as well as careful observation for a potential
respiratory failure. Although at this time, given the
copious purulent secretions found on the bronchoscopy, as
well as friable airway, the thoracic surgical service was
consulted for potential surgical intervention.
PAST MEDICAL HISTORY: 1. Insulin dependent diabetes
mellitus. 2. Hypertension. 3. Tracheomalacia with chronic
cough. 4. Status post eye surgery. 5. Osteoporosis.
MEDICATIONS ON ADMISSION: 1. Atacand 32 p.o. q.d. 2.
Tramadol 1 t.i.d. 3. Albuterol. 4. Lipitor 40 q.d. 5.
Norvasc 5 p.o. q.d. 6. Bactrim DS b.i.d.
LABORATORY DATA: Sodium 138, potassium 4.2, chloride 99,
bicarbonate 29, BUN 20, creatinine 1.3 down from 1.6, calcium
9.3, phosphorous 4.4, magnesium 1.9.
PHYSICAL EXAMINATION: Vital signs were temperature 98.2,
pulse 70, blood pressure 138/76, respiratory rate 16, 98% on
room air. The patient was a well-developed, well-nourished
male in no apparent distress at the time of discharge.
HEENT: Mucous membranes were moist, no evidence of oral
ulcers. Cranial nerves II-XII were intact. There was no
evidence of cervical lymphadenopathy. Sclerae were
anicteric. Chest: Very coarse breath sounds, no evidence of
wheeze, positive rhonchi. Cardiac: Regular rhythm and rate,
no evidence of murmurs. Abdomen: Soft, nondistended,
nontender with positive bowel sounds and no evidence of
hepatosplenomegaly nor inguinal lymphadenopathy.
Extremities: No evidence of edema, no evidence of rash.
HOSPITAL COURSE: Mr. [**Known firstname **] [**Known lastname 19672**] is a 39-year-old male with
a history of tracheomalacia status post removal of stents
presenting with significant airway obstruction secondary to
heavy secretion as well as bleeding. Because of unstable
respiratory status, the patient was intubated and further
evaluated by the thoracic service. By [**2159-6-14**] the patient
was extubated and underwent another bronchoscopy which showed
interval improvement on examination. The patient was
receiving aggressive pulmonary toilet and was receiving Zosyn
during this period. Further bronchoscopy continued to show
thick copious secretions especially in the left lower lobe
appearing near complete obstruction. These areas were
removed with suction.
By [**2159-6-15**] the decision was made to take the patient to the
operating room to repair the tracheomalacia by performing
posterior membranous tracheobronchoplasty with Marlex mesh.
Surgical findings included inflamed airway, dynamic collapse
which was repaired and postoperatively showed good patency.
Postoperatively the patient remained intubated and
antibiotics were continued. Epidural analgesia was used for
pain control and further adjusted for occasional hypotensive
episodes. The patient was also weaned off of Neo-Synephrine
during postoperative day number one and promptly extubated.
By postoperative day number two the patient underwent another
bronchoscopy to perform a therapeutic postoperative removal
of bilateral secretions which were mildly purulent. Post
bronchoscopy showed distal airways patent and membranous
trachea mildly bulging into the trachea. Lasix was also
initiated at this time and Norvasc and Lopressor were
initiated since blood pressure was stable. The patient
remained in the intensive care unit for continued respiratory
care which included frequent pulmonary toilet as well as
chest physiotherapy along with frequent respiratory care
which would not otherwise be available on the floor of the
hospital. However by postoperative day number five, the
patient had significantly progressed to the point of being
weaned completely off of any supplemental oxygen and
maintaining good oxygen saturation. By postoperative day
number six the patient underwent a bronchoscopy which
revealed a mild amount of secretions, however significantly
improved since beginning of admission and the decision was
made to discharge the patient with a follow-up bronchoscopy
on [**2159-6-23**] by Dr. [**Last Name (STitle) 952**]. At this time the patient was in
very good condition and maintained good oxygen saturation
without any supplemental oxygen support.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with follow up with Dr. [**Last Name (STitle) 952**] for
a bronchoscopy on [**2159-6-23**].
DISCHARGE DIAGNOSES:
1. Status post multiple bronchoscopies.
2. Status post posterior membranous tracheobronchoplasty with
Marlex mesh.
DISCHARGE MEDICATIONS:
1. Albuterol 1-2 puffs inhalation q. 4-6 hours p.r.n. wheeze.
2. Benzonatate 100 mg capsules 1 p.o. t.i.d.
3. Amlodipine 5 mg p.o. q.d.
4. Atorvastatin 40 mg p.o. q.d.
5. Dornase inhalation once daily.
6. Percocet 5/325 one to two tablets p.o. q. 4-6 hours p.r.n.
pain.
7. Colace 100 mg p.o. b.i.d.
FOLLOW UP: The patient was instructed to follow up with Dr.
[**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] on [**2159-6-23**]. The patient is also to follow up
with Dr. [**Last Name (STitle) 49535**] in one week after discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Name8 (MD) 11079**]
MEDQUIST36
D: [**2159-6-21**] 12:49
T: [**2159-6-21**] 13:33
JOB#: [**Job Number 49536**]
cc:[**Last Name (STitle) 49537**]
|
[
"934.1",
"362.01",
"519.1",
"518.82",
"733.02",
"250.51",
"458.2",
"998.11",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.56",
"98.15",
"31.79",
"33.48",
"96.71",
"96.05",
"96.04",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
4928, 5044
|
5067, 5367
|
1061, 1347
|
2108, 4755
|
5379, 5925
|
1370, 2090
|
177, 866
|
889, 1034
|
4780, 4907
|
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