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14796
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Discharge summary
|
report
|
Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Right leg pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V
(not currently on HD or PD), and multiple admissions for
hypertensive urgency/emergency, who presented to the ED for
continued R leg pain that starts in her R buttocks and refers
down her R leg. She describes it as feeling like the pain is
deep within her bone. The pain was [**10-20**] in the AM, and she
felt like she couldn't get out of bed. Denies any swelling of
her RLE. When getting VS in [**Name (NI) **], pt noted to be very
hypertensive at 263/176. The patient reportedly has baseline
SBPs in 130-170s. She took her hydralazine, aliskirien, and
labetalol at 5 AM on day of admission. She denies any recent
recrational drug use including cocaine and amphetamines. She
denies headache, vision changes, double vision, chest pain,
shortness of breath, abdominal pain, BRBPR, dysuria. During MD
interview, the patient was nauseous and had small amount of
emesis of a recent Coolata. Pt states that flushing her PD cath
causes a large amount of stomach pain.
.
Of note, the patient was recently admitted from 08.26-29.08. The
patient initially presented to the ED after referral from her
nephrologist's office where she had complaints of right leg pain
and was found to be hypertensive to 250/145. She was admitted
after initiation of a labetalol drip and nitropaste with
improvement in sbp to 180. The patient did receive 2 U of PRBC's
during this hospitalization for baseline anemia. The patient did
have a work-up for her right leg pain complaints with plain
films of the right hip and MRI of the L-spine which did not
reveal an explanation for her symptoms and did rule out
avascular necrosis. The patient received dilaudid for pain
control and was ambulating without pain prior to discharge. In
addition, the patient completed a course of ciprofloxacin for a
positive UA with negative cultures. The patient was unable to
tolerate peritoneal dialysis for unclear reasons. Peritoneal
dialysate culture was negative for infection.
.
In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA.
BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108.
Initially given labetalol 10 mg IV x 1 and then started on
labetalol gtt for her elevated blood pressures and titrated to 3
mg/min. LENI of R leg was negative. CXR performed. Given
morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan
due to volume overload after talking with radiology. Renal c/s
initiated. A-line placed.
Past Medical History:
- Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old)
when she had swollen fingers, arm rash and arthralgias. Previous
treatment with cytoxan, cellcept; currently on prednisone.
Complicated by uveitis ([**2139**]) and ESRD ([**2135**]).
- CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter
placement [**5-18**]. Pt reluctant to start PD.
- Malignant hypertension. Baseline BPs 180's - 120's. History of
hypertensive crisis with seizures. History of two
intraparenchymal hemorrhages that were thought to be due to the
posterior reversible leukoencephalopathy syndrome.
- Thrombocytopenia. TTP (got plasmapheresisis) versus malignant
HTN.
- Thrombotic events. SVC thrombosis ([**2139**]); related to a
catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]).
Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]).
Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]).
- HOCM: Last noted on echo [**8-17**].
- Anemia.
- History of left eye enucleation [**2139-4-20**] for fungal infection.
- History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion.
- History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
.
PAST SURGICAL HISTORY:
- Placement of multiple catheters including dialysis.
- Tonsillectomy.
- Left eye enucleation in [**2140-4-10**].
- PD catheter placement in [**2141-5-11**].
Social History:
Single. Recently moved into her own apartment. On disability.
Denies EtOH, tobacco or recreational drug use.
Family History:
Negative for autoimmune diseases, thrombophilic disorders.
Maternal grandfather with HTN, MI, stroke in 70s.
Physical Exam:
VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA
GEN: NAD, pleasant female sitting in bed with moon facies
HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema,
MMM, no LAD
CHEST: CTAB except at R base with decreased breath sounds; no
w/r/r
CV: tachy, normal S1S2, II/VI systolic murmur accentuated with
Valsalva
ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing
c/d/i
EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally.
Negative straight leg test, no pain with internal rotation,
external rotation, extension, adduction or abduction. Some pain
on flexion at the hip.
NEURO: II - XII intact to direct testing. No deficit in light
tough sensation. Gait normal.
DERM: no rashes noted
Pertinent Results:
LABS AT ADMISSION:
[**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139
POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18
[**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6
[**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7*
[**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86
MCH-28.1 MCHC-32.8 RDW-18.0*
[**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3
BASOS-0.2
[**2141-9-11**] 07:00AM PLT COUNT-101*
UA: moderate leuk, small blood, negative nitrite, protein 100,
21-50 WBC
.
MICROBIOLOGY:
Urine culture ([**2141-9-11**]): Mixed flora
.
STUDIES:
Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM
Sinus tachycardia. The tracing is marred by baseline artifact.
There is
left atrial enlargement. Compared to the previous tracing of
[**2141-9-5**]
the rate has increased. The axis is more rightward. Otherwise,
no diagnostic interim change.
.
UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM
[**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral,
superficial
femoral, and popliteal veins demonstrate normal flow,
compressibility,
augmentation, waveforms. Appropriate color flow and compression
is noted
within the calf veins. No intraluminal thrombus is present.
IMPRESSION: No evidence of right lower extremity DVT.
.
TTE ([**2140-8-26**]): The left atrium is normal in size. There is
severe symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is a mild resting left ventricular
outflow tract obstruction. The gradient increased with the
Valsalva manuever. The findings are consistent with hypertrophic
obstructive cardiomyopathy (HOCM). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
.
R HIP XR [**2141-9-6**]: No acute fracture or dislocation.
.
MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified
in the bone marrow of the lumbar and lower thoracic spine as
described above, possibly related with anemic changes, please
correlate clinically. There is no evidence of spinal canal
stenosis or neural foraminal narrowing at the different
intervertebral disc spaces.
LAB RESULTS AT DISCHARGE:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0*
100*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2141-9-14**] 06:15AM 6.8* 5.4* 1.6
CALCIUM freeCa
[**2141-9-14**] 11:30AM 0.94*
Brief Hospital Course:
ICU course:
EKG showed no change from prior, and CXR showed a suggestion of
RLL/R diaphragm haziness. IV labetalol was started, and SBPS
dropped from 200s to 130s-160s. The patient had no symptoms of
end-organ damage. The renal team was consulted, and recommended
no change to home medication regimen. The patient was found to
by hypocalcemic, and was started on calcium replacement therapy.
When stable, patient succesfully switched to PO meds and
transferred to the floor.
.
[**Hospital1 **] history:
.
1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her
SBPs ranged from 140s-160s during the day, which is her baseline
systolic blood pressure. She was maintained on her home oral
medication regimen. At night, she became more hypertensive,
with SBP to the 170s-180s, which was controlled with both IV
hydralazine and PO nifedipine. PO nifedipine was most
successful at bringing her SBP back to her baseline. SBP at
discharge was 140. Throughout her hospitalization, the patient
had no symptoms/signs of hypertensive emergency, including no
seizures, no acute worsening of renal function, no headache,
nausea, visual and mental status disturbances, chest pain,
abdominal pain, or urinary symptoms. The renal service followed
her throughout her course and did not recommend any changes to
her regimen, but will follow her closely as an outpatient.
.
2. Right leg pain: Upon arrival on the floor, the patient
complained of [**2143-4-15**] pain in R buttock and posterior thigh, much
exacerbated with standing. Of note, lumbar spine MRI and R hip
XR on most recent admission were both negative. Her pain was
intermittent, likely secondary to sciatica, and had resolved by
the time of her discharge. Her pain when she was symptomatic
was controlled well with PO dilaudid. If the pain recurs, an
MRI of the right hip can be considered to evaluate for
osteonecrosis.
.
3. UTI: The patient had a urinalysis suggestive of UTI, though
she remained asymptomatic throughout. She was treated with a
three day course of ciprofloxacin. Her urine culture showed
mixed flora consistent with skin contamination.
.
4. ESRD: The patient has end-stage renal disease due to her
lupus. The patient's creatinine remained stable at 7.9-8.4
throughout her hospitalization, which was similar to her
baseline renal function. She was followed by the renal consult
service. Her potassium remained stable. Her calcium was low
during admission, and supplemental calcium was given in addition
to starting Calcitriol. She was not dialyzed through her PD
catheter secondary to discomfort, but may reinitiate PD as an
outpatient. Her laboratories will be checked as an outpatient
in renal clinic.
.
5. Anemia: The patient's hematocrit remained near her baseline
low 20s throughout her stay. She has anemia from chronic kidney
disease and chronic disease. The patient is not on Epopoeitin
as an outpatient, likely due to her malignant hypertension.
.
6. Prior SVC thrombus: The patient has a reported history of
prior thrombus related to catheter placement in [**2139**], and was
maintained on warfarin with INR goal 2.5 to 3.0.
.
7. Systemic lupus erythematosus: No active issues. The
patient's home prednisone regimen was continued.
Medications on Admission:
- Prednisone 5 mg Daily
- Coumadin 2 mg at bedtime
- Nifedipine 60 mg Sustained Release Daily
- Hydralazine 50 mg every 8 hours
- Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday
- Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY
- Aliskiren 150 mg Twice daily
- Docusate Sodium 100 mg 2 times a day
- Labetalol 900 mg three times a day
- Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel
movements per day
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
- Hypertensive urgency
- Right lower extremity pain
- Urinary tract infection
Secondary diagnosis:
- Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old)
when she had swollen fingers, arm rash and arthralgias. Previous
treatment with cytoxan, cellcept; currently on prednisone.
Complicated by uveitis ([**2139**]) and ESRD ([**2135**])
- CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter
placement [**5-18**]. Pt reluctant to start PD
- Malignant hypertension. Baseline BPs 180's - 120's. History of
hypertensive crisis with seizures. History of two
intraparenchymal hemorrhages that were thought to be due to the
posterior reversible leukoencephalopathy syndrome
- Thrombocytopenia. TTP (got plasmapheresisis) versus malignant
HTN
- Thrombotic events. SVC thrombosis ([**2139**]); related to a
catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]).
Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]).
Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
- HOCM: Last noted on echo [**8-17**]
- Anemia
- History of left eye enucleation [**2139-4-20**] for fungal infection
- History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera
injection requiring transfusion.
- History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
Discharge Condition:
Stable systolic blood pressure over past 24 hours.
Discharge Instructions:
You were admitted to the hospital for uncontrolled high blood
pressure. You spent one day in the intensive care unit, where
you were treated with intravenous medication to lower your blood
pressure. You were then transferred to a regular hospital
floor, where your blood pressure was managed with your home oral
medications. You were also treated for urinary tract infection
with antibiotics. Your right leg pain improved during
admission, and we are unsure of the cause of this pain. You
should discuss the need for an MRI of the hip if the pain
returns when you meet with your primary care doctor.
Please call your physician or return to the emergency room if
you experience fever, chills, chest pain, difficulty breathing,
abdominal pain, headache, changes in your vision, or any other
symptoms that are concerning.
Please take your medications as prescribed.
- Calcitriol was added to your medications.
- You should hold Coumadin for two days and restart Saturday,
[**2141-9-16**]. You should have your INR checked at your visit in
kidney clinic [**2141-9-18**].
- You can take Dilaudid 2-4 mg every eight hours as needed for
pain. You should be vigilant about taking lactulose if you need
to take Dilaudid.
- You should continue Lactulose as per Dr.[**Name (NI) 12913**]
instructions.
- No other changes were made.
Please keep follow up appointments as described below.
Followup Instructions:
Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at
([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed.
Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00
Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**]
[**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00
|
[
"287.5",
"582.81",
"599.0",
"403.01",
"285.29",
"724.3",
"V12.51",
"710.0",
"790.92",
"276.7",
"425.4",
"252.00",
"585.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
13320, 13377
|
8619, 11868
|
296, 304
|
14822, 14875
|
5347, 8170
|
16308, 16873
|
4475, 4586
|
12337, 13297
|
13398, 13398
|
11894, 12314
|
14899, 16285
|
4173, 4332
|
4601, 5328
|
8184, 8596
|
241, 258
|
332, 2836
|
13517, 14801
|
13417, 13496
|
2858, 4150
|
4348, 4459
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,979
| 171,841
|
6149
|
Discharge summary
|
report
|
Admission Date: [**2169-11-7**] Discharge Date: [**2169-11-13**]
Date of Birth: [**2096-6-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Anemia and melena
Major Surgical or Invasive Procedure:
Endoscopy
Colonoscopy
History of Present Illness:
73 y/o M w/ CAD s/p 4v-CABG [**2155**] (LIMA--> LAD, SVG--> Diag,
SVG--> R1, SVG--> PDA) s/p PCI to native diag [**2-/2169**], DM2,
severe pulmonary HTN, AF (on coumadin), s/d CHF (LVEF 45-55% per
TTE), AF and tachy-brady syndrome s/p PPM and hx UGIB [**1-24**]
Dieulafoy's lesion on p/w 5 days of worsening SOB, weakness,
dark black pasty stools and epigastric discomfort. He has been
having SOB for the past month and is followed in heart failure
clinic by Dr [**First Name (STitle) 437**]. During a recent clinic visit, his home
diuretic was changed from lasix 120 [**Hospital1 **] to torsemide 100mg
daily, however he continued to have dyspnea. On [**2169-11-2**] he was
seen by his PCP for hand cellulitis, at which time he was
started on bactrim and his torsemide dose was doubled to 200mg
daily around the same time. Despite the changes in his diuretic
dose his dyspnea continued, which is associated w/
lightheadedness and presyncopal episodes, along with some mild
epigastric discomfort. He believes the dark stools began on
Thursday; he describes them as as black and pasty. He denies red
or maroon stool, blood in the toilet bowl or on the toilet
paper. He has had UGIB in the past but never presented w/ dark
stools. Of note this morning he took his 200mg of torsemide,
200mg of metoprolol succinate, 10mg of lisinopril and
120mg of diltiazem. He also c/o 10-lb weight gain from 222 lbs
to 232 lbs over the past 1.5-2wks.
.
In the ED, he triggered on arrival for hypotension with initial
BP of 88/40 which dropped to 70s SBP, w/ tachycardia to 110s.
Exam was notable for B/L pitting LE edema, guaiac + melanotic
stool. NGT lavage was negative with yellow looking suction. GI
was consulted who recommended transfusion as HCT was 20.5
(baseline ~35-37) and PPI bolus +ggt. Labs were notable for HCT
as above, BUN of 104 Cr 2.9 and INR 3.9. He was given 10mg PO
vitamin K in ED and had CXR which did not show evidence of
volume overload (Although costophrenic angles were cut off in
view). EKG showed AF w/ PVC's.
.
On transfer, VS: 97.4 72 101/57 14 100% 2L NC. In CCU pt is
stable, awake and comfortable w/o c/o SOB or CP. All other ROS
negative except as above.
.
Past Medical History:
Type II Diabetes
HLD
HTN
CAD s/p CABG ([**2155**]: LIMA-->LAD, SVG-->diag [known
occluded], SVG to R1, and SVG to PDA)
s/p BMS--> native diag [**2-/2169**]
Tachybrady syndrome s/p PPM
AF on Coumadin
Severe pulmn HTN
Systolic/diastolic CHF (EF 35%)
hx Dieulafoy's lesion and gastric AVM's
Anemia
Thrombocytopenia
Leg cramps while ambulating
OSA on CPAP
Spinal stenosis
Elevated amylase (160-180 since [**2160**])
Restrictive and obstructive pulmonary disease
Prostatic PIN
Bladder outflow obstruction
.
Social History:
Mr [**Known lastname **] is a retired truck driver. Former 2 PPD smoker x 20 yrs
(quit 25 years ago). Former heavy EtOH use (quit 15 years ago).
No
history of IVDU. Married, no children.
Family History:
Premature coronary artery disease in brother [**Name (NI) **]
in 50s); father died age 68 from CAD.
Physical Exam:
Admission Exam:
VS: T: afebrile HR:73 RR:18 BP: 82/38 SaO2: 100% on 3LNC
.
GEN: pale-appearing caucasian M in NAD
HEENT: + conjunctival pallor, EOMI, PERRLA
CV: irregular rhythm, nl S1, S2 soft systolic murmur heard at
LLSB that augments w/ respiration.
LUNGS: CTA B/L, no wheeze, rales, rhonchi
ABD: +BS, soft, distended, non-tender, scattered ecchymoses over
the abdomen and back/flank area in band-like distribution
RECTAL: guaiac +, dark pasty melanotic stools
EXT: B/L [**12-24**]+ LE and pedal edema, hyperpigmentation to mid
calves, small healing superficial ulcer about 2cm in diameter on
anterior left shin
NEURO: A&Ox3, no focal neuro deficits
.
Pertinent Results:
Admission Results:
[**2169-11-7**] 10:50AM BLOOD WBC-6.4 RBC-2.53*# Hgb-6.5*# Hct-20.5*#
MCV-81* MCH-25.6* MCHC-31.7 RDW-16.8* Plt Ct-175
[**2169-11-7**] 10:50AM BLOOD PT-38.0* PTT-37.1* INR(PT)-3.9*
[**2169-11-7**] 10:50AM BLOOD Glucose-140* UreaN-104* Creat-2.9*#
Na-132* K-4.9 Cl-95* HCO3-27 AnGap-15
[**2169-11-8**] 04:06AM BLOOD Albumin-3.7 Mg-3.0* Iron-39*
.
Endoscopy:
Granularity and erythema in the whole stomach compatible with
gastritis
Otherwise normal EGD to second part of the duodenum
Recommendations: No source of bleeding identified. Gastritis
noted. No biopsies performed given active bleed.
.
Colonoscopy:
Polyp in the ascending colon (polypectomy)
Polyp in the transverse colon
Polyp in the sigmoid colon
Diverticulosis of the whole colon
Otherwise normal colonoscopy to cecum
Recommendations: Few diverticula noted without active bleeding.
No source of melena identified. 3 polyps noted, small polyp s/p
polypectomy but given bleeding without known source did not
remove polyps. Repeat colonoscopy with polypectomy as outpatient
when patient stabilized is appropriate.
.
Small Bowel Enteroscopy:
Erythema and congestion in the whole stomach compatible with
gastritis
Otherwise normal EGD to proximal jejunum
Recommendations: Mild erythema of stomach. No evidence of active
bleeding or pathology found on enteroscopy. Will proceed with
capsule endoscopy.
.
CT Abdomen and Pelvis:
1. No evidence of retroperitoneal or intraperitoneal hemorrhage.
2. Increased bilateral pleural effusions - right moderate and
left small.
3. Left renal cyst.
4. Minimal dependent gallbladder hyperdensity raising question
of layering
sludge.
5. Mild colonic diverticulosis.
6. Endoscopic Capsule in right colon.
.
Discharge Results:
[**2169-11-13**] 03:00PM BLOOD WBC-5.0 RBC-3.58* Hgb-9.8* Hct-29.5*
MCV-83 MCH-27.3 MCHC-33.1 RDW-15.7* Plt Ct-132*
[**2169-11-13**] 03:00PM BLOOD Plt Ct-132*
[**2169-11-13**] 06:00AM BLOOD PT-17.2* INR(PT)-1.5*
[**2169-11-12**] 07:25AM BLOOD Glucose-168* UreaN-43* Creat-1.9* Na-137
K-4.0 Cl-101 HCO3-27 AnGap-13
Brief Hospital Course:
73 y/o M w/ CAD s/p CABG, s/dCHF (EF 45-55%) HTN, DM2, AF on
Coumadin and hx UGIB p/w SOB, weakness, epigastric discomfort
and melanotic stools w/ Hct 20.5.
.
1. GIB: Initially thought to be UGIB given presentation of
melena and BUN/Cr ratio > 30:1. Pt had anemia with HCT 20.5,
down from baseline 35-36 in [**2169-2-20**]. In ED, NGT Lavage was
negative. EGD did not reveal source of bleed, only gastritis.
Small Bowel Enteroscopy revealed gastritis of stomache.
Colonscopy showed 3 polyps in colon and diverticulosis and 1
small polyp was removed. No clear source of GI bleed was
identified. Pt was given 4 U PRBC for anemia and 2 U FFP for his
elevated INR. HCT improved and stabalized at 26. ASA and
coumadin were initially held. ASA was restarted but coumadin is
held indefinitely. Pt explained the risks of not using coumadin.
Pt encouraged to discuss this issue further with his PCP. [**Name10 (NameIs) **]
follow up outpatient with GI doctor [**First Name (Titles) 4120**] [**Last Name (Titles) **] bleed and
colonic polyps. Pt should get colonoscopy outpatient to remove
remainder of polyps. At time of discharge, hematocrit was 29.5.
.
2. Supratherapeutic INR: INR 3.9 on admission was thought to be
elevated in setting of recent Bactrim use for cellulitis and
decreased PO intake in past few weeks. Patient was given 10 mg
PO vitamin K in ED and 2 units FFP. Coumadin was held in setting
of likely GI bleed. Decision was made not to restart coumadin.
He will discuss this issue outpatient with his PCP.
.
3. CAD/CHF: Initialy held ASA in setting of GI bleed. Resumed
his metoprolol and diltiazem for his atrial fibrillation and his
ACE-I once hematocrit stabilized. Diuretics were re-started
gradually.
.
4. Acute on Chronic Renal Failure: Patient was admitted with Cr
2.9 and a presumed baseline of close to 1.0. Pre-renal picture
in pt with diuretic use and anemia due to GI blood loss. BUN
elevated from UGIB as ratio BUN/Cr > 30:1. Diuretics and ACE-I
were initially held. Patient was given 4 U PRBC which improved
renal function. On discharge, Cr was 1.8.
.
5. IDDM: Patient was continued on home Lantus and ISS.
Medications on Admission:
CYCLOBENZAPRINE - 10 mg - [**12-24**] Tablet(s) at bedtime
DILTIAZEM HCL - 120 mg Capsule, Sust. Release 24 hr twice a day
INSULIN GLARGINE [LANTUS] - 70 units daily at bedtime
INSULIN LISPRO [HUMALOG PEN] - Sliding Scale prior to meals
LISINOPRIL - 10 mg daily
METOPROLOL SUCCINATE - 200 mg once a day
METOPROLOL SUCCINATE - 100 mg qPM
OMEPRAZOLE - 40mg once a day
POTASSIUM CHLORIDE - 10 mEq once a day
PRAMIPEXOLE [MIRAPEX] - 0.125 mg 2 Tablet(s) by mouth qhs
SILDENAFIL [REVATIO] - 20 mg three times a day
SIMVASTATIN - 80 mg Tablet - 0.5 Tablet every day
TAMSULOSIN [FLOMAX] - 0.4 mg at bedtime
TORSEMIDE - 100 mg Tablet - 2 Tablet(s) by mouth qAM
WARFARIN - 2.5mg daily
ASPIRIN - 81 mg daily
MULTIVITAMIN - 1 Tablet by mouth daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Gastrointestinal Bleed
Acute on Chronic Renal Insufficiency
Supratherapeutic INR
.
Secondary Diagnoses:
Diabetes Mellitus
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **]:
.
You were admitted to [**Hospital1 18**] with a gastrointestinal bleed. An
EGD, colonoscopy and capsule endoscopy were performed and were
unable to identify the source of the bleeding. A CT scan of your
abdomen and pelvis were also performed to look for other sources
of bleeding outside of your gastrointestinal track and no
bleeding was identified.
.
The following changes were made to your medications:
.
1. Your Coumadin was held during this hospitalization as it was
high on admission and you had an active bleed. You should ask
your outpatient physician when to resume your Coumadin.
2. Your Aspirin was also held this hospitalization because of
your bleed. You should also ask your outpatient physician when
to resume your Aspirin.
3. Start taking Pantoprazole 40 mg by mouth twice a day for two
weeks. Start taking this medication on [**11-13**] and continue taking
twice a day through [**11-27**]. After [**11-27**], you should begin taking
this medication once a day.
.
No other changes were made to your medications and you should
resume taking all other medications as previously prescribed.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please keep all follow-up appointments as below:
.
Department: GASTROENTEROLOGY
When: TUESDAY [**2169-11-21**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: CARDIAC SERVICES
When: FRIDAY [**2169-12-1**] at 11:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2169-12-6**] at 10:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2170-2-16**]
|
[
"276.1",
"416.8",
"428.42",
"250.00",
"285.1",
"578.9",
"790.92",
"585.3",
"427.31",
"428.0",
"584.9",
"V45.81",
"V45.01",
"414.01",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.19",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
9084, 9090
|
6164, 8295
|
322, 345
|
9295, 9295
|
4092, 6141
|
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|
3298, 3400
|
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|
8321, 9061
|
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|
3415, 4073
|
9234, 9274
|
265, 284
|
373, 2551
|
9310, 9422
|
2573, 3077
|
3093, 3282
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,693
| 172,475
|
42527
|
Discharge summary
|
report
|
Admission Date: [**2195-6-21**] Discharge Date: [**2195-7-4**]
Date of Birth: [**2114-4-22**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is an 81 yo male with h/o A fib, CAD, ischemic EF 20%,
TIA in [**2194-2-23**], and recent GI illness who presented to [**Hospital1 **]
[**Location (un) 620**] with hypotension. Of note the he was discharged in early
[**2195-5-23**] with systolic CHF and ? gastroparesis vs bowel gut
edema. Since his discharge he was admitted to Brochton where he
was ruled out for MI and had an EGD. He has since been at [**Location (un) 22092**] Short Term Rehab and has had increase somulence (in the
setting of marinol), decrease po intake due to fear of
nausea/vomiting, overall decreased weight since being discharged
from [**Hospital1 **]. He had emesis today at rehab.
.
The pt presented to [**Hospital1 **] [**Location (un) 620**] with lethargy with vitals of T
99.1 BP60/30 RR16 02 sat 100% by NC. CTA per notes with no PE
and ? infiltrate. CT abd/pelvis showed increased thickening of
transverse colon. He had a low mixed venous sat, an increased
CVP, and cold/clammy extremities. Thus he was felt to be in
cardiogenic shock. A R IJ was placed under "relatively sterile
conditions." Labs were notable for a WBC of 18 with 90%
neutrophils, therapuetic INR of 2.6, ABG of 7.46/20/149/14.2, NA
123, bicarv of 24, bili of 1.9, alk ph 174, ALT 49, AST 69,
lactate 2.1, trop T 0.024, and CK 131. Per report he received a
zosyn 3.375mg IV, hydrocortisone 100mg IV, and 5 L of NS. K+
was hemolyzed at 6.6 and pt got 1 amp of calcium chloride, 1 amp
of D50, and 8 units of regular insulin. On route to [**Hospital1 **] he
received vancomycin 1 gram IV x1, his levophed was weaned from
24 to 20, and he made 200cc of urine.
.
On arrival to the [**Hospital1 **] ICU his vitals were T94.5 107/79 22 95% on
2L. He reported no pain.
.
Review of systems: Notable for negative for chest pain, jaw
pain, arm pain, orthopnea, PND, or peripheral edema.
(-) Denies fever, chills, cough, shortness of breath, chest
pain, diarrhea, abdominal pain. Denies arthralgias or myalgias.
Past Medical History:
#. Atrial Fibrillation- with sick sinus syndrome, s/p pacemaker
#. Coronary artery disease
#. Ischemic sCHF - EF 25% s/p ICD placement [**6-30**]
#. TIA in [**2194-2-23**]
#. Spinal stenosis
#. Peripheral Neuropathy
#. BPH
#. History of Polymyalgia Rheumatica
#. Seronegative RA
#. GERD/hiatal hernia
Social History:
Patient is married with 3 daughters. [**Name (NI) **] lives in [**Hospital 4382**](Sunrise) with his wife, and walks with a walker. He is
retired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1474**] police officer. Former smoker (quit 40 years
ago). Social ETOH. No illicit or IV drug use
Family History:
Family history signficant for mom with myocardial infarction at
age 79, father died of TB at age 48, brother with liver disease
secondary to ETOH use.
Physical Exam:
Vitals: T94.5 107/79 22 95% on 2L.
General: Alert, oriented to self, location, [**2195-5-23**], thought it
was 25th.
HEENT: right eye crusted initially and pt unable to open it,
mmm, oropharynx clear
Neck: JVD was to the angle of the jaw
Lungs: + crackles on the right lung up to [**1-25**], decreased breath
sounds on the left
CV: irreg, irreg no murmurs, rubs, gallops
Abdomen: + bs, soft, NTND
Ext: cool extremities, 1+ pulses bilaterally, no clubbing,
cyanosis or edema
Pertinent Results:
Admission labs:
[**2195-6-21**] 09:24PM BLOOD WBC-18.7* RBC-5.51 Hgb-13.3* Hct-42.7
MCV-77* MCH-24.1* MCHC-31.1 RDW-19.3* Plt Ct-295
[**2195-6-21**] 09:24PM BLOOD PT-29.3* PTT-41.7* INR(PT)-2.9*
[**2195-6-21**] 09:24PM BLOOD Glucose-170* UreaN-36* Creat-1.2 Na-127*
K-4.4 Cl-97 HCO3-20* AnGap-14
[**2195-6-21**] 09:24PM BLOOD ALT-49* AST-77* CK(CPK)-90 AlkPhos-214*
Amylase-30 TotBili-2.9*
[**2195-6-21**] 09:24PM BLOOD Albumin-2.7* Calcium-8.0* Phos-4.3 Mg-2.0
[**2195-6-21**] 09:24PM BLOOD TSH-2.1
[**2195-6-22**] 05:31AM BLOOD Cortsol-52.8*
[**2195-6-22**] 11:03AM BLOOD Lactate-1.2
.
Cardiac Enzymes:
[**2195-6-21**] 09:24PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2195-6-22**] 05:31AM BLOOD CK-MB-2 cTropnT-0.03* proBNP-[**Numeric Identifier 92032**]*
[**2195-6-22**] 02:38PM BLOOD CK-MB-NotDone cTropnT-0.01
.
Discharge labs:
[**2195-7-3**] 03:07AM BLOOD WBC-12.5* RBC-5.09 Hgb-12.7* Hct-39.6*
MCV-78* MCH-25.0* MCHC-32.1 RDW-22.2* Plt Ct-99*
[**2195-7-3**] 03:07AM BLOOD PT-23.9* PTT-33.6 INR(PT)-2.3*
[**2195-7-3**] 03:07AM BLOOD Glucose-63* UreaN-16 Creat-0.7 Na-130*
K-4.4 Cl-97 HCO3-23 AnGap-14
[**2195-7-3**] 03:07AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9
.
[**2195-6-23**] Echo:
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed with septal,
anterior and apical akinesis with hypokinesis elsewhere (LVEF=
15 %). Cannot exclude apical thrombus. The right ventricular
cavity is mildly dilated with borderline normal free wall
function. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a very small pericardial effusion.
Compared with the prior study (images reviewed) of [**2195-5-27**],
ventricular function appears similar. Estimated pulmonary artery
systolic pressure is similar.
.
[**2195-6-25**] Rest Thallium:
Mild reversible perfusion defect in the inferior wall at 20
minutes. Mild-to-moderate left ventricular enlargement.
.
[**2195-6-27**] CXR:
Moderate cardiomegaly is stable. Left transvenous pacemaker lead
terminates in standard position in the right ventricle. There is
an abandoned right-sided lead. Right PICC remains in place.
There is no pneumothorax. If any, there is a small right pleural
effusion. Bibasilar opacities, greater on the right side, are
stable consistent with atelectasis.
.
[**2195-6-30**] 5:26 am URINE Source: CVS.
**FINAL REPORT [**2195-7-2**]**
URINE CULTURE (Final [**2195-7-2**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2195-7-2**] 4:19 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2195-7-2**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2195-7-2**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2195-6-21**] Blood culture x 2: negative
[**2195-7-2**] Blood culture: no growth to date
Brief Hospital Course:
The pt is an 81 yo male with h/o A fib, CAD, ischemic EF 20%,
TIA in [**2194-2-23**], and recent GI illness who presents with
hypotension likely secondary to cardiogenic shock.
.
1. Cardiogenic shock: Hypotension was suspected to be secondary
to poor EF. No evidence of infection or other cause of
hypotension at the time. ECHO showed EF of 15% with severely
depressed LV function. BP temporarily supported with pressors.
A thalium cardiac imaging test was done to determine if the
patient would benefit from reperfusion. It was decided that
patient would not benefit from this procedure and was medically
managed instead. Patient's perfusion and blood pressure
improved, best seen in improved creatinine. Patient is on
beta-blocker, ACE-I, and aspirin. Patient and family decided to
become DNR/DNI and go home with hospice.
.
2. Afib: Patient is on carvedilol, amiodarone, digoxin, and
coumadin. INR therapeutic at discharge.
.
3. Poor po intake: This has been an ongoing issue for the
patient. Palliative care was consulted. They recommended reglan
and ritalin. Protonix was increased as well. Given goals of
care, no feeding tube was persued.
.
4. ARF: Resolved with diuresis and improved forward flow
.
5. Urinary tract infection: Patient on a 10 day course of
cefpodoxime
.
6. Leukocytosis: Patient has had leukocytosis throughout
admission even prior to development of UTI. This is an ongoing
issue. No other active source of infection other than UTI.
.
7. Tachy-brady syndrome: Patient has ICD/pacemaker placed.
Daughter would like to leave ICD/pacemaker placed until further
discussion with patient and family.
.
8. CAD: Given time lapse since last stent, Plavix was
discontinued. Patient will continue on ASA, beta-blocker, and
ACE-I. It was decided no overall benefit in revascularization.
.
9. Hyponatremia: Stable prior to discharge. Likely [**2-24**] CHF.
.
10. Elevated LFTs: Likely [**2-24**] congestive hepatopathy. Stable
during this hospitalization.
.
11. BPH: Continue finasteride
.
12. Seronegative RA: Continue home hydroxychloroquine and
prednisone
.
# GERD/hiatal hernia: Increased Protonix to 40mg po qday
.
# Eye drops: Continue home eye drops
.
# Depression: Stopped remeron [**2-24**] sedation for 24 hours when
given remeron in MICU. Palliative care consult done. Started
Ritalin.
.
# Code: Patient made DNR/DNI and will go home with hospice
Medications on Admission:
ASA 81 mg daily
plavix 75mg daily
coreg 6.25mg [**Hospital1 **]
amiodarone 200mg daily
coumadin 1mg daily
aldactone 12.5mg daily
lasix 20mg daily
prednisone 3mg daily
plaquenil 200mg [**Hospital1 **]
zestril 2.5 mg daily
megace 20mg QID
remeron 7.5 mg QHS
protonix 20mg dailky
proscar 5mg daily
MVI
senna
miralax
clotrimazole cream
zinc oxide ointment
gentamycin tear opthalmic solution QID
Ilotycin opthalmic ointment QID
vitamin D 1000 U daily
Tums 650mg TID
acetaminophen prn
Discharge Medications:
1. Evaluation and Admit to Hospice Care
Please perform evaluation and admit to hospice care
2. Morphine Concentrate 20 mg/mL Solution Sig: 0.25 ml PO hour
as needed for discomfort, pain, SOB.
Disp:*30 ml* Refills:*0*
3. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*0*
4. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*0*
5. Atropine 1 % Drops Sig: Two (2) drops sublingual Ophthalmic
every four (4) hours as needed for increased secretions.
Disp:*1 bottle* Refills:*0*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Gentamicin 0.3 % Drops Sig: One (1) Drop Ophthalmic Q4H
(every 4 hours).
11. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 9 days.
Disp:*36 Tablet(s)* Refills:*0*
12. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
Disp:*30 Tablet(s)* Refills:*2*
14. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
15. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
17. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
20. Erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) drop
Ophthalmic QID (4 times a day).
21. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
22. Senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
23. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VistaCare
Discharge Diagnosis:
Acute on Chronic systolic heart failure
Hyperlipidemia
CAD
Atrial fibrillation
BPH
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted with SOB. You were diuresed and your symptoms
improved. You had cardiac imaging to determine if you would
benefit from catherization. It was decided that you would not
benefit from catherization and your medications were adjusted
instead to help improve your heart function.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
While in the hospital you developed a urinary tract infection.
We have started you on an antibiotic, Cefpodoxime.
.
We have made the following changes to your medications:
1. Ritalin 5mg in AM and 2.5mg in PM
2. Stop Plavix
3. Stop aldactone
4. Stop Remeron
5. Start Digoxin 0.125 mg DAILY
6. Increase Coumadin to 2.5mg daily
6. Cefpodoxime Proxetil 200 mg every 12 hours for 9 days
7. Stop megace
8. Start Reglan 10mg before meals
9. Increase Protonix to 40mg every day
Followup Instructions:
Please follow up with your cardiologist after discharge from
rehab.
Completed by:[**2195-7-4**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12852, 12892
|
7608, 9984
|
282, 289
|
13030, 13030
|
3610, 3610
|
14047, 14145
|
2947, 3099
|
10514, 12829
|
12913, 13009
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10010, 10491
|
13165, 13694
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4439, 7585
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3114, 3591
|
13723, 14024
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2063, 2285
|
4215, 4423
|
231, 244
|
317, 2044
|
3626, 4198
|
13045, 13141
|
2307, 2610
|
2626, 2931
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,324
| 101,687
|
47012
|
Discharge summary
|
report
|
Admission Date: [**2177-2-25**] Discharge Date: [**2177-2-28**]
Date of Birth: [**2117-9-30**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 59-year-old gentleman
who has a history of multiple myocardial infarctions in the
past including an inferior myocardial infarction in [**2171**] and
a non-Q-wave myocardial infarction in [**2176-11-19**] who is
admitted from [**Hospital6 33**] with an unstable anginal
syndrome, a positive troponin, and negative creatine kinases.
The patient had been having several days of worsening
exertional chest pain associated with some shortness of
breath, diaphoresis; his typical anginal symptoms which led
him to present to the outside hospital, at which time his
studies became concerning for an acute coronary syndrome. He
was started on Lopressor, Plavix, aspirin, Integrilin, and
nitroglycerin and transferred to [**Hospital1 190**] for further care.
The patient's most recent cardiac catheterization prior to
this admission revealed the following: an ejection fraction
of 38%, a normal left main, a 60% tubular middle left
anterior descending artery with a totally occluded first
diagonal, faint left-to-left collaterals, a distal left
anterior descending artery of 90%, a small ramus with a
proximal 70%, circumflex system with a 90% first obtuse
marginal inferior lesion, and a 70% superior pole lesion, a
diffusely diseased third obtuse marginal. The right coronary
artery had mild diffuse disease with a moderate in-stent
restenosis on previously placed posterior descending artery
stent; unchanged from [**2175-8-20**] catheterization, and a
posterior left ventricle that was totally occluded and filled
by right-to-right collaterals. Left ventricular
end-diastolic pressure was 20 mm; and at that time the
patient had stent to the first obtuse marginal with
additional percutaneous transluminal coronary angioplasty of
the upper pole of the first obtuse marginal. The proximal to
middle left anterior descending artery lesion underwent
successful percutaneous transluminal coronary angioplasty and
stenting, and the distal left anterior descending artery was
treated with a stent also. The first diagonal which had an
in-stent restenosis could not be treated at that time.
The patient was directly admitted to the catheterization
laboratory at [**Hospital6 33**], at which time he
underwent a limited study notable for in-stent restenosis of
the proximal left anterior descending artery stent placed in
[**2175-8-20**] and a 90% distal left anterior descending
artery occlusion, and a distal left anterior descending
artery that was subtotally occluded immediately proximal to a
prior distal left anterior descending artery stent. The
proximal left anterior descending artery 80% in-stent
restenosis underwent successful brachy therapy, and a stent
was placed in the distal left anterior descending artery
proximal to a prior stent to treat a restenosis. The
procedure was complicated by hypotension in to the 70s with
bradycardia into the 40s, in a sinus rhythm.
An echocardiogram done on the catheterization table revealed
no evidence of tamponade. It was felt that the patient was
having an severe vagal reaction. He was started on dopamine
which was eventually increased to 10 mcg/kg per minute, and
the Coronary Care Unit team was then asked to evaluate and
observe the patient overnight while peripheral anatropes were
weaned.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post inferior myocardial
infarction in [**2171**], status post non-Q-wave myocardial
infarction in [**2176-11-19**]. Most recent intervention in
[**2176-11-19**].
2. Hypercholesterolemia.
3. Hypertension.
4. Cluster headaches.
MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d.,
Cardizem 240 mg p.o. q.d., Lipitor 10 mg p.o. q.d.,
Paxil 10 mg p.o. q.d., multivitamin.
ALLERGIES: BETA BLOCKER apparently causing bronchospasm.
FAMILY HISTORY: Family history notable for coronary artery
disease and diabetes in multiple family members.
SOCIAL HISTORY: The patient is a divorced high school
teacher with six children. He does not smoke. There is no
illicit drug use such as cocaine.
PHYSICAL EXAMINATION ON PRESENTATION: Admission physical
examination with vital signs revealing afebrile, blood
pressure of 100/60, pulse of 80s on 10 mcg/kg per minute of
dopamine, respiratory rate of 12, oxygen saturation of 98% on
room air. In general, alert and oriented times three.
Cranial nerves II through XII were intact. Head, eyes, ears,
nose, and throat revealed pupils were equal, round, and
reactive to light. Extraocular movements were intact.
Sclerae were anicteric. The oropharynx was clear. Neck was
supple, no lymphadenopathy, no jugular venous distention.
Chest was clear to auscultation bilaterally. Cardiovascular
revealed a regular rhythm with a normal rate. No murmurs,
rubs or gallops. Abdomen was soft, nontender, and
nondistended, normal active bowel sounds. Extremities
revealed soaked dressing, no femoral bruits. No firmness or
ecchymosis consistent with a hematoma, preserved distal
pulses.
PERTINENT LABORATORY DATA ON PRESENTATION: Admission
laboratories from the outside hospital revealed troponin
of 0.29, creatine kinases were flat. First creatine kinase
at [**Hospital1 69**] was 94.
RADIOLOGY/IMAGING: CT of the abdomen, pelvis, and leg
revealed a 1.5-cm X 1.5-cm hematoma with surrounding fat
stranding. No evidence of an acute hemorrhage or continued
extravasation of fluid.
HOSPITAL COURSE: The patient was admitted to the Coronary
Care Unit for management of hypotension, for which the short
differential included active blood loss which was effectively
ruled out by the CT study and a vagal response necessitating
inotropic support.
Over the course of the first evening in the Coronary Care
Unit the patient became progressively anxious and reported
difficulty urinating, and eventually was given 1 mg of
Ativan. After the dose of Ativan, the patient's dopamine
requirement decreased from 9 mcg/kg per minute to 2 mcg/kg
per minute over the course of an hour and a half.
The following morning, dopamine was discontinued. The
patient had excellent blood pressures, and the groin appeared
stable. The patient's hematocrit was also stable, and
subsequent creatine kinases remained flat. Electrocardiogram
showed no evolving changes.
The patient did suffer nonsustained ventricular tachycardia
while in house.
DISCHARGE DIAGNOSES:
1. Three vessel coronary artery disease; status post left
anterior descending artery intervention times two on current
admission.
2. Hypertension.
3. Exuberant vagal response.
4. Nonsustained ventricular tachycardia in the setting of
unstable angina.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Cardizem 240 mg p.o. q.d.
3. Lipitor 10 mg p.o. q.d.
4. Paxil 10 mg p.o. q.d.
5. Multivitamin.
6. Plavix 75 mg p.o. q.d. (indefinitely).
7. Folate 1 mg p.o. q.d.
DISCHARGE FOLLOWUP: The patient was to follow up for an
electrophysiology study as an outpatient on [**2177-3-6**].
Otherwise, the patient was to follow up with his
cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], for further followup.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-463
Dictated By:[**Name8 (MD) 2653**]
MEDQUIST36
D: [**2177-3-3**] 13:48
T: [**2177-3-4**] 12:27
JOB#: [**Job Number 99685**]
|
[
"300.00",
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"996.72",
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"458.2",
"412",
"414.01",
"411.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"92.27",
"36.01",
"88.56",
"37.22",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
3934, 4027
|
6475, 6731
|
6757, 6958
|
3742, 3917
|
5529, 6454
|
6979, 7451
|
161, 3425
|
3447, 3715
|
4044, 5511
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,763
| 178,519
|
5870
|
Discharge summary
|
report
|
Admission Date: [**2194-12-19**] Discharge Date: [**2194-12-29**]
Date of Birth: [**2124-1-12**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Called by Emergency Department to evaluate
Thalamic Hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 23220**] is a very [**Last Name (un) 1425**] 70 year-old right-handed male
smoker with a past medical history including HTN, HLD, and afib
for which he is on coumadin who presents from [**Hospital3 3583**]
with a left thalamic hemorrhage.
The patient is able to confirm the history as shared by the ED
team and family; he was in his usual state of health until about
4:30 this morning when he was driving independently. He
apparently experienced the sudden onset of numbness on the right
aspect of his face, right arm, and right leg. He was first
evaluated at [**Hospital3 3583**], where a non-contrast CT of the
head
was thought to show a left thalamic hemorrhage measuring
approximately 2.9 by 2.2 cm with extension into the left lateral
and third ventricles. To reverse an INR of 1.9, the patient was
reportedly given 2-4 units of FFP and vitamin k 10 mg IV x 1
before transfer to the [**Hospital1 18**] for further evaluation and care.
Mr. [**Known lastname 23220**] indicates that he has since developed difficulty
expressing himself verbally, although he maintians he can
understand what is being said. He denies prior strokes and
coagulopathies. He denies current headache.
In the ED he was given profilnine and a non-contrast CT of the
head was repeated to evaluate for hemorrhagic expansion.
NEUROLOGICAL, GENERAL REVIEW OF SYSTEMS
- unable to directly assess
Past Medical History:
- atrial fibrillation
- HTN
- HLD
- presumed COPD
- presumed anxiety
- erythrocytosis - regular therapeutic phlebotomy (last
[**2194-12-16**])
PAST SURGICAL HISTORY:
- bilateral cataract surgery per pt
- lap chole [**2189-3-24**] (acute + chronic cholecystitis, cholangitis,
CBD stone)
Social History:
- married
- has four sons
- works as a dispathcher for a courier company - was next
planning to drive a school bus
- Catholic
- served in marines
Family History:
NC
Physical Exam:
Vitals: T: 100.3 P: 70s-80s R: 20 BP: 163/72 SaO2: 98% on 2L
General: Awake, cooperative, NAD but appears frustrated with
difficulties communicating
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
Mucus
membranes moist, no lesions noted in oropharynx. Copious
secretions in oropharynx.
Neck: Supple. No carotid bruits appreciated.
Cardiac: Regular rate, irregularly irregular rhythm.
Pulmonary: Coarse breath sounds bilaterally anteriorly.
Abdomen: Obese. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: Alert. Able to nod in agreement and
answer "yes" when presented verbally.
* Orientation: Oriented to person, place (nods to "hospital"),
month ("yes" to [**Month (only) 404**], "no" to [**Month (only) **]), year ("yes" to [**2194**], "no"
to [**2193**]), situation (indicates "yes" when asked about
right-sided
numbness, hemiparesis)
* Language: Language is non-fluent. Repetition is initially
intact (eg "today is a sunny day in [**Location (un) 86**]"). Comprehension
appears intact; pt able to correctly follow midline and
appendicular commands, difficulty with cross-body commands. Pt
unable to name high (watch) and low frequency objects
(knuckles).
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 3 to 2mm and slightly sluggish. Visual fields
difficult to formally test but patient seems to attend to all
aspects of visual fields.
* III, IV, VI: EOMI with limited upgaze.
* V: Difficult to formally assess facial sensation in the V1,
V2,
V3 distributions (pt says "I don't know" when asked if the right
and left sides feel roughly the same).
* VII: Flattening of right nasolabial fold.
* VIII: Hearing intact to finger-rub bilaterally.
* IX, X: Palate elevates symmetrically.
* [**Doctor First Name 81**]: 5/5 strength in trapezii on left. 0/5 on right.
* XII: Tongue protrudes in midline.
Motor:
* Bulk: No evidence of atrophy.
* Tone: Flaccid in right extremities.
* Drift: No pronator drift on left.
* Adventitious Movements: slight postural tremor with left arm
outstretched.
Strength:
* Left Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Right Upper Extremity: 0 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Left Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
* Right Lower Extremity: 0 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
Reflexes:
* Babinski: flexor left, extensor right
- triple flexion with noxious stimulation of right lower
extremity
Sensation:
* Light Touch: intact bilaterally in left lower extremities,
upper extremities, trunk, face; difficult to asses right-sided
sensation
Coordination
* Pt seemed to perform activities (eg reaching for the arm of a
loved one) with acuity
Gait:
* not evaluated
Pertinent Results:
[**2194-12-24**] 03:56AM BLOOD WBC-16.5* RBC-5.12 Hgb-13.1* Hct-41.4
MCV-81* MCH-25.5* MCHC-31.6 RDW-18.3* Plt Ct-267
[**2194-12-25**] 02:18AM BLOOD WBC-12.9* RBC-5.16 Hgb-13.4* Hct-41.7
MCV-81* MCH-25.9* MCHC-32.1 RDW-18.2* Plt Ct-260
[**2194-12-25**] 02:18AM BLOOD PT-13.7* PTT-24.8 INR(PT)-1.2*
[**2194-12-25**] 02:18AM BLOOD Plt Ct-260
[**2194-12-25**] 02:18AM BLOOD Glucose-135* UreaN-21* Creat-0.9 Na-136
K-3.8 Cl-101 HCO3-26 AnGap-13
[**2194-12-24**] 03:56AM BLOOD ALT-25 AST-30 AlkPhos-79 TotBili-0.6
[**2194-12-20**] 01:02AM BLOOD CK-MB-3 cTropnT-<0.01
[**2194-12-19**] 08:59AM BLOOD cTropnT-0.01
[**2194-12-25**] 02:18AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1
[**2194-12-20**] 01:02AM BLOOD %HbA1c-5.7
[**2194-12-20**] 01:02AM BLOOD Triglyc-104 HDL-25 CHOL/HD-5.4 LDLcalc-90
[**2194-12-20**] 01:02AM BLOOD Osmolal-292
[**2194-12-23**] 05:12AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
Imaging:
CXR [**2194-12-24**]:
Mild edema at the base of the left lung has worsened. More
severe
consolidation in the right lower lung has also progressed and
could be either
asymmetric edema or edema and new aspiration or developing
pneumonia. Heart
size top normal, is unchanged and mediastinal vascular caliber
is upper limits
of normal. Nasogastric tube passes as far as the distal
esophagus but the tip
is indistinct. No pneumothorax.
CXR [**2195-11-22**]:
Exam is technically limited by respiratory motion artifact.
Cardiac
silhouette appears enlarged but pulmonary vascularity is within
normal limits
for technique. The lungs are grossly clear except for an
apparent right
retrocardiac opacity which could be due to either atelectasis or
infectious
pneumonia. Standard PA and lateral chest radiograph would be
helpful to more
fully evaluate this region when the patient's condition allows.
Ct head [**2194-12-20**]:
The left thalamic hemorrhage is again noted and allowing for
expected evolution, not significantly changed from prior. The
hyperdense
focus measures 2.7 x 2.3 cm compared to 3.2 x 2.0 cm,
previously. There is a similar amount of surrounding vasogenic
edema. There is persistent mass
effect on the posterior [**Doctor Last Name 534**] of the left lateral ventricle but
no evidence of ventriculomegaly. There is unchanged hyperdense
material in the left lateral ventricle. Small amount of
hyperdense material in the right ventricle is also unchanged.
There is no shift of the normally midline structures. The
basilar cisterns are preserved. There is no new hemorrhage or
acute major vascular territory infarction. The visualized
paranasal sinuses and mastoid air cells are well aerated. No
osseous abnormality is identified.
IMPRESSION: No significant change in the left thalamic
parenchymal hemorrhage with intraventricular extension. No new
intracranial hemorrhage or other acute abnormality.
CT head [**2194-12-19**]:
1. 3.2 x 2 cm left thalamic parenchymal hemorrhage with
extension into the
left lateral ventricle, unchanged from the exam four hours
earlier. No
herniation or midline shift.
2. No other areas of acute abnormality.
EKG: [**2194-12-19**]
Atrial fibrillation with slow ventricular response. Low limb
lead voltage.
ST segment depressions in leads V2-V3 suggest possible anterior
myocardial
ischemia. Compared to the previous tracing of [**2184-4-14**] normal
sinus rhythm has been replaced by atrial fibrillation and the
anterior ST segment abnormalities are new. Clinical correlation
is suggested
Brief Hospital Course:
70 year old man with a h/o HTN, AF on Coumadin presents with an
acute onset of right sided numbness, weakness and speech
difficulty. Initially taken to [**Hospital3 **] where a head CT
revealed a lateral left thalamic bleed without any ventricular
spillage; INR was 1.9. Speech deteriorated since arrival at the
[**Hospital1 **] ED and had
marked difficulty speaking out even simple words and appears
frustrated. His speech is dysarthric with severe anomia, and
some difficulties with repetition. Follows complex commands.
Right facial weakness. Dense right sided HP with
hemisensory loss. A Repeat head CT showed increase in size of
Hge with lateral extension into the parietal white matter and
ventricular cavity. Received FFP, vitamin K and Proplex.
He was admitted to the neuro-icu for close monitoring and BP
control. As he a reported heavy alcohol user, he was started on
a CIWA scale. The patient was initially full code. His
language began to improve some the following morning, was
slightly more fluent and had some improved naming. His course
was complicated by etoh withdrawal, and he would become
tachycardic, diaphoretic and very agitated requiring him to
receive diazepam according to a withdrawal activity scale. He
continue to improve to the point he was able to transfer out of
the ICU on [**2194-12-22**]. He had failed speech and swallow eval and
was receiving medications an feeds through [**First Name8 (NamePattern2) **] [**Last Name (un) **]-gastric tube.
On the floor the patient continued to withdraw and there was
difficulty controlling his blood pressure. In addition he
likely had an aspiration event, and began to have difficulty
maintaining his oxygen saturation and became very tachypneic,
requiring him to be placed back into the ICU. A follow up xray
confirmed a worsening pneumonia. He was started on broad
spectrum antibiotics (ciprofloxacin, cefepime, and vancomycin).
A family meeting was held about the patient's desires about
intubation. We informed the family that he may require
intubation, and could be a temporizing measure to help overcome
the pneumonia. The family, after much internal discussion,
believes that the patient's would not want to be intubated no
matter the circumstance. They agreed to continue with current
care, i.e. antibiotics and fluids, and to see if the patient's
respiratory status improved.
Over the course of two days the patient did have a somewhat
significant improvement in respiratory status. He was
transferred out of the ICU but continued to have difficulty with
blood pressure control. He was on clonidine patch, diltiazem,
hydralazine, HCTZ, and lisinopril and still required additional
PRN medications. Because of his recalcitrant hypertension, he
underwent a renal ultrasound to assess for secondary causes of
hypertension. Results of this study are currently pending. He
also underwent repeat CT head on [**2194-12-29**] due to worsening
dysarthria and inattentiveness which was essentially unchanged
from his prior study [**2194-12-20**]. Another family meeting was held
[**2194-12-29**] and after discussion, the family had wished to stop
continued aggressive care including antibiotics and blood
pressure control as they believed it would not be consistent
with his wishes to continue care given his diagnosis and
prognosis. Therefore, he was made comfort-measures only
following the meeting and will be discharged on ativan,
morphine, tylenol PR, and scopolamine patch PRN for comfort
care.
Medications on Admission:
- warfarin 10 mg po daily
- lisinopril 10 mg po daily
- diltiazem 240 mg po daily
- atenolol 25 mg po bid
- simvastatin 40 mg po daily (last filled [**2194-6-28**]), lovastatin
40
mg po qhs (last filled [**2194-10-20**])
- spiriva 1 cap inh daily
- proair 2 puffs inh qid
- diazepam 2 mg po tid
- levitra 20 mg po daily prn
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety: sublingual tablets please. PRN
for anxiety.
Disp:*60 Tablet(s)* Refills:*2*
2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain.
Disp:*30 Suppository(s)* Refills:*0*
3. Morphine Concentrate 20 mg/mL Solution Sig: 0.25 mL PO Q4H
(every 4 hours) as needed for pain: may titrate upward as needed
for comfort.
Disp:*30 mL* Refills:*0*
4. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours as needed for
secretions.
Disp:*10 patches* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
left thalamic hemmorhage
aspiration pneumonia
alcohol withdrawl
Discharge Condition:
Awake, alert, follows some basic commands. R facial droop.
Dysarthric. RUE plegia, RLE triple flexion. Antigravity in
LUE, LLE. Upgoing toe on R.
Discharge Instructions:
You were found to have a hemorrhage in your brain (left
thalamus) at the time of admission. Your hospital course was
complicated by alcohol withdrawl, aspiration pneumonia, and
persistent hypertension despite multiple antihypertensive
agents. After a meeting with your family, it was decided that
you would not want to continue aggressive care given your
diagnosis and prognosis. It was decided that comfort-measures
only care would be most consistent with your wishes.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2195-1-23**] 10:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
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icd9cm
|
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|
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,876
| 185,358
|
37619
|
Discharge summary
|
report
|
Admission Date: [**2165-11-27**] Discharge Date: [**2165-12-6**]
Date of Birth: [**2091-1-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
Intubation
Pericardial tap and drain placement
History of Present Illness:
74 yo man with CHF and EF of 20%, A fib on coumadin s/p recent
AVJ ablation who was recently started on HD, presents s/p
mechanical fall backwards on [**11-27**] onto back of head down [**6-12**]
steps w/o LOC. Patient eventually transferred to the CCU for
management of large pericardial effusion and evidence of early
tamponade, seen on echo.
.
Presented to OSH A&O x 3, neurologically intact. CT demonstrated
SAH without mass effect & C6-7 widening. Pt developed nausea and
AMS, was intubated for airway protection, was started on
levophed for hypotension, given FFP and vitamin K, and then
transferred to [**Hospital1 18**] for further management.
At the [**Hospital1 18**] ED, CT torso demonstrated a moderate pericardial
effusion and bilateral pleural effusions. He also had signs of
active bleeding into his left thigh.
.
According to his wife and 4 daughters, at baseline Mr. [**Known lastname 27462**] is
able to mow the lawn & perform many ADLs/IADLS without chest
pain. He was very well until ~ 1 month ago when he developed "a
cold," and was hospitalized with acute on chronic renal failure,
course c/b afib with RVR, volume overload and hypotension. He
had 2 prolonged hospitaliztions but according to his wife was
home now and finally getting back to his baseline functional
status. He has dyspnea on exertion which has been improving
since starting HD, as has his LE edema. No history of orthopnea,
PND, or syncope.
He has had symptoms of orthostatic hypotension since starting HD
which are worse on his dialysis days. His fall was witnessed and
was clearly mechanical.
Echo on [**11-28**] demonstrated a severely depressed LVEF (20-25%),
as well as a large pericardial effusion with evidence of early
tamponade. As such, the patient was transferred to the CCU.
Patient underwent pericardiocentesis on [**11-29**], and 1350cc
serosanguinous fluid drained (drain left in place).
.
Past Medical History:
Atrial fibrillation on coumadin, s/p ablation recently (unclear
if afib vs AVN ablation)
CHF with EF 10-15% s/p PPM/ICD ([**7-16**])
ESRD on HD(last HD = [**2165-11-27**])
s/p liver transplant for cryptogenic cirrhosis, on chronic
immunosuppression ([**2157-6-7**], [**Hospital1 1774**])
Social History:
Non-smoker. No alcohol, drugs. Lives with wife. [**Name (NI) **] 4 daughters.
Family History:
Non-contributory
Physical Exam:
Vitals: T:98.4degrees Farenheit, BP: 135/70 mmHg, HR 96 bpm, RR
20 bpm, O2: 96%
Gen: responsive, alert & oriented, asking where his wife is
[**Name (NI) 4459**]: No conjunctival pallor. No icterus. + ETT
NECK: In C-collar, unable to assess JVP, carotids.
CV: PMI laterally displaced, mid clavicular line. RRR. nl S1,
S2. No murmurs, rubs, clicks, or [**Last Name (un) 549**]. Cardiac sounds
distant.
LUNGS: Rhonchorous sounds transmitted from the upper airways.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged by palpation. No abdominal bruits.
EXT: WWP, Trace edema in RLE, 1+ pitting edema in LLE. Full
distal pulses bilaterally. No femoral bruits.
SKIN: No rashes/lesions, ecchymoses.
NEURO: CN II-XII intact, MAEE
PSYCH: appropriate
Pertinent Results:
Cardiac Studies:
ECHO [**2165-11-28**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is severe regional left ventricular
systolic dysfunction with akinesis of the mid to distal inferior
and inferolateral walls. Overall left ventricular systolic
function is severely depressed (LVEF= 20-25 %). Right
ventricular chamber size and free wall motion are normal. There
is abnormal diastolic septal motion/position consistent with
right ventricular volume overload. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is a large pericardial effusion. The
effusion appears circumferential. Stranding is visualized within
the pericardial space c/w organization. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
IMPRESSION: Severe left ventricular systolic dysfunction. Large
pericardial effusion with evidence of early tamponade.
.
Cardiac Cath [**2165-11-29**]:
1. Opening pericardial pressure was 18 mm Hg. This fell to 15 mm
Hg
after removal of 100 cc of serosanguinous fluid from the
pericardial
space. After removal of 1350 cc of serosanguinous fluid, the
pericardial
pressure fell to -5 mm Hg.
FINAL DIAGNOSIS:
1. Pericardial tamponade.
2. Successful removal of 1350 cc of serosanguinous pericardial
effusion.
.
ECHO [**2165-11-30**]: IMPRESSION: Concentric left ventricular
hypertrophy with global hypokinesis and more severe hypokinesis
of the inferior wall. Mild mitral regurgitation. Mild pulmonary
hypertension. Trivial pericardial effusion which is slightly
more prominent around the right atrium.
Compared with the prior study (images reviewed) of [**2165-11-28**],
the large pericardial effusion has mostly resolved. Estimated
pulmonary artery pressures are slightly higher. The left
ventricular ejection fraction appears slightly more vigorous.
.
ECHO [**2165-12-4**]: LV systolic function appears depressed. RV with
depressed free wall contractility. There is no aortic valve
stenosis. There is a trivial/physiologic pericardial effusion.
.
Other Imaging Studies:
CT C-Spine:
1. Widening of the ventral intervertebral disc space at the
C6-C7 level,
suggestive of anterior longitudinal ligament rupture. No
associated fracture is identified at this level. Please note,
patient has a cardiac pacer and cannot get MR.
2. Multilevel degenerative change with a prominent posterior
osteophyte noted at the C5 to C6 level.
.
CT Head:
1. Diffuse bilateral subarachnoid hemorrhage, right greater than
left.
2. Small amount of intraventricular hemorrhage in the left
lateral and 4th
ventricles. No associated hydrocephalus.
3. Left parietal subgaleal hematoma.
4. Fluid in the nasopharynx and bilateral ethmoid sinuses most
likely
attributed to intubation.
.
CT CHEST: The aorta opacifies normally without evidence of
traumatic injury. The pulmonary arteries opacify normally
without evidence of pulmonary embolism. The heart is mildly
enlarged and there is a large simple pericardial effusion. No
mediastinal or hilar lymphadenopathy is identified. There are
moderate bilateral pleural effusions which are simple with
adjacent atelectasis. No masses or nodules are identified. An
AICD is in place. An endotracheal tube terminates above the
carina. Secretions are noted at the carina. An NG tube is noted
within the esophagus terminating in the stomach.
.
CT ABDOMEN: The liver, spleen, adrenal glands, and pancreas are
normal in
appearance. There two low-density lesions in the upper pole of
the right
kidney which most likely represents a renal cyst. The left
kidney is somewhat small in appearance, but otherwise
unremarkable. There is no mesenteric or retroperitoneal
lymphadenopathy. There is no free fluid or free air within the
abdomen. There is atherosclerotic disease of the descending
aorta with no evidence of traumatic injury. Specifically, there
is atherosclerotic disease at the origin of the celiac trunk
with narrowing and post stenotic dilitation.
.
CT PELVIS: There are no pelvic masses. There is a small amount
of simple
free fluid in the pelvis. A Foley is noted within the bladder.
There is
diverticulosis of the descending colon without evidence of
diverticulitis.
The small bowel is unremarkable in appearance. There is a
hematoma noted
adjacent and posterior to the left iliac bone which measures 2.8
x 8.3 cm. There is a focus of high-density material in the
hematoma likely representing a small amount active
extravasation. Also noted is stranding in the subcutaneous
tissues.
.
BONE WINDOWS: There is loss of height involving the L1 and T12
vertebral
bodies, of indeterminate chronicity. No discrete fractures are
identified. There are no suspicious lytic or sclerotic lesions.
.
IMPRESSION:
1. Acute hematoma in the left lower back with evidence of active
bleeding.
2. Large simple-appearing pericardial effusion and moderate
simple bilateral pleural effusions with adjacent atelectasis.
3. Small amount of free fluid in the pelvis, likely related to
patient's
history of renal failure.
.
CT Head [**2165-11-28**]: IMPRESSION:
1. No significant change in diffuse subarachnoid hemorrhage.
2. Intraventricular hemorrhage, which appears slightly more
prominent
compared to prior study, without evidence of new hydrocephalus
.
Upper Extremity US [**2165-11-30**]: IMPRESSION: Deep vein thrombosis
in the left subclavian and axillary veins.
.
CT C-Spine [**2165-12-3**]: No abnormal motion noted at the C6-C7
interspace on the currently acquired radiographs, although the
extension view is suboptimal. Given the findings displayed on
the recent CT, it is still highly suspicious for an underlying
injury to the anterior longitudinal ligament.
.
CT Head [**2165-12-3**]: IMPRESSION:
1. Continuing evolution of multiple areas of subarachnoid
hemorrhage within the bilateral frontal lobes, left parietal
lobe, and suprasellar cistern. No evidence of new hemorrhage.
2. Interval resolution of hemorrhage within the occipital horns
of the
lateral ventricles.
.
Pathology:
Pericardial Fluid: - Negative for malignant cells. - See
cytology C09-[**Numeric Identifier 84396**] for correlation
.
Lab Values:
On admission:
WBC 17.3* HGB 8.4* HCT 27.6* Platelets 246
PT 25.1* PTT 39.9* INR 2.4*
Glucose 171* BUN 29* CRN 3.5* 139 4.3 101 28 14
Brief Hospital Course:
In summary, Mr [**Known lastname 27462**] is 74 yo man with CHF and non-ischemic
cardiomyopathy (20%), A fib on coumadin s/p recent ablation, CKD
on HD s/p fall c/b subarachnoid hemorrhage, who was found to
have b/l pleural effusions and pericardial effusion.
.
# Pericardial effusion/pericardial tamponade: believed to be
chronic due to size; perhaps secondary to uremia (requiring
dialysis), complication from ablation (bleed/trauma), or due to
viral pericarditis (patient had URI recently) s/p
pericardiocentesis. Cytology negative for malignancy. No
evidence of infection at this time. Given high RBC ct in fluid,
suspect that it may be slow bleed from prior trauma from
pacemaker placement or from ICD placement months ago.
Pericardial fluid culture neg, AFP/anaerobic pending.
- no antiplatelets, on heparin gtt for LUE DVT (see below,
neurosurgery aware, PTT goal 50-70). Coumadin was restarted
prior to discharge.
- monitor on telemetry
- TTE yesterday showed no reaccumulation of fluid.
- will need repeat ECHO in 4 weeks.
.
# Pleural effusions: stable during admission and patient was
without increasing oxygen requirements or respiratory distress,
therefore pleural effusions were not drained. He should have a
repeat CXR to assess if he becomes hypoxic again.
.
# s/p liver transplant: initially patient was unable to take PO
given aspiration risk and NG tube was unable to be placed,
therefore sirolimus was not administed for one day. Liver was
consulted and recommended increase sirolimus dosing to 3 mg
daily per hepatology recs. Rapamune level on discharge is 6.7.
- continue Rapamune (sirolimus) 3mg po daily
- check [**Last Name (un) **] levels on Monday, [**12-9**]. Please fax results
to hepatologist Dr. [**First Name (STitle) **].
- f/u with transplant at [**Hospital1 1774**] next week on Tuesday.
.
# Atrial fibrillation: Rate controlled. Anticoagulation was
reversed on admission due to subarachnoid hemorrhage and held
due to the high risk of bleeding. Anticoagulation was restarted
after patient was found to have LUE DVT (see below). Beta
blocker continued while in the hospital. INR this am was 1.3.
Home dose of warfarin is 5 mg daily. Please d/c heparin gtt 48
hours AFTER INR > 2.0.
.
# Hypertension: Patient was started on Carvedilol during
admission instead of metoprolol tartrate and started on
Valsartan for afterload reduction in setting of low EF.
# Systolic heart failure: Poor EF, currently stable. Has Biv
ICD. Interrogated today and found to be working properly.
-continue bblocker, [**Last Name (un) **]
-holding statin given liver enzyme elevation and transplant.
.
# CKD on HD: pt was continued on regular hemodialysis schedule
while in the hospital. Last dialysis was today.
.
# LUE swelling: LUE US noted to have DVT in the left subclavian
and axillary veins, unclear if related to pacer placement 6
months ago. Patient was started on low dose coumadin, INR 1.3.
Will need to bridge with heparin gtt given patient's renal
dysfunction.
- Will need daily INRs and coumadin adjustment with goal INR
[**3-12**].
- Please d/c heparin gtt 48 hours AFTER INR > 2.0.
.
# Subarachnoid hemorrhages: After fall, patient's head CT showed
SAH. Neurosurgery was consulted. Pt was treated with keppra
for seizure prevention. The patient's SAH was re-imaged shortly
after starting anticoagulation and did not show interval
worsening of the hemorrhages.
.
# C6-C7 widening; cervical spine instability: may require
c-spine stabilization procedure which patient refused at this
time. Patient's admission CT C spine showed C6-7 widening, with
10mm step off. Patient was maintained in a c-collar. Flexion
extension films were obtained and demonstrated 3mm stepoff
concerning for anterior ligamentous injury. Orthopedics
evaluated the patient and recommended six more weeks of
continuing c-collar and follow up with ortho in two weeks.
- continue c.collar for at least 6 weeks
- f/u with ortho on Friday as scheduled.
# Aspiration: Video swallow showed silent aspiration to all
consistancies. He will need to remain NPO. Paitent had IR guided
NG tube placed during admission. Will need PEG until C collar
comes off and he gets another video swallow. He will also need
ENT consult to scope and check cords to see if he has bilat
vocal cord movement. For now, will keep in NGT and give all
nutrition and meds via this.
# Leukocytosis: unclear etiology, and no focal sxs, afebrile.
Pt was closely monitored given his immunosuppressed state and
white count normalized without intervention.
Medications on Admission:
Rapamycin 1mg daily
[**First Name9 (NamePattern2) 23146**]
[**Last Name (un) **] 5mg daily
ASA 81mg daily
Niaspan 500mg daily
Omeprazole 20mg [**Hospital1 **]
Phoslo 2 tabs TID
Digoxin 0.125 QOD
Metoprolol 100mg [**Hospital1 **] (family to clarify if succinate or
tartrate)
Discharge Medications:
1. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
2. Calcium Acetate 667 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 4,000-11,000
units Injection PRN (as needed) as needed for line flush.
4. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
5. Carvedilol 12.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day).
6. Warfarin 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4
PM: check INR daily, goal [**3-12**].
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: Five (5) cc PO BID (2
times a day).
9. Guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
10. Valsartan 40 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
11. Niacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Sub Arachnoid Hemmorhage
Pericardial Effusion
Neck Trauma
S/P fall
LUE Deep Vein thrombosis
Acute on chronic Systolic congestive Heart Failure
Liver Transplant
Chronic Kidney Injury
Discharge Condition:
stable
Discharge Instructions:
You had a fall and sustained some bleeding in your head. You
were seen by neurologists and the bleeding is stable. We have
discontinued your warfarin for now and will keep you on Heparin
intravenously to manage the blood clot in your left arm. You
also had a pericardial effusion that was drained. An
echocardiogram was done on [**1-4**] which showed no reaccumulation
of fluid. You should have another echocardiogram checked in [**4-10**]
weeks. There was fluid in your lungs that has been resolving
slowly. You now do not need oxygen. You were having trouble
swallowing and needed a feeding tube. A video swallow study
showed that you will need to continue to have a tube until at
least the collar can be removed. You may need a tube through the
stomach wall soon, this will be a lot more comfortable.
.
Medication changes:
1. Increase Sirolimus to 3mg.
2. Stop metoprolol
3. Start Carvedilol to slow your heart rate
4. Start Keppra to prevent seizures
5. Stop Omeprazole and start Lansoprazole
6. Stop Digoxin
7. Start Diovan to help your heart work better
8. Decrease your warfarin to 2 mg.
Followup Instructions:
Spine surgery/Orthopedics:
Dr. [**Last Name (STitle) 363**] Phone: [**Telephone/Fax (1) 3573**] Date/Time: Friday [**12-13**] at
9:00am. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 1773**]. [**Location (un) **]. [**Location (un) 86**].
.
Cardiology:
[**Location (un) 270**] Cardiology
Dr. [**Last Name (STitle) 76716**] Phone: [**Telephone/Fax (1) 9219**] Date/Time: [**12-18**] at
11:15.
[**Location (un) 28667**], [**Apartment Address(1) **] [**Location (un) **].
.
Hepatology:
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) **] Date/time: [**2165-12-10**] at
3:30pm.
Completed by:[**2165-12-8**]
|
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|
[
[
[]
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[
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"96.71",
"96.6",
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|
[
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,696
| 127,003
|
48688+48689
|
Discharge summary
|
report+report
|
Admission Date: [**2110-4-28**] Discharge Date: [**2110-5-30**]
Date of Birth: [**2042-7-13**] Sex: F
Service:
CHIEF COMPLAINT: Bladder pain, nausea and vomiting.
HISTORY OF PRESENT ILLNESS: this is a 67 year old female
with a history of bipolar disorder, hypertension,
hypercholesterolemia, who now complains of dysuria and
bladder pain for one and a half weeks. The patient initially
called her primary care physician numerous times and
complained of this bladder discomfort and dysuria. She also
reports having gone to [**Hospital6 **] Hospital Emergency
Room on [**4-21**]. She received treatment but did not take it.
She was again seen by her primary care physician on [**4-23**]
for the same symptoms. She was prescribed Ciprofloxacin but
did not take it, reporting that she was allergic to the
medication because of a rash and chest pain that she
developed. The patient was once again seen in the Emergency
Department on [**4-25**] for the bladder pain. She was found
to have a urinary tract infection which was seen on
urinalysis. She received a prescription for Keflex at the
time, which again she did not take. She did take some
Pyridium with some improvement in symptoms. The urine
culture from that date was contaminated.
She presented to the Emergency Department at [**Hospital1 346**] on [**4-28**]. She complained of
several days of nausea and vomiting and a vague history of
ingesting some chemical that burned. She reported no
suicidal or homicidal ideation but it was difficult to gather
information, due to the patient's sedation from Ativan.
At this time, the patient was also complaining of bladder
pain and bilateral leg pain. The patient had been refusing
all tests and intravenous in the Emergency Department. She
was evaluated by psychiatry and deemed not competent to leave
against medical advice and she was then started on fluids.
She was given 2 mg of Ativan for sedation, in order to
prepare her for a CT scan.
PAST MEDICAL HISTORY: 1.) History of bipolar disorder. 2.)
Hypercholesterolemia. 3.) History of pelvic pain. 4.)
History of femur fracture. 5.) Hypertension. 6.) Urinary
tract infection. 7.) Chronic bladder pain.
ALLERGIES: Bactrim, develops a rash. Ampicillin, develops a
rash. Levaquin, rash and chest pain.
MEDICATIONS:
On admission, she was on Lipitor, Lopressor, Keflex for three
days, Pyridium.
SOCIAL HISTORY: She lives with a male partner for 20 years.
She has three children. She has a history of drinking one
white russian per day. She reports to have stopped drinking
two months ago. No history of tobacco or any other drug use.
She also has a history of verbal and/or physical abuse from
her male partner.
REVIEW OF SYSTEMS: Positive for weight loss and ear pain.
PHYSICAL EXAMINATION: On physical examination, her
temperature was 96.5; blood pressure 102/58; heart rate 68;
respiratory rate 17; oxygen saturation 94% on room air.
General: She was an older female, lying in bed, asleep,
arouses with difficulty to voice. She opened her eyes when
asked to. HEAD, EYES, EARS, NOSE AND THROAT: Normal
cephalic, atraumatic. Pupils are equal, round, and reactive
to light and accommodation. Oropharynx clear. Mucous
membranes slightly dry. Scabs on the lower lip. Neck
examination: No jugular venous distention. Chest clear to
auscultation bilaterally. Cardiovascular: Regular rate and
rhythm, no murmurs, rubs or gallops. Abdomen: Positive
bowel sounds, soft, nondistended with diffuse tenderness
throughout to palpation, no masses palpable. Extremities:
Trace edema bilaterally lower extremities.
On admission, she was found to have a white blood cell count
of 7.2 with 55 neutrophils and 28 bands, 12 lymphocytes and 5
monocytes. She also had an increase in creatinine from .8
which is her baseline to 1.8 and she had an anion gap of 21.
She has a positive urinalysis with trace protein, moderate
leukocytes, no microscopic analysis. A second urinalysis was
also positive with trace blood, 30 protein, trace glucose,
trace ketones, small bilirubin, negative leukocytes with 0 to
2 red blood cells, 0 white blood cells and no bacteria.
A head CT was obtained and was negative for any acute
process.
HOSPITAL COURSE: Once the patient was admitted to the
medicine service, she was found to have a pneumonia on chest
x-ray. She was started on Ceftriaxone. She was initially
refusing all work-up. On hospital day number four, [**5-1**], she was found to have an incarcerated femoral hernia on
the right. At this time, the patient was taken to the
operating room and transferred to the surgery service after a
small bowel resection and a hernia repair.
On postoperative day number four, the patient was unable to
be weaned from the ventilator. Swan was placed with a wedge
pressure of 8, pulmonary artery pressure of 45 over 25,
stomach vascular resistance 714, cardiac index 2.8. On
postoperative day number four, she also had a worsening
pneumonia develop and she was treated with Meropenem for
enterococcus flucon. On postoperative day number eight, she
continued to have fevers. Bronchoscopy was performed at the
time and it demonstrated left lower lobe collapse. Gram
stain and cultures were taken. Gram negative rods grew and
Gentamycin was added. She also grew Klebsiella on a sputum
culture.
Ultimately, three colonies grew and none of them were
identified. The patient remained on SIMV with low blood
pressures and fevers.
On postoperative day number 11, the patient's ventilator
changes were made from SIMV to pressure control. On
postoperative day number 13, she was rebronchoscoped with
minimal findings. On postoperative day number 14, the
patient was taken for a tracheostomy and a #8 Pore-Tex tube
was placed. On postoperative day number 18, infectious
disease was consulted. She was continued on Meropenem,
Gentamycin for Klebsiella in her sputum. On postoperative
day number 18, she went for a VAC procedure. Antibiotics
were held prior to VAC.
Following the procedure, the patient continued with fevers
and she had bilateral opacities on chest x-ray. She also had
a chest CT done which showed a small left effusion, confluent
opacities, left greater than right, positive air bronchograms
in the left upper lobe, the lingula of the left lower lobe
and the right middle lobe. She also had small nodular
opacities diffusely, likely to be an infection versus septic
emboli.
On [**5-25**], which is postoperative day 21, the patient was
bronchoscoped again with the findings of tracheal edema. The
patient was heavily sedated at the time she had episodes of
hypotension. The systolic blood pressure was to the 80's
with bradycardia and high respiratory rates. This was
relieved with bagged mask ventilation and Ativan. She was
suctioned without much success and received 20 mg of
Dexamethasone.
On postoperative day number 22, her tracheostomy tube was
changed for a longer one because the prior tube was rubbing
up against the posterior wall. At this time, the patient was
transferred to the Medical Intensive Care Unit service.
After her transfer to the Medical Intensive Care Unit
service, she was successfully weaned on day two to a
tracheostomy collar. The ventilator she was on had no further
signs of respiratory distress. She received aggressive chest
therapy and physical therapy. She remained afebrile
throughout the rest of her hospital course.
On [**5-27**], one of her blood cultures that was drawn on [**5-26**] grew
gram positive cocci in pairs and clusters and she was started
on Vancomycin. Blood cultures were redrawn at the time. She
also had an extensive work-up for the previous fevers. She
had a transesophageal echocardiogram done which was negative
for endocarditis. She had lower extremity Dopplers which
were negative for deep vein thrombosis and she was also found
to have an elevated lipase up to 546. CT scan of the abdomen
showed no evidence of pancreatitis. It was sent to
pathology. Preliminary [**Location (un) 1131**] was resolving pneumonia. Her
blood cultures were further revealing to be coagulase
negative staph. Vancomycin was stopped.
The patient was also found to have a normal chromic anemia
with a hematocrit of 34. Her iron studies were normal, most
likely anemia of chronic disease.
The patient was seen by psychiatry and deemed to be stable.
She was restarted on Respiradol .5 p.o. twice a day. The
patient remained on trach collar with no signs of respiratory
distress. She continued to receive aggressive physical
therapy.
The patient was discharged in stable condition to a
rehabilitation facility on a tracheostomy collar, on no
antibiotics.
DISCHARGE DIAGNOSES:
incarcerated femoral hernia, status post small bowel
resection.
Tracheostomy for prolonged ventilator dependence.
Post pyloric feeding tube placement.
Enterobacter and Klebsiella pneumonia.
Pancreatitis.
Bipolar disorder.
DISCHARGE MEDICATIONS:
Heparin 5,000 subcutaneous three times a day.
Albuterol one neb q. six hours.
Ipitroprium bromide one neb q. six hours.
Erythropoietin 20,000 units, one injection q. week.
Bisacodyl 5 mg two tablets oral q. day.
Lamtidine 20 mg tablets twice a day.
Metoprolol 50 mg three times a day.
Dulcosate 100 mg oral q. day.
Acetaminophen 325 mg one to two tablets every four to six
hours as needed.
Lorazepam .5 mg tablet, one to four tablets p.o. every four
to six hours as needed for anxiety.
Oxycodone 5 mg every four to six hours as needed for pain.
Respiratione .5 mg one tablet twice a day.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] in two
weeks. Please call to schedule an appointment.
The patient is to call primary care physician for [**Name9 (PRE) 702**]
in one to two weeks after discharge. It is crucial that she
receive agressive chest physical therapy, and general PT. The
goal is to red-cap her trach with plans for decanulation.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 7586**]
MEDQUIST36
D: [**2110-5-29**] 11:23
T: [**2110-5-29**] 22:37
JOB#: [**Job Number 102385**]
Admission Date: [**2110-4-28**] Discharge Date: [**2110-5-30**]
Date of Birth: [**2042-7-13**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 65-year-old woman who
presented to the [**Hospital1 69**] on
[**2110-4-28**] complaining of some discomfort suprapubic, nausea
and vomiting. She had a 1??????-week recent history of dysuria,
pain and burning when she urinated, suprapubic pain, and had
been in contact with her primary care physician. [**Name10 (NameIs) **] had
been seen in an outside hospital emergency room on [**2110-4-21**]
and received antibiotics but she did not take these and the
subsequently saw her primary care physician two days later,
and was prescribed Cipro but she didn't take that because of
some reported allergy. The follow-up results of those urine
cultures actually was negative. On [**4-25**] she was seen also
in an emergency room for bladder pain, and then a urinary
tract infection was seen at that time on her urinalysis.
Keflex was started, which again she didn't take. She did get
some Pyridium as well and that actually improved some of her
symptoms, and then she subsequently developed nausea and
vomiting. She was noted to have slightly altered thinking
and ended up coming into the Emergency Department but refused
tests and IV. In addition to this she had a remote history
of bipolar disorder and was deemed in the emergency room as
incompetent to leave and was hospitalized therefore.
On further review of systems it turns out she had a 30-pound
weight loss in the last six months from poor appetite,
chronic constipation requiring frequent Fleet enemas, and
multiple trips to the primary care physician but refused [**Name Initial (PRE) **]
colonoscopy which was recommended.
PAST MEDICAL HISTORY: 1. Bipolar disorder. 2.
Hypercholesterolemia. 3. Chronic pelvic pain. 4. Femur
fracture. 5. High blood pressure. 6. Urinary tract
infections. 7. Chronic bladder pain.
MEDICATIONS ON ADMISSION: 1. Lipitor. 2. Lopressor. She
was not on lithium prior to her admission and per the family
she evidently had stopped taking it on her own.
PAST SURGICAL HISTORY: No previous abdominal surgeries.
SOCIAL HISTORY: She did not have any tobacco history,
although she did have one drink per day of alcohol until
about two months prior to her admission. She lives with a
male partner with a history of verbal abuse .
ALLERGIES: Levofloxacin gives a rash, question of chest
pain; ampicillin gives a rash; Bactrim gives a rash.
HOSPITAL COURSE: She was admitted and placed on a 1:1 sitter
for safety, was n.p.o. on intravenous fluids. She initially
refused work-up, including abdominal imaging and was seen by the
psychiatry staff. She subsequently developed lower abdominal
pain and a
surgical consultation was obtained. A nasogastric tube was
placed and approximately two liters of dark brown fluid was
drained. A Foley catheter was placed as well and left lower
lobe pneumonia was diagnosed. She was started on ceftriaxone
on the third hospital day.
A subsequent CT scan showed a small bowel obstruction with a
right inguinal hernia without bowel wall thickening, free fluid
or
air, and the hernia seemed to be the cause of the
obstruction. The patient was brought to the operating room
with the findings actually of a right femoral hernia.
Perioperative she had to be reintubated in the operating room
for precipitous drop in her saturations. The operation was
on [**2110-5-1**]. They did not find any evidence of a bowel
ischemia or infarction, however the right femoral hernia was
incarcerated and the cause of the small bowel obstruction.
Thus she had undergone an exploratory laparotomy, a small
bowel resection, and a femoral hernia repair.
Postoperatively she was followed by the psychiatry team and
by the primary care team. Initially she had a Swan-Ganz
catheter and eventually that was changed over to a
triple-lumen catheter.
Her postoperative course was significant for difficulty
weaning off of the ventilator and her antibiotics had been
broadened in the setting of her operation to ceftazidime,
Flagyl, as well as fluconazole. Cultures from sputum were
the only positive growth and that was yeast, Enterobacter and
Klebsiella. All of these bacteria were sensitive to the
antibiotics that were used. Her antibiotics were changed
several times during her postoperative course. Meropenem and
gentamicin were the subsequent antibiotic regimen that she
underwent and she received a full 14-day course of these.
Also, her perioperative course and postoperative course
involved multiple bronchoscopies with lavage and pulmonary
toilet and multiple cultures being sent. This was for
ongoing fevers, difficulty weaning from the vent and
essentially a worsening picture on her multiple x-rays,
worsening pneumonia in the left middle and lower lung zones,
and bilateral patchy opacities.
The infectious disease team was consulted because no
significant improvement was made in her lungs based on their
x-ray appearance and based on her ventilator dependence,
despite being on excellent antibiotic coverage for the
bacteria that was grown. They recommended a tissue biopsy
from the thoracic surgeons. Thoracic surgery was called and
the patient underwent a video-assisted thoracoscopic surgery
procedure on [**2110-5-22**], which subsequently grew out no
bacteria. Antibiotics were stopped and she did have an
approximately 14-day course or maybe slightly longer, and she
continued to intermittently have a difficult time weaning off
the ventilator. Some of this was believed to be an anxiety
component and eventually she did tolerate a tracheostomy
collar. A tracheostomy was placed after it was clear that
she was unable to wean off the vent, and discussions were
held with the family for improved pulmonary toilet and for
pulmonary rehabilitation. A tracheostomy would be the best
avenue, and she had that placed percutaneously at the bedside
in the intensive care unit. Eventually the patient was
transferred to the medical intensive care unit. A chest CT
and VATS revealed no evidence of neoplastic disease, which
was a concern given the lack of improvement in the x-rays.
The patient eventually had a speech follow up with a
Passy-Muir valve which was successful and she was able to
speak. She had a postpyloric tube placed by interventional
radiology and tolerating tube feeds at goal, which was 70 an
hour with the aim to gradually wean off tube feeds as she can
eat and be off the ventilator obviously.
The patient has ongoing requirements for excellent pulmonary
toilet, chest physical therapy encouragement, has been out of
bed multiple times and will thusly need physical therapy
however. The medical intensive care unit team is following
her currently and the patient will be going to a
rehabilitation center. On [**2110-5-28**] her tracheostomy was
changed to a #6 Shiley cuffless tracheostomy because she was
having some intermittent obstructive type symptoms with the
previous tracheostomy, and since then she had had no
problems.
CURRENT MEDICATIONS:
1. Ativan 0.5 to 2 mg p.o. IV q. [**2-23**] p.r.n.
2. Tylenol p.r.n. for fever.
3. Subcutaneous heparin t.i.d.
4. Dilaudid 0.5 IV q. 3-4 hours p.r.n.
5. Colace 100 p.o. q.d. p.r.n. per her feeding tube.
6. Lopressor 25 mg p.o. t.i.d. through her tube or with valve
in place swallowing. This will be held for heart rate less
than 55 and systolic blood pressure of less than 100.
7. Pepcid 20 mg through her feeding tube b.i.d.
8. Dulcolax suppository q. day p.r.n.
9. Erythropoietin 20,000 units subcutaneous once weekly.
10. Atrovent nebulizers q. 6 hours, albuterol nebulizers q. 6
hours.
TUBE FEEDS: Peptamen full strength 70 mL an hour, otherwise
things go through her feeding tube, all her other
medications. No intravenous fluids.
DISPOSITION: She will require physical therapy. She is
discharged to rehabilitation. Ongoing tracheostomy care and
Passy-Muir with speech and swallow following as well as
physical therapy.
FOLLOW UP: She will have outpatient follow up with her
primary care physician and also with Dr. [**Last Name (STitle) **] in two weeks
from discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 35739**]
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2110-5-30**] 09:06
T: [**2110-5-30**] 09:31
JOB#: [**Job Number 102386**]
|
[
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] |
icd9cm
|
[
[
[]
]
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[
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"97.23",
"31.1",
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] |
icd9pcs
|
[
[
[]
]
] |
8695, 8918
|
8941, 10309
|
12159, 12301
|
12706, 17245
|
12325, 12359
|
18212, 18632
|
2796, 4226
|
2733, 2773
|
149, 185
|
17266, 18200
|
10338, 11935
|
11958, 12132
|
12376, 12688
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,521
| 154,808
|
45589
|
Discharge summary
|
report
|
Admission Date: [**2149-9-11**] Discharge Date: [**2149-9-24**]
Date of Birth: [**2075-9-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 73 year old male with history of prostate
cancer, lung cancer, transitional cancer of the left ureter, and
a recently identifed brain mass. He presented to the ED today
with worsening shortness of breath. He has had gradual worsening
of his respiratory status over the last 4-5 months, but severe
worsening over the last few days. He reports he can walk
approximately 100ft easily without SOB, which is per patient
decreased from 2 weeks ago (although can't even complete a full
sentence due to difficulty breathing on exam). Also with
increasing cough, non productive. + sensation of throat and
airway being closely and not being able to take a deep breath.
He has chest pain throughout his thorax. Per patient he is
smoking 1.5 ppd (x 60 years); although his family reports that
he has increased to 4 ppd. He also reports increasing lower
extremity edema over the last few weeks.
.
The patient had plans to see Dr [**Last Name (STitle) **] (heme-onc) on [**2149-9-15**]
for medical clearence prior to debulking of his brain mass. Dr
[**Last Name (STitle) 724**]
Family reports that he has increased his cigarette smoking. Last
spoke with family [**2149-9-10**] regarding increased pedal edema and
weeping. Patient is awaiting neuro-surgery to debalk a lesion.
Needs to be seem by medical oncology for clearance -- prior to
surgery.
Past Medical History:
1. transitional cell bladder carcinoma -- dx after hematuria in
[**2144-3-1**]. A mass was found in his left renal pelvis. He later
underwent an ureteroscopy on [**2144-3-9**], followed by a left
nephroureterectomy
on [**2144-3-13**]. He subsequently left ureter and left kidney
resection at [**Hospital1 69**]. The pathology
was papillary transitional cell carcinoma. He then received
multiple biopsies of the bladder and resections of recurrent
transitional cell carcinomas via cystoscopies on [**2145-9-8**] and
[**2147-4-18**].
2. prostate cancer
3. non-small cell lung cancer - dx [**2149-1-29**]; underwent right
lower lobe lobectomy
4. hit by a train in [**2099**].
5. Brain Mass - unclear if mets or primary brain tumor; his
neurological problem began in early [**2149-8-1**] when he
was running into things on the left side. He put on a sweater
incorrectly, and he left his car door open in a parking lot. He
has imbalance and pressure-type pain in the mid-frontal region
that is worsened with changes in body position. He had an
outside head MRI on [**2149-8-12**] that showed a large mass in the
right occipital brain. He was sent to [**Hospital1 827**] for consideration of Cyberknife radiosurgery. The
plan as of early [**Month (only) **] was to debulk the tumor after medical
clearence.
Social History:
He was smoking 2 packs of cigarettes for 60 years until his
diagnosis of lung cancer. Currently smoking 4ppd. He does not
drink alcohol or use illicit drugs.
Family History:
His mother died of liver cancer at the age of 90, while his
father passed away from a stroke at age 56. He has 7 sisters and
they are healthy. His son and daughter are healthy.
Physical Exam:
Vitals - 97.3 BP 118
General - very thin, skin appears greyish, speaking in short
sentences due to difficulty breathing
HEENT - PERRL, MMM
Neck - supple
CV - RRR, no murmur appreciated
Resp - scattered wheezes throughout, no crackles, decreased
breath sounds in on right
Abd - mildly distended, multiple healed scars, no guarding or
rigidity, non-tender
Ext - 4+ pitting edema b/l up to mid thigh
Neuro - AAO x 3, decreased strength with left hand; difficult to
assess strength in legs given gross edema
Pertinent Results:
[**9-11**]: CK, Troponin negative x 3.
134 | 99 | 53
---------------< 126
4.8 | 23 | 1.7
WBC-9.6 HGB-13.2* HCT-38.9*
NEUTS-94.4* BANDS-0 LYMPHS-3.5* MONOS-1.5* EOS-0.4 BASOS-0.1
UA negative
Imaging:
[**2149-9-11**] CTA -
1. Interval progression of known nonsmall cell lung cancer, with
endobronchial soft tissue lesions particularly in the left lower
lobe and new lung nodules.
2. No evidence of PE or aortic dissection.
3. Coronary vascular calcifications.
4. Similar/slightly enlarged appearance of metastatic disease in
mediastinum, liver, and spleen.
5. New permeative lesion in left scapula.
[**2149-9-11**] CXR - Evidence of lung tumor in right upper lobe area.
No evidence of additional acute parenchymal infiltrates or CHF.
[**2149-9-15**] CXR: IMPRESSION:
1. Right upper lobe mass and multiple pulmonary nodules, not
substantially changed.
2. Worsening mucoid impaction in left lower lobe and apparent
new small left pleural effusion.
Brief Hospital Course:
1). SOB - The patient was evaluated by pulmonary for ? etiology
of shortness of breath. A CTA was negative for PE, and a
negative BNP and no signs of fluid overload on imaging ruled out
CHF. Pulmonary felt that the patient may have respiratory
distress secondary to mucoid plugging, but elected to complete
his 7-day antibiotic regimen of levofloxacin which he had
started as an outpatient. The patient was also started on
Bactrim prophylaxis for PCP given his immunocompromised state
and given albuterol, iptratropium, and mucomyst nebulizer
therapy PRN. His shortness of breath resolved the day of
admission and the patient was saturating 99% on RA for the rest
of his stay.
2). Oncology: Neurosurgery, neurology, radiation oncology and
hemetology/oncology were all consulted during the patient's
stay. External records were obtained from the [**Hospital1 882**]. Under
the recommendation of Dr. [**Last Name (STitle) **] heme/onc decided that the
patient was a poor candidate for chemotherapy and recommended
surgery. The patient was evaluated by Dr. [**Last Name (STitle) **] with input
from radiation/oncology and the decision was made to puruse
surgery for the brain lesion.
Throughout his stay the patient was maintained on IV steroids to
decrease brain edema.
3). Lower extremity edema: CHF is negative, and albumin was
normal. We kept the legs elevated and used intermittant lasix
to diurese the patient with mild resolution. Per outside notes
the pedal edema developed concurrently with the patient's
steroids, and this was considered the most likely etiology of
his edema.
[**9-12**]: no sign of CHF. per outside notes [**1-2**] steroids.
4) Tachycardia - The patient was tachycardic on presentation,
most likely secondary to increased work of breathing and
dehydration. We gave the patietn fluids overnight and monitored
on telemetry (negative). His tachycardia resolved overnight.
5). Elevated creatinine: Patient was mildly pre-renal due to
intravascular depletion. It resolved with gentle hydration.
Medications on Admission:
Prilosec 20 mg po daily
Percocet 2-3 tabs po daily
Norvasc 10 mg po daily,
Prednisone 40 daily
Lasix 10 mg daily
Levaquin since [**9-8**] for possible PNA
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
12. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell. Q4-6H (every 4 to 6 hours) as needed for mucous
production.
13. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours) as needed
for pain.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q6-8H (every
6 to 8 hours) as needed for anxiety.
18. Nicotine Polacrilex 2 mg Lozenge Sig: One (1) Lozenge Mucous
membrane Q1-2H () as needed for craving to smoke.
19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
20. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
21. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
22. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 2 days: started in am of [**9-23**] .
23. Dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours) for 2 days: start [**9-25**].
24. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): start [**9-27**].
25. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
26. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
27. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Shortness of breath
2. Metastatic lung cancer
3. Lower extremity edema
4. Tachycardia
5. Elevated creatinine
Discharge Condition:
respiratory function improved
neurologically stable
Discharge Instructions:
Please take your medicines as prescribed. If you have worsening
shortness of breath, chest pain, fevers, chills, or any other
concerning symptoms please contact a physician [**Name Initial (PRE) 2227**].
Please call [**Telephone/Fax (1) **] if you have any worsening headache,
fever, drainage from or redness at your incision.
Completed by:[**2149-9-24**]
|
[
"197.7",
"V10.46",
"276.52",
"584.9",
"197.8",
"305.1",
"368.46",
"934.9",
"198.3",
"V10.50",
"782.3",
"518.82",
"V58.65",
"401.9",
"162.8",
"E912"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
9774, 9846
|
4935, 6967
|
339, 346
|
10002, 10056
|
3959, 4912
|
3242, 3420
|
7172, 9751
|
9867, 9981
|
6993, 7149
|
10080, 10438
|
3435, 3940
|
280, 301
|
374, 1726
|
1748, 3051
|
3067, 3226
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,099
| 108,517
|
9529
|
Discharge summary
|
report
|
Admission Date: [**2133-3-25**] Discharge Date: [**2133-4-20**]
Date of Birth: [**2090-5-28**] Sex: F
Service: CARDTHOR SURGERY
HISTORY OF PRESENT ILLNESS: This is a 42 year old woman with
a history of multiple medical problems starting with the
following:
1. Congenital hepatic fibrosis.
2. Hepatitis C with demonstrated liver lesions.
3. End-stage renal disease on hemodialysis.
4. History of bilateral deep venous thromboses and status
post placement of an IVC filter.
5. History of Streptococcal infection of a dialysis
catheter.
6. History of aortic insufficiency and mitral regurgitation.
7. Status post splenectomy.
8. History of intraperitoneal bleed.
9. History of Klebsiella sepsis in [**2132-1-11**].
10. Asthma.
The patient had multiple medical admissions over the year;
the most recent one of note was for increasing shortness of
breath in [**2132-12-11**], for which she saw Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **].
The patient also had a history of VRE.
ALLERGIES:
1. Metronidazole.
2. Neomycin.
3. Penicillin.
4. Sulfa.
MEDICATIONS ON ADMISSION:
1. Ambien 5 mg p.o. q. h.s.
2. Colace 100 mg p.o. twice a day.
3. Folate 1 mg p.o. q. day.
4. Protonix 40 mg p.o. twice a day.
5. Nephrocaps 1 tablet q. day.
6. Renagel 800, four tablets three times a day.
7. Coumadin 2.5 mg p.o. q. day.
8. Zyrtec 10 mg p.o. q. day
9. Lactulose 30 cc twice a day and three times a day.
The patient was admitted on the 13th for a work-up of her
aortic murmur and her known four plus aortic insufficiency
and three plus mitral insufficiency. Her exercise tolerance
test had shown no perfusion defects and an ejection fraction
of 72%. She was admitted to the Cardiology Service for
elective catheterization prior to her double-valve surgery.
Also of note was the notation that the patient's
glomerulonephritis was probably status post a Streptococcal
infection that ultimately results in end-stage renal disease
and hemodialysis. She then developed a line infection that
gave her the endocarditis and, hence, the increasing murmurs
and insufficiency of her heart valves.
PHYSICAL EXAMINATION: When she was admitted to Cardiology
she was noted to be thin with a blood pressure of 124/53,
saturating 98% on room air with a heart rate in sinus at 81;
respiratory rate of 20. Her carotids had no bruits. She had
no jugular venous distention. Lungs were clear anteriorly.
She did have both systolic and diastolic murmurs. Her
abdomen was soft and nontender with good bowel sounds. She
had no extremity edema and had bilateral distal pulses. She
was alert and oriented.
Prior work-up had also shown an echocardiogram in [**2132-12-11**], which showed mild left atrial enlargement, symmetric
left ventricular hypertrophy and a normal ejection fraction.
Her aortic valve gradient was 23 with a peak of 44 at that
time.
Her pulmonary function tests in [**Month (only) **] also of [**2132**], were
done.
On [**2133-3-18**], she had a CT scan of the chest which
showed stable tree and [**Male First Name (un) 239**] opacities and the right apex was
consistent with bronchiolitis.
LABORATORY: Prior to admission were white blood cell count
of 6.8, hematocrit of 36.6, platelet count of 348,000.
Sodium 138, potassium 5.1, chloride 104, CO2 21, BUN 26,
creatinine 8.3 with a platelet count of 73,000. INR was 1.4.
She did also, as noted in Past History, have a history of
hepatic encephalopathy that had resolved. She also had a
prior history of infection with Clostridium difficile.
HOSPITAL COURSE: Cardiac catheterization was done which
showed normal coronary arteries, aortic insufficiency, mitral
regurgitation. The patient had hemodialysis one day
preoperatively while also on the Cardiology Service and was
followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**], the Renal attending, for
monitoring of her renal status. She did have a left arm AV
fistula in place and she was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) 411**] of Cardiothoracic Surgery for her valve replacement.
She was also seen by Dr. [**Last Name (STitle) 11442**], the Chief Resident.
Her ejection fraction was normal. Her murmurs are radiated
to bilateral neck, Grade III/VI both systolic and diastolic.
Her last set of laboratories prior to the Operating Room was
sodium 138, potassium 4.4, chloride 103, CO2 23, BUN 30,
creatinine 8.6, white count of 5.4, blood sugar of 100,
hematocrit of 34 and platelet count of 190,000.
On[**Last Name (STitle) 32377**]5th, she underwent double valve replacement with a 19
CarboMedics mechanical aortic valve and a [**Street Address(2) 11599**]. [**Male First Name (un) 923**]
mechanical mitral valve by Dr. [**Last Name (Prefixes) **]. She was
transferred to Cardiothoracic Intensive Care Unit in stable
condition on a Neo-Synephrine drip, Propofol drip and a
protenin infusion. She was also treated perioperatively with
Linezolid for her allergies and intolerance of Vancomycin and
penicillin.
[**Last Name (STitle) **], there was concern with increased chest tube
bleeding and Dr. [**Last Name (Prefixes) **] mobilized the Operating Room
team to bring her back to explore her mediastinum to rule out
any sources of bleeding. The patient was brought down to the
Operating Room. A transesophageal echocardiogram was
performed which did not show an effusion and the patient's
bleeding decreased; the patient was returned to the
Cardiothoracic Intensive Care Unit. The patient did, over
the course of the first day, have an increased PR interval
and went into atrial fibrillation. The patient was started
immediately on Amiodarone on postoperative day one and was
extubated. The patient was V-paced for better control of her
rate.
She did well over the first couple of days. She did pick up
some volume and then became a little more lethargic over the
next couple of days. She received intravenous heparin to
cover her valves in preparation for starting her on Coumadin,
but her platelet count continued to drop. HIT antibodies
were sent which were negative. The patient began to require
a little bit of increased amount of pressor support other
than the Neo that the patient had come up on. The patient
was also started on Dopamine on postoperative day six for
blood pressures that waned in the 90s over 50s. The patient
was continually followed every day by the Renal Service. The
Clinical Nutrition Service also saw the patient.
The patient went back into sinus rhythm after the amiodarone
was started and then went back into atrial fibrillation the
following day. On postoperative day seven, of note, the
patient's white count rose acutely from 10.9 to 25.6, and an
Infectious Disease consultation was immediately obtained.
Also of note, the central line was pulled from the right
internal jugular site and there was some purulence at that
site. In addition, the patient was producing some greenish
sputum. Cultures were sent off; urinalysis was sent. E.
coli came back in the urine. The patient was then
immediately started on triple antibiotic therapy,
Ceftazidime, Vancomycin and Gentamicin. The white count
decreased the next day to 17.6. Blood cultures had all been
sent off on day six and came back with Gram negative rods.
The patient's lactate rose over the next couple of days to
7.5 and the patient started to have respiratory symptoms with
increased dyspnea as well as continuing persistent
hypotension. The patient was restarted on CVVH on
postoperative day 10. Pressor requirements were such that
she was now on Neo-Synephrine at 5, Dopamine at 5, and she
continued to be V-paced. She was transfused as needed. Her
lactate came back down slightly to 6.5. Liver enzymes were
all elevated. Approximately day eight, a right upper
quadrant ultrasound was obtained. The patient's mixed venous
was also at 65% at that point.
Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] from General Surgery also saw the
patient on postoperative day nine, and agreed that her
gallbladder probably needed to be drained. This was done
under Radiology. On that day, her total bilirubin was 21.9.
She continued to have increased work of breathing and was
reintubated. Levophed was added in to her pressor regimen.
A bedside echocardiogram showed increasing pleural effusions
with tricuspid regurgitation. As sensitivities came back,
the patient was switched back only to Ceftazidime, then
Amikacin was added in at the recommendation of Infectious
Disease on postoperative day 11.
On postoperative day 11, the hunt continued for other sources
of possible sepsis. The patient had a pericardiocentesis
done by Cardiology which drained 250 cc of fluid. The
patient continued to have a dropped SER with an increasing
cardiac output and cardiac index of approximately 4 with a
growing septic picture. Filling pressures rose to CVP of 24
and PA pressures of 54/30. Bilateral chest tubes were placed
with a decrease in the amount of effusions. The right IJ and
radial A-line cultures came back as E. coli.
Pericardiocentesis fluids were also sent for culture. The
patient also had a CVVHD. All of these volume management and
hemodialysis issues continued to be followed on a daily and
sometimes twice daily basis by the Renal Service.
On postoperative day 12, the patient's lactate rose to 14.2
and the patient was clearly showing signs of jaundice. The
patient, at that point, had a right Quinton catheter and a
left femoral A-line. The patient was continued on Vancomycin
at this point, Ceftazidime and Amikacin. Also of note on
that day was increasing right upper extremity edema.
The patient was also seen by Social Work for discussion with
the family.
The patient's Levophed requirement also increased and was now
at 0.5. Metabolic Service was also consulted. The
Hyperalimentation attending saw the patient and recommended
TPN changes. The patient was on Levophed at 0.6,
Neo-Synephrine at 6.0, and Dopamine at 5.0. Pitressin was
added in to the pressor regimen at 0.04.
The patient showed signs of worsening distal perfusion with
decreased pulses in her extremities and the INR continued to
rise. The patient also had multiple episodes of epistaxis
bleeding also from around the NG tube. On postoperative day
13, the patient had an ultrasound of the belly which showed
ascites in bilateral lower quadrants. All fluids had come
back as E. coli; that included pleural fluid, pericardial
fluid, cultures from urine. Bile fluid proved to have
Vancomycin resistant Enterococcus. The patient was started
on Linezolid again and the Vancomycin was discontinued as it
was resistant. The patient continued to look more grave and
increasingly septic as the antibiotic regimen was shifted
again in an attempt to bring her sepsis under control.
On postoperative day 15, the patient was hypothermic; also,
possibly due to her CVVH, her white count rose to 24.9. She
did develop some metabolic alkalosis which was addressed by
the Renal Team by changing her CVVHD fluid to normal saline
from the bicarbonate included solution that they had been
using. On postoperative day 16, she required continuing
pressor support and was increasingly more jaundiced. She was
on Dopamine at 3.0, Levophed at 0.2, Neo-Synephrine at 0.3
and Pitressin at 0.04. She was receiving maximal pressure
support with aggressive antibiotic therapy and control of her
renal status and volume management by the Renal Service.
On postoperative day 17, the Quinton catheter tip came back
positive for [**Female First Name (un) 564**] albicans. Blood cultures which had also
been sent also came back positive for [**Female First Name (un) 564**]. The patient
continued to be followed very closely by all services,
including the GI Service, General Surgery, Renal, and daily
consultations by the Infectious Disease service for
management of her sepsis and multiple antibiotic therapy.
On postoperative day 20, Amphotericin was added in to the
Amikacin regimen. She also remained on Ceftazidime and
Linezolid. Her lactate was 7.8 and her liver failure was
well documented by enzymes and coagulopathy.
The patient continued to spiral and with a very poor
prognosis. On postoperative day 22, she had increasing
metabolic acidosis, was again dialyzed. She required
platelets and fresh frozen plasma and heart disease
increasingly worse oxygenation. She was passing clotted
blood and frank blood from her NG tube and had a systemic
anasarca picture. Her central line which had also been
withdrawn also came back positive for [**Female First Name (un) 564**] albicans.
On[**Last Name (STitle) 14810**]perative day 23, the patient was clearly dusky, not
oxygenating well and her sepsis continued. She was on
Neo-Synephrine at 4.0, Dopamine at 4.0, Levophed at 0.5. Her
PT on that morning was 43 with an INR of 13.2. Prior to this
day, discussions had been had by the Renal attending and Dr.
[**Last Name (Prefixes) **] as well as the Infectious Disease Services input
as to her prognosis and maximal aggressive therapy had been
attempted to try and reverse her picture, but the patient
expired in the Cardiothoracic Intensive Care Unit at 05:50
a.m. on [**4-20**]. The patient was pronounced by Dr. [**First Name4 (NamePattern1) 6382**]
[**Last Name (NamePattern1) 32378**] in the Cardiothoracic Surgery Unit.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement and mitral valve
replacement.
2. Status post Septicemia with Escherichia coli and [**Female First Name (un) 564**]
albicans.
3. End-stage renal disease with hemodialysis.
4. Congenital hepatic fibrosis.
5. Hepatitis C.
6. Status post Streptococcal infection of dialysis catheter.
7. Status post bilateral deep venous thromboses with
placement of IVC filter.
8. Status post splenectomy.
9. Status post intraperitoneal bleed.
10. Status post Klebsiella sepsis in [**2133-1-10**].
11. Asthma.
DISPOSITION: The patient was discharged and expired in the
Cardiothoracic Intensive Care Unit on [**2133-4-20**].
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2133-4-22**] 11:47
T: [**2133-4-22**] 12:00
JOB#: [**Job Number 32379**]
|
[
"396.3",
"038.42",
"575.0",
"785.59",
"428.0",
"585",
"427.31",
"997.1",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"88.53",
"35.24",
"39.61",
"35.22",
"88.57",
"37.23",
"42.23",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
13439, 14357
|
1134, 2151
|
3585, 13418
|
2174, 3567
|
178, 1108
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,780
| 149,672
|
8651+55966
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-6-24**] Discharge Date: [**2140-8-16**]
Date of Birth: [**2110-10-7**] Sex: F
Service: SURGERY
Allergies:
Percocet / Codeine
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
renal/pancreas transplant [**2140-6-24**]
transplant pancreactomy
right iliac thrombectomy
fasciotomies of 4 extremities [**2140-6-25**], IVC filter
abdominal wound debridement
renal bx [**2140-7-22**]
central line insertion
bilateral plantar movement disorder
Past Medical History:
DMII (dx'd age 2)
CAD
living donor kidney tx (failed [**2132**])
calcium deposits with calciphylaxis
MPGN
parathyroidetomy
.
Meds:
diazepam
neurontin
quinidine sulfate
NPH
Humulin
Phos-lo
Norvasc
Lopressor
Lipitor
Banadryl
Epogen
Heparin
Iron
Social History:
Lives at home with her parents. Works as a tutor. no illicit
drug use. She occasionally drinks alcohol and has no history of
tobacco abuse.
Family History:
She is the 7th of 9 children. Father has type II diabetes. She
has a sister with type I diabetes.
Pertinent Results:
[**2140-8-16**] 06:00AM BLOOD WBC-5.3 RBC-2.99* Hgb-8.8* Hct-27.0*
MCV-90 MCH-29.4 MCHC-32.5 RDW-17.4* Plt Ct-427
[**2140-8-16**] 06:00AM BLOOD Plt Ct-427
[**2140-8-16**] 06:00AM BLOOD Plt Ct-427
[**2140-8-16**] 06:00AM BLOOD PT-32.1* INR(PT)-3.4*
[**2140-8-16**] 06:00AM BLOOD Glucose-124* UreaN-29* Creat-1.3* Na-134
K-5.6* Cl-102 HCO3-23 AnGap-15
[**2140-8-16**] 06:00AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.4*
[**2140-7-21**] 06:15AM BLOOD TSH-13*
[**2140-7-23**] 10:08AM BLOOD T4-5.8 calcTBG-0.92 TUptake-1.09
T4Index-6.3
[**2140-7-22**] 06:00AM BLOOD T4-6.1 T3-59* Free T4-1.1
[**2140-8-16**] 06:00AM BLOOD FK506-13.0
Brief Hospital Course:
She underwent a simultaneous pancreas-kidney transplant with
duodenal loop mid ileostomy by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] assisted by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] on [**2140-6-25**]. Please see operative report for details.
She was sent to the SICU postoperatively given concern for
elevated intra-abdominal pressure. On [**2140-6-25**] she was taken back
to the OR for abnormal pancreatic duplex ( Absence of flow
within the splenic vein and loss of diastolic flow on Doppler
waveforms consistent with splenic venous obstruction to the
pancreatic transplant)and underwent exploratory lap, transplant
pancreatectomy and 4 compartment fasciotomies of bilateral lower
extremities. The etiology of the compartment syndrome was
unknown. She also suffered a right iliac thrombosis requiring
thrombectomy. An IVC filter was placed on [**2141-6-27**]. Insulin was
resumed. [**Last Name (un) **] followed making recommendations. On [**2140-6-27**] she
returned to the OR for fasciotomy of the right forearm, wrist
and hand, mediannerve decompression right wrist; fasciotomy left
forearm,wrist and hand, median nerve decompression left wrist.
This procedure was done by Dr. [**Last Name (STitle) 30291**] from plastics.
Postop course was complicated by delayed graft function
requiring CVVHD because she wasn't able to handle hemodialysis.
She was given milrinone. She experienced rapid afib and required
cardioversion and amiodarone. Hemodialysis was eventually
started for several weeks. Nephrology followed closely
throughout this complicated hospital course. A renal biopsy was
done on [**7-21**] given concern for rejection. This was consistent
with cellular/acute rejection. There was concern for a humoral
rejection given findings of +/- vascular staining for C3.
There was no significant staining for IgG, IgA, IgM, Kappa, or
Lambda. Albumin and fibrin were non-contributory. The C4d
stain was negative with focal staining in less than 10% of the
peritubular capillaries. She was initially given OKT3 with
solumedrol. This was stopped when she experienced pulmonary
edema which required intubation. Solumedrol was given for 5 days
and prednisone continued at 20mg qd. Urine output gradually
increased. Creatinine started to trend down. Hemodialysis was
stopped. Creatinine decreased to a low of 1.4. She continued on
cellcept 1 gram [**Hospital1 **], prednisone 20mg qd, and prograf 7mg [**Hospital1 **].
Prograf levels were slow to increase. She reached a level on [**8-15**]
at 13.6. Goal prograf level was [**9-21**].
Early in the postop course she experienced a LUL pneumonia
which responded to IV vanco and zosyn. Sputum was positive for
E.coli and pseudomonas. Subsequent CXRs were improved. A cardiac
echo was done given significant fluid retention. Prominent
symmetric left ventricular hypertrophy with left and right
ventricular cavity sizes and low normal left ventricular
systolic function was noted. A TSH was checked given significant
fluid retention. This was 13 and felt to be secondary to sick
thyroid. T3 & T4 were wnl.
She underwent closure of the lower extremities and
debridement of the abdominal wound on [**7-15**] (please see operative
report). A abdominal wound vac was placed and changed q 72
hours. The transplant ureter was transected during this
procedure and repaired. JP drain was in place. Fluid from the JP
was sent for creatinine and revealed values similar and less
than the serum creatinine ruling out a urinary leak. The foley
was removed and she experienced urinary freqeuency attributed to
bladder deconditioning secondary to being anuric prior to
transplant. Urinalysis and cultures were negative for infection.
On [**7-29**] she grew out klebsiella from the abdomenal wound
sensitive to meropenum. She received six days of meropenum.
Neurology and orthopedics as well as PT evaluated her for
bilateral plantar flexion deformities and ankle contractures
from prolonged immobility. Neurology expressed concern for
possible nerve injury due to compartment syndrome. Orthopedics
recommended afo's,splinits, arom and prom activities. Neurology
agreed with Ortho's plan though suggested boots should be 4hrs
on and 4 hours off. Adjustable multipodis boots were obtained,
but were not used at this time due to the calf incisions and
potential for injury to incisions. PT/OT worked with her
extensively. Rehab was recommended. Nutrition followed her due
to poor po intake. A tube feeding was utilized for post pyloric
feedings. This was removed eventually when her appetite
gradually improved.
She experienced significant pain in her extremities and
abdomen that was managed with methadone, dilaudid pca, po
dilaudid. Methadone was stopped per patient request. PCA
dilaudid was stopped and intermittent dilaudid IV prior to
dressing changes was utilized for break thru pain med. She was
able to get out of bed with max assist to the chair. Psychiatry
and social support provided support as she was quite depressed
from prolonged and complicated course. Antidepressants were
deferred. Mood improved with physical improvement.
IV heparin was utilized until coumadin was therapeutic. INR
goal of 2.3 was achieved on [**8-15**] on 5mg. INRs should be check
daily until she remains stable in the 2-3 range. Coumadin was
decreased to 2mg qd on [**8-16**] for INR of 3.4.
The plan was to discharge to [**Hospital3 **] with
follow up Monday [**8-22**] at 0800am with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**].
Medications on Admission:
lopressor 25bid, phoslo 667 tid, NPH, cardizem 180 hs, clonidine
0.1mg HD, lantus 30 units qam, humalog qam, epogen with
dialysis, valium 2mg tid, neurontin 100mg [**Hospital1 **], lipitor 80mg qd,
quinine.
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-14**]
Drops Ophthalmic PRN (as needed).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
8. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
once a day as needed.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO HS (at bedtime).
16. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
19. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
21. Hydromorphone 2 mg/mL Syringe Sig: 0.5-1 mg Injection Q2H
(every 2 hours) as needed: prior to abdominal dressing change.
22. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
23. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO twice a day.
24. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
25. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous lunch.
26. Insulin Lispro (Human) 100 unit/mL Solution Sig: follow
sliding scale Subcutaneous four times a day: see printed scale.
27. Outpatient [**Name (NI) **] Work
PT/INR qd
fax to [**Telephone/Fax (1) 697**] attn: [**Name6 (MD) 5036**] [**Name8 (MD) 5039**], RN Coordinator
28. Outpatient [**Name8 (MD) **] Work
Q MONDAY & Thursday Labs:
CBC, chem 7, calcium, phosphorus, ast, t.bil, albuumin,
urinalysis and trough prograf level.
fax to [**Telephone/Fax (1) 697**] attn: [**Name6 (MD) 5036**] [**Name8 (MD) 5039**], RN
29. Epogen 20,000 unit/2 mL Solution Sig: One (1) Injection
once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] hosp
Discharge Diagnosis:
esrd
s/p renal/pancreas transplant [**2140-6-24**] with loss of pancreas
transplant
pancreas transplant removal
right iliac thrombus s/p thrombectomy
compartment syndrome of 4 extremities
Humoral rejection of renal transplant, resolved
DM I
CAD
Discharge Condition:
stable
Discharge Instructions:
Call Transplant office [**Telephone/Fax (1) 673**] if fever, chills, nausea,
vomiting, decreased urine output, weight gain of 3 pounds in a
day, increased wound drainage/pus/bleeding from abdominal wound
or of arm/leg incisions.
PT/INR qd -send to [**Telephone/Fax (1) 697**] attn: [**Name6 (MD) 5036**] [**Name8 (MD) 5039**], RN
coordinator
Labs every Monday & Thursday for cbc, chem 7, calcium,
phosphorus, albumin, ast, t.bili and trough prograf.Fax to
[**Telephone/Fax (1) 697**]
Followup Instructions:
Call [**Telephone/Fax (1) 673**] to schedule follow up appointment with
transplant surgeon-Dr. [**First Name (STitle) **] for Friday [**8-19**]
Completed by:[**2140-8-16**] Name: [**Known lastname 5318**],[**Known firstname 1163**] Unit No: [**Numeric Identifier 5319**]
Admission Date: [**2140-6-24**] Discharge Date: [**2140-8-16**]
Date of Birth: [**2110-10-7**] Sex: F
Service: SURGERY
Allergies:
Percocet / Codeine
Attending:[**First Name3 (LF) 2648**]
Addendum:
On [**7-29**] Split-thickness skin graft of bilateral
lower extremity fasciotomy sites, abdominal wall debridement
and abdominal wall closure was done.
Heparin and coumadin started for Left IJ thrombus noted on U/S
[**8-3**]. This was done for L arm swelling >R arm.
On PE:
A&O
Left cvl to be removed prior to d/c to rehab.
Lungs clear
Cor-rrr
Abd-wound vac to suction. ND. +bowel sounds
GU-voiding q 2-3 hours. u/o 2500cc/day
ext-1+bilat
skin-sacral stage 2 decub. (~2cmx1cm)
bilat calves with skin grafts. Muscle very superficial with skin
graft visible. L calf with superior aspect with grey slough area
where graft not taking. Bilat forearm incisions with sm amt dry
scabbing. No erythema/drainage.
Major Surgical or Invasive Procedure:
renal/pancreas transplant [**2140-6-24**]
transplant pancreactomy
right iliac thrombectomy
fasciotomies of 4 extremities [**2140-6-25**], IVC filter
abdominal wound debridement
renal bx [**2140-7-22**]
central line insertion
bilateral plantar movement disorder
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] hosp
Discharge Diagnosis:
left IJ thrombus [**2140-8-3**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**]
Completed by:[**2140-8-16**]
|
[
"728.88",
"482.1",
"453.41",
"557.0",
"585.6",
"250.41",
"729.9",
"997.2",
"482.82",
"276.7",
"427.31",
"736.79",
"998.83",
"354.0",
"996.86",
"453.8",
"996.81",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.82",
"46.01",
"38.7",
"83.09",
"93.59",
"55.69",
"55.23",
"45.91",
"54.72",
"39.95",
"52.6",
"86.59",
"56.82",
"82.09",
"38.09",
"99.15",
"04.43",
"86.69",
"86.22",
"00.93",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
12824, 12872
|
1754, 7349
|
12538, 12801
|
10723, 10732
|
1111, 1731
|
11264, 12500
|
990, 1092
|
7606, 10363
|
12893, 13083
|
7375, 7583
|
10756, 11241
|
239, 245
|
568, 813
|
829, 974
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,006
| 167,524
|
13047
|
Discharge summary
|
report
|
Admission Date: [**2170-7-5**] Discharge Date: [**2170-7-10**]
Service: CARDIOTHOR
CHIEF COMPLAINT: The patient was found to have coronary
artery disease during a workup being performed prior to right
hip surgery.
HISTORY OF PRESENT ILLNESS: An 85-year-old man who is status
post inferior myocardial infarction in [**2160**] with no history
of chest pain, pressure or shortness of breath found to have
severe coronary artery disease upon workup for right hip
surgery. He is status post right total hip replacement and
right total knee replacement with a breakdown of his hip
prosthesis for which he was scheduled to have a re-operation
after his bypass surgery. Cardiac catheterization done on
[**6-11**] showed normal left main, 30-40% left anterior
descending artery, 80% circumflex, 85-90% right coronary
artery, 95% obtuse marginal and ejection fraction of 35-40%
and 1-2% mitral regurgitation.
PAST MEDICAL HISTORY: Significant for, as stated previously,
inferior myocardial infarction, seizure disorder, complete
heart block status post permanent pacemaker insertion, mild
dementia, prostate carcinoma status post radiation therapy,
sleep apnea, osteoarthritis, degenerative joint disease,
atrial fibrillation, giant cell arthritis, peripheral
neuropathy, diverticulitis status post colostomy in [**2164**],
status post right knee replacement and right hip replacement
with breakdown of his prosthesis.
MEDICATIONS ON ADMISSION: Include:
1. Aspirin 81 q. day.
2. Tylenol 1000 mg p.r.n.
3. Prednisone 2.5 mg q. day.
4. Dilantin 100 mg q. day.
5. Thiamine 100 mg q. day.
6. Colace 100 mg b.i.d. p.r.n.
7. Isosorbide 30 mg q. day.
8. Atenolol 12.5 mg q. day.
9. Citrucel b.i.d.
ALLERGIES: He has no known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: He is a retired restaurant owner. Denies
tobacco use. Alcohol use: One to two drinks per day. Lives
in [**Location 5087**] with his daughter.
PHYSICAL EXAMINATION: General: Thin elderly man in no acute
distress. Pleasant continence. Alert and oriented times
three. Appears stated age. Skin well hydrated. Mild dry
erythematous patch of skin on his sternum. HEENT: Pupils
equal, round and reactive to light. Extraocular movements
intact. Normal buccal mucosa. No dentures. Neck is supple.
No jugular venous distention. No lymphadenopathy. No
thyromegaly. Chest is clear to auscultation bilaterally.
Right chest with a permanent pacemaker scar that is
well-healed. Heart regular rate and rhythm. S1, S2 with a
2/6 systolic murmur heard best at the left sternal border.
Abdomen soft and non-tender, non-distended, normoactive bowel
sounds with a mid abdominal scar that is well-healed.
Extremities are warm with no edema, no cyanosis. Right hip
and knee scars are well-healed. No varicosities. Mild
bilateral spider veins of both extremities. Neuro: Cranial
nerves II through XII grossly intact with positive motor
deficits due to severe right hip pain. Patient dependent on
walker for ambulation. Pulses: Femoral 2+ bilaterally.
Dorsalis pedis 2+ bilaterally. Posterior tibial nonpalpable
and radial 2+ bilaterally.
RADIOLOGY: Chest x-ray preoperatively showed cardiomegaly
without evidence of congestive heart failure or acute
pulmonary processes.
LABORATORY: Sodium 136, potassium 4.4, chloride 99, carbon
dioxide 27, BUN 22, creatinine 0.9, glucose 67, ALT 16, AST
20, alk phos 102, total bilirubin 0.3. PT 13.7, PTT 30.8,
INR 1.3. White count 5.6, hematocrit 35.2, platelet count
136,000. Urinalysis by dipstick is negative.
HOSPITAL COURSE: On [**7-5**] the patient was directly
admitted to the Operating Room at which time he underwent
coronary artery bypass grafting times three. Please see the
Operating Room note for full details. In summary, the
patient had a coronary artery bypass graft times three with
the LIMA to the LAD, saphenous vein graft to OM and saphenous
vein graft to the RCA. He tolerated the operation well and
was transferred from the Operating Room to the Cardiothoracic
Intensive Care Unit. The patient did well in the immediate
postoperative period. His anesthesia was reversed, he was
weaned from the ventilator and successfully extubated. He
remained hemodynamically stable throughout the day of his
operation; however, to maintain an adequate blood pressure
the patient did require a Neo-Synephrine drip at 0.5
mcg/kg/min. On postoperative day one the patient remained
hemodynamically stable. His Neo-Synephrine drip was weaned
to off. The patient was started on Lasix and Lopressor. On
postoperative day two the patient remained hemodynamically
stable off Neo-Synephrine for 24 hours and he was transferred
to the floor for continuing postoperative care and cardiac
rehabilitation. Once on the floor with the assistance of the
Nursing staff and physical therapist the activity level of
the patient was slowly advanced. On postoperative day three
the patient's chest tubes and temporary pacing wires were
removed and on postoperative day four it was decided that the
following day the patient would be stable and ready to be
transferred to rehabilitation for a recuperative period prior
to his hip replacement surgery. The day prior to transfer
the patient's physical examination is as follows:
Vital signs: Temperature 97.1, heart rate 74, blood pressure
150/54, respiratory rate 18, oxygen saturation 95% on room
air. Weight preoperatively 60 kilograms, at discharge 69
kilograms.
Laboratory data: White count 6.9, hematocrit 35.1, platelet
count 161,000. Sodium 134, potassium 4.3, chloride 99, CO2
26, BUN 18, creatinine 0.8, glucose 79, magnesium 18.
PHYSICAL EXAMINATION: Alert and oriented times three. Moves
all extremities. Follows commands. Respiratory: Clear to
auscultation bilaterally, however, decreased at the bases.
Cardiac: Regular rate and rhythm. S1, S2 with a 2/6
systolic ejection murmur at the left sternal border. Sternum
is stable and intact. Incision closed with staples. Open to
air, clean and dry. Abdomen is soft and non-tender,
non-distended. Normoactive bowel sounds. Extremities are
cool with 2+ pedal edema bilaterally. Left saphenous vein
graft site incision with DermBond, no erythema, a small
amount of serous drainage from the mid incision line.
DISCHARGE MEDICATIONS: Include:
1. Lasix 20 mg b.i.d. times two weeks.
2. Potassium chloride 20 mEq b.i.d. times two weeks.
3. Colace 100 mg b.i.d.
4. Ranitidine 150 mg b.i.d.
5. Aspirin 325 mg q. day.
6. Dilantin 100 mg q. day.
7. Prednisone 2.5 mg q. day.
8. Tylenol 650 mg q. 6h. p.r.n.
9. Percocet 5/325 one to two tabs q. 6h. p.r.n.
10. Ibuprofen 400 mg q. 6h. p.r.n.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times three with left internal mammary artery
to left anterior descending, saphenous vein graft to obtuse
marginal and saphenous vein graft to right coronary artery.
2. Seizure disorder.
3. Complete heart block status post permanent pacemaker
insertion.
4. Mild dementia.
5. Prostate carcinoma status post radiation therapy.
6. Sleep apnea.
7. Degenerative joint disease status post right knee
replacement and right hip replacement with breakdown of
prosthesis.
8. Atrial fibrillation.
9. Giant cell arthritis.
10. Peripheral neuropathy.
11. Diverticulitis status post colostomy.
12. Question of a stroke. The patient reports having had a
stroke, however, no outside hospital report confirms that.
DISPOSITION: Patient is to be discharged to rehabilitation.
CONDITION AT DISCHARGE: Good.
FOLLOW UP: He is to follow up with Dr. [**Last Name (STitle) **] in four weeks.
To follow up with Dr. [**Last Name (STitle) 13175**] in four weeks and follow up with
Dr. [**First Name (STitle) **] in four to six weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2170-7-9**] 18:29
T: [**2170-7-9**] 18:25
JOB#: [**Job Number 39924**]
|
[
"412",
"794.39",
"780.39",
"996.4",
"414.01",
"V45.01",
"446.5",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
1774, 1792
|
6703, 7555
|
6322, 6682
|
1456, 1757
|
3594, 5657
|
7589, 8060
|
5680, 6298
|
7570, 7577
|
113, 228
|
257, 917
|
940, 1429
|
1809, 1956
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,883
| 118,744
|
40364
|
Discharge summary
|
report
|
Admission Date: [**2143-10-28**] Discharge Date: [**2143-11-2**]
Date of Birth: [**2082-6-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2143-10-28**] Emergency coronary artery bypass graft x4 with left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to obtuse marginal, diagonal and posterior
descending arteries
History of Present Illness:
61 year old male admitted from ED with left sided chest pain
with nausea and shortness of breath since 6 am this am.Pain
radiates to his left upper back. Referred to cardiac surgery for
revascularization.
Past Medical History:
Hemochromatosis with liver disease
Bradycardia
Hypertension
Knee replacement
Social History:
Race:caucasian
Lives with:wife
Occupation:retired
Tobacco:current [**12-8**] ppd x 46 years
ETOH:none
Family History:
Mother had CABG in [**2102**]'s
Physical Exam:
Pulse:55 Resp:18 O2 sat:100/RA
B/P Right: Left:179/93
Height:5'9" Weight:188 lbs
General: supine on cath table, NAD, slightly anxious
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: IABP 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:
[**2143-10-28**] Cardiac Cath: 1. Three vessel coronary artery disease:
see above comments section 2. R 8Fr femoral artery Fiberoptix
40cc intra-aortic balloon pump (IABP) inserted for residual
chest pain 3. CT surgery (Dr. [**First Name (STitle) **] consulted: plan for CABG
later today. 4. Patient to be transferred to CCU for further
management: plan for NTG gtt, heparinization and echocardiogram.
[**2143-10-28**] 10:30AM BLOOD WBC-5.4 RBC-4.32* Hgb-12.9* Hct-37.1*
MCV-86 MCH-29.9 MCHC-34.8 RDW-14.4 Plt Ct-130*
[**2143-10-29**] 03:00AM BLOOD WBC-8.8# RBC-3.34* Hgb-9.9* Hct-29.3*
MCV-88 MCH-29.7 MCHC-33.8 RDW-14.7 Plt Ct-72*
[**2143-11-1**] 04:55AM BLOOD WBC-9.6 RBC-3.09* Hgb-9.1* Hct-26.5*
MCV-86 MCH-29.4 MCHC-34.2 RDW-15.4 Plt Ct-128*
[**2143-10-28**] 10:30AM BLOOD PT-13.6* PTT-141.2* INR(PT)-1.2*
[**2143-10-30**] 05:08AM BLOOD PT-13.4 PTT-33.1 INR(PT)-1.1
[**2143-10-28**] 10:30AM BLOOD Glucose-149* UreaN-16 Creat-1.3* Na-140
K-4.2 Cl-109* HCO3-20* AnGap-15
[**2143-11-1**] 04:55AM BLOOD Glucose-106* UreaN-28* Creat-1.4* Na-131*
K-4.3 Cl-95* HCO3-29 AnGap-11
[**2143-10-28**] 10:30AM BLOOD ALT-21 AST-26 AlkPhos-69 Amylase-66
[**2143-10-28**] 11:43AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.7
Brief Hospital Course:
Mr. [**Known lastname 88515**] presented to Emergency room on [**10-28**] with chest
pain. He immediately was brought for a cardiac cath which
revealed severe three vessel disease. Despite medical
management, Mr. [**Known lastname 88515**] continued to have residual chest pain. An
IABP was inserted and he was shortly later brought to the
operating room where he underwent an emergent coronary artery
bypass graft. Please see operative report for surgical details.
Following surgery he remained intubated and was transferred to
the CVICU for invasive monitoring in stable condition. He awoke
neurologically intact and was weaned and extubated without
difficulty. His chest tubes and pacing wires were removed per
protocol. He was started on betablocker, statin, aspirin and
diursed toward his pre-op weight. Pain control was an issue due
to chronic back pain inaddition to his post-operative pain. His
pain was controlled with dilaudid. He was evaulated by physical
therapy for strength and conditioning and on POD# 5 he was
claered for discharge to home. Pt to go home on PO lasis for
left pleural effussion.
Medications on Admission:
Lisinopril 10mg QD
Vitamin B12
Omeprazole
Plavix - last dose:[**2143-10-28**] 600mg
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. omeprazole 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:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
6. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
8. hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4
hours) as needed for pain.
9. 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:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronery Artery Disease s/p Emergent Coronary Artery Bypass
Graft x4
Past medical history:
Hemochromatosis with liver disease
Bradycardia
Hypertension
Knee replacement
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+ bilateral 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**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] at 12/20 at 1:15 in the [**Hospital **] medical office
building
Cardiologist: Ask your primary care doctor for a referral for a
cardiologist
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 3549**] [**Name (STitle) **] in [**3-11**] 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**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2143-11-2**]
|
[
"V43.65",
"414.01",
"275.03",
"401.9",
"338.18",
"573.8",
"411.1",
"724.5",
"305.1",
"414.2",
"511.9",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"88.56",
"36.15",
"37.22",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
5378, 5453
|
2986, 4100
|
332, 550
|
5664, 5904
|
1756, 2962
|
6744, 7395
|
1019, 1052
|
4235, 5355
|
5474, 5543
|
4126, 4212
|
5928, 6721
|
1067, 1737
|
282, 294
|
578, 784
|
5565, 5643
|
900, 1003
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,576
| 171,856
|
50214
|
Discharge summary
|
report
|
Admission Date: [**2128-11-14**] Discharge Date: [**2128-12-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
mental status changes
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
Mr. [**Known lastname 104743**] is an 81 year old man with a history of PAF, PVD,
hypertension and MSSA endocarditis who presents from home with
mental status changes. He was accompanied by his daughter who
stated that she had noticed the patient was increasingly
confused, and had subjective fevers. He had a fall last night
without hitting head or loss of conciousness. He also has been
having increased dyspnea on exertion that has progressed over
several weeks. The patient has also had worsening lower
extremity edema. Today, his legs have become warm, red and
tender. He also has difficulty walking due to the pain.
He was diagnosed with MSSA endocarditis in [**3-5**] and he
finished a 6 week course of iv abx in mid [**Month (only) 958**]. He later had
MSSA grow out from his knee and had hardware there removed. He
has no knee pain currently.
In the ED he was started on IV oxacillin.
Past Medical History:
Paroxysmal atrial fibrillation
Peripheral vascular disease
Hypertension
MSSA mitral valve endocarditis
Septic left knee joint prosthesis, status post surgical removal
of left knee hardware
History of Clostridium difficile gastritis
History of an elevated PSA with reported negative biopsies.
Social History:
[**Last Name (un) **] any tobacco, alcohol, and IVDA
Currently lives at rehab facility, but prior to that was living
w/ daughter
[**Name (NI) **] was able to do [**Name (NI) 5669**], drive car prior to left knee
replacement
Family History:
Non-contributory
Physical Exam:
VS: T 100.1 HR 89 BP 114/71 RR 20 Sat 94%RA
Gen: Elderly man in bed in no apparent distress.
HEENT: NCAT, mmm, PERRL.
CV: irregular, III/VI HSM radiating to axilla.
Pulm: CATB/l with bibasilar scant crackles, no rhonchi
Abd: +ecchymosis
Ext: +TTP below knees, bilateral swelling, weeping.
Neuro: A/A Ox3, president [**Last Name (un) 2450**], location, date, day.
Pertinent Results:
[**2128-11-14**] 02:45AM GLUCOSE-127* UREA N-52* CREAT-2.2* SODIUM-140
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-30 ANION GAP-18
[**2128-11-14**] 02:45AM CALCIUM-9.5 PHOSPHATE-2.6* MAGNESIUM-1.8
[**2128-11-14**] 02:45AM WBC-21.2*# RBC-4.50*# HGB-12.5* HCT-38.5*
MCV-86 MCH-27.8 MCHC-32.5 RDW-14.7
[**2128-11-14**] 02:45AM PLT COUNT-263
[**2128-11-14**] 02:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-0.2 PH-5.0 LEUK-NEG
[**2128-11-14**] 02:45AM URINE HYALINE-[**7-9**]*
[**2128-11-14**] 02:45AM PT-28.0* PTT-45.5* INR(PT)-5.8
[**2128-11-14**] 02:45AM cTropnT-0.04*
[**2128-11-14**] 02:45AM CK(CPK)-55
[**2128-11-14**] 03:23AM LACTATE-3.4*
CXR: Interval development of small bilateral pleural effusions
and mild left lower lobe atelectasis. Cardiomegaly without
evidence for heart failure.
NCHCT: Stable appearance of the brain without evidence of
intracranial hemorrhage or mass effect
LENIS: No evidence of deep venous thrombosis in either lower
extremity.
ECG: Atrial fibrillation with rapid ventricular response
Loss of R waves in leads V1 and V2 consider old anteroseptal
infarct
Inferior/lateral ST-T changes may be due to myocardial ischemia
Repolarization changes may be partly due to rate/rhythm
No change from previous
ECHO: ([**11-16**]) The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 60-70%). Right ventricular chamber size
and free wall motion are normal. The aortic root is moderately
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild to moderate ([**2-1**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is borderline pulmonary artery systolic hypertension. There is a
moderate sized pericardial effusion subtending primarily the
inferior and posterior walls. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade. No right atrial or right ventricular diastolic
collapse is seen.
Video Swallow: Mild-to-moderate oropharyngeal dysphagia and
weakened oral phase, resulting in premature spillover and silent
aspiration of thin liquids.
ECHO ([**11-24**]):
1. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
2. The aortic valve leaflets are moderately thickened. Mild to
moderate ([**2-1**]+) aortic regurgitation is seen.
3. The mitral valve leaflets are mildly thickened.
4. There is moderate pulmonary artery systolic hypertension.
5. There is a moderate sized, circumferential, pericardial
effusion with
fibrin deposits on the surface of the heart. There are no
echocardiographic signs of tamponade.
6. Compared with the findings of the prior report of [**2128-11-22**],
the pericardial effusion may be smaller.
Brief Hospital Course:
1) Pneumonia: Patient was initially admitted due to cellulitis
and delirium. On hospital day # 3 patient became more agitated
and was noted to be hypoxic. A new left lower lobe pneumonia
was found on CXR. Given his poor mental status, aspiration was
presumed. He was transferred to the ICU due to hypoxia,
hypotension , and atrial fibrillation with rapid ventricular
response. His pneumonia was treated with Levofloxacin and
Metronidazole and subsquently Vancomycin as well (sputum grew
MSSA). He required significant amount of supplemental oxygen,
however mechanical ventilation was avoided (he is DNR/DNI in any
case). His mental status improved with treatment and his oxygen
was weaned. He had a speech and swallow evalutaion which showed
a significant risk for further aspiration and so he was
maintained on thickened liquids, and pureed solids with
aspiration precautions at meal times. He will require a repeat
evaluation as his mental status returns to normal.
2) Cellultitis: Given history of MSSA endocarditis, he was
initially started on Oxacillin for bilateral lower extemity
cellulitis. His chronic lower extremity edema was felt to be
the risk factor for developing this infection. His antibiotic
was changed to Vancomycin when he clinical course worsened. An
attempt to change back to Oxacillin resulted in a worsening of
the cellulitis so he was changed to Vancomycin to complete a 14
day course. He also had local wound care and his cellulitis
resolved nicely.
3) Atrial fibrillation: He has a history of PAF was was in
atrial fibrillation throughout his hospital course. His rate
was difficult to control and was complicated by episodes of
hypotension. He was tried on a sotalol drip and a diltiazem
drip, but these medications had to be stopped due to low blood
pressure. Eventually he was loaded on digoxin with good effect.
Metoprolol was started and titrated up and a heart rate of
80-90 bpm was achieved. He may need further titration of his
lopressor dose for rate control. He will need to have digoxin
levels checked if his renal function worsens in the future. He
was maintained on coumadin and was supratherapeutic at time of
discharge. He will need his coumadin restarted once his INR
drops to below 2.5.
4) Delirium: The patient was intermittently delirious throughout
his hospital stay. It was felt to be due to his infections.
His mental status improved as his clinical status improved. Low
dose Seroquel at bedtime and prn was utilized. Wean off
psychotropic meds as mental status improves.
5) CHF: Patient likely has diastolic dysfunction worsened by
atrial fibrillation and tachycardia. His echocardiogram
revealed a normal EF. After his fluid resuscitation in the ICU,
he required aggressive diuresis with IV lasix. He was then
transitioned to his home PO regimen of Lasix 40mg daily. His
beta blocker was titrated up as above. He would benefit from an
ACE-I being restarted as an outpatient.
6) Pericardial Effusion: A moderate effusion was seen by Echo.
Serial Echocardiograms were followed and the effusion remained
unchanged of slightly improved. The etiology was not clear,
although fluid overload was possible. As the patient and family
did not wish for aggressive diagnostic measures and the
patient's clinical course was positive, no further diagnostic
studies were performed. Patient should have a follow-up Echo to
evaluate this as an outpatient.
7) Hypernatremia: Due to free water deficit from poor PO intake.
Treated with D5W for 2-3 liters. Sodium improved as mental
status improved and PO intake increased. Will need periodic
(2x/week) sodium checks at rehab and needs encouragement to have
good free water intake.
8) Acute on Chronic Renal Failure: Baseline creatinine is about
1.2-1.6. Early in hospital course creatinine ranged from
2.2-2.4. By the time of discharge, creatinine was stable near
baseline at 1.6.
9) Urinary retention: Still with foley in. Needs foley to be
removed and have voiding trial at Rehab. It still retaining,
needs urology follow-up.
10) Code Status: DNR/DNI
Medications on Admission:
1.Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2.Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO QD (once a day).
3.Lisinopril 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4.Furosemide 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5.Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6.Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO QD
(once a day).
8.Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
9.Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
2. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Ascorbic Acid 90 mg/mL Drops Sig: Five Hundred (500) mg PO
DAILY (Daily).
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
8. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID PRN ().
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Start when INR < 2.5. Titrate to goal INR 2.0-3.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Aspiration Pneumonia
Diastolic Congestive Heart Failure
Atrial Fibrillation
Delirium
Cellulitis
Pericardial Effusion
Hypernatremia
Acute Renal Failure
Chronic Renal Failure
Urinary Retention
Discharge Condition:
good, mental status improved, oxygenation improved
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Notify your doctor if you experience chest pain, shortness of
breath, palpitations, or other concerning symptoms.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 28190**] [**Name (STitle) 16528**] in 1 week. Please call to
schedule appt. ([**Telephone/Fax (1) 104744**]
Repeat echocardiogram in [**3-4**] weeks
Repeat speech and swallow evaluation in [**2-1**] weeks
|
[
"599.7",
"349.82",
"403.91",
"507.0",
"790.92",
"038.9",
"518.82",
"427.31",
"682.6",
"423.9",
"458.9",
"276.52",
"788.20",
"995.92",
"584.5",
"707.12",
"428.31",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"96.6",
"99.04",
"00.17",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11484, 11629
|
5445, 9530
|
284, 309
|
11864, 11917
|
2231, 5422
|
12180, 12432
|
1815, 1833
|
10348, 11461
|
11650, 11843
|
9556, 10325
|
11941, 12157
|
1848, 2212
|
223, 246
|
337, 1241
|
1263, 1557
|
1573, 1799
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,987
| 177,227
|
22095
|
Discharge summary
|
report
|
Admission Date: [**2119-9-20**] Discharge Date: [**2119-9-28**]
Date of Birth: [**2040-7-6**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy (x2)
History of Present Illness:
79 y.o male with hx of severe COPD recently treated at [**Hospital 40576**] for SBO and LLL pneumonia, discharged on [**9-14**],
returned on [**9-15**] to ED with hemoptysis, was treated in ED for
pneumonia with Tequin and discharged home. On [**9-19**] pt had
another episode of hemoptysis at home associated with syncope.
Admitted again to [**Hospital6 302**], intubated, CT showed
cavitation on the L side and b/l pneumothoracies R>L,
pneumomediastinum, L pleural effusion and evidence of aspiration
on right. B/L chest tube placed and bronchoscopy was performed
which showed b/l lower lobe bleeding. On [**9-20**] patient
trasferred to [**Hospital1 18**] for further management of hemoptysis with
possible endobronchial ablative therapy.
Past Medical History:
PMH:
COPD with FEV1 1.4
Lipomas, several removed "many years ago"
SBO
Colon polyps, s/p L colectomy.
glaucoma
Cholecystecomy
Social History:
Lives with wife. Former [**Name2 (NI) 1818**] for 30 years, but quit 18 years
ago.
Family History:
Father with liver cancer.
Mother with cancer- unknown.
Physical Exam:
Tm: 97.1, Tc:97.0, BP: 109-160/31-62, P: 58-79, RR: 21(17-26),
O2: 90% on 4l nc
Gen: NAD, AAOx3
HEENT: perrla, eomi, mmm
Neck: no jvd, no lad
Chest: rrr, nl s1s2, no m/r/g
Lungs: Bronchial breath sounds throughout, rales at Left lower
lung field
Abd: soft, nt, nd, normal bowel sounds
Extremities: multiple soft/firm/mobile/nontender/subcutaneous
nodules at forearm b/l, UE with non pitting edema r>l, LE with
edematous knees, edematous feet, 2+ peripheral pulses.
Back: multiple subcutaneous nodules as described above
Pertinent Results:
CT chest/abd/pelvis-IMPRESSION:
1. Bilateral lower lobe consolidation with possible cavitation
on the left. On the right, there is obstruction of the right
lower lobe bronchus with appearance suggesting possible hilar
mass surrounding this bronchus.
2. Large left sided pleural effusion with component of
loculation.
3. Right sided pneumothorax and right chest wall dissecting
subcutaneous air. Dissection of air is likely the explanation
for free air seen in the intraperitoneal space within the
abdomen.
4. Multiple cystic lesions of the pancreas. Findings may relate
ot diffuse IPMT. Further evaluation with MRCP could be
performed.
5. 5.1 x 6.5 cm well delineated cystic lesion in the left upper
quadrant.
this may represent a exophytic renal cyst, peritoneal inclusion
cyst from prior surgery, another pancreatic cyst, or possibly a
duplication cyst.
*
Bronchial brushings and washings- negative for malignant cells,
no positive cultures, no positive fungal culture
*
[**Hospital6 302**] sputum from suction- gram [**Last Name (un) **] with GP cocci
in pairs, culture with yeast only
Brief Hospital Course:
Upon transfer to [**Hospital1 18**] pt had bronchoscopy which revealed clot
in anterior segment RUL. Blood clot was removed and BAL gram
stains and cultures negative. Shortly after procedure pt had
recurrent hemoptysis and was transferred to MICU. Pt was
evaluated and found to have a cavitating pneumonia along with
likely superimposed aspiration pneumonia. He was continued on
Zosyn started at OSH and Vancomycin was started secondary to
spike following intervention of Bronch. On [**9-22**] a second
bronchoscopy was performed, multiple clots and fresh blood was
found which resolved with flushing. Both brochoscopies
determined the most likely bleeding site to be the bronchial
artery of the RUL. Pt arrived to [**Hospital1 18**] with b/l pneumothoracies,
which are resolving though a small right loculated pocket
remains. Chest tube was removed [**9-22**]. Pt was extubated [**9-23**] and
was saturating 95% on 2l NC on transfer to floor. While in the
MICU required minimal blood support with 2 u PRBC and fluid
boluses to bring up blood pressure. Also c/b episode of
hypertension to 160's treated with hydralazine. Upon transfer to
floor all cultures were obtained, without a single positive
bacterial culture noted. Vancomycin was discontinued. Pt
required IV fluids to resolve orthostatic hypotension. Pt was
noted on several occasions, particularly at night, to desaturate
to approximately 83-86% for a matter of minutes. At these times
he responded to suction and nebulizers, and it is felt that
these episode are due to mucous plugging. He was started on
guafenesin to treat this. Towards the end of hospitalization,
interventional pulmonary performed a thoracentesis and was able
to drain 1400cc of serosangiunous fluid. The gram stain and
fluid analysis are not suggestive of empyema, but this fluid is
exudative and due to higher than normal ,ynphocyte % could be
related to lymphoma, therefore it will be absolutely essential
to follow cytology from this fluid which is currently pending.
He will be discharged to rehabilitation for physical therapy and
to complete a 14 day course of Zosyn. As on out patient it will
be essential to work up incidental finding, CT abd showed
retroperitoneal air and a 7x5 cm soft tissue mass.
Medications on Admission:
Advair 500/50
Spiriva
alphagan eye drops
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5503**] [**Hospital1 **] Convalescent Home - [**Location (un) 5503**]
Discharge Diagnosis:
Pneumonia
Pneumothorax
Discharge Condition:
stable
Discharge Instructions:
Please return to the emergency room if you develop increased
shortness of breath, fever, hemoptysis, or other concerning
symptoms.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 57752**] at
the appointment scheduled for [**Last Name (LF) 2974**], [**10-13**] at 9am.
Please schedule an appointment with your pulmonologist Dr.
[**Last Name (STitle) 18199**].
Completed by:[**2119-9-28**]
|
[
"511.9",
"496",
"786.3",
"518.81",
"577.2",
"507.0",
"512.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.04",
"33.24",
"34.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5450, 5563
|
3104, 5359
|
320, 339
|
5630, 5638
|
1989, 3081
|
5817, 6133
|
1377, 1433
|
5584, 5609
|
5385, 5427
|
5662, 5794
|
1448, 1970
|
270, 282
|
367, 1112
|
1134, 1261
|
1277, 1361
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,938
| 178,153
|
2615
|
Discharge summary
|
report
|
Admission Date: [**2179-1-31**] Discharge Date: [**2179-2-6**]
Date of Birth: [**2118-6-11**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
R-sided weakness
Major Surgical or Invasive Procedure:
s/p tPA
History of Present Illness:
Code Stroke:
Neurology at bedside within 3 min from code stroke activation.
Time (and date) the patient was last known well: 20:00
NIH Stroke Scale Score: -17-
t-[**MD Number(3) 6360**]: Yes Time t-PA was given 22:46
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
NIH Stroke Scale score was 17:
1a. Level of Consciousness: 0
1b. LOC Question: 1
1c. LOC Commands: 2
2. Best gaze: 1
3. Visual fields: 2
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 4
6a. Motor leg, left: 0
6b. Motor leg, right: 3
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 1
10. Dysarthria: 1
11. Extinction and Neglect: 0
Reason for Consult: aphasia, rightsided plegia
History of Present Illness: Mr. [**Known lastname 13165**] is a 61yo LHM with a
history of atrial fibrillation (not on coumadin), psychotic
disorder, type II DM, hypertension, history of left MCA aneurysm
and resulting SAH s/p aneurysmal clipping via left
frontotemporal craniotomy in [**2161**] by Dr. [**Last Name (STitle) 1128**] at [**Hospital1 2025**], post
stroke epilepsy managed on dilantin monotherapy who presents
today as a code stroke for complaints of right sided weakness.
The history is provided by the wife, who provides a patchy
history.
At baseline, Mr. [**Known lastname 13165**] is quite independent. He enjoys
watching TV, he can ambulate without difficulties and has no
baseline speech or language deficits. Off late, he has been
experiencing some generalized weakness due to fatigue. He has
been compliant with his medications.
The patient was in this state of health until approximately 8pm
this evening. His wife was with him watching TV until about 8PM.
She briefly stepped away to use the bathroom, and when she
returned, he was lying on the couch with his right arm and leg
hanging over the couch. He was unable to move his right arm
volitionally, and he was complaining "I can't breathe". She
immediately called 911. On arrival to the ED, his fingerstick
was 209.
Review of systems: Unable to obtain from the patient himself as
he is in quite a bit of distress, significantly dysarthric.
He was given tpA (for further details see Stroke Fellow's note)
and admitted to the neuro ICU
Past Medical History:
- Psychotic disorder NOS(?): Was briefly noted on discharge
summary from [**2162**]. Currently on low dose fluphenazine. Tried to
obtain more history from the wife about this, but she was
clueless about this particular diagnosis.
- Atrial fibrillation: Has been noted in the past, coumadin was
deferred due to falls
- MCA aneurysmal subarachnoid hemorrhage: Clipped in [**2161**] by Dr.
[**Last Name (STitle) 1128**] at the [**Hospital1 2025**]. Op report was faxed over from [**Hospital1 2025**], but it
does
not include the make/model of the clip used. A left
frontotemporal craniotomy approach was used. A large amount of
blood clot was removed from the area in question.
- Post stroke seizures: Admitted to neuromedicine in [**2162**] under
attending Dr. [**Last Name (STitle) 10442**] where he presented with aphasia and right
hemiparesis. His CT scan showed quite a bit of frontotemporal
encephalomalacia at that time. He received an LP
(unremarkable)as well as EEG monitoring which showed numerous
bursts of semi-rhythmic 2 to 4 hertz activities, which occurred
every few seconds involving broad regions of the left
hemisphere, especially the left central and left anterior
temporal regions. These were intermixed with focal slowing and
occasional sharp wave discharges. He was started on dilantin
therapy. His symptoms improved thereafter. He has since never
presented to the [**Hospital1 18**]. His wife today reports that his
seizures tend to occur once a year, and generally involve loss
of consciousness with shaking of both arms and legs.
- Hypertension
Social History:
Currently, Mr. [**Known lastname 13165**] is unemployed (he didn't work after his
aneurysmal rupture). He quit smoking in [**2172**], and had been
smoking 1ppd since his early 20s. He walks at home with a cane,
and occasionally uses a bath seat at home to shower. He does not
drink or do illicit drugs. He has three grown children.
Family History:
Negative for seizures or strokes.
Physical Exam:
Admission Physical Exam:
Vitals: 97.8, 144/98, 80, 16, 100%
General: Awake, cooperative, in mild distress. Intermittently
stares blankly and may laugh at times inappropriately.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: Obese, soft, NT/ND, no masses or organomegaly noted.
Extremities: warm and well perfused, poor nail hygiene
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert and makes good eye contact.
Significantly dysarthric, and intermittently grimaces and closes
his eyes in distress. Can tell me his name, and that the month
is [**Month (only) 956**], and that his wife's name is [**Name (NI) **]. [**Name2 (NI) **] reports that
he is in [**Hospital3 2576**]. He follows simple midline commands. At
times, he stares blankly at my face. Difficult to test [**Location (un) 1131**].
Comprehends well, and repeats well but with significant
dysarthria.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VF testing was limited by mental
status, possibly a right homonymous hemianopsia noted
III, IV and VI: Right gaze palsy
V: Facial sensation intact to light touch.
VII: Right facial droop involving forehead
VIII: Hearing grossly intact
IX, X: Difficult to test specifically
[**Doctor First Name 81**]: Difficult to test specifically
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Left arm and leg are
antigravity and withdraw to pain. Right arm is plegic below the
deltoids and distally. Right leg is antigravity. He would often
continuous kick his right leg up to maintain it upright.
-Sensory: Difficult to test formally. Senses noxious stimuli in
all four extremities without difficulty.
-DTRs: Diffusely hyporeflexic, Plantar response: downgoing
-Coordination/Gait: Finger nose finger was intact on the left,
gait not tested.
DISCHARGE Physical Exam:
Vitals: Tm 98.5, Tc 97.3, BP 125/87, HR 100, RR 13, SO2 93%
CPAP, FSG 100/103/89/104
General: Awake, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: Obese, soft, NT/ND, no masses or organomegaly noted.
Extremities: warm and well perfused, poor nail hygiene
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert and makes good eye contact.
Significantly dysarthric. Can tell me his name, and that the
month is [**Month (only) 956**], it is [**2178**], and that his wife's name is [**Name (NI) **].
[**Name2 (NI) **] reports that he is in [**Hospital1 18**]. He follows simple midline
commands. At times, he stares blankly. Difficult to test
[**Location (un) 1131**]. Comprehends well, and repeats well but with significant
dysarthria.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VF testing was limited by mental
status, possibly a right homonymous hemianopsia but hard to test
formally
III, IV and VI: EOMI but prefers left gaze, can't bury on right
V: Facial sensation seems to be intact to light touch
bilaterally but hard to formally test
VII: Right facial droop
VIII: Hearing grossly intact bilaterally
IX, X: Palate midline
[**Doctor First Name 81**]: Shoulder shrug normal on left, no shrug on right
XII: Tongue protrudes in midline. Good mvmts in both
directions.
-Motor: Normal bulk, tone throughout. Left arm and leg are [**4-24**].
Right arm and leg are 0/5 throughout.
-Sensory: Difficult to test formally. Senses noxious stimuli in
all four extremities without difficulty. Appears to have
sensation to light touch in all four extremities.
-DTRs: Diffusely hyporeflexic, Plantar response: downgoing on
left, upgoing on right.
-Coordination/Gait: Finger nose finger was intact on the left,
untestable on right, gait not tested.
Pertinent Results:
Reports:
[**2179-1-31**] EKG: Atrial fibrillation with a controlled ventricular
response. Delayed R wave transition in the anterior precordial
leads. Non-specific inferior and anterolateral ST-T wave
changes. No previous tracing available for comparison.
[**2179-1-31**] CTA Head:
IMPRESSION:
1. No acute intracranial abnormality.
2. Encephalomalacic changes in left MCA distribution with ex
vacuo dilatation of the left lateral ventricle.
3. Hyperdensity seen in the expected location of proximal left
MCA may represent a hyperdense MCA sign; however, CTA images are
suboptimal.
4. Unremarkable CT perfusion study.
[**2179-2-1**] EEG:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of nearly continuous left temporal epileptiform
discharges at times briefly periodic. This finding is indicative
of a potential epileptogenic focus in the region. Background is
diffusely slow indicative of a mild to moderate encephalopathy.
The background activity is asymmetric with more slowing over the
left hemisphere suggestive of diffuse cortical and subcortical
dysfunction in this region. Note is made of sinus tachycardia in
this recording.
[**2179-2-1**] TTE: No clot in left Atrium. Markedly dilated RA with
no ASD. Mild symmetric LVH. LVEF is low normal at 50-55%. An
abnormality with the posterior aortic root was seen, can't r/o
aortic dissection.
[**2179-2-1**] NCHCT:
IMPRESSION:
1. No evidence of hemorrhage.
2. Stable encephalomalacia in the left MCA territory.
[**2179-2-1**] Carotid U/S:
IMPRESSION: Right ICA 80-99% stenosis, left ICA less than 40%
stenosis.
[**2179-2-2**] EEG:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of continuous and frequently periodic left temporal
epileptiform discharges. At times, generalized or right
frontocentral epileptic discharges are also present in the
recording. These findings are indicative of multiple areas of
cortical irritability with potential epileptogenicitiy mainly in
the left temporal region. In addition, background activity was
slow in the left hemisphere indicative of diffuse subcortical
dysfunction in this region. Furthermore, background activity was
also mildly slow over the right hemisphere indicative of a mild
encephalopathy of non-specific etiology. No electrographic
seizure is present in the recording. Note is made of borderline
tachycardia throughout the record. Compared to prior day's
recording, this EEG is worse digital extension of periodic
epileptiform discharges the rest of the left hemisphere and
occasional discharges in the right hemisphere. Potential causes
for worsening of electrographic activity are metabolic
abnormalities and alternatively occurrence of new structual
lesions. Clinical correlation is advised.
[**2179-2-2**] CTA H/N:
IMPRESSION:
1. Evolving infarct in posterior half of the left MCA
territory.No evidence of hemorrhage transformation.
2. Chronic infarction with encephalomalacic changes along the
anterior half of the left MCA territory with ex vacuo dilatation
of the left lateral ventricle.
3. High grade short segment stenosis of proximal right ICA as
described above.
[**2179-2-3**] NCHCT
IMPRESSION:
1. Evidence of evolving acute infarction in the superior
division of the left MCA is unchanged from the most recent exam,
with no evidence of hemorrhagic conversion. A focal area of
spared cortex is present at the vertex.
2. Unchanged cystic encephalomalacia and ex vacuo ventricular
dilatation
related to prior left MCA infarct, with associated marked
wallerian
degeneration.
[**2179-2-3**] EEG: Report Pending
[**2179-2-4**] EEG: Report Pending
[**2179-2-5**] EEG: Report Pending
[**2179-2-5**] MRI:
Large area of diffusion abnormality in the left anterior and
middle cerebral artery territories with some edema and mild
rightward shift by 3-4mm representing acute infarct- extent
better seen than prior CT studies.
There are scattered foci of negative susceptibility within the
area of acute infarct which may relate to blood products or
mineralization; however, these did not look dense enough to be
considered as hemorrhage on prior CT head of [**2-3**]- hence,
consider non-contrast CT head to assess for any interval
hemorrhage.
Brief Hospital Course:
Assessment:
Mr. [**Known lastname 13165**] is a 61yo LHM with a history of atrial fibrillation
(not on coumadin [**1-21**] falls), psychotic disorder, type II DM,
hypertension, history of left MCA aneurysm and resulting SAH s/p
aneurysmal clipping via left frontotemporal craniotomy in [**2161**]
by Dr. [**Last Name (STitle) 1128**] at [**Hospital1 2025**], post stroke epilepsy managed on dilantin
monotherapy who presented as a code stroke for complaints of
right sided weakness and slurred speech found to have possible
salvagable areas of brain tissue in the periphery of the left
MCA territory, so was given tPA. The patient did not improve
following tPA. While in house the patient had increased
activity on his EEG so he was kept longer to titrate his
antiepileptics. He was started on Keppra 1000 [**Hospital1 **] which
improved his EEG dramatically. An MRI was obtained which
confirmed both MCA and ACA infarcts and likely some hemorrhagic
conversion. He was discharged to rehab for continued care.
# NEURO: We followed general post-tPA precautions in the ICU
including letting BP autoregulate, monitoring pt on telemetry,
avoiding arterial puncture, antiplatelets and anticoagulation
for 24 hrs and keeping tight glycemic control with the HOB at 30
degrees for aspiration control but to also maximize cerebral
perfusion. Unfortunately pt was unable to get an MRI until
[**2179-2-5**], as his aneurysm clip was of questionable material and
therefore could not be confirmed it was MRI compatible until
this time. While here, we obtained an EEG given pt's hx of
post-stroke seizures, which showed frequent L temporal
spikes/PLEDs, but no definitive seizure activity. We increased
his dilantin from his home dose to 150mg TID. Because he
continued to have increased activity on LTM he was started on
Keppra 1000 mg [**Hospital1 **] which improved his EEG dramatically.
Unfortunately, on d/c the patient still remains completely
plegic on the right side. Additionally he has a worsened
expressive aphasia and questionable sensory loss on the right
side (please see PE for more details). This patient is at high
risk for further stroke. He is now back on his Aspirin 325 mg
daily. His PCP was [**Name (NI) 653**] and this patient has not been a
candidate for anticoagulation given his frequent falls and
non-compliance with medications (related to his psychosis).
However, if this patient ends up in a nursing home and is wheel
chair bound he would very likely benefit from anticoagulation,
whether it be coumadin or dabigatran. If this were to be
started it should not be before the [**8-17**] (2 weeks
from onset of hemorrhage). If coumadin/dabigatran is started
his aspirin should be stopped at that time.
# Cardiovascular: we initially held pt's home antihypertensives
to allow BP to autoregulate as much as possible. He was started
on Metoprolol [**Hospital1 **] for his A Fib. While in the unit he did have
some episodes of A Fib with RVR which responeded to pushes of
metoprolol. His metoprolol tartrate was uptitrated to 37.5 [**Hospital1 **]
and both his rate and pressures were very good from there
forward. He was persistently in A Fib on tele throughout his
admission. We obtained a TTE which showed no clot. After
discussion with pt's PCP [**Last Name (NamePattern4) **] [**2179-2-3**] it was determined to decide
his anticoagulation following his stay in rehab. The PCP is
very involved, knows the patient well and would like to be
involved in the anticoagulation situation.
# Respiratory: Pt uses CPAP at home which he was continued on in
house. He had no other acute issues.
# Endo: pt's hemoglobin A1C and lipids were within goal, but his
triglycerides were elevated to he was started on a low dose
statin. He was put on an ISS while here to maintain euglycemia.
TRANSITIONAL CARE ISSUES:
1. The decision of whether or not to anticoagulate this patient
or not following a stay in rehab should be made in the near
future. He is at very high risk for further embolization and
would likely benefit from anticogulation if he is not falling
and being given his meds regularly. If started it should not be
before [**2179-2-16**]. Additionally, his aspirin should be
stopped at the time anticoagulation is started.
2. Patient will need monitoring of his phenytoin while in rehab.
This should be checked the week of [**2179-2-8**] as his dose was
changed while in house. Goal of 15-20.
3. Patient will need CPAP while at rehab.
4. Final MRI and EEG reads are pending and can be followed up by
PCP or in neurology clinic.
Medications on Admission:
Atenolol 100mg daily
Phenytoin 400mg daily (ER? DR?)
Gabapentin 600mg TID
Lasix 40mg daily
Aleve PRN
Fluphenazine 10mg daily
Discharge Medications:
1. atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
3. fluphenazine HCl 10 mg Tablet Sig: One (1) Tablet PO once a
day.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
7. phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO three times a day.
8. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left MCA and ACA Ischemic Stroke
Atrial Fibrillation
Hypertension
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Completely plegic on right side, some right sided neglect,
non-fluent aphasia, with anomia for low frequency words, but
with preserved comprehension.
Discharge Instructions:
Dear Mr. [**Known lastname 13165**],
You were admitted to the [**Hospital1 18**] inpatient Neurology service
because of your trouble speaking and right sided weakness. You
were diagnosed with a stroke and given tPA, a drug that helps
break up clots. Unfortunately, your neurological deficits were
not helped by this drug. You were also noted to have increased
electrical activity on your EEG, so we added another
anti-seizure medication. At this time you are ready to continue
your recovery at a rehab facility.
The following changes were made to your medications:
STOP Lasix: we were not sure why you were taking this medication
and it can be restarted at the discretion of your rehab
Physicians or your primary Physician
STOP [**Name9 (PRE) 13166**] (If you need a pain med tylenol would be a better
choice)
CHANGE your phenytoin dose to 150 mg three times daily
START Levetiracetam 1000 mg three times daily
START simvastatin 10 mg daily
START docusate sodium 100 mg twice daily
START Senna 8.6 mg twice daily
START Heparin 5000 units Subcutaneously while at rehab
Additionally, we think you would benefit from anticoagulation
with either coumadin or dabigatran but no earlier than
[**2179-2-16**]. We have spoken with your primary Physician and we
will defer the decision to starting this medication to him.
Thank you for letting us participate in your care. We wish you
a speedy recovery.
Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2179-3-22**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"342.81",
"427.31",
"401.9",
"784.51",
"438.89",
"327.23",
"345.90",
"431",
"298.9",
"784.3",
"781.94",
"E934.4",
"434.11",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
18409, 18479
|
12853, 16668
|
329, 338
|
18613, 18613
|
8613, 12830
|
20371, 20724
|
4564, 4599
|
17600, 18386
|
18500, 18592
|
17450, 17577
|
18940, 20348
|
7572, 8594
|
4639, 5161
|
2405, 2606
|
273, 291
|
16694, 17424
|
1117, 2386
|
18628, 18916
|
2628, 4199
|
4215, 4548
|
6627, 7103
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,677
| 108,011
|
10532
|
Discharge summary
|
report
|
Admission Date: [**2128-4-16**] Discharge Date: [**2128-4-16**]
Service: SURGERY
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Nausea, syncope, epigastric pain, and mental status changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a [**Age over 90 **] y/o female with h/o CAD, AS, Afib, chronic GI
symptoms with nausea, who experienced a syncopal episode
yesterday after a hot shower, and then became incontinent of
stool and urine. Systolic BP was 112 on subsequent evaluation,
but patient developed 3 episodes of nausea and vomiting.
Following the last episode, the pt remained home, but the family
reported that last night at 2:30 am she had increased nausea,
significantly worsened cognitive condition, and weakness. The
pt was transferred to the ED where she complained of epigastric
pain radiating to her shoulders.
In the ED, the pt was found to have elevated amylase and lipase
and urinalysis demonstrated cloudy urine with many bacteria.
U/S of the abdomen showed stones in the gall bladder and dilated
intrahepatic ducts, but common bile duct was not well
visualized. Pt was started on levo/flagyl and admitted to the
floor.
Past Medical History:
1. Frequent urinary tract infections
2. dropped bladder not responsive to a pessary
3. atrial fibrillation (currently off Norpace and coumadin)
4. coronary artery disease
5. appendectomy
6. MR
7. anemia
8. anxiety
9. chronic nausea/vomiting, achlorhydria, known pancreatic
abnormalities on CT since [**2126**]
10. hiatal hernia
11. kyphosis
12. macular degeneration and cataracts
13. recurrent episodes of syncope
14. groin hernia
Social History:
Lives alone in a senior housing, does not smoke, drink alcohol
or coffee. Daughter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 951**] is HCP.
Family History:
Noncontributory
Physical Exam:
T 98.0 P 110 BP 99/70 R 28 SaO2 96%
Gen - cachetic, frail, uncomfortable, toxic appearing elderly
woman
Heent - no scleral icterus, perrl, mucous membranes dry
Lungs - clear
Heart - irregular rhythm with SEM
Abd - tenderness in epigastric area
Ext - warm, well perfused
Pertinent Results:
[**2128-4-16**] 05:17PM BLOOD WBC-14.2*# RBC-4.21 Hgb-12.7 Hct-39.1
MCV-93 MCH-30.2 MCHC-32.5 RDW-14.0 Plt Ct-214
[**2128-4-16**] 05:17PM BLOOD Glucose-167* UreaN-23* Creat-1.6* Na-135
K-4.4 Cl-102 HCO3-18* AnGap-19
[**2128-4-16**] 03:55AM BLOOD ALT-22 AST-47* CK(CPK)-50 AlkPhos-147*
Amylase-101* TotBili-0.6
[**2128-4-16**] 03:55AM BLOOD Lipase-147*
[**2128-4-16**] 05:17PM BLOOD Calcium-8.9 Phos-4.7* Mg-1.9
[**2128-4-16**] 08:10AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.009
[**2128-4-16**] 08:10AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
[**2128-4-16**] 08:10AM URINE RBC-[**6-13**]* WBC->50 Bacteri-MANY Yeast-NONE
Epi-0-2
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2128-4-16**] 6:18 AM
IMPRESSION:
1) Thickening of the gallbladder wall secondary to edema
associated with cholelithiasis that might represent acute
cholecystitis, however, generalized third spacing and edema
secondary to pancreatitis might also cause gallbladder wall
edema.
2) Small area of fluid density located anterior to the pancreas
which most likely represent fluid filled stomach, however, fluid
collection in this area cannot be excluded.
Brief Hospital Course:
A general surgery consult was obtained and discussion was
undertaken with the pt's PCP and the family regarding treatment
options. The pt's PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1266**] had had long discussions
with the pt regarding end of life issues. He recommended that
the pt be made comfort measures only. Discussion was made with
the family and they wished to proceed with comfort measures per
pt wishes. The pt passed away on the evening of [**2128-4-16**].
Autopsy was refused by family.
Medications on Admission:
1. Ambien 2.5mg qHS
2. Ativan 0.5mg [**Hospital1 **] prn
3. gabapentin 100mg TID prn
4. atenolol 12.5mg daily
5. folic acid 800mcg daily
6. vitamin E 400unit daily
7. prilosec 20mg daily
8. prochlorperazine 5mg prn
9. lasix 20mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cholecystitis
Pancreatitis
Atrial fibrillation
Coronary artery disease
Urinary tract infection
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
|
[
"424.1",
"577.0",
"574.00",
"599.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4273, 4282
|
3437, 3959
|
280, 286
|
4420, 4429
|
2207, 3414
|
4482, 4489
|
1881, 1898
|
4244, 4250
|
4303, 4399
|
3985, 4221
|
4453, 4459
|
1913, 2188
|
181, 242
|
314, 1233
|
1255, 1687
|
1703, 1865
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,274
| 168,048
|
30737
|
Discharge summary
|
report
|
Admission Date: [**2117-5-13**] Discharge Date: [**2117-5-30**]
Date of Birth: [**2078-3-24**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Chronic Pancreatitis
Major Surgical or Invasive Procedure:
Puestow Procedure
Removal of pancreatic Ductal Calculous
Open cholecystectomy
J-tube placement.
History of Present Illness:
This is a 39-year-old lady is on disability from abdominal pain
which manifests as epigastric pain radiating to the back and
shoulder, it is severe on a daily basis and she has now lost 15
pounds over the last three to four months. She has
malabsorption and steatorrhea which has improved with enzymes
lately. She has positive nausea and vomiting. She has never
been jaundiced but has been once before when she had an acute
pancreatitis flareup.
Past Medical History:
GERD, acute/chronic pancreatitis (1mo ICU stay in [**2114**]), sp
laparoscopy for infertility w/u, sp BCC excision of the neck
chronic bronchitis, cystic fibrosis (recently diagnosed to carry
gene), chronic gastritis, recent endoscopic procedure where an
attempted stone extraction from the pancreas was performed one
week ago that was unsuccessful
Social History:
She smokes pack a day for 15 years.
She used to previously be a heavy drinker but has been sober for
over two years now.
Family History:
Strong family history for colorectal cancer and melanomas in the
family. Her mother has had pancreatitis in the past, although
there is no history of gallstones in the family.
There are other malignancies in the family including colon
cancer, bone cancer, lung cancer, and uterine cancer.
Physical Exam:
Gen: thin lady around 90 pounds. She is not necessarily wasted
or cachectic but has a slight built.
VS: Blood pressure is 78/55 and her pulse is 80.
HEENT: She has no evidence of scleral icterus.
Chest: clear to auscultation.
CV: regular rate and rhythm.
Abd: soft, nontender, and nondistended with positive bowel
sounds. There is no evidence of any inguinal hernias or genital
lesions and rectal exam was deferred.
Musculoskeletal: shows all domains to be intact in both motor
and sensory functions throughout bilaterally.
Skin: within normal limits with the exception of the scars for
her
basal cell removals.
No evidence of any lymphadenopathy in any of her draining nodal
basins.
Pertinent Results:
[**2117-5-14**] 06:35AM BLOOD WBC-15.2* RBC-4.29 Hgb-13.1 Hct-37.9
MCV-88 MCH-30.6 MCHC-34.6 RDW-14.3 Plt Ct-242
[**2117-5-14**] 06:35AM BLOOD Glucose-101 UreaN-6 Creat-0.3* Na-140
K-3.4 Cl-102 HCO3-28 AnGap-13
[**2117-5-13**] 08:59AM BLOOD ALT-8 AST-15 AlkPhos-101 Amylase-32
[**2117-5-13**] 08:59AM BLOOD TotProt-5.7* Albumin-2.8* Globuln-2.9
Calcium-8.8 Phos-4.3 Mg-1.7 UricAcd-3.5
.
[**2117-5-23**] 05:00PM BLOOD WBC-8.5 RBC-3.38* Hgb-10.4* Hct-29.6*
MCV-88 MCH-30.8 MCHC-35.2* RDW-14.6 Plt Ct-433
[**2117-5-13**] 08:59AM BLOOD PT-13.4* PTT-28.3 INR(PT)-1.2*
[**2117-5-20**] 02:24AM BLOOD PT-15.3* PTT-33.2 INR(PT)-1.4*
[**2117-5-13**] 08:59AM BLOOD Glucose-94 UreaN-6 Creat-0.5 Na-139 K-3.9
Cl-104 HCO3-26 AnGap-13
[**2117-5-26**] 07:05AM BLOOD Glucose-151* UreaN-30* Creat-4.2* Na-138
K-3.7 Cl-103 HCO3-26 AnGap-13
[**2117-5-29**] 09:00AM BLOOD Glucose-149* UreaN-17 Creat-1.7* Na-139
K-3.7 Cl-103 HCO3-24 AnGap-16
[**2117-5-17**] 05:53AM BLOOD ALT-22 AST-40 AlkPhos-76 Amylase-15
TotBili-0.5
[**2117-5-18**] 09:30AM BLOOD ALT-22 AST-36 AlkPhos-78 Amylase-14
TotBili-0.4
[**2117-5-18**] 09:30AM BLOOD Lipase-7
[**2117-5-20**] 07:45PM BLOOD Vanco-10.3
[**2117-5-13**] 09:05AM BLOOD Glucose-91 Lactate-1.2 Na-138 K-4.0
Cl-103
.
[**2117-5-23**] 03:36PM URINE Eos-NEGATIVE
[**2117-5-25**] 12:45PM URINE Eos-POSITIVE
[**2117-5-23**] 06:00AM URINE Hours-RANDOM Creat-67 Na-41
[**2117-5-23**] 03:36PM URINE Hours-RANDOM Creat-35 Na-43 TotProt-31
Prot/Cr-0.9*
[**2117-5-25**] 12:45PM URINE Hours-RANDOM Creat-56 Na-68
[**2117-5-18**] 06:36AM URINE UCG-NEGATIVE
[**2117-5-23**] 06:00AM URINE Osmolal-311
[**2117-5-25**] 12:45PM URINE Osmolal-276
.
[**5-22**] - JP amylase = 12
.
MICRO:
[**2117-5-18**] BLOOD CULTURE - STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY. (other samples were negative)
.
[**2117-5-19**] BRONCHOALVEOLAR LAVAGE - negative (oropharyngeal flora
only)
.
Pathology Examination:
SPECIMEN SUBMITTED: GALLBLADDER & PANCREATIC CALCULUS.
Procedure date [**2117-5-13**]
DIAGNOSIS:
1. Gallbladder (A-B): Mild chronic cholecystitis. Unremarkable
lymph node.
2. Pancreatic calculus: Calculi measuring up to 0.4 cm, gross
diagnosis only.
Clinical: Chronic pancreatitis.
.
EKG:
-Cardiology ECG [**2117-5-16**]
Sinus rhythm. Delayed R wave transition in the anterior
precordial leads of unclear significance. No previous tracing
available for comparison
-Cardiology ECG [**2117-5-19**]
Sinus tachycardia. Compared with previous tracing of [**2117-5-16**] the
heart rate is increased. Otherwise, no major change.
.
IMAGING:
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2117-5-16**]
1. No evidence of PE.
2. Significant collapse in consolidation in both bases with
mucous plugging.
.
ABDOMEN (SUPINE & ERECT) [**2117-5-23**]
Nonspecific bowel gas pattern. Bowel obstruction cannot be
excluded. Upper abdominal calcifications consistent with chronic
pancreatitis.
.
RENAL U.S. [**2117-5-23**]
1. No evidence of hydronephrosis. Bilateral mild increase
parenchymal echogenicity consitent with parenchymal renal
disease.
2. Small right kidney
.
DUPLEX DOP ABD/PEL LIMITED [**2117-5-24**]
1. No hydronephrosis.
2. Limited Doppler study, as noted above. Although arterial
waveforms demonstrate a swift upstroke, low amplitudes are
suggested, bilaterally. Given the finding of a significantly
smaller right kidney, renal artery stenosis cannot be excluded
and further workup is warranted.
.
CT PELVIS W/O CONTRAST [**2117-5-25**]
1. Bibasilar ground-glass opacities, suspicious for aspiration
or infection.
2. Tiny bilateral pleural effusions, left greater than right.
3. Findings suspicious for high-grade small-bowel obstruction
likely in the region of the mid ileum and distal to the
jejunojejunostomy.
4. Evidence of Puestow procedure.
5. Evidence of chronic pancreatitis.
6. Two sub 5-mm nonobstructing stones in the lower pole of the
right kidney. Findings were discussed with Dr. [**Last Name (STitle) **] by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4401**] at completion of the examination.
.
ABDOMEN (SUPINE & ERECT) [**2117-5-27**]
1. Unchanged appearance of multiple dilated loops of small bowel
which measure up to 4 cm. Continued followup is recommended.
2. Status post pancreaticojejunostomy with surgical clips noted
within the left upper quadrant area.
3. Chronic pancreatitis as evidenced by multiple small
calcifications projecting over the pancreatic area.
Brief Hospital Course:
She was admitted on [**2117-5-13**] for a Posterolateral
pancreaticojejunostomy (Puestow), Removal of pancreatic
calculus, Open cholecystectomy, Placement of J-tube.
Pain: APS was following this patient given her chronic pain and
pain med usage. Epidural not placed given preop SBP in mid 70's.
Dilaudid PCA Basal rate 0.25mg/hr plus bolus 0.25mg q6min
(titrated bolus dose as needed). Ketorolac 15mg IV q6hr x3days
was added on POD 1. On [**5-13**], increased PCA to .37mg
Bolus/.25mgbasal, Vistaril25mgIM q4hr. On [**5-14**] increased PCA to
.4mgBolus/.37Basal, Ketamine 1-5mg/hr, Vistaril. This regimen
relieved her pain somewhat but she was still complaining of pain
despite the large amounts of narcotics. At times she was very
somnolent secondary most likely to the large narcotic
requirements. She was started on methylphenidate to counter
this. Her pain medications were gradually titrated down and
eventually her pain subsided to the point where she was refusing
all pain medication. However, she did resume her methadone
prior to discharge.
CV: Her HR was mildly tachycardic and her SBPs were persistently
in the 70's-low 100's. EKG's showed only sinus tachycardia.
However, her BP's improved towards the end of her stay and
remained >90.
Resp: She experienced multiple episodes of desats post-op
resulting in triggers on the floor and requiring SICU stays.
CTPA on [**5-16**] was negative for PE. She underwent chest PT and
bronchoscopy with BAL on [**5-19**] which demonstrated bilateral
mucous plugs of which were aspirated. She was started on
vancomycin and levofloxacin. BAL culture was negative. She
also required NEBS, inhalers and acetylcysteine. Her
respiratory status eventually markedly improved and she was
transferred back to the floor. Her antibiotics were
discontinued on [**5-22**]. She was stable on room air prior to
discharge.
GI/Abd: She was NPO with IVF and a NGT. Her J-tube was clamped.
She was started on J-tube feeds on [**2117-5-16**] and advanced slowly
starting with 1/2 strength replete at 10cc/hr and advance
10cc/hr q6hrs to goal and switched to 3/4 strength. Her NGT was
removed on [**5-17**]. Her J-tube feeds were continued until she was
changed over to goal of Probalance 3/4 strength while she was in
SICU on [**5-19**]. This was continued until until [**5-25**] where they
were held given her increased abdominal distension with nausea
and bilious vomiting. However she was still reportedly passing
flatus and having small bowel movements. A CT of her abdomen on
[**5-25**] demonstrated findings suspicious for high-grade small-bowel
obstruction likely in the region of the mid ileum and distal to
the jejunojejunostomy. A NGT was placed after premedication and
had high bilious outputs. Her NGT was removed after a KUB
revealed that the tip was not in the stomach. On [**5-28**] she
refused to have tubefeeds restarted and it was decided to start
her on PO given the clinical improvement of her bowel
obstruction. She tolerated PO well without any further
incident.
Her JP amylase was 12 and was removed on [**5-22**] without
complication. Her abdominal exam on discharge was benign and
wound was C/D/I and staples were removed on prior to discharge.
Her pathology was consistent with mild chronic cholecystitis and
chronic pancreatitis.
GU: Patient went into ARF (oliguric ATN) on [**5-23**] (presumably
prerenal/ischemic ATN secondary to hypotension and NSAIDS and
her urine lytes and osmolality supported this hypothesis). The
renal service was consulted and her ibuprofen was discontinued
and her blood pressure was maintained for SBP>90. Her
vancomycin level on [**5-20**] was 10.3. Her creatinine peaked at 4.2
and gradually decreased to 1.3 on discharge. Her urine output
improved concordingly. Her Foley was removed and she voided
adequately without incident. Renal US was negative for
hydronephrosis and renal artery stenosis.
She began demanding to leave the hospital shortly after she
started PO intake. She wished to return home with her parents
and to her daughter. The team felt that this was reasonable
given that she would closely follow-up with her PCP when she
returns home in [**Location (un) 7188**]. J-tube management was taught and she
was instructed to flush it daily to keep it patent. Throughout
her hospital course, she began refusing selective medications
and on the day prior to discharge she refused all her daytime
medications. At night, she did accept her methadone, nicotine
patch and ativan. She was discharged on these medications.
Medications on Admission:
methadone >20mg tid, oxycodone 5mg q8 prn, MS Contin 2mg q6 PRN,
lexapro 20', protonox 40', prilosec?", ADEK, Vit B, B6,
pangestyme MT 4caps QID
Discharge Medications:
1. Nicotine 21 mg/24 hr Patch 24 hr Sig: [**12-8**] Patch 24 hrs
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Pancreatitis
Pancreatic Calculous
Malnutrition
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
Please resume all regular home medications and take any new meds
as ordered.
.
Continue to ambulate several times per day.
.
Please flush J-tube with water once daily. Please change J-tube
dressing as needed.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-9**] weeks. Please call
([**Telephone/Fax (1) 2363**] to schedule an appointment.
|
[
"577.8",
"263.9",
"518.81",
"997.4",
"530.81",
"577.1",
"491.9",
"486",
"584.5",
"575.11",
"934.1",
"560.9",
"277.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.96",
"96.6",
"46.39",
"51.22",
"33.24",
"52.09"
] |
icd9pcs
|
[
[
[]
]
] |
12119, 12125
|
6871, 11430
|
306, 404
|
12224, 12233
|
2425, 6848
|
13410, 13555
|
1411, 1703
|
11626, 12096
|
12146, 12203
|
11456, 11603
|
12257, 13387
|
1718, 2406
|
231, 268
|
432, 883
|
905, 1256
|
1272, 1395
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,715
| 144,697
|
24006
|
Discharge summary
|
report
|
Admission Date: [**2129-10-4**] Discharge Date: [**2129-10-8**]
Date of Birth: [**2088-11-22**] Sex: M
Service: MEDICINE
Allergies:
Lamictal
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
Fever, tachycardia, thrombocytopenia
Major Surgical or Invasive Procedure:
lumbar puncture
blood patch
History of Present Illness:
Mr. [**Known lastname 3647**] is a 40 year-old gentleman with history of HIV (CD4
of 639 two weeks ago, not on HAART), presenting with fever x4
days and [**Known lastname **]. Patient first noted fever on the morning of
[**2129-10-1**]. On Saturday and Sunday he had fevers, rigors, and
general malaise. Maxiumum temperature at home was 104 degrees
yesterday. On Monday morning, he woke up to take a shower and
noticed a [**Date Range **] on his trunk and thighs. He started lamictal 12
days prior and was told by his psychiatrist to watch out for a
[**Last Name (LF) **], [**First Name3 (LF) **] he called his psychiatrist who referred him to his PCP.
[**Name10 (NameIs) 3754**] is no mucosal involvement of [**Name10 (NameIs) **] and no blistering or
draining skin lesions. He also started zyprexa 12 days ago. He
stopped the lamictal on Monday and saw his PCP on Tuesday. At
his PCP's office he was found to have a diffuse [**Name10 (NameIs) **] and was
tachycardiac to 135. Given the tachycardia, patient was
referred to ED.
.
In the ED, initial vitals were: 103.8 132 122/81 16 98% on RA.
Exam was notible for diffuse [**Name10 (NameIs) **] on trunk, arms, and legs.
Labs were notable for new thrombocytopenia to 71 (132 on
[**2129-9-21**]), creatinine of 1.4 (1.0 on [**2129-9-21**]), Na of 132, ALT of
80, AST of 117, LDH of 730. A blood smear was reviewed by
hematology and was significant for burr cells and teardrop
cells, but no shistocytes. UA did not show evidence of UTI, CXR
did not show pneumonia. Patient received one dsoe of ceftriaxone
1 g IV x1, acetaminophen 1000 mg PO, oxycodone, valium 10 mg PO
x1, hydromophone 1 mg IV x1, and 4L IV NS. Transfer vitals are:
102.1, 109, 109/76, 18, 97% on RA.
.
On arrival to the MICU, patient complains of fevers and chills.
He also endorses severe bilateral fronto-temporal headache for
three days. Denies photophobia, visual changes, new neck
stiffness (pt with chronic neck stiffness at baseline),
numbness, tingling, weakness. Pt complains of nausea, but no
vomiting. No sick contacts. Only recent travel is to [**State 1727**] 2
weeks ago.
.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies cough, shortness
of breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias.
Past Medical History:
HIV with CD4 of 639 2 weeks ago
Depression
TMJ syndrome
PPH:
Psychiatrist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13825**] at [**Hospital1 778**]
Therapist: [**First Name8 (NamePattern2) **] [**Last Name (un) 61114**] at [**Hospital1 778**].
Prior med trials include Celexa and Paxil for 3 months each,
without effect
-[**Hospital1 1680**] Triangle Program for three months, [**Month (only) 547**]-[**2123-4-21**]
-Two inpatient admissions to [**Hospital1 1680**] HRI during this period for
SI
-[**2123-1-19**] [**Hospital1 **] 4 admission for methamphetamine-induced
psychosis
-[**2122-11-21**] [**Hospital1 1680**] HRI admission for methamphetamine-induced
psychosis
-No history of suicide attempts
-No history of violence
PMH:
PCP: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2392**], [**Name12 (NameIs) 778**] [**Telephone/Fax (1) **]
-HIV positive ([**2123-4-21**])
Social History:
Non-smoker. Pt sober from ETOH, clean from recreational drug
use. MSM. Employed as a PA in orthopedics. Lives alone.
Family History:
Hemachromatosis (mother), colon CA (PGF, dx'd age 75), colon
polyps, dx'd age 80, Type II DM at age 80 (father)
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, appeared slightly uncomfortable
HEENT: Sclera anicteric, dry mucus membranes, + conjunctival
injection, no oral ulcers, no blistering of lips
Neck: supple, JVP not elevated, no LAD
CV: Tachy, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
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
Skin: Diffuse erythematous, macular papular [**Year (4 digits) **] on trunk,
axilla, upper arms, thigh. Skin feels hot, very mildly tender to
palpation.
DISCHARGE PHYSICAL EXAM:
General: comfortable, NAD
HEENT: Sclerae anicteric, MMM, no oral ulcers, no blistering of
lips
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
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
Psych: mood "better", no active SI/HI, patient does have anxiety
Skin: barely visible macular [**Year (4 digits) **] on torso
Pertinent Results:
ADMISSION LABS:
[**2129-10-4**] 11:35AM BLOOD WBC-9.1 RBC-4.42* Hgb-13.4* Hct-37.4*
MCV-85 MCH-30.2 MCHC-35.7* RDW-12.7 Plt Ct-71*#
[**2129-10-4**] 11:35AM BLOOD Neuts-59 Bands-7* Lymphs-27 Monos-1*
Eos-0 Baso-0 Atyps-6* Metas-0 Myelos-0
[**2129-10-4**] 11:35AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Schisto-OCCASIONAL Burr-2+ Tear Dr[**Last Name (STitle) 833**]
[**2129-10-4**] 05:15PM BLOOD PT-12.5 PTT-33.6 INR(PT)-1.1
[**2129-10-5**] 02:18PM BLOOD ESR-17*
[**2129-10-4**] 11:35AM BLOOD Ret Aut-0.9*
[**2129-10-4**] 11:35AM BLOOD Glucose-126* UreaN-17 Creat-1.4* Na-132*
K-3.4 Cl-96 HCO3-24 AnGap-15
[**2129-10-4**] 11:35AM BLOOD ALT-80* AST-117* LD(LDH)-730* CK(CPK)-54
AlkPhos-58 TotBili-1.0
[**2129-10-4**] 11:35AM BLOOD Lipase-10
[**2129-10-4**] 11:35AM BLOOD Calcium-8.5 Phos-1.7* Mg-1.7
[**2129-10-4**] 11:35AM BLOOD Hapto-29*
[**2129-10-4**] 11:45AM BLOOD Lactate-1.6
[**2129-10-4**] 09:31PM BLOOD Lactate-1.1
PERTINENT INTERVAL LABS:
[**2129-10-4**] 09:07PM BLOOD WBC-7.7 RBC-4.06* Hgb-12.2* Hct-34.6*
MCV-85 MCH-30.2 MCHC-35.4* RDW-12.8 Plt Ct-70*
[**2129-10-5**] 03:37AM BLOOD WBC-7.2 RBC-3.62* Hgb-10.9* Hct-31.1*
MCV-86 MCH-30.3 MCHC-35.1* RDW-12.8 Plt Ct-66*
[**2129-10-6**] 05:50AM BLOOD WBC-6.2 RBC-3.65* Hgb-10.8* Hct-31.3*
MCV-86 MCH-29.6 MCHC-34.5 RDW-12.9 Plt Ct-101*#
[**2129-10-4**] 09:07PM BLOOD Neuts-53.4 Lymphs-41.0 Monos-1.9* Eos-3.6
Baso-0.2
[**2129-10-6**] 09:10AM BLOOD Parst S-NEGATIVE
[**2129-10-6**] 12:50PM BLOOD Parst S-NEGATIVE
[**2129-10-6**] 05:50AM BLOOD Ret Aut-0.9*
[**2129-10-6**] 05:50AM BLOOD ALT-61* AST-44* LD(LDH)-504* AlkPhos-42
TotBili-0.5
[**2129-10-5**] 02:17PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2129-10-5**] 02:18PM BLOOD ANCA-NEGATIVE B
[**2129-10-5**] 02:18PM BLOOD CRP-70.8*
[**2129-10-5**] 02:17PM BLOOD HCV Ab-NEGATIVE
ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA [**Doctor Last Name **])
IGG/IGM
Test Result Reference
Range/Units
A. PHAGOCYTOPHILUM IGG <1:64 <1:64
A. PHAGOCYTOPHILUM IGM <1:20 <1:20
Anaplasma phagocytophilum is the tick-borne [**Doctor Last Name 360**]
causing Human Granulocytic Ehrlichiosis (HGE).
HGE is distinct and separate from Human Moncytic
Ehrlichiosis (HME), caused by Ehrlichia chaffeensis.
Serologic crossreactivity between A. phagocyto-
philum and E. Chaffeensis is minimal (5-15%).
Test Result Reference
Range/Units
PARVOVIRUS B-19 ANTIBODY 3.55 H
(IGG)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
IgG persists for years and provides life-long immunity.
To diagnose current infection, consider a Parvovirus
B19 DNA, PCR test.
Test Result Reference
Range/Units
PARVOVIRUS B-19 ANTIBODY <0.9
(IGM)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
Results from any one IgM assay should not be used as a
sole determinant of a current or recent infection.
Because IgM tests can yield false positive results and
low levels of IgM antibody may persist for months post
infection, reliance on a single test result could be
misleading. If an acute infection is suspected, consider
obtaining a new specimen and submit for both IgG and IgM
testing in two or more weeks. To diagnose current
infection, consider a parvovirus B19 DNA,PCR test.
Test Result Reference
Range/Units
PARVOVIRUS B19 DNA, QL REAL Not Detected Not Detected
TIME PCR
This test was developed and its performance
characteristics have been determined by [**Company 30232**] [**Doctor Last Name **] Institute, Chantilly, VA.
Performance characteristics refer to the
analytical performance of the test.
Test Result Reference
Range/Units
M.PNEUMONIAE AB IGM, EIA 32 <770 U/mL
Reference Range:
<770 U/ml Negative
770-950 U/mL Low positive
>950 U/mL Positive
[**2129-10-7**] 06:00AM BLOOD FLUORESCENT TREPONEMAL ANTIBODY
(FTA-ABS)-PND
[**2129-10-6**] 12:50PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG-PND
[**2129-10-5**] 02:17PM BLOOD [**Male First Name (un) **] MOUNTAIN SPOTTED FEVER AB IGG,
IGM-PND
DISCHARGE LABS:
[**2129-10-8**] 06:25AM BLOOD WBC-6.9 RBC-3.78* Hgb-11.7* Hct-32.8*
MCV-87 MCH-31.0 MCHC-35.7* RDW-13.0 Plt Ct-184#
[**2129-10-8**] 06:25AM BLOOD Glucose-99 UreaN-18 Creat-0.9 Na-140
K-3.5 Cl-104 HCO3-30 AnGap-10
[**2129-10-8**] 06:25AM BLOOD ALT-113* AST-64* LD(LDH)-324* AlkPhos-55
TotBili-0.6
[**2129-10-8**] 06:25AM BLOOD Albumin-3.6 Calcium-8.7 Phos-4.6* Mg-2.3
URINE:
[**2129-10-4**] 04:25PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2129-10-4**] 04:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2129-10-5**] 03:26AM URINE Hours-RANDOM Creat-28 Na-51 K-10 Cl-50
[**2129-10-5**] 03:26AM URINE Osmolal-211
CSF:
[**2129-10-4**] 11:40PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-86
Lymphs-0 Monos-14
[**2129-10-4**] 11:40PM CEREBROSPINAL FLUID (CSF) TotProt-61*
Glucose-56
TEST RESULT SOURCE
---- ------ ------
Syphilis (VDRL) Non-Reactive (-) CSF
Test Requested
--------------
Herpes Simplex Virus PCR
Specimen Source: Cerebrospinal Fluid
Result
------
Negative
Report Status
-------------
FINAL
Analyte Specific Reagent
MICRO:
MRSA CULTURES ([**10-4**]): Negative
URINE CX ([**10-4**]): no growth
Blood cultures ([**10-4**] x4): no growth
Blood culture ([**10-6**] x2): NGTD
[**2129-10-4**] 11:40 pm CSF;SPINAL FLUID Source: LP.
**FINAL REPORT [**2129-10-8**]**
GRAM STAIN (Final [**2129-10-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2129-10-8**]): NO GROWTH.
LYME SEROLOGY (Final [**2129-10-6**]):
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
Reference Range: No antibody detected.
RAPID PLASMA REAGIN TEST (Final [**2129-10-6**]):
NONREACTIVE.
Reference Range: Non-Reactive.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2129-10-6**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2129-10-6**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2129-10-10**]):
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
CMV Viral Load (Final [**2129-10-7**]):
CMV DNA not detected.
Performed by PCR.
Detection Range: 600 - 100,000 copies/ml.
HBV Viral Load (Final [**2129-10-7**]):
HBV DNA not detected.
HCV VIRAL LOAD (Final [**2129-10-6**]):
HCV-RNA NOT DETECTED.
HIV-1 Viral Load/Ultrasensitive (Final [**2129-10-7**]):
125,000 copies/ml.
OVA + PARASITES (Final [**2129-10-7**]):
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
BLASTOCYSTIS HOMINIS. CLINICAL SIGNIFICANCE UNCERTAIN.
IMAGING:
CXR ([**10-4**]):
FINDINGS:
An ovoid density projecting over the left perihilar region at
the eighth, may represent an orthogonal imaged vessel and is
stable from the prior study over 4 years ago. There is no
evidence of suspicious opacities, there is no pleural effusion
or pneumothorax. The cardiomediastinal silhouette and hila are
normal.
IMPRESSION: No acute cardiothoracic process including no
evidence of
pneumonia.
Brief Hospital Course:
============================
BRIEF HOSPITAL SUMMARY
============================
Mr. [**Known lastname 3647**] is a 40 year-old gentleman with history of HIV (CD4
of 639 two weeks ago, not on HAART), presenting with fever x4
days, [**Known lastname **] and thrombocytopenia. After a thorough infectious
work-up, it is believed to have been the result of a
hypersensitivity reaction to lamictal. Upon ceasing lamictal,
the [**Known lastname **] improved dramatically, LFTs improved, thrombocytopenia
resolved, and fever resolved.
============================
ACTIVE ISSUES
============================
# Fever: Unclear etiology. Fever resolved after the first 36
hours of the hospitalization. Initial concern for meningitis
given headache and fever and macular/papular [**Known lastname **] (although no
purpura); LP performed without evidence of meningitis (headache
has resolved, no meningismus). No evidence of pneumonia or UTI.
Possibly viral infection with viral exanthem. [**Known lastname **] not
consistent with erysipelas or cellulitis. Patient with recent
travel to [**State 1727**] - considered (although less likely) rickettsial
infection, lyme disease. However [**State **] is not consistent with
these infections. Fever most likely secondary to systemic
inflammation from anti-epileptic hypersensitivity reaction. LDH
elevated to 709 and AST/ALT mildly elevated. Patient was
initially treated with vancomycin for concern for cellulitis in
the MICU, and shortly discontinued therafter considering low
likelihood of cellulitis. Patient was empirically treated for
herpes meningitis, and discontinued empiric treatment w/
acyclovir after obtaining LP results. Patient received 2-3 days
of cephalosporin to treat for STI, discontinued after RPR
returned negative. Continued to treat with doxycycline to cover
chlamydia and tick-born illnesses. Our colleagues in infectious
diseases were consulted and guided our management. Many
cultures and send-outs were sent on this patient (see lab
section), which came back nearly all negative.
.
# [**State **]: Pt received systemic steroids (methylprenisolone 125 mg
IV x1) x1 in the MICU w/ symptomatic improvement. Differential
diagnosis broad in immunocompromised patient. Likely infectious
etiology (viral exanthem/tick-borne) vs. drug eruption. Most
likely anti-epileptic hypersensitivity syndrome. Drug eruptions
occur more frequently in HIV infected patients and increased
frequency is seen in more severely immunocompromised patients.
Anti-epileptic hypersensitivity reaction can cause headache,
flu-like syndrome, fever, [**State **], LFT abnl (and rarely SJS/TEN).
SJS and TEN can present with prodrome of fever and malaise.
Patient is at increased risk of SJS given HIV infection as well
as lamictal is one of the most commonly implicated medications.
In addition to rickettsial illness as mentioned above,
considered viral etiology such as VZV, parovirus. [**State **] not
entirely consistent with syphillis or gonococcas. Our
dermatology colleagues were consulted and aided our management
of this patient's [**State **]. The [**State **] never included mucous
membranes, and improved significantly after discontinuing
lamictal and topical treatment. We initiated: clobetasol cream
0.05% [**Hospital1 **] to arms, legs, chest, back x 7 days, desonide cream or
fluocinolol 0.01% cream [**Hospital1 **] to face/groin x 7days. No skin
biopsy performed considering considerable improvement in [**Hospital1 **].
.
# Thrombocytopenia: Platelets decreased (71K) from baseline upon
admission, but improved to normal by time of discharge (>130K).
Concern in ED for TTP given fever, acute renal failure, evidence
of hemolysis, and thrombocytopenia, although no shistocytes seen
on smear. Coags were normal. Given smear without shistocytes,
TTP is less likely. No altered mental status. Thrombocytopenia
more likely secondary to drug reaction (most likely) or
infection. Heme-onc was consulted, and recommendations were
appreciated.
.
# Transaminitis: Elevated AST/ALT/LDH. Likely [**12-22**] drug reaction.
No RUQ tenderness. No elevated bili or alk phos to suggest
gallbladder pathology. LFTs trending down. Pt should have LFTs
drawn week after discharge to continue to trend.
.
# Acute renal failure: Likely in setting of dehydration given
fever. Cr 1.4 on admission, improved to 0.9 by discharge with IV
fluid rehydration. No evidence of obstruction, urinating fine.
FeNa 1.6%, indeterminate. Renally dosed meds, avoided
nephrotoxins.
.
# Depression: Was started on lamictal for what appears to be
manic symptoms. Pt was anxious throughout hospitalization. Pt
did have passive SI on day 3 of hospitalization (coping with
recent break-up of partner). Mood much improved by day of
discharge. Continued home medications of Pristiq 100 mg daily
and valium. held lamictal and zyprexa. Patient should have close
out-patient psych follow-up, which was communicated with
patient. Inpatient psych was consulted, and recommendations
appreciated.
.
# Headache: Patient had headache in the middle of
hospitalization, likely secondary to post-LP headache (HA
positional --> worse with sitting up). Gave the patient
fiorecet, advised to drink coffee, narcotics for pain relief.
Pt received a blood patch by anesthesia, with improvement in
headache.
====================
TRANSITIONAL ISSUES
====================
1. MEDICATION CHANGES:
STOP zyprexa and lamictal. These medications are the most likely
cause of your [**Month/Day (2) **]/drug reaction. In the future avoid
anti-convulsants as these medications can cause a similar
reaction in the future.
Start doxycycline 100mg tablet 1 tab every 12 hours for 12 days
Start Desonide 0.05% Cream 1 Application to face and groin twice
daily for 12 days or until your [**Month/Day (2) **] goes away
Start Clobetasol Propionate 0.05% Cream 1 Application to arms
legs and chest twice daily for 12 days or until your [**Month/Day (2) **] goes
away.
2. LFTS: Please have blood drawn at least one day before your
visit to PCP to check your liver function. We have attached a
prescription for this.
3. FOLLOW-UP: Patient was provided with phone number of his PCP,
[**Name10 (NameIs) **] should follow-up within one week of discharge. Patient
should follow-up within one to two weeks with his
psychiatrist/therapist, for mental health care.
4. OUTSTANDING LABS: Labs should be followed-up by primary care
physician:
[**2129-10-7**] 06:00AM BLOOD FLUORESCENT TREPONEMAL ANTIBODY
(FTA-ABS)-PND
[**2129-10-6**] 12:50PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG-PND
[**2129-10-5**] 02:17PM BLOOD [**Male First Name (un) **] MOUNTAIN SPOTTED FEVER AB IGG,
IGM-PND
Medications on Admission:
diazepam 10 mg Tab TID
Flonase 50 mcg daily
MVI
Pristiq 100 mg daily
Lamictal 25 mg daily
Zyprexa 5 mg qHS
Discharge Medications:
1. Pristiq 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 12 days.
Disp:*24 Capsule(s)* Refills:*0*
3. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 12 days.
Disp:*1 tube * Refills:*0*
4. desonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) for 12 days.
Disp:*1 tube* Refills:*0*
5. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
6. Outpatient Lab Work
LFTs
please fax to Dr. [**Last Name (STitle) 2392**] at [**Telephone/Fax (1) 34420**]
draw week of [**2129-10-9**]
Discharge Disposition:
Home
Discharge Diagnosis:
DRESS syndrome secondary to lamictal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 3647**],
It was a pleasure taking care of you. You were admitted to the
hospital for fever, [**Known lastname **] and elevated liver function tests. We
think that these symptoms were caused by a hypersensitivity
reaction to anti-epileptic medications (lamictal). We were also
concerned about a possible infectious disease causing your
symptoms and worked you up for several tick borne illnesses.
Your symptoms have improved and we think that it is safe for you
to go home. We would like you to continue taking doxycycline
for an additional 12 days. For your drug [**Known lastname **], you should also
continue using your steroids creams for 12 days or until your
[**Known lastname **] goes away.
.
We have made the following changes to your medications:
STOP zyprexa and lamictal. These medications are the most
likely cause of your [**Known lastname **]/drug reaction. In the future avoid
anti-convulsants as these medications can cause a similar
reaction in the future.
Start doxycycline 100mg tablet 1 tab every 12 hours for 12 days
Start Desonide 0.05% Cream 1 Application to face and groin twice
daily for 12 days or until your [**Known lastname **] goes away
Start Clobetasol Propionate 0.05% Cream 1 Application to arms
legs and chest twice daily for 12 days or until your [**Known lastname **] goes
away.
.
Your liver function is improving but we want to make sure that
it continues to trend down. Please have your blood drawn at
least one day before your visit to your PCP to check your liver
function. We have attached a prescription for this.
Followup Instructions:
please call you PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 5723**] to schedule a follow up
appointment. We would like to make sure that you are seen
within under one week after discharge.
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
|
[
"285.9",
"584.9",
"349.0",
"311",
"E936.3",
"300.00",
"E849.7",
"693.0",
"780.60",
"339.3",
"V08",
"287.5",
"E879.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"03.95"
] |
icd9pcs
|
[
[
[]
]
] |
21089, 21095
|
13546, 18927
|
309, 339
|
21176, 21176
|
5586, 5586
|
22943, 23284
|
3911, 4025
|
20372, 21066
|
21116, 21155
|
20240, 20349
|
21327, 22086
|
9913, 13523
|
4065, 4864
|
22115, 22920
|
2506, 2812
|
18947, 20214
|
232, 271
|
367, 2487
|
5602, 9897
|
21191, 21303
|
2834, 3757
|
3773, 3895
|
4889, 5567
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,841
| 130,403
|
53460
|
Discharge summary
|
report
|
Admission Date: [**2142-10-19**] Discharge Date: [**2142-10-24**]
Service: MEDICINE
Allergies:
Nsaids/Anti-Inflammatory Classifier
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Intubated [**2142-10-19**]
History of Present Illness:
85 yo female with past medical history of emphysema and dementia
was transferred from the floor with altered mental status and
hypercarbia.
The patient initially presented to the ED with altered mental
status and lethargy. Upon arrival to the ED, temp 96.9, HR 60,
BP 200/110, RR 15, and Pulse ox 100% on 3L with her exam notable
for being alert but not oriented. Initial CXR was notable for
stable cardiomegaly only and her head CT did not demonstrate any
new changes. She received ceftriaxone and vancomycin to cover
for meningitis. Initial labs were notable for a normal WBC at
6.8. She was then admitted to the medical floor where she was
noted to be somnolent and an ABG demonstrated pH 7.19, PCO2 90,
and PO2 92. She was then transferred to the MICU.
Further history was obtained from her family and OMR as patient
could not cooperate with history. According to her
granddaughters, at baseline when she is in familiar
surroundings, she speaks, is able to perform her ADLs with
assistance, and ambulates with a walker. She is less interactive
with strangers. Over the three days prior to admission, her
family noted that she was increasingly lethargic, difficult to
arouse, and less interactive. She was then brought in by her
family for altered mental status. According to her family, ROS
was notable for possible increased urinary urgency, increased
work of breath, abdominal pain, and poor sleeping for 3 days
prior to admission. Her family otherwise denies fevers, chills,
nausea, vomiting, chest pain, cough, diarrhea, or constipation.
Past Medical History:
1. Congestive heart failure (EF in [**2135**] 40%)
2. Coronary artery disease s/p anterior-IMI in 9/[**2137**].
3. Type 2 Diabetes Mellitus
4. COPD
5. Hypertension.
6. Obesity.
7. Degenerative joint disease.
8. Status post total abdominal hysterectomy.
9. Anemia, baseline hematocrit 31.
10. Chronic renal failure, baseline creatinine 1.1-1.5
11. History of being guaiac positive.
12. Meningioma.
Social History:
Lives with son and daughter-in-law and goes to day care during
the week
Denies etoh, tobacco, or drug use
Family History:
Non-contributory
Physical Exam:
T 96 / BP 159/60 / HR 75 / RR 24 / Pulse ox 96-100% on room air
GENERAL: slightly agitated and in mild distress,
SKIN: no rashes, no lesions
HEENT: NC/AT, Anicteric, EOMI, PERRL, tongue swelling
NECK: No stiffness, No masses, No LAD, no bruits
CHEST: Lungs Clear to Asculation, No Wheezes/Rhonchi/Crackles
HEART: RRR, No Murmurs/Gallops/Rubs
BACK: No CVA Tenderness, No spinal tenderness
ABDOMEN: NABS, Soft, No organomegaly, No masses, No guarding, No
rebound
EXT: 2+ LE edema, right LE greater in size than left (chronic).
1+ DP pulses bilaterally.
NEURO: Cranial Nerves: II-XII intact; moving all extremities.
responsive to painful stimuli
Pertinent Results:
[**2142-10-19**] CXR: IMPRESSION: No acute pulmonary process. Massive but
stable cardiomegaly. There is underlying pulmonary arterial
hypertension as identified on [**2141-4-11**] chest CT.
[**2142-10-19**] CT head without contrast: wet read: no evidence of acute
ich. likely meningiomas again seen, not signficantly changed
from prior.
Brief Hospital Course:
85 yo F with CHF, T2DM, COPD, and dementia admitted with altered
mental status found to have profound hypercarbia and worsened
cardiac function on echo. The patient was maintained on BiPAP
to improve her hypercarbia, and her mental status improved. The
patient and her family decided to be DNR/DNI and to go home with
hospice care. Social work and palliative care met with the
patient and family and arranged for services.
# Acute on chronic respiratory failure. Significant
hypercarbia/respiratory acidosis. Likely etiology is
intercurrent MI or ischemic insult to the heart resulting in
worsened CHF as evidenced by TTE with progression of cardiac
dysfunction. She was aggressively diuresed, and responded well
to lasix 80mg IV. Patient family decided on [**2142-10-21**] that patient
was DNR/DNI and wanted to take the patient home with hospice
care. Her respiratory status was stable at the time of
discharge.
# Altered mental status. Likely secondary to
hypercardia/respiratory acidosis. Her mental status improved
over her 5 days in the ICU. She was maintained on BiPAP to
improve her ventilation.
# Congestive heart failure. Progressive failure on echo with
clinical signs of fluid overloaded.
- Diurese. Monitor electrolytes twice daily while diuresing.
- Consider restarting beta blocker. To consider starting low
dose ACEi as tolerated if CRI stable.
# Elevated LFTs. Likely secondary to congestion in the setting
of worsening CHF. Her LFT's improved throughout her hospital
course.
# Hypernatremia. She was thought to be free water deplete. We
replace her free water based on her free water deficit with D5W.
Medications on Admission:
Albuterol 1-2 puffs qid prn cough
Aspirin 325mg PO daily
Atenolol 50mg PO daily
Atrovent 2 puffs [**Hospital1 **]
Colchicine 600mcg PO daily
KDur 20mEq daily
Lasix 60mg PO daily
Sertraline 50mg PO daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed.
Disp:*10 units* Refills:*0*
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
treatment Inhalation Q4H (every 4 hours) as needed.
Disp:*25 treatments* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
10. Roxanol Concentrate 20 mg/mL Solution Sig: 2.5-10 mg PO q1h
as needed for patient comfort: Please administer 2.5-10mg every
one hour as needed for patient comfort. .
Disp:*1 Bottle* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. COPD
2. Congestive heart failure (EF in [**2135**] 40%)
3. Hypertension
SECONDARY DIAGNOSIS:
1. Coronary artery disease s/p anterior-IMI in 9/[**2137**].
2. Type 2 Diabetes Mellitus
3. Obesity.
4. Degenerative joint disease.
5. Status post total abdominal hysterectomy.
6. Anemia, baseline hematocrit 31.
7. Chronic renal failure, baseline creatinine 1.1-1.5
8. History of being guaiac positive.
9. Meningioma.
Discharge Condition:
Stable - Patient was tolerating oral intake.
Discharge Instructions:
While you were in the hospital, you were diagnosed with
worsening heart failure and COPD. You were kept on oxygen while
you were here which helped your breathing. Please continue to do
this at night as you can tolerate. You will be going home with
hospice services who will help keep you most comfortable.
Followup Instructions:
You have follow-up appointments scheduled with the following
providers. If you are unable to keep these appointments or if
you would like to cancel these appointments, please call
[**Telephone/Fax (1) 250**] to make any changes.
1. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2142-10-30**] 11:30
2. Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2142-11-9**] 2:20
|
[
"585.9",
"250.00",
"412",
"403.90",
"276.2",
"294.8",
"492.8",
"276.0",
"428.0",
"518.84",
"428.22",
"285.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
6782, 6853
|
3494, 5129
|
266, 294
|
7331, 7378
|
3130, 3471
|
7732, 8231
|
2432, 2450
|
5383, 6759
|
6874, 6874
|
5155, 5360
|
7402, 7709
|
2465, 3024
|
205, 228
|
322, 1873
|
3040, 3111
|
6990, 7310
|
6893, 6969
|
1895, 2293
|
2309, 2416
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,381
| 100,136
|
50941+50942
|
Discharge summary
|
report+report
|
Admission Date: [**2150-12-24**] Discharge Date: [**2150-12-26**]
Date of Birth: [**2092-10-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58f with breast cancer, HTN, CHF, PAF s/p PVI presents with
shortness of breath, increasing over the past day. She notes
that the symptoms became gradually, with increasing dyspnea on
exertion and a productive cough but that she then developed
palpitations, with increased dyspnea related to this. Her pulse
was fast and irregular. She came into the emergency department
and was found to be in rapid atrial fibrillation; a chest x-ray
revealed a pneumonia. She recieved levofloxacin and IV
diltiazem in the ED and was admitted.
Past Medical History:
1. PAF s/p pulm vein isolation, w/ recurrence s/p radiation, now
on amiodarone.
2. CHF diastolic EF 62% by MRI [**3-6**]
3. Breast cancer Stage II status post right mastectomy and
status post six months of tamoxifen therapy, now s/p XRT
4. Hypertension.
5. Hyperlipidemia.
Social History:
Patient is married and lives with her husband. She denied
smoking or alcohol use.
Family History:
NC
Physical Exam:
t 99.4, bp 134/86, hr 122, rr 18, spo2 96% 2L nc
gen- pleasant f, looks age, mild distress, non-toxic
heent- anicteric, op clear with mmm
neck- no jvd/lad/thyromegaly
cv- tachy, irreg irreg, no m/r/g
pul- moves air well, slight bibasilar rales r>l
abd- soft, nt, nd, nabs
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, no pitting/color changes/indentations
neuro- a&ox3, no focal cn/motor deficits
Pertinent Results:
[**2150-12-24**] 10:00PM BLOOD WBC-6.5 RBC-4.33 Hgb-13.0 Hct-36.7
MCV-85# MCH-29.9 MCHC-35.4*# RDW-14.7 Plt Ct-150
[**2150-12-26**] 06:00AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-139
K-4.3 Cl-105 HCO3-25 AnGap-13
[**2150-12-24**] 10:00PM BLOOD CK(CPK)-54 TotBili-0.6
[**2150-12-24**] 10:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2150-12-26**] 06:00AM BLOOD CK(CPK)-81
[**2150-12-26**] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2150-12-25**] 06:40AM BLOOD ALT-31 AST-18 AlkPhos-76 TotBili-0.5
[**2150-12-25**] 06:40AM BLOOD TSH-4.6*
Brief Hospital Course:
58f with breast cancer, htn, chf, paf s/p pvi admitted with
pneumonia and afib with rapid ventricular response
.
Afib -- Mrs. [**Known lastname **] is maintained on amiodarone at home in sinus
rhythm. It was felt that her pneumonia was the likely culprit
in this exacerbation back into fibrillation. She was seen by
the EP staff who felt she would do well with a loading dose of
amiodarone of 400mg twice daily for three days; she would then
return to her usual dose of 200mg daily. This was begun with a
good response. Sinus rhythm was quickly re-instated. Her
symptoms of dyspnea and palpitations seems to improved with
reversion to sinus. She was discharged with one day of
loading-dose amidodarone left in sinus rhythm, with rates
generally in the 70's.
.
Pneumonia -- Although clinically mild, it was felt sufficient to
cause her loss of sinus rhythm. She had no O2 requirement and
was treated with a course of levofloxacin. By the time she was
discharged, she was afebrile with decreased cough and sputum
production. Micro data was unrevealing.
Medications on Admission:
Pantoprazole 40mg daily
Amiodarone 200mg daily
Metoprolol 25mf twice daily
Warfarin 2mg mon-fri and 1mg sat-sun
ASA 325mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Warfarin 1 mg Tablet Sig: One (1) Tablet PO SAT-SUN ().
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO MON-FRI ().
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 days: Take 2 pills twice a day on Saturday and
Sunday, then return to 200mg once a day.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular response
Pneumonia
Secondary:
1. PAF s/p pulm vv isolation, w/ recurrence s/p radiation, now
on amiodarone.
2. CHF, one episode post cardioversion, diastolic EF 55% 2/04
3. Breast cancer Stage II status post right mastectomy and
status post six months of tamoxifen therapy, now s/p XRT
4. Hypertension
5. Hyperlipidemia
Discharge Condition:
Good, in sinus rhythm, with improved symptoms
Discharge Instructions:
You were admitted for a pneumonia and a rapid heart rate; your
heart rate was controlled with a temporarily increased dose of
amiodarone, and you were given antibiotics for the pneumonia.
.
Call your PCP or return to the ED for fevers/chills, chest pain,
shortness of breath, lightheadedness, loss of conciousness, or
other concerning symptoms.
.
Take 400mg of amiodarone twice a day on Saturday and Sunday,
then return to your usual dose of 200mg once a day on Monday.
Followup Instructions:
Please see your primary care doctor in the next 1-2 weeks; call
[**Telephone/Fax (1) 2740**] to make an appointment.
.
Provider: [**Last Name (NamePattern4) 105871**] NP/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2151-3-4**] 8:00
.
Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) **] DX RM2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2151-3-9**] 11:00
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2151-3-19**] 3:15
Admission Date: [**2150-12-27**] Discharge Date: [**2150-12-31**]
Date of Birth: [**2092-10-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Central line placement and removal
History of Present Illness:
HPI: 58 yo woman w/ h/o afib s/p ablation, chf(ef55%), htn,
breast ca who was just d/c'd yesterday([**12-26**]) afternoon w/ dx of
PNA and PAF on amiodarone load with coumadin and levofloxacin
after being treated with ceftriaxone/azithro while in house.
Returns to the ED with episode of acute onset of SOB, unable to
get breath, she tried to go to bed and went to bed around
midnight, but remained SOB and dry cough ('felt I was drowning')
around 1:30am also felt 'I was in afib with very fast heart
rate'. SOB improved with sitting up. Pt reported 2 lb weight
gain from Friday to Sat. No LE edema. Denied chest pain,
palppitations.
.
On way to [**Name (NI) **], pt received 100mg lasix, in ED, found to have
BP200's, with heart rate 100 initially in afib but subsquently
converted to sinus spontaneously. Temp 99.8, and O2sat 80's in
RA, RR50's was placed on nitro gtt and CPAP initially, BP
subsquently dropped to 80's/30's, stopped nitro gtt. Pt was
placed on 4L O2 NC improvment in sats to 99% and 250cc bolus and
then started on dopamine.
.
While in ED remained hypotensive as HR 110's and was started on
dopamine peripherally again at 2.5-5mcg/kg/min. She has
diuresed about 1700 UOP since arrival. As dopamine taken off,
HR improved and converted to NSR in 80's. Then she started
rigoring and spiked a temp to 103. She was transferred to the
MICU for close monitoring and a dopamine drip that was quickly
weaned off.
Past Medical History:
1. PAF s/p pulm vein isolation, w/ recurrence s/p radiation, now
on amiodarone.
2. CHF diastolic EF 62% by MRI [**3-6**]
3. Breast cancer Stage II status post right mastectomy and
status post six months of tamoxifen therapy, now s/p XRT
4. Hypertension.
5. Hyperlipidemia.
Social History:
Patient is married and lives with her husband. She denied
smoking or alcohol use.
Family History:
NC
Physical Exam:
T99.8/103.0 HR 78-127 BP199-149--> 94/65 RR28 O2sat 96% on
6L
GEN: aao, nad
HEENT: PERRL OP clr, JVD flat
CV: tachy, irreg, irregular, no murmurs
Lung: diffused coarse BS bilaterally
ABD: +bs. soft. nt. nd.
Ext: trace edema on LE, 2+ dp pulses b/l, warm well perfused.
Neuro: a&ox3, no focal cn/motor deficits
Pertinent Results:
[**2150-12-26**] 06:00AM BLOOD WBC-6.6 RBC-3.85* Hgb-11.4* Hct-33.2*
MCV-86 MCH-29.7 MCHC-34.4 RDW-14.7 Plt Ct-151
[**2150-12-27**] 02:10AM BLOOD WBC-10.6# RBC-4.29 Hgb-13.0 Hct-38.2
MCV-89 MCH-30.2 MCHC-34.0 RDW-14.7 Plt Ct-237#
[**2150-12-31**] 04:45AM BLOOD WBC-6.3 RBC-3.57* Hgb-10.9* Hct-30.6*
MCV-86 MCH-30.6 MCHC-35.7* RDW-14.8 Plt Ct-194
[**2150-12-26**] 06:00AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-139
K-4.3 Cl-105 HCO3-25 AnGap-13
[**2150-12-28**] 03:48AM BLOOD Glucose-103 UreaN-14 Creat-0.7 Na-140
K-3.6 Cl-105 HCO3-26 AnGap-13
[**2150-12-31**] 04:45AM BLOOD Glucose-86 UreaN-13 Creat-0.8 Na-140
K-3.6 Cl-103 HCO3-28 AnGap-13
[**2150-12-26**] 06:00AM BLOOD CK(CPK)-81
[**2150-12-26**] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2150-12-27**] 02:10AM BLOOD CK(CPK)-147*
[**2150-12-27**] 02:10AM BLOOD cTropnT-<0.01
[**2150-12-27**] 08:17PM BLOOD CK(CPK)-175*
[**2150-12-27**] 08:17PM BLOOD CK-MB-2 cTropnT-<0.01
[**2150-12-28**] 03:48AM BLOOD CK(CPK)-178*
[**2150-12-28**] 03:48AM BLOOD CK-MB-2 cTropnT-<0.01
[**2150-12-27**] 02:10AM BLOOD CK-MB-2 proBNP-1576*
[**2150-12-28**] 03:48AM BLOOD calTIBC-225* VitB12-604 Folate-17.1
Ferritn-326* TRF-173*
[**2150-12-27**] 12:17PM BLOOD TSH-3.1
.
Echo: The left atrium is mildly dilated. There is borderline
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Probably moderate (2+)
mitral regurgitation is seen (views suboptimal; seen well in
apical 3 chamber view only). The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (tape reviewed) of [**2148-9-13**],
mitral
regurgitation is now more prominent (as visualized in the apical
3 chamber view). Estimated pulmonary artery systolic pressure
is now higher.
Brief Hospital Course:
A/P: 58 yo woman w/ h/o afib s/p ablation, h/o chf, htn, breast
ca, recent admission with LLL PNA and afib w/ RVR admitted with
increased shortness of breath and now fevers and hypotension.
.
.
Respiratory Distress: Ultimately it was felt that her symptoms
developed from her underlying pneumonia and an episode of rapid
atrial-fibrillation that caused pulmonary edema. She was
diuresed with good effect with IV furosemide and a two gram
sodium diet.
Her antibiotic coverage was transitioned from levofloxacin to
azithromycin. Urine and blood cultures failed to grow anything
and she was initially febrile, early in the hospital course,
despite antibiotic treament. She was, however, afebrile, during
the forty-eight hours prior to discharge on azithromycin. She
continued to cough intermittently, but this was well controlled
with benzonatate.
.
Hypotension: Occuring in the ED and resolving by the time she
reached the MICU, her hypotension, although originally felt due
to septic physiology, was ultimately thought to be secondary to
overdiuresis and anti-hypertensive therapy while in the ED.
Once her fluid status and heart rate were optimized, she
remained normotensive for the rest of the admission.
.
PAF: She was continued on her amiodarone load with good effect,
as she remained in sinus rhythm for the rest of the admission.
Warfarin was also continued. She was discharged on her home
dose of amiodarone 200mg daily.
Medications on Admission:
meds:
1. Lopressor 75 mg b.i.d.
2. Amiodarone 400 mg p.o. [**Hospital1 **]
3. Coumadin 2 mg p.o. M-F, 1mg Sa/Sun
4. ASA 325mg qd
5. Levofloxacin 500mg qd
6. pravachol
7. lisiniopril
8. clonidine
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 5X/WEEK
(MO,TU,WE,TH,FR).
3. Warfarin 1 mg Tablet Sig: One (1) Tablet PO 2X/WEEK ([**Doctor First Name **],SA).
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
6. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Capsule(s)* Refills:*0*
7. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO three
times a day for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
12. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO HS
(at bedtime) as needed.
Disp:*50 ML(s)* Refills:*0*
13. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation four times daily as needed for shortness of breath or
wheezing.
Disp:*2 inhalers* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Congestive heart failure
Atrial fibrillation with rapid ventricular response
Pneumonia
Secondary:
1. PAF s/p pulm vein isolation, w/ recurrence s/p radiation, now
on amiodarone.
2. CHF diastolic EF 62% by MRI [**3-6**]
3. Breast cancer Stage II status post right mastectomy and
status post six months of tamoxifen therapy, now s/p XRT
4. Hypertension.
5. Hyperlipidemia.
Discharge Condition:
Good, with improved symptoms, afebrile, good oxygen saturation
Discharge Instructions:
You were admitted with pna, a rapid heart rate from your atrial
fibrillation, and congestive heart failure; you got diuretics
for the CHF, amiodarone for the atrial fibrillation, and
azithromycin for the pneuomonia.
.
Call your doctor or return to the ED for fever/chills, shortness
of breath, rapid heart rate, chest pain, lightheadedness or loss
of conciousness, or other concerning symptoms.
.
Follow-up as below
Followup Instructions:
Please see your primary care doctor, Dr. [**First Name (STitle) 1609**], in the next [**1-4**]
weeks; call [**Telephone/Fax (1) 2740**] to make an appointment.
.
Provider: [**Last Name (NamePattern4) 105871**] NP/DR [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2151-3-4**] 8:00
.
Provider: [**Name10 (NameIs) 326**] [**Name11 (NameIs) **] DX RM2 RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2151-3-9**] 11:00
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2151-3-19**] 3:15
|
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
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13739, 13796
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47,477
| 156,091
|
35568
|
Discharge summary
|
report
|
Admission Date: [**2112-1-26**] Discharge Date: [**2112-2-2**]
Date of Birth: [**2040-10-3**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
CC: LE weakness, numbness.
Major Surgical or Invasive Procedure:
Thoracic laminectomy T9-11
History of Present Illness:
HPI: 71F with 17yr hx of metastatic breast ca, with mets to
head,spine, hips, ribs. Mets diagnosed 4.5 yrs ago after c/o
neck pain. Received XRT to cervical spine at that time. Has been
on cycles of Tamoxifen and Aromasin since for the rest of the
metastasis. Has now been c/o lower thoracic pain for 4-6 weeks,
with radiation around abdomen bilat. Pain is worst after
sitting/standing. Over past couple of weeks, noticed that when
she lays on one side, ipsilateral leg becomes numb and weak.
Symptoms improve upon change of position. Has had worsening
difficulty walking, with mainly getting to sitting or standing
possition the most difficult. She went to OSH today as her
symptoms had worsened significantly overnight, mainly c/o
excruciating lower thoracic pain. Over the course of the
afternoon, she noticed that her legs, mainly the left, became
significantly weaker and number. She was able to stand with
support and ambulate to the bathroom but felt very unsteady and
with her legs not appropriately "following command", "shaking".
Symptoms failed to improve upon change of position, as they
typically would otherwise. She denies any bowel/bladder
incontinence or abnormal sensation but states it may have been
harder to pass urine than usual.
Past Medical History:
PMHx: Metastatic breast ca;
Social History:
lives with husband
Family History:
nc
Physical Exam:
PHYSICAL EXAM:
87 157/70 18 100%
Mental status: Awake and alert, cooperative with exam, normal
affect. Uncomfortable due to back pain.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5- 5- 5 5- 5
L 5 5 5 5 5 4- 5- 3 3 5-
Increased tone proximally in Lt LE
Sensation: Decreased to light touch in both LE, abdomen with
level at about T10 on Rt, T12 on Lt; Bevor -; propioception
decreased both LE.
Reflexes: B T Br Quad Ac
Right 2 2 2 2 1
Left 2 2 2 3 2
Toes upgoing bilaterally, Lt brisker than Rt.
Clonus on Lt
Rectal exam normal sphincter control
Pertinent Results:
MRI: metastatic lesions throughout entire spine; T9-11
metastasis
infiltrating entire vertebrae at those levels and causing severe
cord compression (T9-10); dorsal epidural collection extending
up
to T6;
Brief Hospital Course:
Pt was admitted to hospital and had evaluation showing thoracic
metastatic disease. She was started on steroids and readied for
the OR. On [**2-5**] she was brought to OR where under general
anesthesia she underwent thoracic decompressive laminectomy with
excision of extradural tumor. She tolerated this procedure well,
was extubated, transferred to PACU and then floor. Her diet and
activity were advanced. She had high pain med requirement as
pre-op. Her wound was clean and dry and JP drain that was
placed intra-op was removed on POD#3. She had MRI that showed
decreased compression and continued intra and extradural mets.
She was evaluated by PT and recommended for PT. She was seen by
radiation oncology and will need post op XRT 2 weeks post op
which is to occur closer to home where she has had XRT in the
past. Her steroids are to be weaned down to 2mg [**Hospital1 **] and then
further instructions per oncologist.
Medications on Admission:
Medications prior to admission: Motrin, Lorazepam, Zetia,
Oxycontin, Compazine, Aromasin
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
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. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
7. Exemestane 25 mg Tablet Sig: One (1) Tablet PO daily ().
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q6H (every 6 hours) as needed
for severe pain.
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours).
17. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO three times
a day: 2 TAB TID FOR 4 DAYS THEN 2 TAB [**Hospital1 **] FOR 4 DAYS THEN 1 TAB
[**Hospital1 **].
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
Metastatic breast cancer to thoracic spine
Discharge Condition:
NEUROLOGICALLY IMPROVED
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ remove dressing 2/15/09/ begin daily showers [**2112-2-2**]
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for one week.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
PLEASE HAVE STAPLES REMOVED AT REHAB [**2112-2-9**]
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NOT NEED XRAYS PRIOR TO YOUR APPOINMENT
Completed by:[**2112-2-2**]
|
[
"336.3",
"198.5",
"198.4",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.4"
] |
icd9pcs
|
[
[
[]
]
] |
5518, 5589
|
2760, 3695
|
345, 374
|
5675, 5700
|
2531, 2737
|
7018, 7271
|
1758, 1762
|
3835, 5495
|
5610, 5654
|
3721, 3721
|
5724, 6995
|
1792, 1813
|
3753, 3812
|
279, 307
|
402, 1655
|
1828, 2512
|
1677, 1706
|
1722, 1742
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,242
| 129,236
|
1886
|
Discharge summary
|
report
|
Admission Date: [**2186-12-24**] Discharge Date: [**2186-12-31**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1572**]
Chief Complaint:
Lower extremity pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 88 y/o male with a history of 3VD (s/p CABG),
CHF, AF on coumadin, OA of hip s/p b/l replacements who presents
with complaints of LE swelling. Patient has noted worsening b/l
lower extremity swelling over the last month, which had
developed notable skin break down with weeping, erythema, and
pain. Patient feels that his weight is up 6lbs from his dry
weight of 185. The patient has not experienced any chest pain,
shortness of breath, palpitations, or cough. He has no history
of PND, orthopnea, and has not experienced any abdominal
discomfort, early satiety, n/v. The patients legs have become
increasingly more painful, such that the patient could not walk.
He tries to walk 100 to 200 yards daily.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. He denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope or presyncope.
.
In the ED, initial vitals were 97.1, HR 56, BP 123/53, 100% on
2L. Due to concern of cellulitis, the patient was given 1g of IV
vanc. He was noted to have a HR that dropped 40, during which he
was asymptomatic. An EKG showed a wideded QRS, loss of P waves,
and irrecular rhythm. He was admitted to the CCU for further
evaluation and monitoring.
Past Medical History:
1. CARDIAC RISK FACTORS:: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: CABG x 3 in [**2179**] following MI
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
.
1. AVNRT status post ablation greater then 10 years ago.
2. Atrial fibrillation.
3. Low back pain status post surgery.
4. Left hip replacement complicated by staph infection five
to seven years ago.
5. Status post bilateral cataract surgery.
6. Benign prostatic hypertrophy.
Social History:
Smokes four cigars two days times 15 years. Occasional alcohol
reported as four to six drinks per week. The patient was the
chairman of Bandwagon, Incorporated.
Family History:
No family history of early MI, otherwise non-contributory
Physical Exam:
VS: T=96.3 BP=140/55.HR=56 RR= 12 O2 sat= 100% on 2L
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**3-1**] holosystolic blowing murmur at USB.
No thrills, lifts. + S3
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTA B/L
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ b/l LE edema to mid shin, cool LLE with more
pronounced edema.
SKIN: Sebborahic kerratosis on chest, marked erythema and
ecchymosis with ulserations b/l.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Labs on admission:
[**2186-12-24**] 12:20PM BLOOD WBC-7.7 RBC-3.68* Hgb-11.4* Hct-32.4*
MCV-88 MCH-30.8 MCHC-35.0 RDW-15.2 Plt Ct-392
[**2186-12-25**] 05:54AM BLOOD WBC-8.6 RBC-3.38* Hgb-10.7* Hct-29.9*
MCV-88 MCH-31.6 MCHC-35.7* RDW-15.3 Plt Ct-362
[**2186-12-26**] 05:06AM BLOOD WBC-7.1 RBC-3.17* Hgb-9.9* Hct-28.3*
MCV-89 MCH-31.2 MCHC-35.0 RDW-15.3 Plt Ct-345
[**2186-12-27**] 07:06AM BLOOD WBC-7.0 RBC-3.32* Hgb-10.4* Hct-29.7*
MCV-89 MCH-31.3 MCHC-35.1* RDW-15.4 Plt Ct-389
[**2186-12-28**] 05:15AM BLOOD WBC-5.9 RBC-3.07* Hgb-9.7* Hct-27.6*
MCV-90 MCH-31.6 MCHC-35.2* RDW-15.4 Plt Ct-385
.
[**2186-12-24**] 12:20PM BLOOD PT-30.5* PTT-40.1* INR(PT)-3.1*
[**2186-12-25**] 05:54AM BLOOD PT-27.7* PTT-40.7* INR(PT)-2.8*
[**2186-12-26**] 05:06AM BLOOD PT-26.8* PTT-40.9* INR(PT)-2.7*
[**2186-12-27**] 07:06AM BLOOD PT-23.6* PTT-40.0* INR(PT)-2.3*
[**2186-12-28**] 05:15AM BLOOD PT-23.6* PTT-38.5* INR(PT)-2.3*
.
[**2186-12-24**] 12:20PM BLOOD Glucose-91 UreaN-23* Creat-1.0 Na-127*
K-4.2 Cl-89* HCO3-29 AnGap-13
[**2186-12-25**] 05:54AM BLOOD Glucose-110* UreaN-19 Creat-0.8 Na-128*
K-4.2 Cl-92* HCO3-30 AnGap-10
[**2186-12-26**] 05:06AM BLOOD Glucose-102 UreaN-20 Creat-1.1 Na-129*
K-4.0 Cl-91* HCO3-32 AnGap-10
[**2186-12-27**] 07:06AM BLOOD Glucose-106* UreaN-25* Creat-0.9 Na-130*
K-4.2 Cl-93* HCO3-32 AnGap-9
[**2186-12-28**] 05:15AM BLOOD Glucose-94 UreaN-22* Creat-1.0 Na-131*
K-4.2 Cl-93* HCO3-31 AnGap-11
.
[**2186-12-25**] 04:36PM BLOOD ALT-14 AST-24 LD(LDH)-201 AlkPhos-79
TotBili-0.9
.
[**2186-12-25**] 05:54AM BLOOD CK(CPK)-179*
[**2186-12-24**] 08:16PM BLOOD CK(CPK)-184*
[**2186-12-24**] 12:20PM BLOOD CK(CPK)-308*
.
[**2186-12-25**] 05:54AM BLOOD CK-MB-8 cTropnT-0.08*
[**2186-12-24**] 08:16PM BLOOD CK-MB-10 MB Indx-5.4 cTropnT-0.07*
[**2186-12-24**] 12:20PM BLOOD cTropnT-0.06*
[**2186-12-24**] 12:20PM BLOOD CK-MB-15* MB Indx-4.9
.
[**2186-12-24**] proBNP-[**Numeric Identifier 10515**]*
.
[**2186-12-24**] 12:20PM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
[**2186-12-28**] 05:15AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.9
.
[**2186-12-25**] 04:36PM BLOOD Albumin-3.3*
.
[**2186-12-24**] 12:20PM BLOOD Osmolal-265*
[**2186-12-27**] 07:06AM BLOOD TSH-2.2
[**2186-12-24**] 12:38PM BLOOD Lactate-1.5
.
Labs prior to discharge [**2186-12-30**]:
.
4.6 9.6* 27.2 385, WBC/H/H/Pltl
108* 14 0.8 132* 4.1 95* 30 Glu/BUN/Cr/Na/K/Cl/HCO3
INR 2.4
ESR 63
Ca/Ph/Mg 8.0* 2.7 1.9
Urinalysis:
.
[**2186-12-25**] 04:33PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2186-12-25**] 04:33PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-TR
[**2186-12-25**] 04:33PM URINE RBC->50 WBC-[**3-29**] Bacteri-FEW Yeast-NONE
Epi-0-2
[**2186-12-24**] 08:16PM URINE Hours-RANDOM UreaN-719
[**2186-12-24**] 08:16PM URINE Osmolal-470
.
Microbiology:
.
Urine Cx - negative.
MRSA Nasal swab screen - negative.
Blood Cx - 11/30 [**12-25**] are negative.
.
Imaging/Studies:
.
ECG [**12-24**] - Atrial fibrillation with slow ventricular response.
Left axis deviation.
Intraventricular conduction defect. Non-specific ST-T wave
abnormalities.
Compared to the previous tracing of [**2186-2-6**] atrial fibrillation
with
slow ventricular response has appeared and the QRS complexes are
now wider.
Clinical correlation and repeat tracing are suggested.
TRACING #1
Read by: [**Last Name (LF) 10516**],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
42 0 156 532/500 0 -48 151
CXR [**2186-12-24**] -
PORTABLE UPRIGHT CHEST RADIOGRAPH: The lungs are clear with
minimal left
basilar atelectasis noted. The inspiratory effort is suboptimal,
limiting
evaluation for mild CHF. Cardiomegaly persists in this patient
status post
median sternotomy and CABG. Aorta is noted to be slightly
unfolded and
ectatic. No pleural effusions or pneumothorax is identified.
There is left
basilar atelectasis.
IMPRESSION:
Cardiomegaly without overt CHF or pneumonia.
.
LENI [**2186-12-25**] - IMPRESSION: No left lower extremity DVT.
.
ECHO [**2186-12-25**] -
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated with moderate global
hypokinesis. The right ventricular cavity is dilated. Free wall
motion could not be assessed. The ascending aorta is moderately
dilated. The aortic valve leaflets are moderately thickened. No
aortic stenosis is suggested. Trace aortic regurgitation is
seen. The mitral valve leaflets and supporting structures are
moderately thickened. No mitral stenosis is seen. There is
moderate thickening of the mitral valve chordae. Moderate (2+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Left ventricular cavity
enlargement with moderate global hypokinesis c/w diffuse
process. Moderate pulmonary artery systolic hypertension.
Moderate mitral regurgitation. Right ventricular cavity
enlargement. Dilated ascending aorta.
Compared with the prior report (images unavailable for review)
of [**2182-2-8**], the severity of mitral regurgitation and the
estimated pulmonary artery systolic pressure are higher. The
left ventricle is now larger with more depressed global systolic
function.
.
ECG [**2186-12-25**] -
Probable atrial fibrillation with moderate ventricular response.
Left
axis deviation. Intraventricular conduction delay. Non-specific
ST-T wave
abnormalities. Compared to tracing #2 the ventricular response
has increased.
TRACING #3
Read by: [**Last Name (LF) 10516**],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 0 152 458/479 0 -48 129
.
ECG [**2186-12-26**] -
Atrial fibrillation. The most prominent complex has a left
anterior fascicular
block, intraventricular conduction delay patern. The two other
beats have
a less leftward axis and the Q waves in the early precordial
leads are probably
ventricular. Since the previous tracing of [**2186-12-25**] the overall
rate has
decreased and late coupled beats have appeared.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
47 0 158 510/487 0 -46 131
.
HIP [**2186-12-28**] -
FINDINGS: No prior examination. Total left hip arthroplasty is
in place.
However, the acetabular portion is vertically oriented,
indicating migration
overtime from the normal position. Extensive heterotopic new
bone is seen.
Although this may merely reflect the postoperative changes, the
possibility of
an acute fracture cannot be unequivocally excluded. Extensive
degenerative
changes seen involving the right hip and the lumbar spine.
.
Femur [**2186-12-29**]
FINDINGS: As seen on [**12-28**], the left acetabular component of the
total hip
replacement is superiorly migrated and vertically oriented with
extensive
heterotopic new bone. The femoral component is well seated and
no femur
fracture is identified. There are degenerative changes noted
about the hip
and about the knee. It should be noted that about the distal
component of the
total hip replacement in the mid shaft of the femur, there is a
thick
periosteal reaction and chronic infection cannot be totally
excluded.
Brief Hospital Course:
Patient is a 88 y/o male w/ a hx of MI s/p CABG x3, AF on
coumadin, and CHF who presents with worsening lower extremity
edema, found to have EKG concerning for critical conduction
disease.
# Atrial fibrillation with slow ventricular response: The
patient was found to be in a.fib with slow ventricular response
in the ED (HR in the 40's to 50's). He was admitted to the CCU
where he was evaluated by EP. They felt that he did not require
emergent pacemaker placement, but offered an elective placement.
The patient decided that he did not wish to have a pacemaker
placed. He continued to be in afib with a HR in the 50's during
his hospitalization. He continued to be anticoagulated with
warfarin given his afib.
# Acute on chronic systolic heart failure: The patient came
into the ED with worsening LE edema x 1 month and a markedly
elevanted BNP. His CXR was also consistent with heart failure
with vascular congestion, cephalization, and kerly-B lines. The
patient's weight was reportedly up from dry weight by 6 pounds.
He was diuresed with IV lasix and eventually switched over to po
lasix ***. He was continued on lisinopril. He had a TTE which
showed and EF of 35-40% and left ventricular cavity enlargement
with moderate global hypokinesis consistent with a diffuse
process. Moderate pulmonary artery systolic hypertension.
Moderate mitral regurgitation. Right ventricular cavity
enlargement. Dilated ascending aorta.
Compared with the prior report (images unavailable for review)
of [**2182-2-8**], the severity of mitral regurgitation and the
estimated pulmonary artery systolic pressure are higher. The
left ventricle was now larger with more depressed global
systolic function.
.
# CAD: The patient has a history of CAD, s/p MI with CABG. No
complaints of chest pain during this hospitalization. EKG with
lasteral ST depressions and slightly elevated cardiac margers.
He is not on ASA given his anticoagulation with coumain due to
his risk for bleeding. His beta blocker was held due to
bradycardia, down to 30s. Patient was asymptomatic during this
time.
.
# RHYTHM. Patient was admitted to the CCU with concerning EKG.
EKGs 20 min apart, show loss of P wave, with formation of a
broadened QrS with LBBB and irregular rate. Rhythm strip upon
arrival to floor more consistent with AF with slow ventricular
response. Patient has a history of AF, and is on
anticoagulation. It was felt that he did not require a temporary
pacing wire at this time. Patient was without symptoms from
bradycardia. Patient was continued on coumadin and his INR
ranged 2.0 - 3.1. On dat prior to discharge, INR was 2.4. INR
should be monitored on daily with goal of [**2-26**]. His INR will be
followed by Dr. [**Last Name (STitle) 578**], and values should be called in to him
([**Telephone/Fax (1) 6937**]).
.
# LE wounds. Likely from weeping LE edema. No DVT was noted on
LENI. Patient was given vanc in ED. Patient had no evidence no
fever, leukocytosis. Likely erythema from chronic venostasis
with possible superimposed infection. Patient was continued on
IV vancomycin until MRSA screen returned negative. He was then
started on Keflex 500mg Q6H. This should be continued for
another 4 days after discharge. At discharge exam was
consistent with PuE/PE: Palp DP/PT. venous stasis changes with
hyperpigmentation anterior tibial region BL. superficial skin
breaks BL LE L>R. +serosanginous drainage. No SOI. For wound
care it was indicated adaptic, kerlex, softsorb, Ace BL, waffle
boots b/l. Patient was provided with Tramadol 50mg PO BID.
.
# Left hip pain. Patient had difficulty w/ ambulation. This
pain was deemed chronic. A hip Xray was obtained which showed
migration of the acetabulum from the normal position. Extensive
heterotopic new bone was seen. This was felt Although this may
merely reflect the postoperative changes or chronic septic
arthritis. A tap was discussed to r/o chronic septic arthritis.
No femoral fracture was identified. Given that patient was
afebrile, w/o leukocytosis and performing a tap would require
reversal of his INR with a hightened risk of stroke in this
elderly gentleman, a joint tap was deferred for future
evaluation and if his symptoms were to worsen. Patient should
follow up with Dr. [**Last Name (STitle) 5322**] as an outpatient. For pain management
he was provided with Tramadol 50mg PO BID. With this regimen
patient was able to ambulate with walker and assisstance from
staff. He should have fall precautions while in rehab and
requires active rehabilitation. Mobility should be WBAT with a
walker.
.
# Urinary urgency and incontinence and BPH. This is reported to
be chronic by the patient. Patient reported having difficulty
urinating while supine. His UA showed trace proteinuria, w/
trace Leukocytes and few bacteria. Patient was asymptomatic
other than difficulty to void. He was started on Tamsulosin
with slight improvement in his symptoms and ability to void
while supine using a urinal. Tamsulosin should be continued at
rehabilitation and patient will require OP Urology evaluation.
.
# Anemia. Patient's HCT ranged between 32-27 throughout
admission. Fe was low and TIBC/Ferritin/B12/Folate were pending
at discharge. There were no signs of active bleeding. Patient
was guiac negative x1. He was asymptomatic, had no melena or
hematochezia. No record of OP colonoscopy or endoscopy were not
available. These should be followed up with PCP upon discharge.
Patient should have his HCT rechecked within 2day of discharge
from the hospital.
.
Patient was prescribed a low salt, heart healthy diet, he was
continued on coumadin and should continue with bowel regimen for
BMs at lease EOD. He was discharged to rehab in a
hemodymamically stable condition with BP of 120/52 and HR of 50,
afebrile and saturations of 94-96% on room air. Patient is
DNR/I per discussion with him.
Medications on Admission:
Warfarin 2.5mg MWF
Warfarin 2mg T,Th, S,Sun
Lasix 60mg daily
Lisinopril 10mg daily
Toprol XL 25mg daily
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day.
4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 6 days: .
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Ferrous Sulfate 324 mg (65 mg Iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY
(Daily).
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for pain.
11. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
12. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) ml PO
three times a day as needed for constipation.
13. Multivitamins Oral
14. Outpatient Lab Work
Please obtain Chem7 and PT/PTT on day of admission and EOD
thereafter. Please call in results to Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 10517**].
15. Anticoagulation
Please adjust coumadin dosing to goal INR of [**2-26**]
16. Follow up
Please arrange follow up appointments for patient while in
rehabilitation. Please call PCP on patient arrival.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
Coronary Artery disease
Bradycardia
Acute on Chronic Systolic Congestive Heart Failure
Lower Extremity Cellulitis
Atrial fibrillation on Warfarin
Discharge Condition:
stable
Discharge Instructions:
You had a slow heart rate and an episode of congestive heart
failure that was treated with diuretics and your Toprol was
held. Your leg wounds were evaluated by the wound nurse [**First Name (Titles) **] [**Last Name (Titles) 10518**]y service, you are on antibiotics and dressing changes to
treat these ulcerations. You were seen by an orthopedic doctor
who said that you should be further evaluated for chronic septic
arthritis. Per discussion with your and Dr. [**Last Name (STitle) **], it was
agreed that risk of stroke from stopping the coumadin required
for the procedure was too great. You should follow up with Dr.
[**Last Name (STitle) 5322**] from orthopedics within one week or should your symptoms
worsen.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
Cardiology:
[**Known firstname **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 6937**], please call him for an
appointment within 4weeks of discharge from the hospital.
.
Primary Care: Please call Dr.[**Name (NI) 10094**] office after you are
discharged from the hospital and the rehabilitation center,
[**Telephone/Fax (1) 10519**].
.
Please call Dr.[**Doctor Last Name **] office at [**Telephone/Fax (1) 10520**] within 2 weeks
to schedule an appointment with this Urology specialist to
follow up your BPH.
.
Please call Dr.[**Doctor Last Name 10521**] office, orhtopedics) to set up a follow
up apointment within one week of discharge from the hospital,
[**Telephone/Fax (1) 10522**].
Completed by:[**2187-1-1**]
|
[
"V43.64",
"285.9",
"788.41",
"V45.82",
"788.30",
"V45.81",
"600.01",
"414.00",
"428.23",
"272.4",
"427.31",
"428.0",
"459.81",
"715.95",
"707.19",
"426.3",
"719.45",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
18436, 18488
|
10923, 16803
|
293, 299
|
18678, 18687
|
3635, 3640
|
19556, 20294
|
2609, 2668
|
16958, 18413
|
18509, 18657
|
16829, 16935
|
18711, 19533
|
2683, 3616
|
2010, 2104
|
233, 255
|
327, 1915
|
3655, 10900
|
2135, 2414
|
1937, 1990
|
2430, 2593
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,121
| 177,081
|
34638
|
Discharge summary
|
report
|
Admission Date: [**2127-4-30**] Discharge Date: [**2127-5-30**]
Date of Birth: [**2065-12-24**] Sex: M
Service: MEDICINE
Allergies:
Ativan / Prochlorperazine
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
DLBCL, inability to keep up with transfusion requirements
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 61-year-old man with a history of diffuse large
B-cell lymphoma status post six cycles of R-CHOP between [**6-/2126**]
and [**10/2126**], status post five cycles of high-dose methotrexate
and one dose of intrathecal methotrexate, and s/p 3 cycles of
ESHAP chemotherapy and two doses of intra-thecal ARA-C. His
last cycle of ESHAP was [**Date range (1) 79455**]. Mr. [**Known lastname **] is well known
to the [**Known lastname 3242**] service, his last admission being from [**2127-2-23**] to
[**2127-4-25**] and complicated by fever and neutropenia secondary to
clostridium difficile infection (stool C. diff negative prior to
discharge), typhlitis, VRE urosepsis, upper and lower extremity
DVTs, and atrial fibrillation with rapid ventricular rate. He
was discharged to [**Hospital3 105**] and returns because of a
falling platelet count and inability to keep up with his
transfusion needs while maintaining anticoagulation with
lovenox.
Since discharge the patient reports that he has had difficulties
with episodes of dry heaves and was started on marinol the day
prior to transfer. He has also had some mild abdominal
discomfort intermittantly that improves somewhat with eating.
He has had a few episodes of diarrhea as well. He has not had
any frank fevers, however, his wife notes that his temperature
has been rising somewhat. He has had variable PO intake, at
times eating well and at times eating little to nothing at
mealtimes. The swelling in his upper and lower extremities has
decreased remarkably and he has lost nearly 30 pounds of weight.
He states he was placed on oxygen 2 days ago, but has not had
any shortness of breath. He has been working with physical
therapy at [**Hospital1 **], but is not up walking yet.
ROS: as above. In addition, he notes no upper respiratory
symptoms (runny nose, sore throat), cough, reflux, shortness of
breath, chest pain, blood per rectum, dysuria, rashes,
arthralgias.
Past Medical History:
Oncologic History:
Mr. [**Known lastname **] initially presented to an outside hospital in [**6-25**]
with a 30-pound weight loss over the prior 6 months. He was
worked up and found to have a soft tissue mass in the cardiac
ventricles involving the myocardium and extending into the
interatrial septum. He was also noted to have multiple pulmonary
nodules, bilateral pleural effusions, a pericardial effusion,
large bilateral adrenal masses, and diffuse soft tissue masses
involving both kidneys. The [**Hospital 228**] hospital course was
complicated by the development of tamponade physiology, and the
patient ultimately underwent a pericardial window. A renal
biopsy on [**2127-7-23**] confirmed diffuse large B-cell lymphoma (Stage
4B), and a pericardial biopsy on [**2127-7-25**] also was consistent with
large B-cell lymphoma. He was diffusely immunoreactive for CD20
and co-expressed Bcl-2 and Bcl-6. CD43, CD5, TdT, Bcl-1, S100
were negative. LMP for EBV was negative. CD10 and CD30 were
weekly expressed. In addition, a bone marrow biopsy demonstrated
bone marrow involvement by lymphoma. The patient was initiated
on R-CHOP on [**2126-7-26**] and received six cycles between [**7-/2126**] and
[**10/2126**] and is also status post five cycles of high-dose
methotrexate and one dose of intrathecal methotrexate.
CT abdomen on [**2-11**] showed evidence of new liver lesion
concerning for disease recurrence. CT guided liver biopsy on
[**2127-2-26**] was positive and on further evaluation was found to have
involvement in his heart, chest wall and retropharyngeal space.
He also was assumed to have it in his CSF, even though the first
LP had only one aytpical cell. He received a total of 3 cycles
of ESHAP chemotherapy and two doses of intra-thecal ARA-C. His
last cycle of ESHAP was [**Date range (1) 79455**]. No discrete hepatic
lesions were noted on CT abdomen on [**3-21**]. Flow cytometry showed
indefinite evidence of lymphomatous involvement of the CSF. He
was followed by neuro-oncology in-house who recommended no
further IT ARA-C and to follow his neurologic symptoms
clinically, and to re-refer him back to his outpatient
neuro-oncologist (Dr. [**Last Name (STitle) 79456**] if he had any worsening
confusion or neurologic symptoms. Given that he had received 3
x IT chemo and 3 cycles of high-dose Ara-C, it was felt to be
sufficient for CNS prophylaxis.
Other Medical History:
# Large B Cell lymphoma as above
# Recent C Diff Colitis
# Hx of DVTs, upper & lower extremities, on Lovenox
# Strep viridans bacteremia (1 bottle; PICC-associated? treated
w/ ceftriaxone/PCN/ceftriaxone x4 weeks total)
# Erythema nodosum, right forearm ([**8-/2126**])
# Intermittant atrial fibrillation with RVR
# Cardiogenic Syncope
# History of febrile neutropenia
# Typhlitis
# VRE Urosepsis
# Nephrolithiasis
# Anemia
# Gerd
Past Surgical History:
# Amputation of right 2nd digit after electrical accident
Social History:
Social History: (Per OMR)
The patient is married and has one son. [**Name (NI) **] is a retired
engineer. + 60 pk year history of tobacco, but quit in [**Month (only) 205**] of
[**2125**], just prior to his diagnosis of lymphoma due to symptoms of
profound weakness. Drinks socially, ~ 2 drinks per month. No
illicit drug use. One son is alive and healthy, and is also a
physician. [**Name10 (NameIs) **] has been able to accomplish basic ADLs with
minimal assistance, but is dependent on advanced ADLs.
Family History:
FHx:
Family History: (per OMR)
Father - died of [**Name (NI) **]
Mother - SLE, DM, CAD; died age 75
Brother - cardiac arrythmias
Brother - prostate CA
Son - healthy
Physical Exam:
V/S: T 99.0, BP 112/78, HR 78, RR 18, 97% on 2L NC
GEN: Thin, pale, male in NAD
HEENT: Sclera anicteric, left pupil 4 mm, right pupil 3 mm, both
pupils reactive to light. MMM, OP clear.
NECK: No lymphadenopathy, left IJ central line with dried blood
under the dressing
CHEST: Decreased BS bilaterally without wheezes, rhonchi, or
crackles.
CV: RRR, normal s1 and s2, no murmurs or extra heart sounds
appreciated
ABD: +BS, soft, non-tender, no hepatosmplenolmegaly
EXT: Warm, well perfused. 2+ edema in the left LE and 1+ edema
in the right upper extremity. 2+ DP pulse on right, not
appreciable on left secondary to edema.
SKIN: sacral ulcer, no rashes noted
NEURO: A&O x 3, decreased strength throughout. Unable to
dorsiflex ankles bilaterally. Reflexes 0-1+ bilaterally
throughout.
Pertinent Results:
Admission Labs:
[**2127-4-30**] 03:34PM BLOOD WBC-0.5*# RBC-3.04* Hgb-9.8*# Hct-27.1*
MCV-89 MCH-32.3* MCHC-36.2* RDW-16.3* Plt Ct-38*
[**2127-4-30**] 03:34PM BLOOD Neuts-24* Bands-2 Lymphs-62* Monos-8
Eos-0 Baso-2 Atyps-0 Metas-2* Myelos-0
[**2127-4-30**] 03:34PM BLOOD PT-13.4 PTT-26.7 INR(PT)-1.1
[**2127-4-30**] 03:34PM BLOOD Gran Ct-129*
[**2127-4-30**] 03:34PM BLOOD Glucose-111* UreaN-12 Creat-0.5 Na-140
K-4.8 Cl-103 HCO3-31
[**2127-4-30**] 03:34PM BLOOD ALT-9 AST-15 LD(LDH)-265* AlkPhos-82
TotBili-0.6
[**2127-4-30**] 03:34PM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.3* Mg-1.7
Microbiology:
[**2127-5-2**] 4:45 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2127-5-3**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2127-5-3**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Imaging:
[**2127-4-30**] CXR - The left internal jugular line tip is at the
cavoatrial junction. Cardiomediastinal silhouette is stable.
There is interval development of bilateral pleural effusions and
bibasal atelectasis. There is also increased opacity in the
right upper lung that is seen in addition to the known cavity
demonstrated on [**2127-3-21**] chest CT. No pneumothorax is
demonstrated. Small bilateral pleural effusions are present
that appears to be increased since the prior study.
[**2127-5-2**] RUE ultrasound - IMPRESSION:
1. Overall unchanged appearance of right upper extremity DVT
extending
through the subclavian, axillary, and brachial veins. Peripheral
flow in the subclavian and brachial veins indicates nonocclusive
thrombus in these
vessels. However, thrombus remains occlusive in the axillary
vein.
2. Occlusive thrombus in the basilic vein, not well visualized
previously,
but likely unchanged.
3. Persistent respiratory variability of the left subclavian
vein indicates the SVC remains patent, without occlusive central
propagation of right subclavian thrombus.
[**2127-5-3**] ECG - Normal sinus rhythm. Axis is minus 40 degrees.
Possible biatrial enlargement. Poor R wave progression in leads
V1-V4. Non-specific ST-T wave changes diffusely. Compared to the
previous tracing of [**2127-4-25**] there is no diagnostic interval
change. Consider left ventricular hypertrophy.
[**2127-5-4**] CXR - The left central venous line tip is at the
cavoatrial junction. Cardiomediastinal silhouette is unchanged
including left ventriculomegaly. The lung volumes are
unchanged, slightly decreased compared to more remote prior
studies. The known severe emphysema with bibasilar opacities,
pleural effusion and known right upper lung consolidation
appears to be unchanged as well. There is no evidence of
interval development of pulmonary edema.
[**2127-5-6**] CXR - FINDINGS: In comparison with the study of [**5-4**],
there is again evidence of chronic pulmonary disease with
bilateral pleural effusions and atelectatic changes at the
bases. The retrocardiac opacification is somewhat more prominent
than on the previous study. Central catheter remains in place.
[**2127-5-7**] CT Torso with contrast - IMPRESSION:
1. New moderate bilateral pleural effusions with associated
atelectasis.
There is no new consolidation within the lung parenchyma to
suggest presence of pneumonia.
2. Unchanged appearance of right upper lobe consolidation with
central
cavitation.
3. Previously identified left chest wall mass and cardiac masses
are not
visualized on the current study, consistent with continued
interval
improvement in lymphoma.
4. Resolution of wall thickening involving the cecum and
ascending colon.
5. Cholelithiasis within the gallbladder neck, but no CT
evidence of acute
cholecystitis.
6. Bilateral renal cortical thinning, most consistent with
scarring.
7. Unchanged adrenal fullness.
8. Extensive atherosclerotic disease of the distal aorta, with
unchanged
bilateral common iliac artery aneurysms and significant
intramural clot on the right.
[**2127-5-14**] ECHO - The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. 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 appears structurally normal with trivial mitral
regurgitation. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2127-4-9**], no
change.
[**2127-5-15**] CXR - IMPRESSION: Regression of previously identified
bilateral pleural effusion. Unfortunately, no lateral view has
been obtained which could identify the presence or absence of
remaining pleural effusion accumulating in the posterior sinuses
in this patient in standing position.
[**2127-5-16**] Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study
SPIROMETRY 11:03 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 4.74 4.52 105 4.36 96 -8
FEV1 3.10 3.18 98 2.76 87 -11
MMF 2.24 3.03 74 1.90 63 -15
FEV1/FVC 65 70 93 63 90 -3
LUNG VOLUMES 11:03 AM Pre drug Post drug
Actual Pred %Pred
TLC 7.24 6.88 105
FRC 4.65 3.88 120
RV 2.59 2.36 110
VC 4.83 4.52 107
IC 2.59 3.00 86
ERV 2.06 1.52 136
RV/TLC 36 34 104
He Mix Time 2.50
DLCO 11:03 AM
Actual Pred %Pred
DSB 9.31 26.50 35
VA(sb) 6.22 6.88 90
HB 9.50
DSB(HB 11.36 26.50 43
DL/VA 1.83 3.85 47
[**2127-5-18**] CT Torso with contrast - IMPRESSION:
1. Significant interval decrease of bilateral pleural effusions.
Multiple
small focal nodularities, consistent with tree-in-[**Male First Name (un) 239**]
appearance,
predominantly in the right lung but also seen in the left lung,
concerning for infectious process. Unchanged surgical sutures
and apical scar in the right lung.
2. No acute changes in the abdomen compared to the CT torso
performed 10 days ago. Unchanged left-sided common femoral/iliac
DVT. IVC filter in expected. position. Unchanged gallstones
without evidence of acute cholecystitis. Slightly prominent
pancreatic duct.
Brief Hospital Course:
Mr. [**Known lastname **] is a 61 year old male with diffuse large B cell
lymphoma, s/p multiple cycles of treatment, most recently his
third cycle of ESHAP chemotherapy with a history of upper and
lower extremity DVTs, atrial fibrillation with RVR, and recent
C. difficile colitis who was admitted with neutropenia and
thrombocytopenia and inability to keep up with his transfusion
requirements.
#. Diffuse large B cell lymphoma - The patient is s/p multiple
cycles of chemotherapy, including several cycles of intrathecal
chemotherapy that were felt sufficient for CNS prophylaxis. The
patient had a CT scan on [**2127-5-7**] that demonstrated a dramatic
remission of his formerly bulky disease. Repeat CT scan on [**5-18**]
failed to identify recurrent lymphoma. However, when the
patient developed hypercalcemia and delerium it was felt that
his Diffuse large B cell lymphoma had likely recurred. His
hypercalcemia eventually responded to pamidronate, fluids and
calcitonin. However, his delerium did not fully resolve. Given
the patient's likely disease recurrence despite multiple rounds
of chemotherapy, it was felt that the patient was unlikely to
benefit from additional chemotherapy. In discussion, with the
patient and his family, it was decided not to pursue additional
diagnostic studies such as a lumbar puncture or a bone marrow
biopsy. The patient's care was shifted towards comfort measures
and he passed aways peacefully on [**2127-5-30**] with his family at his
side.
# The patient had multiple other medical issues that required
treatment during this admission. He was neutropenic secondary
to his most recent ESHAP therapy. His is ANC nadired at 37. He
was placed on neutropenic precautions while he remained
neutropenic. The patient required multiple transfusions of
platelets during this admission. His platelet levels eventually
recovered as his neutropenia resolved. The patient had a
history of RUE DVT and was noted to have a thrombus in his right
iliac artery aneurysm. His dose of lovenox had to be lowered in
order to continue anticoagulation while the patient's platelets
were so low. During this hospitalization, he completed
treatment for his previously documented Afib and his symptoms
resolved.
#. Atrial fibrillation with RVR - The patient has a history of
intermittant afib with RVR, particularly in response to lasix.
The patient was initially kept on the metoprolol regimen that he
came from [**Hospital1 **] on. After a couple of days in the hospital
the patient had a rising oxygen requirement and was given
several small doses of lasix to remove extra fluid from his
multiple transfusions. He over went into afib with rvr in the
middle of the night and usually responded to 25-50 mg PO of
metoprolol tartrate. On [**5-10**] the patient was in afib with rvr,
assymptomatic and hemodynamically stable, for multiple hours and
did not respond to 50 mg PO metoprolol. Cardiology was
informally consulted and they recommended returning to the
patient's prior regimen of metoprolol succinate 200 mg daily and
metoprolol tartrate 50 mg Q midnight and stopping diuresis. The
patient responded very well to this regimen initially. However,
after the patient had difficulties with hypercaclemia, he became
more delerious and stopped eating and drinking. The patient
became more hypotensive despite fluid and electrolyte repletion.
Pt had sustained afib with RVR and required transfer to ICU on
[**5-26**]. He required Neo gtt to maintain his MAP >60. Digoxin
loading was attempted; however, his hr did not respond. He was
then tried on amiodarone. During this time, a family discussion
was held and it was decided to transition goals of care to
comfort. He actually converted into NSR upon transfer back to
[**Month/Day (4) 3242**] service, off neo, on [**5-28**].
.
#. Hypoxia - The patient did not require oxygen during his
previous admission, however, he was on 2L NC when trasfered from
the OSH. The patient was noted to become hypoxic, particularly
at night, requiring increased amounts of oxygen (up to 4L NC) to
keep his O2 sats greater than 90%. Chest x-rays and CT-chest
showed no evidence of infection, but did show new bilateral
pleural effusions compared to imaging from his prior admission
in addition to his previously known lung disease.
Interventional pulmonology was [**Name (NI) 653**], however, they did not
feel that the effusions were large enough to drain. Lasix was
used to try to remove some of the extra fluid and the patient's
oxygen requirement did decrease such that his O2 sats were 95%
or greater sitting up during the day, however, he continued to
require oxygen while lying in bed and sleeping. A repeat ECHO
was performed, however, it showed no change from his prior study
appoximately a month earlier. Pulmonology was consulted Repeat
x-ray showed improvement in the patient's effusions, and his
oxygen requirement resolved on its own, likely a delayed effect
of diuresis, requiring several days for fluid shifts to
transpire. The patient also underwent pulmonary function
testing due to concern for emphysema based on CT scan and prior
smoking history and need for such testing if stem cell
transplant were to be considereed. The patient was noted to
have a very low DLCO. It was felt that this was most likely
multifactorial, arising from emphysema, underlying lung disease
and scar from his prior pneumonia, and possibly chronic
thromboembolic disease given his known DVTs.
Medications on Admission:
Neutraphos 2 grams TID
Metoprolol tartrate 100 mg [**Hospital1 **]
Reglan 10 mg PO QIDACHS
Reglan 10 mg IV BID prn nausea
Protonix 40 mg daily
Acyclovir 400 mg PO Q8H
Fluconazole 200 mg PO daily
Multivitamin, 1 tab daily
Flagyl 500 mg IV Q8H
Zofran 8 mg Q6H prn nausea
Simethicone
Mylanta 80 mg, 1 tab QID prn
Marinol 5 mg Q4H prn nausea
Magnesium sulfate 1g IV Q6H
Methadone 2.5 mg TID
KCl 40 mEq TID
Lidoderm patch 5% to back 12 hours on and 12 hours off
Filgrastin 300 mcg sc daily for ANC <[**2117**]
Lovenox 60 mg Q12H (held on morning of admission)
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnoses:
1. Diffuse large B cell lymphoma s/p 3rd cycle of ESHAP
chemotherapy
2. Thrombocytopenia secondary to chemotherapy
3. Neutropenia secondary to chemotherapy
4. Hypoxia secondary to pleural effusions
5. Atrial fibrillation with rapid ventricular rate
6. Deep venous thromboses
7. C. difficile colitis
Discharge Condition:
expired
Discharge Instructions:
NONE
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2127-6-21**]
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28,558
| 187,031
|
33916
|
Discharge summary
|
report
|
Admission Date: [**2184-7-21**] Discharge Date: [**2184-7-27**]
Date of Birth: [**2117-4-25**] Sex: F
Service: NEUROSURGERY
Allergies:
Adhesive Tape
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
difficulty ambulating
Major Surgical or Invasive Procedure:
lateral extracavitary approach T4 corpectomy, fusion
History of Present Illness:
67F with h/o ovarian cancer with leg weakness found to have T4
metastatic lesion.
Past Medical History:
uterine CA
Social History:
never smoked
married
Family History:
nc
Physical Exam:
a and 0x3
perl
ht: irreg, nl S1,S2
lungs:cta
abd: soft, nt
ext no edema
neuro: motor full [**Last Name (un) 36**] intact LT
Pertinent Results:
TTE [**2184-7-26**]
ECHOCARDIOGRAPHIC MEASUREMENTS
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 2.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 5.0 cm <= 5.0 cm
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: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% >= 55%
Left Ventricle - Stroke Volume: 50 ml/beat
Left Ventricle - Cardiac Output: 3.47 L/min
Left Ventricle - Cardiac Index: 2.27 >= 2.0 L/min/M2
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: *3.9 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 16
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.80
Mitral Valve - E Wave deceleration time: 171 ms 140-250 ms
TR Gradient (+ RA = PASP): *38 to 54 mm Hg <= 25 mm Hg
FINDINGS
The patient reverted to sinus rhythm at 9:44am during the study.
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal IVC diameter (<2.1cm)
with >55% decrease during respiration (estimated RAP (0-5mmHg).
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV systolic dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV
systolic function.
AORTA: Normal aortic diameter at the sinus level. Moderately
dilated ascending aorta. No 2D or Doppler evidence of distal
arch coarctation.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. Moderate
(2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**1-21**]+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor apical views.
CONCLUSIONS
The left atrium is elongated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with hypokinesis of the basal half of the
inferior wall. The remaining segments contract normally (LVEF =
50 %). Right ventricular chamber size is normal. with borderline
normal free wall function. The ascending aorta is moderately
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Trace aortic regurgitation
is seen. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. Moderate (2+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
c/w CAD. Moderate mitral regurgitation most likely due to
papillary muscle dysfunction. Moderate pulmonary artery systolic
hypertension. Dilated ascending aorta.
Brief Hospital Course:
67 y/o F with PMHx of metastatic uterine cancer was admitted
electively and brought to OR where under general anesthesia she
underwent T4 vertebrectomy/fusion. She lost 2 liters of blood
intra-op and was kept intubated ppost op and transferred to the
ICU. She was extubated POD#1 without difficulty. She was
transferred to neuro stepdown. Her diet and activity were
advanced. She had drain placed intra-op that was removed POD#2.
Her hematocrit was followed and was low and she had
transfusions. She developed Atrial Fibrillation with RVR on
POD#3 with sBPs in 90/60s and pt was transferred to the CCU. Pt
was placed on an Amiodarone gtt for 24hrs and was converted to
Amiodarone 400mg po BID with Metoprolol for rate control. There
was no evidence of rate related ischemia and BP remained stable.
Pt spontaneously converted to sinus rhythm on [**7-25**] and did not
require any cardioversion. Thyroid function was normal,
transaminases were normal, Alkaline phosphatase was mildly
elevated which is more likely related to the bony mets. Pt will
be following up with Dr. [**Last Name (STitle) **] in Cardiology. She will need
to continue Amiodarone 400mg [**Hospital1 **] for 7 days and then decrease to
Amiodarone 200mg daily on [**8-3**]. Given her CHADs score of
1, decision was made to continue Aspirin 325mg daily to decrease
stroke risk. She then transferred back to neurosurgery. Her
incision was clean and dry. She was evaluated by PT and cleared
for dc to home with rolling walker.
Medications on Admission:
decadron
oxycodone
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: take this regimen for 7 days, completing on
[**8-2**].
Disp:*28 Tablet(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Please do not start this regimen until [**8-3**] after
completing seven days of the higher dosed regimen.
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on pain med.
Disp:*60 Capsule(s)* Refills:*0*
7. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for muscle spasm.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
T4 metastatic lesion
atrial fibrillation
anemia of blood loss
uterine cancer
Discharge Condition:
neurologically stable
Discharge Instructions:
While in the hospital, you developed an arrthymia called atrial
fibrillation. You were started on a anti-arrythmic medication
called Amiodarone and should continue taking 400mg twice daily
for one week, then decrease to 200mg daily ongoing. You will
need to have your liver function and thyroid function monitored
regularly while on this medication. We have also started you
on Metoprolol 37.5mg twice daily for blood pressure & heart rate
control. You should continue taking Aspirin 325mg daily to help
decrease your risk of stroke.
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in
follow up/ take daily showers
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for
signs of infection
?????? You are required to wear back brace whenever out of
bed.
?????? You may shower briefly back brace.
?????? Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
?????? Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
?????? Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
?????? Clearance to drive and return to work will be addressed
at your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by
pain medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
Cardiology: You have a follow up appointment with Dr. [**Last Name (STitle) **]
on [**8-31**] at 1:20pm.
PLEASE RETURN TO THE OFFICE IN 7 DAYS FOR REMOVAL OF YOUR
STAPLES/SUTURES,PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN
APPOINTMENT
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT
Completed by:[**2184-7-27**]
|
[
"198.5",
"V10.42",
"V10.43",
"733.13",
"458.29",
"285.1",
"427.31",
"336.3",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"03.53",
"81.05",
"84.51",
"84.52",
"81.04"
] |
icd9pcs
|
[
[
[]
]
] |
6382, 6388
|
3830, 5335
|
300, 354
|
6508, 6531
|
716, 3807
|
8534, 8976
|
553, 557
|
5404, 6359
|
6409, 6487
|
5361, 5381
|
6555, 8511
|
572, 697
|
239, 262
|
382, 465
|
487, 499
|
515, 537
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,851
| 128,560
|
37638
|
Discharge summary
|
report
|
Admission Date: [**2130-9-29**] Discharge Date: [**2130-10-3**]
Date of Birth: [**2049-5-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
low chest pain radiating to back
Major Surgical or Invasive Procedure:
Left thoracostomy tube insertion for evacuation of pleural
effusion
History of Present Illness:
Mr. [**Known lastname 20083**] is s/p AVR(21mm St. [**Male First Name (un) 923**] tissue)/ascending aorta
replacement/CABGx1(LIMA-LAD) on [**9-22**] who had an uneventful post
op course. He was discharged to home on [**9-26**] and had been doing
well until tonight when he experienced
severe low left sided chest pain, worse with inspiration or
movement, and a feeling like something bad was happening. He
went to an outside hospital where CXR showed large L sided
pleural effusion, a CTA showed large L effusion of mixed
density, anterior hematoma, and an aortic disection proximal to
the aortic
graft from the level of the RCA to just above the graft with no
significant pericardial effusion, no extravisation of contrast.
Past Medical History:
aortic insufficiency
coronary artery disease
ascending aortic dilatation
peripheral vascular disease
h/o deep vein thrombophlebitis
Social History:
retired electronics assembler
rare ETOH use
never smoked
Family History:
father died of stroke at 44 years old
Physical Exam:
VS: T: 98.7 HR 59 SB SBP: Sats: 93% RA
General: sitting in chair in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple
Card: RRR
Resp
GI: benign
Extr: warm no edema
Incision: sternal clean dry intact, no erythema
Neuro: non-focal
Pertinent Results:
CXR:
[**2130-9-29**] Status post cardiovascular surgery. Chest tube
placement.
Interval placement of left-sided chest tube with reduction in
size of left
pleural effusion but development of a small-to-moderate lateral
pneumothorax. The residual pleural effusion is moderate to
large in size and is associated with adjacent atelectasis
involving the lingula and left lower lobe. Unchanged widening
of cardiomediastinal contours corresponding to the presence of
mediastinal fluid on recent outside chest CT. Unchanged patchy
and linear atelectasis at right lung base.
[**2130-9-30**] Left chest tube has been removed. Left pleural effusion
has markedly decreased in size, now small. Left pneumothorax has
decreased in size, now small. Atelectasis in the lingula and
left lower lobe have also markedly improved, not completely
resolved. Cardiomediastinal contours are unchanged. The patient
has known mediastinal fluid on outside CT.
Right lower lobe atelectasis is unchanged.
[**2130-10-2**] 05:50AM BLOOD WBC-9.6 RBC-2.80* Hgb-8.7* Hct-26.1*
MCV-93 MCH-31.2 MCHC-33.5 RDW-15.4 Plt Ct-219
[**2130-9-29**] 04:42AM BLOOD WBC-10.9 RBC-3.09* Hgb-9.9* Hct-29.2*
MCV-94 MCH-31.9 MCHC-33.9 RDW-14.5 Plt Ct-183
[**2130-10-1**] 06:55AM BLOOD UreaN-22* Creat-0.8 K-4.6
[**2130-9-29**] 04:11AM BLOOD Glucose-170* UreaN-24* Creat-0.9 Na-139
K-5.0 Cl-105 HCO3-24 AnGap-15
Brief Hospital Course:
Mr. [**Known lastname 20083**] was admitted on [**2130-9-29**] for low back pain. He was
admitted to the CVICU started on esmolol drip to a goal SBP of <
110. A left chest-tube was placed which drained 1 Liter of
serosanguious fluid which was removed overnight. He had rapid
atrial fibrillion IV bolus of amiodarone and PO amiodarone was
started. His beta-blocker was continued and he converted to
sinus brady within 24 hours. He transferred to the floor on
[**2130-9-30**] hemodynamically stable. He was started on an ACE. His
hematocrit was followed closely. Electrolytes were replaced as
needed. His pain was controlled with tramadol. He continued to
do well and was discharged to home with VNA on HD #4. Pt. is to
make all follow up appts. as per discharge instructions.
Medications on Admission:
atorvastatin 10mg daily, finasteride 5mg daily, omeprazole 20mg
daily
lopressor 50 mg three times daily, tylenol prn, aspirin 81mg
daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Omeprazole 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*
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:*1*
5. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
Disp:*10 dropperette* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 days: 400 mg daily until [**10-7**], then one tab (200 mg)daily
ongoing.
Disp:*60 Tablet(s)* Refills:*1*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
AVR/CABGx1/Asc aorta replacement [**2130-9-22**]
Left lower extremity DVT
aortic insufficiency
coronary artery disease
ascending aortic dilatation
peripheral vascular disease
postop A Fib
left pleural effusion s/p left tube thoracostomy
Discharge Condition:
stable
Discharge Instructions:
Take medications as directed on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 10 weeks.
Shower daily, let water flow over wounds and pat dry with a
towel.
Do not use lotions, creams, or powders on wounds.
Call our office for temperature >101.5, sternal drainage.
Followup Instructions:
Dr. [**Last Name (STitle) 10740**] for 1-2 weeks ([**Telephone/Fax (1) 40144**]).
Dr. [**Last Name (STitle) 7047**] for 2-3 weeks.
Dr. [**Last Name (STitle) **] [**2130-10-26**] at 1:00 PM @ [**Hospital Ward Name **] 2A
CT chest to be scheduled in AM of [**10-26**] prior to visit with Dr.
[**Last Name (STitle) **]
Wound check and chest xray [**10-9**] monday - please go to clinical
center [**Location (un) 470**] to radiology for chest xray and then to [**Hospital Ward Name **] 6
for wound check
Completed by:[**2130-10-3**]
|
[
"997.1",
"512.1",
"E878.8",
"518.0",
"441.01",
"V45.81",
"V42.2",
"997.39",
"427.31",
"V12.51",
"443.9",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
5573, 5631
|
3149, 3935
|
355, 424
|
5912, 5921
|
1764, 3126
|
6271, 6802
|
1428, 1467
|
4123, 5550
|
5652, 5891
|
3961, 4100
|
5945, 6248
|
1482, 1745
|
282, 317
|
452, 1181
|
1203, 1337
|
1353, 1412
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,732
| 171,305
|
36522
|
Discharge summary
|
report
|
Admission Date: [**2158-1-21**] Discharge Date: [**2158-1-27**]
Date of Birth: [**2096-1-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
shortness of [**First Name3 (LF) 1440**]
Major Surgical or Invasive Procedure:
[**2158-1-21**] - left-sided thoracentesis ([**2145**] mL drained)
History of Present Illness:
62yo male with history of refractory biphenotypic leukemia,
disseminated fusarium [**Year (4 digits) 2**], who presents with shortness of
[**Year (4 digits) 1440**].
.
The patient was recently admitted to BMT in [**12/2157**] for febrile
neutropenia and hypoxia. He had been doing well at home until
yesterday when he developed shortness of [**Year (4 digits) 1440**] and [**Year (4 digits) **] after
receiving PRBC and platelets (with 20mg PO lasix). He developed
the [**Year (4 digits) **] on the way home and received the PO lasix at home with
no improvement in his [**Year (4 digits) **]. His wife reports "decent" urine
output after lasix administration. He also reports fever of
102.0 at home. He was recently started on home oxygen at night
but, given his shortness of [**Year (4 digits) 1440**], he used it around the clock
with mild relief of his dyspnea. Given the lack of significant
improvement in his symptoms, he came to the ED for further
evaluation.
.
In the ED inital vitals were, T- 99.0, HR- 148, BP- 103/70, RR-
28, SaO2- 94% on RA. The patient did not look well clinically
and continued to complain of shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] he was
placed on BiPAP with improvement in his symptoms. CXR revealed
interstitial edema and left-sided pleural effusion. His ED stay
was complicated with a-fib with RVR which was treated with IV
fluids and digoxin 0.5mg x1 with improvement in his HR from 140s
to 110s. Initially he was thought to be relatively hypotensive
but his baseline [**First Name3 (LF) **] pressures are in the high 90s/low 100s
systolic. His BP trended up in the ED and remained in the
110-120 range. He was covered broadly with vancomycin, cefepime
and levofloxacin in the ED. [**First Name3 (LF) **] cultures were drawn and are
pending. Labs pertinent for WBC 2.1 (10% neutrophils, 71%
blasts), plt 24, normal renal function, INR 1.7, trop < 0.01,
lactate 1.6 and d-dimer 1829. He was never hypoxic. He denies
chest pain, abdominal pain, LE edema, rash but does report
decreased urine output without dysuria. He last urinated at
10pm and has not gone since.
.
On arrival to the ICU, vital signs were T- 97.8, HR- 114, BP-
113/59, RR- 25, SaO2- 100% on 4L NC. Patient was weaned off
BiPAP and is comfortable and satting well on 4L NC. He has no
acute complaints and reports resolution of his [**First Name3 (LF) **].
Past Medical History:
Past Medical History:
PAST ONCOLOGIC HISTORY:
Biphenotypic Leukemia - Initially presented with "autoimmune
pancytopenia" treated with steroids and IVIG. In [**3-/2157**] his
cytopenias worsened and he was noted to have about 90% blasts
and he was transferred to [**Hospital1 18**]. Preliminary bone marrow biopsy
was suspicious for a biphenotypic leukemia and therapy was
initiated with hyperCVAD. His day 14 marrow showed persistent
disease and his regimen was changed to 7+3. Day 14 and two
subsequent marrows all continued to show persistent involvement
with leukemia. Further chemotherapy was held as he was found to
have disseminated fusarium [**Hospital1 2**] in the setting of prolonged
neutropenia. He was ultimately discharged on GM-CSF and daily
Ambisome infusions. He was admitted to the [**Hospital Unit Name 153**] on [**2157-7-27**] for
neutropenic fever and abdominal pain of unknown etiology. While
hospitalized he was treated with a 10-day course of decitabine
without complications. He underwent MEC reinduction ([**9-25**]), C2
decitabine x10d (D1 [**11-1**]) and on 3rd cycle decitabine Day 22
[**12-21**] (D1 [**11-29**])
.
Of note he had a complicated admission from ([**Date range (1) 82692**]) with
cardiac tamponade s/p pericardiocentesis, pleural effusions s/p
thoracentesis for 2.1L [**10-29**]. [**10-19**] marrow with persistent blasts
accoutning for 80% or marrow cellularity. [**11-4**] repeat TTE w/o
pericardial effusion, EF 45-50. He was eventually d/c'ed home on
[**2157-11-11**] on linezolid to treat VRE. His cardiologist is Dr.
[**Last Name (STitle) **].
.
OTHER PMH:
Disseminated Fusarium ([**5-15**]):treated with Ambisome and
Voriconazole
H/O Hepatitis B (on Lamivudine)
S/P appendectomy
S/P umbilical hernia repair
Atrial fibrillation
Social History:
Currently on disability. Wife is a retired physician. [**Name10 (NameIs) **]
from [**Country 5976**]. Nonsmoker, no EtOH, no IVDU.
Family History:
One brother died of ALL. Denies DM, CAD, strokes, other CAs.
Physical Exam:
ADMISSION EXAM:
.
Vitals: T- 97.8, HR- 114, BP- 113/59, RR- 25, SaO2- 100% on 4L
NC
General: Alert, oriented, no acute distress
[**Country 4459**]: Sclera anicteric, MMM, oropharynx clear, NC in place
Neck: supple, JVP 10cm, no LAD
Lungs: Decreased [**Country 1440**] sounds at the bases with scattered
bilateral crackles, good respiratory effort, no wheezes.
CV: Increased rate, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISHCARGE EXAM:
.
Vitals: 99.3/96.7 94/56 103 18 94%RA
General: Alert, oriented, no acute distress
[**Country 4459**]: Sclera anicteric, MMM, oropharynx clear, NC in place
Neck: supple, no JVD, no LAD
Lungs: Decreased [**Country 1440**] sounds at the bases with scattered
bilateral crackles, good respiratory effort, no wheezes.
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
.
[**2158-1-20**] 11:25PM [**Year/Month/Day 3143**] WBC-2.1*# RBC-3.87* Hgb-11.1* Hct-29.7*
MCV-77* MCH-28.8 MCHC-37.5* RDW-13.7 Plt Ct-24*
[**2158-1-20**] 11:25PM [**Year/Month/Day 3143**] Neuts-10* Bands-0 Lymphs-15* Monos-2
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 Blasts-71*
[**2158-1-20**] 11:25PM [**Year/Month/Day 3143**] PT-17.6* PTT-40.5* INR(PT)-1.7*
[**2158-1-20**] 11:25PM [**Year/Month/Day 3143**] Glucose-154* UreaN-22* Creat-0.8 Na-133
K-4.7 Cl-99 HCO3-23 AnGap-16
[**2158-1-20**] 11:25PM [**Year/Month/Day 3143**] CK(CPK)-10*
[**2158-1-20**] 11:25PM [**Year/Month/Day 3143**] CK-MB-1 proBNP-2859*
[**2158-1-20**] 11:25PM [**Year/Month/Day 3143**] cTropnT-<0.01
[**2158-1-21**] 05:37AM [**Year/Month/Day 3143**] CK-MB-1 cTropnT-<0.01
[**2158-1-21**] 05:37AM [**Year/Month/Day 3143**] Albumin-3.0* Calcium-7.7* Phos-4.2
Mg-1.5*
[**2158-1-20**] 11:38PM [**Year/Month/Day 3143**] Lactate-1.6
[**2158-1-20**] 11:38PM [**Year/Month/Day 3143**] Type-[**Last Name (un) **] O2 Flow-2 pO2-112* pCO2-39
pH-7.39 calTCO2-24 Base XS-0 Intubat-NOT INTUBA
.
DISCHARGE LABS:
[**2158-1-27**] 12:00AM [**Year/Month/Day 3143**] WBC-0.6* RBC-3.03* Hgb-9.0* Hct-24.1*
MCV-80* MCH-29.7 MCHC-37.4* RDW-13.4 Plt Ct-16*
[**2158-1-27**] 12:00AM [**Year/Month/Day 3143**] Neuts-6* Bands-0 Lymphs-17* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-76*
[**2158-1-27**] 12:00AM [**Year/Month/Day 3143**] PT-14.7* PTT-33.3 INR(PT)-1.4*
[**2158-1-27**] 12:00AM [**Year/Month/Day 3143**] Glucose-91 UreaN-15 Creat-0.6 Na-136
K-4.1 Cl-103 HCO3-27 AnGap-10
[**2158-1-27**] 12:00AM [**Year/Month/Day 3143**] ALT-12 AST-16 LD(LDH)-126 AlkPhos-105
TotBili-0.3
[**2158-1-27**] 12:00AM [**Year/Month/Day 3143**] Calcium-8.1* Phos-3.5 Mg-2.1
[**2158-1-26**] 12:00AM [**Year/Month/Day 3143**] IgG-612*
.
MICROBIOLOGIC DATA:
[**2158-1-21**] [**Month/Day/Year **] culture (x 2) - pending
[**2158-1-21**] MRSA screen - pending
[**2158-1-21**] Urine culture - no growth
[**2158-1-21**] Urine legionella antigen - pending
[**2158-1-21**] Pleural fluid - 2 strains of VSE
.
IMAGING STUDIES:
[**2158-1-21**] 2D-ECHO - The left ventricular cavity size is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. Mild (1+)
mitral regurgitation is seen. There is a very small pericardial
effusion. The effusion is echo dense, consistent with [**Month/Day/Year **],
inflammation or other cellular elements. The echo findings are
suggestive but not diagnostic of pericardial constriction.
Limited study. Normal biventricular systolic function with
septal shutter suggestive of constriction. Mild mitral
regurgitation. Left pleural effusion. Compared with the findings
of the prior study (images reviewed) of [**2157-12-22**], the patient is
now in atrial fibrillation with a rapid ventricular response.
The rest of the findings are similar.
.
[**2158-1-21**] CHEST (PORTABLE AP) - Decreased left lower lobe opacity
is consistent with decreased atelectasis and pleural effusion.
Right pleural effusion with adjacent atelectasis is unchanged.
Cardiomegaly and widened mediastinum are stable. Right PICC tip
is in the mid-to-lower SVC. Mild-to-moderate vascular congestion
is stable.
.
[**2158-1-22**] CT CHEST W/O CONTRAST - Stable bilateral non-hemorrhagic
pleural effusions with significantly increased left lobar
collapse and increased surrounding ground-glass opacities
representing microatelectasis versus superimposed infectious
process. Small stable pericardial effusion. Likely anemia.
Stable minimal non-pathologic mid thoracic vertebral compression
fracture without associated retropulsion.
Brief Hospital Course:
IMPRESSION: 62M with extensive medical history who presents with
shortness of [**Month/Day/Year 1440**].
.
# DYSPNEA - dyspnea is likely multifactorial. The patient has
known pleural effusions with recent [**Month/Day/Year **] transfusion. Symptoms
developed after transfusion making fluid overload a definite
possibility. In addition, in an immunocompromised patient
presenting with fevers and [**Last Name (LF) **], [**First Name3 (LF) **] acute infectious etiology
must be high on the differential. However CT Chest revealed more
chronic inflammatory changes as opposed to active infectious
changes. It did show pleural effusions and patient had 2 L
removed. Pleural fluid + for VSE, which patient has had in the
past. Fluid was exudative appearing and was not c/w empyema.
Patient was initially covered on broad spec abx and was narrowed
to vancomycin (he was also cont' on home ppx). Sputum, [**First Name3 (LF) **]
cultures negative. Given patient's h/o of VRE bacteremia,
immunosuppression and longstanding VSE in pl fluid, will treat
with vancomycin x 6wks, the course given to patients for
empyema/abscess. Patient was sent home with close follow up with
750mg IV vanc [**Hospital1 **], and a vanc trough is due at the next visit
with dose titrations as needed.
Patient also presented with afib with RVR and HR was stabilized
with home medications over the course of his stay. ECHO did not
show any concern structural abn, very small stable pericadial
effusion. This would have definitely contributed to his
presentation. Patient responded to the treatment above and was
satting on RA ~72 hours prior to discharge.
WRT to patient's longstanding and frequent reaccumulation of
pleural fluid, a discussion with the IP team led to conclusion
that patient is not candidate for pleurex given neutropenia and
frequent infections, including possible pna currently. Also not
candidate for pleuridesis given h/o constrictive pericarditis
and thrombocytopenia. Will need serial thoracentesis for comfort
prn SOB. Given that patient has had many of these in the past,
these should be done judiciously as each successive [**Female First Name (un) 576**] may
introduce new pathogens and possibly pna/infections. Patient has
appt on [**2158-1-26**] for [**Female First Name (un) 576**] and patient should keep appt should he
be discharged prior so that everything can be explained to
patient and a plan be made. Should patient have worsening SOB,
he should call IP at [**Telephone/Fax (1) 7769**] and make an urgent appointment
for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 576**]. This was communicated to the patient and wife.
.
# ANEMIA, DECREASED HEMATOCRIT - His cell counts have been
decreased in the setting of his underlying malignancy, but
following his thoracentesis there was a 6 point drop in his
hematocrit without CT chest evidence of hemothorax. He was
closely monitored and received 1 unit of packed red cells for
that hematocrit, with overall improvement. His hemolysis labs
were reassuring. Patient did not have any BM to guaiac and
rectal exam was not done given his neutropenia. His
post-transfusion hematocrit was stable.
At baseline, patient requires frequent transfusions and was
subsequently transfused a couple of more times on the BMT
service. Patient tolerated transfusions and was given lasix 20IV
post to avoid positive fluid balance.
.
# ATRIAL FIBRILLATION - Patient has a history of going into RVR
to 140s, doing well since IV fluid resuscitation in the ED.
Digoxin level was within normal limites this admission and we
continued this medication. Patient was restarted on home metop
and dilt slowly given low SBP and concern for [**Last Name (NamePattern4) 2**],
eventually titrated back to home medications with HR in the
80-100 range and SBP in the 90-100 range.
.
# HISTORY OF NEUTROPENIC FEVER - Patient presented with a
temperature of 102.0 at home for which he took Tylenol. He has
remained afebrile since admission, still and was antibiosed
since admission with broad-spectrum antibiotics. No other
obvious infectious source have been noted other than his
pneumonia. We also continued his Bactrim, Acyclovir prophylaxis
with Voriconazole given his history of disseminated Fusarium
[**Last Name (NamePattern4) 2**]. [**Last Name (NamePattern4) **], urine and sputum cultures were unrevealing.
.
# REFRACTORY BIPHENOTYPIC LEUKEMIA - Patient is currently s/p
cycle two of Dacogen, althought he never had improvement in his
cell counts. He receives packed red [**Last Name (NamePattern4) **] cells and platelet
transfusions as an outpatient, his last being on [**2158-1-19**]. He is
followed closely by Dr. [**Last Name (STitle) **] from Oncology and his cycle 3 for
chemotherapy has been on hold this admission.
.
# HBV [**Last Name (STitle) **] - Previous core antibody positivity. He was
continued on his home Lamivudine medication.
.
# Hyponatremia - Patient developed hyponatremia to 128, urine
lytes obtained and more consistent with hypovolemia with Na <10.
TRANSITION OF CARE ISSUES:
1. f/u with Dr. [**Last Name (STitle) **] in clinic on Sunday, [**1-29**] - will monitor
counts and transfuse as needed. Also will f/u on vanc trough and
adjust dose appropriately.
2. f/u with ID per Dr. [**Last Name (STitle) **]/Dr. [**Last Name (STitle) 724**]. Patient has long h/o
both and two attendings will be in communication about patient's
progress and outpatient f/u's.
Medications on Admission:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
2. Diltzac ER 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
4. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation every four (4) hours as needed for shortness of
[**Last Name (STitle) 1440**] or wheezing.
8. lamivudine 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every
12 hours).
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for anxiety or insomnia.
12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
13. Home O2- Home Oxygen 2L via nasal cannula, with ambulation
only, pulse dose for portability (for ambulatory sats 86% on RA,
95% on 2L)
RA sat at rest 92% dx: cardiomyopathy with pleural effusions
Discharge Medications:
1. vancomycin 750 mg Recon Soln Sig: One (1) injection
Intravenous twice a day for 5 weeks.
Disp:*70 injection* Refills:*0*
2. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
3. Diltzac ER 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation every four (4) hours as needed for wheezing,
shortness of [**Last Name (STitle) 1440**].
9. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. voriconazole 200 mg Tablet Sig: 1.5 Tablets PO Q12H (every
12 hours).
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every [**2-24**]
hours as needed for insomnia.
12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
Disp:*qs Capsule(s)* Refills:*0*
14. Home O2
Home Oxygen 2L via nasal cannula, with ambulation only, pulse
dose for portability (for ambulatory sats 86% on RA, 95% on 2L)
RA sat at rest 92% dx: cardiomyopathy with pleural effusions
15. Outpatient Lab Work
Vancomycin trough at next outpatient visit ([**2158-1-29**])
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
afib with RVR
pleural effusion/empyema
secondary:
refractory biphenotypic leukemia, Hep B
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1005**],
You were admitted for [**Known lastname **], fever, and shortness of [**Known lastname 1440**]. You
were found to have pleural effusions as well as atrial
fibrillation. Your heart medications have been titrated. The
fluid from your lungs were removed and it was found that
Entercoccus, vancomycin sensitive, was present. You will be on
Vancomycin for another 5 weeks, for a total of 6 wks of therapy
(started [**2158-1-21**]).
The following changes have been made to your medications:
STOP levofloxacin
START vancomycin, to be continued for another 5 weeks
START colace as needed for constipation.
You have several follow up appointments with your oncologist as
well as infectious disease specialist.
Followup Instructions:
You have the following appointments:
You are being followed by the infectious disease doctors as [**Name5 (PTitle) **]
and they will get in touch with you when they make an
appointment for you, should they feel that they need to see you.
Department: BMT/ONCOLOGY UNIT
When: SUNDAY [**2158-1-29**] at 8:30 AM [**Telephone/Fax (1) 447**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2158-1-31**] at 12:00 PM
With: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: BMT CHAIRS & ROOMS
When: TUESDAY [**2158-1-31**] at 12:00 PM
|
[
"789.59",
"427.31",
"276.61",
"070.30",
"288.00",
"780.61",
"511.9",
"423.2",
"276.1",
"118",
"041.04",
"205.00",
"286.7",
"284.19",
"510.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
18161, 18213
|
9860, 15287
|
345, 413
|
18348, 18348
|
6122, 6122
|
19263, 20119
|
4806, 4868
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265, 307
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441, 2842
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6138, 7194
|
18363, 18475
|
2886, 4642
|
4658, 4790
|
8201, 9837
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,792
| 139,877
|
21462
|
Discharge summary
|
report
|
Admission Date: [**2115-10-23**] Discharge Date: [**2115-10-28**]
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
woman recently discharged from [**Hospital1 188**] after sustaining subdural and subarachnoid secondary
to fall from a wheel chair, which was managed non-operatively
as per the family wishes. She was discharged in stable
condition to home, but at home was noted to have increasing
lethargy and some decreased movement, as well as increased
somnolence over the 2 days prior to admission. She was seen
at an outside hospital, underwent an MRI, which showed a
worsening subdural hematoma and she was transferred to this
facility for further management.
PAST MEDICAL HISTORY: Remarkable for hypertension; a left
stroke in [**2113**], seizure history, diabetes, dementia, and
right subdural hematoma.
PAST SURGICAL HISTORY: Remarkable for placement of a PEG.
MEDICATIONS ON ADMISSION:
1. Dilantin.
2. Lansoprazole.
3. Lopressor.
4. Norvasc.
5. Colace.
6. Iron.
7. Lisinopril.
8. Sliding scale insulin.
ALLERGIES: She has no known drug allergies.
PHYSICAL EXAMINATION: Temperature was 97.9 degrees, heart
rate was 67, blood pressure was 137/56, respiratory rate was
10, O2 saturation was 97 percent on room air. She was in no
apparent distress, responsive to stimuli. Pupils were 3 mm
bilaterally. Carotids were 2 plus without bruits. Lungs
were clear to auscultation bilaterally except for a decreased
breath sounds at the bases. Heart showed regular rate and
rhythm. Abdomen was soft, minimally distended, bowel sounds
positive. Extremities showed no clubbing, cyanosis or edema.
They were warm.
HOSPITAL COURSE: The patient was admitted to the hospital
for frequent neurological assessment. She was brought to the
operating room where she underwent a right frontal and
parietal burr hole and craniotomy with the evacuation of
subdural hematoma as well as placement of subdural drain.
She tolerated this procedure well and was transferred to the
intensive care unit for a close monitoring postoperatively.
On the first postoperative day, the patient was found to have
split T-wave on monitor. She was intubated at that time and
unable to complain of pain. She was given some doses of
Lopressor and a nitro drip was started. A cardiology consult
was obtained who felt that this was most likely an old
arrhythmia and consistent with a left bundle-branch block
with conduction delay. She was monitored with cardiac
enzymes and she did rule out times 3 for an MI. Her
neurological status improved postoperatively. She was
extubated and tolerated this well. She was awake and alert.
She withdrew to pain and moved all 4 extremities. She did
have her baseline hemiparesis. Her subdural drain had
minimal output and was discontinued on [**2115-10-25**]. She had a
postoperative CT after the drain removal and she did well.
She was transferred to the neuro step down unit. She was
seen by both Occupational Therapy and Physical Therapy and
did well.
DISPOSITION: She was discharged to home today [**2115-10-28**].
FOLLOW UP: She is scheduled to followup with Dr. [**First Name (STitle) **] in 7 to
10 days with a repeat CT.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2115-10-28**] 17:59:46
T: [**2115-10-29**] 05:12:11
Job#: [**Job Number 56656**]
|
[
"852.20",
"426.3",
"E884.3",
"780.39",
"250.00",
"294.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"01.39",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
937, 1102
|
1680, 3088
|
875, 911
|
3100, 3465
|
1125, 1662
|
120, 703
|
726, 851
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,900
| 102,643
|
16713+56800
|
Discharge summary
|
report+addendum
|
Admission Date: [**2153-1-4**] Discharge Date: [**2153-1-18**]
Date of Birth: [**2079-1-15**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Lower extremity ischemia
Major Surgical or Invasive Procedure:
Right below knee amputation [**2153-1-11**]
History of Present Illness:
This is a 74 year old female with multiple medical problems
including peripheral vascular disease status-post a bilateral
femoral to dorsalis pedis bypasses with vein graft in '[**50**] who
now presents with right [**Doctor Last Name **] extremity pain 48 hours after
having a hemodialysis catheter inadvertanly placed in her right
femoral artery on [**2152-12-20**]. She says that the pain started 48
hours ago and was accompanied by discoloration of her right
foot. History at time of admission was limited because patient
was a poor historian.
Past Medical History:
1.CHF: last exacerbation two months ago
2.Aortic stenosis: s/p AVR c St. Jude's valve->coumadin, goal
INR=2.5-3.5
3.Type 2 DM x 10 years; with neuropathy
4.CRI: Cr~1.2 [**1-/2151**]; Cr~2.0 since [**2152-5-25**]
5.COPD
6.Morbid obesity
7.Severe post-op delerium [**12/2150**]
8.Post-op respiratory failure requiring re-intubation [**12/2150**]
9.Unclear psychiatric history-on risperdal, stelazine
10. Bilateral femoral to DP bypass with vein graft '[**50**]
11 Vein patch angioplasty of left femoral-DP vein graft [**2152-7-13**].
12. Osteomyelitis
13. Schizophrenia
Social History:
Pt is a widow who currently lives with a daughter. She quit
smoking cigarettesafter a 10 pack year history. She does not
drink alcohol. She uses a walker to ambulate. She has home
physical therapy.
Family History:
Noncontributory.
Physical Exam:
ON admission
Neuro: alert, awake, no acute distress
CV: irreg irreg rhythm, 2/6 SEM
Pulm: clear to auscultation bilaterally, pt c some increased
work of breathing
Abd: soft, non-tender, non-distended, normoactive bowel sounds
Extr: right lower extremity mottled and mildly tender to touch,
slightly cooler than left
Pulses: RIGHT: 1+ femoral, 1+ popliteal, palpable graft,
negative DP and PT; LEFT: 1+ femoral, 1+ popliteal, palpable
graft, 1+ DP, monophasic PT
Pertinent Results:
SEROLOGIES:
[**2153-1-4**] 07:40PM BLOOD WBC-6.1 RBC-3.69* Hgb-10.5* Hct-32.9*
MCV-89 MCH-28.4 MCHC-31.8 RDW-16.4* Plt Ct-125*
[**2153-1-5**] 05:00AM BLOOD WBC-6.4 RBC-3.69* Hgb-10.8* Hct-34.0*
MCV-92 MCH-29.4 MCHC-31.9 RDW-16.5* Plt Ct-134*
[**2153-1-6**] 07:13AM BLOOD WBC-5.8 RBC-3.77* Hgb-11.1* Hct-35.4*
MCV-94 MCH-29.4 MCHC-31.3 RDW-16.3* Plt Ct-144*
[**2153-1-7**] 02:10AM BLOOD WBC-5.3 RBC-3.45* Hgb-10.0* Hct-31.4*
MCV-91 MCH-28.9 MCHC-31.8 RDW-16.3* Plt Ct-137*
[**2153-1-8**] 04:24AM BLOOD WBC-5.6 RBC-3.46* Hgb-9.9* Hct-31.1*
MCV-90 MCH-28.5 MCHC-31.7 RDW-16.6* Plt Ct-157
[**2153-1-8**] 06:59PM BLOOD WBC-6.4 RBC-3.49* Hgb-10.1* Hct-31.8*
MCV-91 MCH-28.8 MCHC-31.6 RDW-16.5* Plt Ct-159
[**2153-1-9**] 02:05AM BLOOD WBC-5.8 RBC-3.46* Hgb-9.8* Hct-31.9*
MCV-92 MCH-28.4 MCHC-30.9* RDW-16.7* Plt Ct-161
[**2153-1-10**] 03:01AM BLOOD WBC-5.8 RBC-3.37* Hgb-10.1* Hct-31.8*
MCV-94 MCH-29.8 MCHC-31.6 RDW-16.4* Plt Ct-157
[**2153-1-10**] 02:28PM BLOOD WBC-5.2 RBC-3.55* Hgb-10.1* Hct-32.8*
MCV-92 MCH-28.5 MCHC-30.8* RDW-16.2* Plt Ct-175
[**2153-1-11**] 03:56AM BLOOD WBC-5.8 RBC-3.41* Hgb-9.8* Hct-31.6*
MCV-93 MCH-28.7 MCHC-31.0 RDW-16.2* Plt Ct-178
[**2153-1-12**] 01:11AM BLOOD WBC-5.4 RBC-3.21* Hgb-9.2* Hct-29.1*
MCV-91 MCH-28.6 MCHC-31.6 RDW-16.3* Plt Ct-167
[**2153-1-13**] 04:52AM BLOOD WBC-5.7 RBC-3.11* Hgb-8.8* Hct-28.6*
MCV-92 MCH-28.4 MCHC-30.8* RDW-16.2* Plt Ct-188
[**2153-1-14**] 05:45AM BLOOD WBC-6.8 RBC-3.16* Hgb-8.9* Hct-28.7*
MCV-91 MCH-28.3 MCHC-31.1 RDW-16.2* Plt Ct-200
[**2153-1-4**] 07:40PM BLOOD PT-15.6* PTT-29.8 INR(PT)-1.5
[**2153-1-5**] 05:00AM BLOOD PT-14.2* PTT-82.2* INR(PT)-1.3
[**2153-1-6**] 07:13AM BLOOD PT-14.9* PTT-29.5 INR(PT)-1.4
[**2153-1-7**] 02:10AM BLOOD PT-17.7* PTT-78.8* INR(PT)-2.0
[**2153-1-7**] 10:18AM BLOOD PT-18.3* PTT-86.6* INR(PT)-2.1
[**2153-1-7**] 08:09PM BLOOD PT-21.3* PTT->150* INR(PT)-2.9
[**2153-1-8**] 04:24AM BLOOD PT-18.4* PTT-69.1* INR(PT)-2.1
[**2153-1-8**] 10:50AM BLOOD PT-18.3* PTT-64.4* INR(PT)-2.1
[**2153-1-8**] 06:24PM BLOOD PT-22.3* PTT-150 IS HIG INR(PT)-3.1
[**2153-1-9**] 02:05AM BLOOD PT-18.3* PTT-42.4* INR(PT)-2.1
[**2153-1-9**] 04:20AM BLOOD PT-18.4* PTT-47.2* INR(PT)-2.1
[**2153-1-9**] 08:19PM BLOOD PT-19.0* PTT-62.1* INR(PT)-2.3
[**2153-1-10**] 03:01AM BLOOD PT-20.3* PTT-69.8* INR(PT)-2.6
[**2153-1-10**] 12:25PM BLOOD PT-21.4* PTT-76.3* INR(PT)-2.9
[**2153-1-10**] 02:28PM BLOOD PT-22.3* PTT-57.3* INR(PT)-3.1
[**2153-1-11**] 03:56AM BLOOD PT-21.6* PTT-90.9* INR(PT)-2.9
[**2153-1-12**] 01:11AM BLOOD PT-17.5* PTT-67.4* INR(PT)-1.9
[**2153-1-13**] 04:52AM BLOOD PT-17.9* PTT-71.3* INR(PT)-2.0
[**2153-1-14**] 05:45AM BLOOD PT-19.8* PTT-34.4 INR(PT)-2.5
[**2153-1-4**] 07:40PM BLOOD Glucose-177* UreaN-87* Creat-2.2* Na-144
K-5.1 Cl-103 HCO3-34* AnGap-12
[**2153-1-5**] 05:00AM BLOOD Glucose-53* UreaN-87* Creat-2.3* Na-144
K-4.7 Cl-103 HCO3-35* AnGap-11
[**2153-1-6**] 07:13AM BLOOD Glucose-185* UreaN-98* Creat-2.6* Na-143
K-5.2* Cl-102 HCO3-35* AnGap-11
[**2153-1-7**] 02:10AM BLOOD Glucose-123* UreaN-109* Creat-3.2* Na-143
K-5.9* Cl-102 HCO3-32* AnGap-15
[**2153-1-8**] 04:24AM BLOOD Glucose-167* UreaN-110* Creat-3.3*
Na-148* K-5.0 Cl-110* HCO3-33* AnGap-10
[**2153-1-8**] 06:59PM BLOOD Glucose-185* UreaN-52* Creat-2.0*#
Na-148* K-4.4 Cl-113* HCO3-26 AnGap-13
[**2153-1-9**] 02:05AM BLOOD Glucose-108* UreaN-58* Creat-2.1* Na-148*
K-4.4 Cl-113* HCO3-32* AnGap-7*
[**2153-1-10**] 03:01AM BLOOD UreaN-70* Creat-2.3* Na-142 K-4.8 Cl-108
HCO3-30* AnGap-9
[**2153-1-11**] 03:56AM BLOOD Glucose-195* UreaN-79* Creat-2.6* Na-143
K-5.5* Cl-106 HCO3-33* AnGap-10
[**2153-1-12**] 01:11AM BLOOD Glucose-91 UreaN-56* Creat-2.0* Na-140
K-5.0 Cl-106 HCO3-31* AnGap-8
[**2153-1-13**] 04:52AM BLOOD Glucose-144* UreaN-65* Creat-2.2* Na-142
K-4.9 Cl-105 HCO3-35* AnGap-7*
[**2153-1-14**] 05:45AM BLOOD Glucose-107* UreaN-71* Creat-2.2* Na-142
K-5.2* Cl-105 HCO3-33* AnGap-9
[**2153-1-6**] 04:57PM BLOOD CK(CPK)-52
[**2153-1-7**] 02:10AM BLOOD CK(CPK)-47
[**2153-1-6**] 04:57PM BLOOD CK-MB-NotDone cTropnT-0.36*
[**2153-1-7**] 02:10AM BLOOD CK-MB-6 cTropnT-0.31*
[**2153-1-9**] 02:05AM BLOOD cTropnT-0.53*
[**2153-1-4**] 07:40PM BLOOD Calcium-7.7* Phos-4.5 Mg-2.6
[**2153-1-8**] 06:59PM BLOOD Calcium-8.3* Phos-4.6* Mg-2.2
[**2153-1-10**] 02:28PM BLOOD Calcium-7.8* Phos-4.2 Mg-2.4
[**2153-1-13**] 04:52AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.4
[**2153-1-14**] 05:45AM BLOOD Calcium-7.7* Phos-3.9 Mg-2.5
RADIOLOGY
[**2153-1-5**] Angiogram: 1) Nonvisualization suggesting complete
occlusion of the right femoral to dorsalis pedis artery bypass
graft. 2) Markedly diseased right superficial femoral artery
with a long mid and distal segment occlusion, which
reconstitutes distally through the profunda collaterals to the
popliteal artery.
3) Complete occlusion of the right posterior tibial and
anterior tibial arteries. Single-vessel runoff through a small
and diseased peroneal artery.
4) Occlusion of most of the dorsalis pedis artery, starting just
distal to its proximal portion. No visualization of plantar
arteries or the posterior tibial artery is seen within the
right foot.
[**2153-1-6**] CXR: Left effusion. Left lower lobe infiltrate not
excluded.
[**2153-1-6**] CT Head: No acute intracranial hemorrhage or mass effect.
If there is clinical concern for acute stroke, MRI with
diffusion weighted imaging is recommended.
[**2153-1-10**] pMIBI: 1) Normal myocardial perfusion. : No angina with
no significant ECG changes over baseline. 2) Normal left
ventricular cavity size. Calculated ejection fraction of 49%,
however upon visual inspection, the left ventricular function is
likely within normal limits.
[**2153-1-11**] CXR: Proximally positioned right internal jugular
catheter. Left basilar opacity consistent with atelectasis,
consolidation and/or effusion.
MICROBIOLOGY:
[**2153-1-7**] Sputum Cx: SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA}
Sensitive to Levoquin
Brief Hospital Course:
This is a 73 year old female with peripheral vascular disease
status-post bilateral femoral to DP bypasses in '[**50**] who was
admitted on [**2153-1-4**] with ischemia of her right lower extremity.
She was started on anticoagulation on admission and underwent an
angiogram on [**2153-1-5**] which demonstrated near complete occlusion
of the right femoral to DP bypass graft. She was planned for
operative below-knee amputation, but had a pre-operative course
complicated by hypercapnic respiratory failure requiring
extubation on [**2153-1-7**] and a 2-day stay in the intensive care
unit. She was extubated on [**2153-1-8**] without complication and chest
x-ray and sputum culture revealed that she had had pneumonia
which was exacerbating her baseline COPD; she was started on
levoquin for this pneumonia and had no further respiratory
exacerbations in the remainder of her hospital course. She was
taken to the operating room on [**2153-1-11**] where a below knee
amputation was done. Post-operatively she did well, with good
pain control. She was transferred out of the vascular intensive
care unit on post-operative day 2 in stable condition and her
diet was advanced to a regular diet. Anticoagulation was resumed
for her heart valve and she was found to be therapeutic by
post-operative day 3 with INR of 2.5. [**Last Name (un) **] Diabetes was
consulted for management of blood sugars. Physical therapy
worked with her and deemed her to be not safe for home, so
rehabilitation services were sought. The patient was discharged
to rehab with planned follow-up with vascular surgery within [**12-3**]
weeks. All questions were answered to her satisfaction upon
discharge.
Medications on Admission:
Fortaz 1 mg po qd
Protonix 40 mg PO qd
Lasix 120 mg PO BID
Lantus insulin 60 units qd
risperdal 0.5 mg PO QD
Stelazine 1 mg Po QD
Amiodarone 200 mg PO QD
Lipitor 10 mg PO QD
Predniosone 30 mg PO QD
Colace 100 mg PO BID
Cardizem 300 mg PO QID
Flagyl 500 mg PO QID
Coumadin 7.5 mg po QD
KCl 20 mg PO BID
Aluminum Hydroxide 15 mg PO QID
Aranesp 60 qwk
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed.
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Goal INR 2.5 to 3.5 for artificial heart valve.
10. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days: 2-week course started on [**1-6**].
12. Trifluoperazine HCl 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
14. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: 5-10 MLs
PO Q8H (every 8 hours) as needed.
15. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: Two (2)
units Subcutaneous four times a day: per sliding scale, with
goal sugars 80-120.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
(1) left lower extremity ischemia
(2) Pneumonia, St. [**Male First Name (un) 1525**] heart valve, s/p CABG, COPD, chronic
renal insufficiency
Discharge Condition:
Fair
Discharge Instructions:
Please contact the office or come to the emergency room with any
worsening pain at your incision not improved with narcotics,
worsening drainage or redness at the incision, or any questions.
Take all medications as prescribed.
Followup Instructions:
Please contact the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] to set-up a
follow-up appointment within 1-2 weeks. [**Telephone/Fax (1) 1393**]
Completed by:[**2153-1-15**] Name: [**Known lastname 8754**],[**Known firstname 1911**] Unit No: [**Numeric Identifier 8755**]
Admission Date: [**2153-1-4**] Discharge Date: [**2153-1-18**]
Date of Birth: [**2079-1-15**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
patient discharged defered until appropiate bed facility could
be found and acute renal failure secondary to contrast.Renal
consulted.Patient required hemodialysis x1 for hyperkalemia of
5.5 and volume over load. With recovery of renal function and
stablization of potassium. on [**2153-1-16**] patient required iv lasix
diuresis for chf with compensation of chf. Her lasisix dosing
was changed to 120mgm [**Hospital1 **] ( 80mgm qpm/120mgmqam). Patient was
evaluated by wound /skin care nures for rt. buttock and sacral
wound. recomendations were [**Doctor First Name **] air mattress. qd cleansing with
saline with aquacel dressing qd. application to surrounding
areas with aloe [**Doctor First Name 840**] ointment with each dressing changes and
prn.
[**Last Name (un) 616**] service followed patient for dm managment. fasting
glucoses remained > 200 even with continued lantus HS dosing
adjustment.patient scake on d/c rx is current largine dosing and
regular insulin sliding scale .
patient being anticoagulated for St. [**First Name5 (NamePattern1) 744**] [**Last Name (NamePattern1) 8756**] goal inr 2.5-3.5.
Had been receiving 7.5mgm qhs, [**2153-1-17**] dose 2.5 inr [**2153-1-18**] 4.1.
hold coumdain tonight and check inr qd. adjust dosing for goal
inr. bun ranges during admission 70-108, cr ranges 2.2-2.6-2.2,
K= ranges 4.7-5.9-5.4 hct stable x 72 hrs 29.7
Renal: bun/cr 108/2.2 K= 5.4. will need to moniter renal
function and treat as required.
wound clean dry and intact.
[**2153-1-18**] d/c to rehabilitation. stable
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1933**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2153-1-18**]
|
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icd9cm
|
[
[
[]
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] |
[
"39.95",
"99.07",
"88.48",
"84.15",
"96.71",
"96.04",
"88.42",
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icd9pcs
|
[
[
[]
]
] |
14523, 14727
|
8247, 9926
|
338, 384
|
12074, 12080
|
2298, 7462
|
12355, 14500
|
1782, 1800
|
10325, 11818
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11909, 12053
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9952, 10302
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12104, 12332
|
1815, 2279
|
274, 300
|
412, 960
|
7471, 8224
|
982, 1551
|
1567, 1766
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,163
| 140,109
|
18333
|
Discharge summary
|
report
|
Admission Date: [**2118-5-10**] Discharge Date: [**2118-5-11**]
Date of Birth: [**2085-3-12**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Motrin Ib
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Throat tightness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
33 year-old man transferred from OSH for treatment of throat
tightness and pneumonia. He is admitted to the ICU for closer
monitoring given concern of allergic reaction and history of
severe [**Known lastname **] [**Location (un) **] reaction in [**2110**].
His current symptoms started several days ago with URI-type
symptoms. Patient developed chest tightness, sore throat, dry
cough, and sensation of "lips feeling leathery" and dry over the
course of three days (since Saturday). He notes that his
girlfriend was [**Name2 (NI) **] with [**Name (NI) 50513**] symptoms and he may have
picked something up from her.
Over the weekend he had taken aspirin on-and-off for four days
(not containing Motrin per his report). Around this time he
developed worsening throat tightness, and he decided to go to
[**Location (un) **] ED for further evaluation. From [**Location (un) **] ED he was
transferred to [**Hospital1 18**].
In the ED at [**Hospital1 18**], his initial vital signs were T 97.2, HR 92,
BP 148/108, RR 20, satting 95% RA. He was noted to be talking in
full sentences, although his voice was hoarse. On exam, there
was no stridor or wheezing. Labs were remarkable for a white
count of 9.5 with 72% polys, no bands. CBC was otherwise normal
with normal BMP. An EKG showed NSR with no ischemic changes. CXR
showed indistinctness of the left heart border with concern of
atalectasis versus pneumonia. Patient had already received
ceftriaxone at OSH for concern of pneumonia and was given
azithromycin here at [**Hospital1 18**]. In addition he received 4 mg of
Zofran, 4 mg of morphine and 125 mg of methylprednisolone.
During his time in the ED he felt increasing throat tightness,
and due to the complicated history of [**Known lastname **]-[**Location (un) **] reaction,
he was admitted to the ICU for closer monitoring. Vitals at time
of transfer were T 97.8, HR 80, BP 140/80, RR 18, satting 97%
RA.
Of note, in [**2110**] the patient was admitted to [**Hospital1 18**] for SJS
involving the airway mucosa- his hospital course was complicated
by DVT and LUL pulmonary embolism. He had a long admission
requiring intubation (from [**9-28**] to [**10-19**]) and ultimately
tracheostomy placement. He had presented originally with SOB and
fever three months after treatment of pneumonia with ceftriaxone
and levofloxacin. At presentation he had a vesicular rash. His
micro work-up was all negative with the exception of an elevated
IgM and IgG for Mycoplasma pneumonia. He had a deep skin biopsy
that showed erythema multiforme. He was initially treated with
vancomycin, acyclovir, ceftriaxone, which was later changed to
levofloxacin, and then to azithromycin (for a 21-day course
total of antibiotics). During the admission, he had thick
blood-tinged expectorant from his lungs felt to be consistent
with desquamation caused by [**Known lastname **]-[**Location (un) **] syndrome. Note is
made from that discharge summary that he had a very traumatic
intubation and that the anesthesiologist performing the
procedure saw a desquamated, ulcerated, and "raw-appearing"
posterior pharynx.
REVIEW OF SYSTEMS:
Positive for subjective fevers/chills over the last few days.
Also with intermittent stomach pain. No diarrhea. No nausea or
vomiting. No urinary symptoms. No rash or joint pain.
Past Medical History:
Mycoplasma pneumonia infection complicated by SJS, DVT and PE
([**2111-9-9**])
Social History:
He works as an engineer. He is divorced and has a son. Social
alcohol use, tobacco use (1 pack per week). No intravenous drug
use.
Family History:
NC
Physical Exam:
HR 78, BP 147/95, RR 17, sat 97%
General: young man, no acute distress, +hoarse voice
HEENT: no conjuntival injection or edema; no tongue swelling;
oropharynx clear with no erythmea or exudate; small blistering
along inferior gingival surface, otherwise clear buccal and
palate mucosal without ulceration or erosion
Cardiovascular: RRR, normal s1/s2, no murmurs
Pulmonary: coarse expiratory sounds diffusely, no wheezes, no
stridor over anterior or lateral neck
Abdominal: soft, non-tender, normal bowel sounds
Extremities: warm and well-perfused, non-edematous, 2+ dp pulses
Neurological: AAOx3, moving all extremities
Skin: no rashes
Pertinent Results:
[**2118-5-10**] 12:24AM BLOOD WBC-9.5 RBC-4.98# Hgb-15.3# Hct-45.5#
MCV-91 MCH-30.7 MCHC-33.7 RDW-13.6 Plt Ct-366
[**2118-5-10**] 12:24AM BLOOD PT-12.4 PTT-24.8 INR(PT)-1.0
[**2118-5-10**] 12:24AM BLOOD Glucose-92 UreaN-14 Creat-1.0 Na-142
K-4.1 Cl-102 HCO3-28 AnGap-16
[**2118-5-10**] 03:41AM BLOOD Calcium-9.0 Phos-2.8# Mg-2.1
CXR IMPRESSION: Probable lingual scarring. No evidence of
pneumonia.
CT CHEST (PRELIM): Bronchiectasis, no pneumonia
Brief Hospital Course:
# Shortness of breath: Pt presented with 2-3 days of lethargy,
cough, congestion and possible lingular infiltrate on chest
x-ray. Exam was remarkable for coarse breath sounds diffusely,
L>R. Pt was started on empiric Levofloxacin and steroids for
possible SJS. HE was notably tachycardic and dehydrated on exam,
he was given 2liters of IVF and HR trended down with increased
UOP. Pt was started on nebs and reported improved breathing and
cough. Due to abnormal findings on CT chest from [**2111**], he
underwent a follow up CT which was notable for resolution of
nodules and subtle tree/[**Male First Name (un) 239**] opacities. Levofloxacin was
initially continued for CAP and pt was called out to floor but
on the floor it was thought that his symptoms were mainly due to
URI like process so abx were discontinued. the pt was discharged
with supportive care on albuterol/ipratropium, fluticasone
inhalers. he is to f/u with his PCP in the next week.
# History of [**Known lastname **]-[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 15813**]: occurred in the setting of
Motrin use and Mycoplasma pneumoniae infection. Currently
patient with no evidence of mucosal sloughing or rash. Steroids
started empirically and stopped after resolution of oral &
throat discomfort, no evidence of rash. On discharge the pt was
stable without any evidence of SJS.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever for 10 days.
Disp:*60 Tablet(s)* Refills:*0*
2. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for cough or sore
throat for 10 days.
Disp:*30 Lozenge(s)* Refills:*0*
3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-1**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing or
sob for 10 days.
Disp:*1 inhaler* Refills:*0*
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) for 10 days.
Disp:*1 inhaler* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute bronchitis vs Viral syndrome with reactive airways
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to shortness of breath and cough. At first
there was concern that you could develop symptoms similar to
your past admission for [**Known lastname **]-[**Location (un) **] syndrome. You were given
IV steroids and antibiotics and transferred to the ICU for
monitoring. You fortunately did not develop any life threatening
respiratory symptoms or any concerning symptoms for
[**Known lastname **]-[**Location (un) **]. It is thought that you likely suffer from a
viral illness with reactive airways, and that antibiotics are
not needed. You should take fluticasone inhaler for 10 days,
albuterol/ipratropium inhaler, tylenol, and cepacol as needed
for the next few days to control your wheezing and respiratory
symptoms. 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 with any
concerning symptoms at all.
Followup Instructions:
Please follow up with your PCP in the next 7 days.
|
[
"079.99",
"466.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7144, 7150
|
5051, 6424
|
301, 307
|
7250, 7250
|
4579, 5028
|
8384, 8438
|
3902, 3906
|
6479, 7121
|
7171, 7229
|
6450, 6456
|
7400, 8361
|
3922, 4560
|
3456, 3636
|
245, 263
|
335, 3437
|
7265, 7376
|
3658, 3738
|
3754, 3886
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,135
| 164,088
|
6507
|
Discharge summary
|
report
|
Admission Date: [**2160-7-11**] Discharge Date: [**2160-7-24**]
Date of Birth: [**2090-6-26**] Sex: F
Service: SURGERY
Allergies:
Cardizem / Lipitor
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
pedestrian struck by car
Major Surgical or Invasive Procedure:
[**2160-7-18**] tracheostomy, PEG
History of Present Illness:
HPI; 70y F struck by motor vehicle in front lawn, presented to
to OSH w/GS 15, subdquent mental status deterioration, intubated
and transfered. Injuries include SAH/SDH w/small midline shift
R L2 transverse process fx
T12 burst fx
R acetabular non-displaced fx
R inf and L sup pubic ramus fx.
R 6th rib fx
L medial femoral condyle, proximal fibula
Past Medical History:
PMH: DES x2, DM requiring insulin, Stroke
PSH: CABG, aorto-[**First Name9 (NamePattern2) 24978**]
[**Last Name (un) 1724**]:
1) Zocor/simvastatisn 80 mg, 2) Glucotrol/glipizide 10mg,
3)prozac/fluoxetine 20mg [**Hospital1 **] 4) Plavix 75 mg
5) Glucophage/metformin 1000mg [**Hospital1 **] 6) lisinopril 10 mg
7) Niaspain 500mg 8) coreg/carvediol 25mg [**Hospital1 **]
9) lasix/furosemide 40mg 10) lantus 45 mig
11) fentanyl patch 50mcg q72hrs 12) spironolactone 25 mg
Social History:
Soc: Live at home with husband
Family History:
NC
Physical Exam:
On discharge:
Vitals: afebrile, P 81, BP 143/63, RR 18, 100% RA
Exam: awake, spontaneously opening eyes & moving extremities,
occasionally following commands, non-verbal
EOM full, PERRL
Face symmetric
Trach site CDI
Chest coarse bs bilaterally
Heart regular, no MRG
Abdomen soft, round, NT, NT, PEG site CDI
LE 1+ edema bilaterally
Pertinent Results:
[**2160-7-23**] 02:06AM BLOOD WBC-16.2* RBC-2.80* Hgb-8.3* Hct-26.8*
MCV-96 MCH-29.5 MCHC-30.9* RDW-16.0* Plt Ct-280
[**2160-7-21**] 07:27AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.028
[**2160-7-21**] 07:27AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2160-7-21**] 07:27AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
Date 6 Specimen Tests Ordered By
All [**2160-7-11**] [**2160-7-13**] [**2160-7-16**] [**2160-7-19**] [**2160-7-21**] All
BLOOD CULTURE CATHETER TIP-IV MRSA SCREEN Mini-BAL SPUTUM SPUTUM
NOT PROCESSED URINE All INPATIENT
[**2160-7-21**] CATHETER TIP-IV WOUND CULTURE-FINAL negative
[**2160-7-21**] BLOOD CULTURE Blood Culture negative
[**2160-7-21**] URINE URINE CULTURE-FINAL negative
[**2160-7-21**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-gram
stain GPC, GNR, no culture growth
[**2160-7-21**] MRSA SCREEN MRSA SCREEN-FINAL neg
[**2160-7-19**] SPUTUM NOT PROCESSED INPATIENT
[**2160-7-16**] BLOOD CULTURE Blood Culture, Routine-FINAL neg
[**2160-7-16**] URINE URINE CULTURE-FINAL INPATIENT
[**2160-7-16**] BLOOD CULTURE Blood Culture, Routine-FINAL neg
[**2160-7-16**] Mini-BAL GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
neg
[**2160-7-13**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
neg
[**2160-7-11**] MRSA SCREEN MRSA SCREEN-FINAL neg
[**2160-7-11**] URINE URINE CULTURE-FINAL {GRAM NEGATIVE ROD(S)}
<1000.
Brief Hospital Course:
Admitted to TSICU from ED for neurological checks while on the
ventilator.
Hospital course by systems:
NEURO: Initial CT head demonstrated traumatic SAH/SDH with 2mm
midline shift, which did not increase on subsequent scans
throughout her hospitalization. Off sedation, she opened her
eyes spontaneously and does some tracking. She does not follow
commands, however. She was initially placed on dilantin for
seizure ppx, but this was changed to keppra.
CV: Hemodynamically stable throughout her admission, she did
have intermittent tachycardia related to pain and anxiety. An
Echo on [**7-17**] demonstrated LVEF 20%, which was markedly lower
than her prior LVEF of 55% on admission. There was also
evidence of RH strain and she leaked troponins, which was
thought to be demand ischemia in the setting of failure and
tachycardia.
PULM: Trached enroute to [**Hospital1 18**], pt remained ventilated despite
being off sedation for many days. After one week, a
tracheostomy was placed to facilitate weaning off ventilation.
She remained on high pressure support and PEEP and her wean was
not successful by the time of discharge. Her poor respiratory
reserve was complicated by VAP for which she received a 5 day
course of antibiotics.
GI: A dobhoff was placed for tube feeds and after failure to
wean from ventilation, a PEG was inserted at the same time as
the tracheostomy was placed. Tube feeds were advanced to goal
and she tolerated these without problem.
HEME: SC heparin was started on HD7 per neurosurgery
recommendations. Vascular surgery did not feel it was warranted
to place IVC filter at this time. Initial thrombocytopenia,
from inadequate resuscitation, resolved by HD7. She had no
bleeding events. PE was suspected on [**7-21**], but CTA chest was
negative for embolism.
ENDO: Pt maintained on home diabetic regimen, but sugars
remained elevated. Prior to discharge, a DM consult was
obtained to assist with insulin regimen. She will be discharge
on this current regimen.
ID: Afebrile through the first part of her hospitalization, pt's
respiratory status diminished on HD5 and CXR demonstrated a L
lower lung field opacity concerning for pneumonia. SHe was
started on broad spectrum antibiotics (vanc/cipro/cefepime) and
sputum cultures were sent. Cultures did not grow any organisms
and antibiotics were stopped after a 5 day course.
Medications on Admission:
1) Zocor/simvastatisn 80 mg,
2) Glucotrol/glipizide 10mg,
3)prozac/fluoxetine 20mg [**Hospital1 **]
4) Plavix 75 mg
5) Glucophage/metformin 1000mg [**Hospital1 **]
6) lisinopril 10 mg
7) Niaspain 500mg
8) coreg/carvediol 25mg [**Hospital1 **]
9) lasix/furosemide 40mg
10) lantus 45 mig
11) fentanyl patch 50mcg q72hrs
12) spironolactone 25 mg
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML
Mucous membrane TID (3 times a day) as needed for oral care.
2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Hospital1 **]: One
(1) Appl Ophthalmic PRN (as needed) as needed for on vent.
3. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ml
Injection TID (3 times a day).
4. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Twenty (20) mL PO Q6H
(every 6 hours).
5. Niacin 250 mg Capsule, Sustained Release [**Hospital1 **]: One (1)
Capsule, Sustained Release PO BID (2 times a day) as needed for
hypertriglecyremia.
6. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2
times a day).
7. Senna 8.8 mg/5 mL Syrup [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Levetiracetam 100 mg/mL Solution [**Hospital1 **]: Five (5) mL PO BID (2
times a day).
9. Fentanyl 75 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze.
11. Carvedilol 12.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day) as needed for HTN, CAD.
12. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: One (1) mL
Injection ASDIR (AS DIRECTED).
13. Oxycodone 5 mg/5 mL Solution [**Hospital1 **]: [**4-6**] mL PO Q4H (every 4
hours) as needed for pain.
14. Lisinopril 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. Lasix 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
Injuries include SAH/SDH w/small midline shift
R L2 transverse process fx
T12 burst fx
R acetabular non-displaced fx
R inf and L sup pubic ramus fx.
R 6th rib fx
L medial femoral condyle, proximal fibula
Discharge Condition:
Stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel) prior to your injury, you may safely resume
taking this on [**2160-8-18**].
?????? You haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 3 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
??????Please follow up with Dr [**Last Name (STitle) **] in 4 weeks call the trauma
clinic to make an appointment. Call ([**Telephone/Fax (1) 376**] to make an
apointment.
??????Please follow up with Dr [**Last Name (STitle) 1005**] about the pelvic fractures,
Right humerus fracture and the L femoral fracture. Call ([**Telephone/Fax (1) 15940**] to make an appointment in 4 weeks.
??????Please follow up with Dr [**Last Name (STitle) **] about the T12 Burst fracture.
Call ([**Telephone/Fax (1) 2007**] to make an appointment.
Completed by:[**2160-7-24**]
|
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"250.70",
"808.2",
"997.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"38.93",
"43.11",
"33.24",
"38.91",
"96.6",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
7721, 7795
|
3113, 3189
|
303, 338
|
8043, 8052
|
1642, 3090
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|
1271, 1275
|
5884, 7698
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7816, 8022
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5516, 5861
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3218, 5490
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1290, 1290
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1304, 1623
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239, 265
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366, 716
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738, 1207
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1223, 1255
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,957
| 106,674
|
38789
|
Discharge summary
|
report
|
Admission Date: [**2131-1-17**] Discharge Date: [**2131-1-24**]
Date of Birth: [**2060-8-6**] Sex: F
Service: MEDICINE
Allergies:
Tramadol / Oxycodone / Penicillins
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
History of Present Illness:
70F with COPD on home O2, presented to OSH with shortness of
breath, now admitted to [**Hospital Unit Name 153**] for respiratory failure. Per
family, has shortness of breath particularly with exertion at
baseline, only able to ambulate several feet. This was
significantly worse today. Daughter does not think she used her
CPAP last night due to falling asleep in chair. Had mild
nonproductive cough, no fevers/chills/GI symptoms. Daughter
also notes she has had some falls at home and noted an egg on
the back of her head. Yesterday she complained to daughter of
having difficulty holding things.
.
At [**Hospital3 3583**], O2 sat 81% on RA. Given lasix 40 IV,
solumedrol 125 mg, levaquin 750 mg IV. Also noted to have
minimal STEs inferiorly and heparin thus started, received
SLNTG, 5 mg lopressor, ASA 325 mg PR. Received calcium,
kayexalate, insulin/D50 for hyperkalemia (6.3) with new ARF
(creatinine 4.7). NIPPV trialed but ultimately required
intubation. ABG 7.12/119/181/41 on bipap. WBC 13.4 with 12%
bands. BNP 277. Did have BP drop to 70s at OSH, responded to
250 cc bolus.
.
In the ED, initial vs were: T98.5 P73 BP 93/49, 100% O2 sat on
vent. SBP remained in 90s-110s. Trop 0.04 here; ECG faxed to
cards who did not feel c/w ischemia and recommended d/c heparin
gtt. CXR obtained with ?RUL pneumonia. Patient was given vanc
and aztreonam here.
.
On the floor, patient intubated and sedated.
.
Review of systems: unable to obtain as patient is intubated and
sedated. Positives per family as above. ALso noted
constipation yesterday.
Past Medical History:
- COPD on home O2
- HTN
- Hypothyroidism
- Venous stasis
- Post herpetic neuralgia
- Anxiety/depression
- Osteoporosis
- Obstructive sleep apnea on CPAP
Social History:
Quit smoking 9 years ago after [**12-20**] PPD smoking history. No
EtOH. Lives at home. Daughter is [**Name2 (NI) **] [**Telephone/Fax (1) 86113**]
Family History:
Father had COPD.
Physical Exam:
General: Intubated, sedated, no distress.
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear.
Subcutaneous fluctuant collection on posterior head more on left
side.
Neck: obese, supple, JVD elevation difficult to appreciate,
slightly erythematous ?lymph node at angle of mandible on left
side.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi but prolonged expiratory phase.
CV: Regular rate and rhythm, normal S1 + S2, [**12-23**] SM at RUSB with
some radiation to carotids, and [**12-23**] holosystolic murmur at apex.
Abdomen: soft, appears non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: needs assessment off sedation. Hyperreflexic L patellar
reflex compared to right. Withdraws bilaterally to babinski.
Pertinent Results:
[**2131-1-17**] 05:30PM LACTATE-0.8
[**2131-1-17**] 05:23PM GLUCOSE-130* UREA N-64* CREAT-3.5* SODIUM-141
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-33* ANION GAP-12
[**2131-1-17**] 05:23PM CK-MB-7 cTropnT-0.04*
[**2131-1-17**] 05:23PM WBC-5.7 RBC-2.74* HGB-8.4* HCT-26.1* MCV-95
MCH-30.8 MCHC-32.3 RDW-13.0
[**2131-1-17**] 05:23PM PLT COUNT-145*
[**2131-1-17**] 11:55AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-NEG
[**2131-1-17**] 11:12AM TYPE-ART RATES-/16 TIDAL VOL-550 O2-60
PO2-109* PCO2-53* PH-7.44 TOTAL CO2-37* BASE XS-10 -ASSIST/CON
INTUBATED-INTUBATED
[**2131-1-17**] 10:55AM FIBRINOGE-372
Micro:
Blood cultures 3/3 No growth x2 sets
Urine legionella negative
Sputum [**1-18**]:
GRAM STAIN (Final [**2131-1-18**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2131-1-20**]):
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). RARE GROWTH.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2131-1-19**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
BAL: [**1-18**]
GRAM STAIN (Final [**2131-1-18**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2131-1-20**]):
~4000/ML Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. ~[**2120**]/ML.
FURTHER WORKUP ON REQUEST ONLY Isolates are considered
potential
pathogens in amounts >=10,000 cfu/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2131-1-19**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
BAL:
Bronchial lavage:
NEGATIVE FOR MALIGNANT CELLS.
Pulmonary macrophages and bronchial cells.
ECG: [**1-17**]: Sinus rhythm. Low QRS voltage in the limb leads.
Non-diagnostic repolarization
abnormalities. No previous tracing available for comparison.
CXR:[**1-17**]
1. Mild pulmonary vascular congestion.
2. Right upper lobe consolidation, with irregular appearance
that may signify underlying mass. Please correlate with prior
imaging, and/or reimage following treatment and consider CT for
better delineation.
Head CT : [**1-17**]
1. No intracranial hemorrhage or acute intracranial abnormality.
2. 10-mm subgaleal low-attenuation fluid collection, without
underlying bony
abnormality or inflammatory change in the overlying subcutaneous
tissues.
3. Pansinus disease, with fluid in the right maxillary and
sphenoid air cells
and complete opacification of right mastoid air cells.
Chest CT [**1-17**]:
1. Probably right upper lobe pneumonia. **Six-week followup
radiograph to
document resolution is recommended to exclude an underlying
neoplasm**.
2. Bibasilar atelectasis and small nonhemorrhagic pleural
effusions.
3. T8 compression fracture of indeterminate chronicity.
4. Right renal cyst, incompletely characterized. Recommend
correlation with US.
5. Probable pulmonary hypertension.
TTE:
Small, hypertrophied, hyperdynamic left ventricle. No
clinically-significant valvular disease seen.
Brief Hospital Course:
70F with history of COPD on home O2, HTN, presenting with
shortness of breath and hypercarbic respiratory failure.
.
# Hypercarbic respiratory failure. Family gave history of pt
being more tired and lethargic x few days PTA, perhaps due to
hypoventilation. Patient with severe COPD at baseline,
presenting with hypoxia and ABG showing acute on chronic
respiratory acidosis. Thought to be due to worsening
obstructive disease vs. fluid overload vs infection, or
intracranial process causing central respiratory depression, as
patient's family reported pt had recent fall. CT head negative
for intracranial abnormality. Patient was intubated and placed
on a ventilator given her severe CO2 retention. She was
initially treated with vancomycin, levofloxacin and flagyl for
suspected respiratory infection. She was given one dose of
solumedrol 60mg, then started on prednisone 60mg PO daily and
standing albuterol and ipratropium nebulizer treatments for
suspected COPD exacerbation. CT chest showed an irregular
consolidation in the RUL suggestive of infection vs malignancy.
Patient was placed on repiratory isolation in order to rule out
TB. A bronchoscopy was performed and BAL was sent for gram
stain, AFB, culture and cytology; AFB was negative. Sputum gram
stain was positive for gram positive cocci in pairs. Urine
legionella antigen was negative. Patient's antibiotics were
scaled back based on sputum to only levofloxacin on day 2.
(which she completed a 7 day course) The patient was weaned off
the vent and extubated without difficulty on [**2131-1-19**]. Her
prednisone was tapered down to 40 mg po daily and she was
restarted on her home flovent on [**2131-1-20**]. At night the patient
was put on CPAP as she is on BiPAP on home (settings
unknown)--she was asked to have her family bring in her home
BiPAP machine.
She will need to continue her nebulizer treatments, flovent and
prednisone taper. She can be tapered down by 10mg each week, has
been on 40mg since [**1-20**]. She will continue on her oxygen by nasal
cannula at 3 liters
.
# ?Pulmonary Mass: CT and CXR show a ?RUL lung mass concerning
for neoplasm. This lesion appears to have been present
preceeding this hospitalization/infection and warrants REPEAT
IMAGING 6 WEEKS after this infectious process clears. The
patient was made aware of this on [**2131-1-20**] prior to discharge from
the ICU.
This was communicated to [**Doctor Last Name 16901**],who is the assistant for the
patients primary pulmonologist, Dr. [**Last Name (STitle) 58201**] in [**Location (un) 3320**] - ([**Telephone/Fax (1) 86114**]. She will follow-up with him on [**2131-3-9**] at 3:15 pm and
will need to schedule a Chest CT for 6 weeks from now, at [**Telephone/Fax (1) 86115**].
.
# Borderline hypotension. Improved with SBPs >100 consistently.
Concern initially for sepsis/severe pneumonia, but was likely
due to her hypovolemia given history of poor PO intake. Patient
given 500 cc boluses of NS x 2 on admission and her BP improved.
UOP was normal. Blood pressure at the time of discharge was
122/70
.
# Acute Renal Failure: BUN/Cr in ED 69/4.2 (recent past was 1.2
in [**Month (only) **]). Likely prerenal d/t poor forward flow and
hypovolemia. Urine lytes were suggestive of a pre-renal
etiology. Her home ACE-I was held initially then restarted on
[**2131-1-20**]. At time of discharge from the hospital, BUN/Cr improved
at: 25/1.0
.
# ECG changes. Minimal STEs vs. PR depressions on admission.
Troponin was elevated at 0.04 but stable x 3 sets. Serum CK was
mildly elevated at 368 with a CK-MB of 12 on admission and
subsequently trended down to CK of 250s and CK-MB of 6. TTE
demonstrated EF 75%, with mild LVH and mild diastolic
dysfunction, with no regional wall motion abnormalities.
.
# Anemia and thrombocytopenia. Hct last known 29 in [**Month (only) **].
Unclear reason for low plts but these normalized to 195 by time
of discharge from ICU. Iron demonstrated low iron, low TIBC,
consistent with anemia of chronic disease, and HCT remained
stable at 27. TSH was normal.
.
# OSA.
Continued on BiPAP as noted above.
# Osteoporosis
On her Chest CT scan, she was noted to have a compression
fraction at T8 of unknown duration. This is likely related to
her steroids. She was started on calcium and vitamin D and will
need a bisphosphonate started as an outpatient.
# Deconditioning
Given her poor baseline status and intubation, she was evaluated
by physical therapy as an inpatient. Her walking was limited by
her breathing and it was felt that she would benefit from
inpatient pulmonary rehabilitation after discharge.
.
CODE STATUS confirmed as: FULL CODE.
Medications on Admission:
Prednisone 2.5 mg daily
Lisinopril 20 mg daily
Levothyroxine 125 mcg daily
Lasix 20 mg daily
Gabapentin 300 mg TID
Zocor 40 mg daily
KCl 20 meq daily
Paxil 20 mg daily
Flovent 1 puff [**Hospital1 **]
Combivent Q4H prn
Forteo pen 20 mg SC daily
Vitamin D 1000 mg daily
Home O2 at 3LPM
Bipap at nighttime
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): would check finger sticks AC/HS,
prn sliding scale while on steroids.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
10. Albuterol Sulfate 5 mg/mL Solution for Nebulization Sig: One
(1) Inhalation every 4-6 hours as needed for wheezing.
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): taper by 10 mg weekly (started 40mg on [**1-20**]).
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
18. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day): please give separated
from levothyroxine by at least one hour.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Hypercarbic respiratory failure
2. Pneumonia
3. Possible lung mass
4. Acute renal failure
5. Osteoporosis
6. Obstructive sleep apnea
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 diagnosed with respiratory failure. This is
predominantly due to your chronic obstructive pulmonary disease
(emphysema) and also in part due to obstructive sleep apnea. You
also had a pneumonia, for which you have completed a course of
antibiotics. You were ill enough to require intubation and
monitoring in the intensive care unit, but have made good
improvement since you have been here. However, given the
severity of your lung disease, you will need pulmonary
rehabilitation prior to returning home.
Followup Instructions:
PCP: [**Name10 (NameIs) **] schedule a follow-up with your pcp [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 26909**]
at [**Telephone/Fax (1) 86116**] after you are released from your rehab facility.
Pulmonary: Dr. [**Last Name (STitle) 58201**] in [**Location (un) 3320**] - ([**Telephone/Fax (1) 86117**] Friday [**3-9**], [**2130**] at 3:15pm; please call [**Telephone/Fax (1) 86118**] to schedule a Chest
CT, which should be done 6 weeks from your discharge (mid [**Month (only) **])
|
[
"458.9",
"401.9",
"486",
"496",
"276.2",
"285.29",
"518.81",
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"733.00",
"244.9",
"300.4",
"327.23",
"287.5",
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icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.71",
"38.91",
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icd9pcs
|
[
[
[]
]
] |
13369, 13441
|
6587, 11235
|
314, 353
|
13621, 13621
|
3223, 4321
|
14339, 14862
|
2307, 2325
|
11588, 13346
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13462, 13600
|
11261, 11565
|
13801, 14316
|
2340, 3204
|
5156, 6564
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4998, 5122
|
1824, 1948
|
255, 276
|
381, 1805
|
13636, 13777
|
1970, 2124
|
2140, 2291
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,737
| 168,411
|
35498
|
Discharge summary
|
report
|
Admission Date: [**2156-3-27**] Discharge Date: [**2156-4-7**]
Date of Birth: [**2083-3-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
thoracentesis with chest tube placement
History of Present Illness:
73 y/o M with hx of RMLobectomy for "benign" mass comes in with
approximately one month of worsening SOB, DOE, orthopnea. Also
with subjective fatigue, 30 lb unintentional weight loss, and
n/v. He does have a productive cough for white sputum, no
hemoptysis. Has back pain associated with this worsening SOB
and has been having extensive workups as an outpatient. He was
thought to have DJD vs. OA as causes of his pain. Recent MRI of
upper back showed suspicious lesion and he was scheduled for
biopsy in the next few weeks. Due to his worsening SOB, his
wife insisted that he come to the [**Name (NI) **] for evaluation.
.
In the ED, his vitals were T 97.6, BP 116/72, HR 136, R 18 98%
on RA. He was tachypneic and tachycardic throughout ED course.
He received 1L NS, dilaudid for pain, and vanco, cefepime and
levofloxacin for coverage of HAP or CAP. Thoracic surgery was
consulted by the ED team.
.
Upon arrival to the floor, the thoracic surgery team examined
him and did a thoracentesis and chest tube placement. The
drained about 2 L of serosanginous fluid. He was breathing
comfortably and pain free. He was tired and wanted to sleep but
otherwise had no other complaints.
Past Medical History:
hyperlipidemia
OA
Social History:
lives independently with his wife on [**Location (un) **]; past hx of
smoking, quite several years ago (20 pack yr hx), no etoh/drugs
Family History:
father with cancer, unknown primary; otherwise noncontributory
Physical Exam:
Vitals: T ? BP 120/60, HR 108, 02 sat 96% on RA, RR 16.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decreased BS at bases, chest tube in place draining pink
serosanginous fluid, few R base crackles, otherwise CTA, no
respiratory distress
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2156-3-27**] 02:25PM BLOOD WBC-17.7* RBC-4.88 Hgb-15.0 Hct-43.2
MCV-89 MCH-30.7 MCHC-34.7 RDW-13.9 Plt Ct-487*
[**2156-3-28**] 04:15AM BLOOD WBC-18.2* RBC-4.41* Hgb-13.7* Hct-39.3*
MCV-89 MCH-31.1 MCHC-34.9 RDW-14.1 Plt Ct-472*
[**2156-3-27**] 02:25PM BLOOD PT-14.6* PTT-30.2 INR(PT)-1.3*
[**2156-3-28**] 04:15AM BLOOD PT-13.5* PTT-31.5 INR(PT)-1.2*
[**2156-3-27**] 02:25PM BLOOD Glucose-116* UreaN-22* Creat-0.9 Na-140
K-4.8 Cl-98 HCO3-26 AnGap-21*
[**2156-3-28**] 04:15AM BLOOD Glucose-131* UreaN-18 Creat-0.9 Na-140
K-5.0 Cl-104 HCO3-24 AnGap-17
[**2156-3-27**] 02:25PM BLOOD ALT-27 AST-44* AlkPhos-93 TotBili-0.9
[**2156-3-28**] 04:15AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.2 UricAcd-PND
[**2156-3-27**] 04:15PM BLOOD Lactate-5.2*
[**2156-3-27**] 06:22PM BLOOD Lactate-5.0*
.
CT chest/abd/pelvis:
CHEST: The aorta is normal in course and caliber without
evidence of
dissection or aneurysm. The central pulmonary arterial tree
opacifies
normally and demonstrates no filling defect to suggest the
presence of a
pulmonary embolism.
There is bulky lymphadenopathy in the anterior, middle and
posterior
mediastinal compartments with the posterior nodes appearing the
largest
measuring 2.9 cm in short axis diameter (S400b:33). Superior
mediastinal
nodes measure up to 1.9 cm in short axis diameter (S3:9).
Conglomerate left hilar lymphadenopathy results in encasement of
the bronchovasculature with the large nodes individually
approximating 2-cm in short axis diameter (S3:9). Nodal
encasement of the airway supplying the lingula and left lower
lobe resulting in complete atelectasis of these portions of the
left lung. Additionally, there is nodal encasement of the left
lower lobe draining pulmonary vein without evidence of
thrombosis at this time, though given this appearance future
thrombosis is a likely complication. Note is also made of
enlarged axillary lymph nodes measuring up to 2.6 cm in short
axis on the right and 1.5 cm on the left. An enlarged lymph node
is noted just above the left hemidiaphragm on series 3, image
107 measuring 2.4 cm in short axis diameter. There is a large
left pleural effusion which layers posteriorly and surrounds the
collapsed lingula and left lower lobe. Irregular (nodular rind)
thickening is noted along the left posterior pleura extending
inferiorly from the level of the carina. There is invasion into
the left posterio chest wall by this malignant appearing pleural
mass. Infiltrative mass is seen extending intercostally into the
chest wall with a thickness of 4.5 cm (S3:105). In addition,
there is a left paraspinal component of this pleural-based mass
which may involve and/or extend into the left lower thoracic
neural foramina (as described on recent MRI). The vertebra and
left ribs are intact, though splayed somewhat by the chest wall
infiltrative mass.
The right lung is essentially clear aside from chronic-appearing
consolidation in the right lung apex, which may be related to
chronic granulomatous disease. In addition, there is some
scarring/suture noted in the right middle lobe which may reflect
the provided history of prior partial resection.
The heart is normal in size with only trace pericardial
thickening versus
effusion noted inferiorly. Extensive calcification along the
tracheobronchial tree is noted. The airway is centrally patent
though collapse of the lingula and left lower lobe appears
secondary to airway compromise at the level of the left
infrahilar region due to the bulky lymphadenopathy.
ABDOMEN: The liver appears normal without focal lesion. The
portal vein is
widely patent. The pancreas, spleen and adrenal glands appear
normal. Kidneys enhance symmetrically and excrete contrast
promptly without evidence of focal concerning renal lesion.
Lymphadenopathy is noted in the retrocrural space measuring up
to 3.2 cm in short axis diameter. Additionally, there is
enlargement of the celiac axis node measuring up to 2.1 cm.
Retroperitoneal lymph nodes are also noted, measuring up to 1.9
cm (series 5, image 24). The abdominal aorta and major branch
vessels appear patent with minimal calcification along the
distal abdominal aorta.
The stomach is essentially collapsed. The duodenum follows a
normal course. No free air or free fluid is seen. A node is seen
inferior to the spleen on series 5, image 36 measuring 11 mm in
short axis
PELVIS: Loops of small and large bowel demonstrate no evidence
of ileus or
obstruction. Please note lack of enteric contrast does limit
evaluation for bowel wall thickening and mesenteric masses.
Mesenteric lymph nodes appear grossly unremarkable. There is a
small nodule in the right iliac fossa on series 5, image 42. No
definite inguinal lymphadenopathy is seen. The urinary bladder
is mostly decompressed. The prostate gland is enlarged with a
transverse diameter of 5.2 cm. Calcified phleboliths are noted
in the pelvis. Distal ureters opacify normally. No
pathologically enlarged lymph nodes are seen along the iliac
chain bilaterally.
BONE WINDOWS: While the left paraspinal and left posterior chest
wall
infiltrative mass is invested between the ribs and appears to
enter several left lower thoracic neural foramina (better
assessed on MRI), there is no bone invasion or evidence of
osseous metastasis. Spinal alignment appears normal with mild
degenerative changes noted in the lower thoracic and lumbar
spine. Old right posterolateral rib fractures may be related to
history of prior partial right lung resection. No acute
fractures are seen. Diffuse body wall edema is noted.
IMPRESSION:
1. Large left posterior pleural mass with invasion into the
chest wall with associated large left pleural effusion.
Abdominal lymphadenopathy as well as bulky mediastinal, left
hilar, axillary lymphadenopathy with compression and collapse of
the left lower lobe and lingula. Overall findings are concerning
for malignancy with lymphoma being a strong consideration.
Correlation with biopsy or cytology (pleural fluid) is
recommended. Please note, if drainage of the left effusion is
attempted, efforts should be made to avoid traversing the
pleural soft tissue abnormality.
2. No evidence of pulmonary embolism or acute aortic process.
Brief Hospital Course:
This is a 73 y/o M with DOE, worsening SOB and large mediastinal
lymphnodes and pleural effusion concerning for malignancy.
.
# Pleural Effusion: possibly malignant effusion vs. emphyema.
Thoracic surgery involved and put in chest tube to drain
effusion. Fluid consistent with exudate. In clinical setting,
does not appear to be infectious. Treated with
vanco/cefepime/levo in the ED. Pathology was equivocal but
lymph node biopsy consistent with large B cell lymphoma. Chest
tube eventually pulled and patient continued to breath well
without signs of effusion clinically.
.
# Lymphoma - had L axillary lymph node biopsy confirming
diagnosis. Was treated initially with dexamethasone and tumor
lysis labs were checked often. Patient then started [**Hospital1 **].
Course was complicated by intense fatigue and constipation. Was
able to move his bowels eventually. Patient also was very
edematous and receiving lasix daily but was still edematous at
the time of discharge.
.
# Dyspnea: pt stable with appropriate RR and O2 sat of high
90s on RA. Will continue O2 NC PRN, although does not seem to
need it. Had stable respiratory status throughout admission.
.
# Pain: likely from metastatic disease, will be exacerbated by
pain caused after thoracentesis. Treated with dilaudid while on
7F and tolerated pain well.
.
# Access - patient had severe swelling in R arm where PICC was
placed, was pulled the day prior to discharge. Did not have a
clot based on UE ultrasound.
.
# Hyperlipidemia: stopped statin because of chemo.
.
# Cardiovascular: held aspirin due to fact that counts would
drop.
.
# Discharged home wtih close follow up checking labs and
following up edema.
Medications on Admission:
Lipitor 10 mg daily
ASA 81 mg daily
Glucosamine supplements
variety of narcotics for "sciatica" pain
Discharge Medications:
1. Neupogen 480 mcg/0.8 mL Syringe Sig: One (1) Injection once
a day.
Disp:*10 syringes* Refills:*0*
2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day: do
not take if having loose stools.
Disp:*30 Capsule(s)* Refills:*2*
5. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Final Diagnosis:
1. Large B cell lymphoma
2. Malignant pleural effusion
Discharge Condition:
patient walking around with walker, afebrile, vital signs
normal, still with 2+ pedal edema, 95% on room air
Discharge Instructions:
You came to the hospital to have evaluation of a mass seen on a
scan done by your PCP. [**Name10 (NameIs) **] admission you were found to have a
large pleural effusion. A chest tube was placed and the fluid
was drained. Then a biopsy of one of your lymph nodes was done
and a diagnosis of large B cell non-Hodgkin's lymphoma was made.
.
For your lymphoma, you were treated with steroids for two days,
and then started on chemotherapy called [**Hospital1 **]. The chemotherapy
lasted 5 days and you tolerated it well except for some severe
fatigue. You will need to continue to follow up closely in the
clinic for outpatient treatment with methotrexate as well as
additional admissions for the [**Hospital1 **] treatment.
.
During your hospital stay, you received a lot of IV fluids and
needed lasix to help remove the fluid and decrease your
swelling. We are not going to send you home with lasix, and the
best way to keep the fluid from collecting in your extremities
is to keep them elevated and keep walking around.
.
You also had a PICC line placed in your R arm and had some
swelling in your R hand. Prior to being discharged, we removed
the PICC line with hopes that the swelling will start to
resolve.
.
In terms of your medicines, you should start the Neupogen shots
tomorrow. You should also take allopurionl 300 mg daily. You
should take a thiamine vitamin, a colace daily for stool
softening and dilaudid pills as needed for pain. These were the
pain pills you were getting while in the hospital. Only take
them if needed.
.
Please call the hospital or be seen in the emergency room for
any fevers with a temperature over 100.4, chills, falls,
shortness of breath, chest pain, abdominal pain, nausea,
vomitting or any other concerns.
Followup Instructions:
Please follow up in the oncology clinic on Saturday, [**2155-4-11**] at
1030 am to have your labs rechecked and be seen by a nurse.
.
Then again follow up in the oncology clinic on Tues [**2155-4-14**] in
the morning at 11 am to get treatment. You will then have an
appointment after treatment with Dr. [**Last Name (STitle) **] at 4pm.
.
Please follow up with the interventional pulmonologist Dr. [**Last Name (STitle) **]
on [**2156-4-23**] at 1030am. His phone number is [**Telephone/Fax (1) 5072**]; you can
call and try to change the appointment to coincide with an
oncology appointment if that would be easier.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2156-4-20**]
|
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icd9cm
|
[
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,128
| 143,131
|
33854
|
Discharge summary
|
report
|
Admission Date: [**2139-1-16**] Discharge Date: [**2139-1-19**]
Date of Birth: [**2094-6-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Zantac / Morphine / Tylenol / Naprosyn / ketorolac
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Abdominal Pain, Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
44 y/o F with ESRD on HD, CAD s/p MI [**2129**], DM, IVC filters with
multiple DVTs in the past who was just admitted [**1-12**] to [**1-15**] for
altered mental status. She presents today with abdominal pain
and altered mental status. Her last admission, she was in HD and
was negative 600-800cc, and subsequently developed hypotension
with SBP in 80s. During that time, her infectious workup,
metabolic workup with LFTs and TFTs, and physical exam besides
mental status were normal at first. She did grow blood cultures
positive for coag neg staph and gran-positive rods in 1 out of 2
sets from [**2139-1-12**]. No other blood cultures following were
positive. This was thought likely contaminate. Regardless, she
was given vanco and had a plan to receive one week of vanco at
HD. She eventually cleared without intervention. She was
discharged to [**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **].
.
Today, she was found altered and with severe abdominal pain. Was
not able to get much history as she is not cooperating. In the
ED, initial vitals were P 97, BP 116/65, R 16, and 100%RA. She
had a femoral line placed and was given cipro, flagyl and vanco.
She had a CT scan showing mesenteric edema. She was noted to
have a lactate of 5.1 and received approximately 2L NS in the
ED. She also had dilaudid for her pain and had some apnea. She
received narcan. She was noted to be hypotensive but did not
require pressors. It improved with fluids. Of note, per HD
nurse, her baseline BPs during HD are usually systolics 80s-90s.
.
She was admitted to the floor and was in severe pain. HD was
started and she was tolerating well. Her vital signs were
stable. She has strange writhing movements and cannot answer
questions appropriately.
Past Medical History:
ESRD on HD with RUE AV fistula
CAD s/p inferior MI (cath [**2129**] with nonobstructive CAD, EF 65%,
inf hypokinesis)
DM II
h/o LLE DVT (no longer on coumadin), popliteal DVT [**2136-8-25**]
s/p IVC filter placement
HTN
Hyperlipidema
GERD
Reported history of MRSA
Social History:
Born in [**Country 2045**]. Moved from [**State 108**] to Mass. recently. Lives at
[**Location **] Manor. Divorced; has 21 and 16 y/o daughters who live
with their father. [**Name (NI) **] tobacco, EtOH, or illicit drug use.
Family History:
Mother died from DM complications, Brother also died from DM
complications, Sister has DM.
Physical Exam:
GENERAL: Lethargic and arousable to sternal rub and voice.
Answers one word answers.
HEENT: Right eye PERRL, EOMI, Artifical left eye, left sided
ptosis, sclera slightly dry MM No nystagmus.
NECK: supple, no appreciable JVD
CARDIAC: RRR, no r/m/g appreciated
LUNGS: transmitted, coarse, upper airways sounds
ABDOMEN: bowel sounds present, soft, non-tender, non-distened,
no hepatosplenomegaly
EXTREMITIES: warm, DP/PT pulses 1+, radial pulses palpable but
faint, no edema, RUE AV fistula with bruit and palpable thrill,
dressing over fistula C/D/I, area without erythema, tenderness
or fluctuance
NEURO: lethargic, arousable to voice and sternal rub but
frequently falls back to sleep, oriented to person, place, year,
follows commands when awake, CN 2-12 grossly intact, strength
[**4-2**] in all four extremities, swollen eyes, has chorea-like
movements and writhing in pain
SKIN: RUE AV fistula site without erythema
Pertinent Results:
Admission Labs:
[**2139-1-15**]
CBC: WBC-4.3 RBC-3.55* Hgb-10.8* Hct-32.4* MCV-91 MCH-30.5
MCHC-33.4 RDW-16.5* Plt Ct-209
Diff: BLOOD Neuts-79.6* Lymphs-14.2* Monos-3.7 Eos-1.8 Baso-0.6
Chemistries: Glucose-264* UreaN-25* Creat-6.9*# Na-138 K-4.2
Cl-93* HCO3-37* AnGap-12 Phos-3.7 Mg-2.3
Serum HCG-<5
Serum tox screen: ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
Discharge Labs:
[**2139-1-19**]
CBC: BLOOD WBC-4.0 RBC-3.17* Hgb-9.7* Hct-30.0* MCV-95 MCH-30.5
MCHC-32.2 RDW-16.9* Plt Ct-209
WBC: BLOOD Neuts-59.3 Lymphs-25.4 Monos-5.2 Eos-9.6* Baso-0.6
Coags: PT-13.2 PTT-31.1 INR(PT)-1.1
Chemistries: Glucose-144* UreaN-15 Creat-7.5*# Na-138 K-4.0
Cl-97 HCO3-30 AnGap-15 Calcium-9.1 Phos-4.2 Mg-2.5
CT Abdomen/Pelvis:
1. Diffuse mesenteric edema, new from [**2138-11-29**], of uncertain
etiology or
significance.
DDx includes hypervolemia, infectious or inflammatory change of
the bowel or mesentery, mesenteric stranding due to ischemic
bowel, or other less likely entities such as lymphoma or chronic
mesenteritis. No history of peritoneal dialysis per clinical
team. No evidence of vascular compromise in this limited study,
but clinical correlation (including lactate level) and
mesenteric CTA might be considered to rule out mesenteric
ischemia.
2. Distended gallbladder. No specific CT evidence of
cholecystitis but
ultrasound or HIDA could be obtained for further evaluation if
clinical
symptoms warrant.
3. Atrophic kidneys and renal osteodystrophy.
CT Head:
1. No acute intracranial process. Note that CT has limited
sensitivity for
the evaluation of acute infarction, and MR can be obtained as
clinically
indicated.
2. Diffuse osteosclerosis most compatible with renal
osteodystrophy.
3. Mucosal opacification and fluid within the paranasal sinuses.
Clinically
correlate for sinusitis
CXR:
Moderate cardiomegaly persists. Pulmonary vasculature
engorgement is mild. There is no edema or pleural effusion but
there is enough azygos distention to suggest elevated central
venous pressure or volume.
Brief Hospital Course:
44 y/o F with ESRD on HD, CAD s/p MI [**2129**], DM, IVC filters with
multiple DVTs presenting with new abdominal pain, hypotension
and missed HD.
# Abdominal pain: She was initially treated with cipro/flagyl
empirically for possible intraabdominal infection. CT showed
mesenteric edema but no other source of pain or infection.
Stool C. Diff was negative. Lactate was normal at 0.9.
Antibiotics were stopped as her pain improved as she had no
signs of infection.
# Toxic Metabolic Encephalopathy: CT head showed no acute
process. Serum tox screens were negative for benzodiazepenes,
barbituates and tricyclic antidepressants. Patient reported
taking diphenhydramine at home for itching. Neurology was
consulted and felt that this likely representated a toxic
metabolic encephalopathy and did not recommend further testing.
After receving hemodialysis on [**2139-1-19**], her mental status
improved. It was thought that her encephalopathy may have been
due to a combination of diphenhydramine, missed dialysis and
OSA.
.
# Obstructive Sleep Apnea: Patient was noted to be apneic
intermittenly throughout the day and was placed on auto-set CPAP
with a range of pressure from [**4-17**] which she tolerated. Patient
was discharged on CPAP, with plans for a formal sleep study to
be arranged.
.
# Hypotension: Patient was continued on her home dose of
fludricort.
.
# ESRD on HD: Patient had hemodialysis on [**2139-1-16**] and [**2139-1-19**].
She was continued on her home dose of sevelamer and nephrocaps.
# Fistula flap: Seen on imaging last week, no evidence of
infection around the graft, working well tonight on HD.
.
# Positive blood cultures: Patient was under treatment with
vancomycin for 7 days for a positive blood culture from [**2139-1-12**]
for coag negative staph and diptheroids. Blood cultures from
this hospitalization ([**2139-1-16**]) had no growth at the time of
discharge. Vancomycin was discontinued on [**2139-1-19**] after 7 days
of treatment.
.
# DM: Patient was treated with glargine 5 units qhs, and a
humalog sliding scale.
.
# CAD: Patient was continued on her aspirin and statin
.
# GERD: Continued on her home omeprazole.
Medications on Admission:
1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Vancomycin 1000 mg IV HD PROTOCOL
13. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic QID (4 times a day) for 7 days: day 1=[**2139-1-15**].
Apply to both eyes.
14. Aranesp (polysorbate) 40 mcg/0.4 mL Syringe Sig: One (1)
Injection Injection once a week.
15. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Application Ophthalmic twice a day.
16. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day.
17. Levemir 100 unit/mL Solution Sig: Six (6) units Subcutaneous
at bedtime.
18. Humalog 100 unit/mL Solution Sig: Per sliding scale
Subcutaneous four times a day: As previous.
19. Renagel 800 mg Tablet Sig: Three (3) Tablet PO three times a
day.
20. Dilaudid 2 mg Tablet Sig: 0.5 Tablet PO every six (6) hours
as needed for pain.
Discharge Medications:
1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal twice a day.
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical once a day as needed for pain.
3. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
4. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as
needed for constipation.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
7. latanoprost 0.005 % Drops Sig: One (1) drops Ophthalmic at
bedtime: ou.
8. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic QID (4 times a day).
12. Aranesp (polysorbate) 40 mcg/0.4 mL Syringe Sig: One (1)
injection Injection once a week.
13. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) application Ophthalmic twice a day.
14. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
15. Levemir 100 unit/mL Solution Sig: Six (6) units Subcutaneous
at bedtime: subcutaneous.
16. sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO three
times a day.
17. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for pain.
18. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
19. Insulin Sliding Scale
Please check fingerstick blood glucose qid and administer
humalog according to the attached sliding scale.
20. CPAP
Settings: Autoset [**4-17**]. If no autoset available, start at
pressure of 8.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 16662**] Nursing and Rehab Center - [**Street Address(1) **]
Discharge Diagnosis:
Toxic Metabolic Encephalopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with confusion. You have blood tests and an
x-ray that did not show any evidence of infection. We think
that your confusion was most likely caused by medications, your
kidney disease, and obstructive sleep apnea, a condition where
you don't breath enough at night. We have started you on CPAP
(continuous positive airway pressure) for your sleep apnea.
Please do not take benadryl for itching, it can make you
confused.
We made no changes in your medications.
Followup Instructions:
Please arrange to see your primary care doctor within one week
of discharge.
We will schedule a sleep study for you, to determine the optimal
settings for your CPAP machine.
|
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11765, 11879
|
2170, 2435
|
2451, 2678
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,023
| 119,268
|
19882
|
Discharge summary
|
report
|
Admission Date: [**2160-1-18**] Discharge Date: [**2160-1-25**]
Date of Birth: [**2084-2-23**] Sex: M
Service: TRAUMA
ADMISSION DIAGNOSIS: Trauma with left acromial fracture and
left rib fractures with hemothorax.
SECONDARY DIAGNOSES:
1. Spinal stenosis.
2. Atrial fibrillation.
3. Coronary artery disease.
4. Hypertension.
5. Status post left total hip replacement.
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
male who was cutting trees on the day of admission and a tree
branch struck his head and left shoulder. The patient was
without loss of consciousness, complains of left shoulder
pain. The patient was transferred from an outside hospital
for further evaluation. The patient is on Coumadin with INR
of 3.2. Tense left upper extremity. Patient with emesis on
arrival to [**Hospital1 18**].
PAST MEDICAL HISTORY: Atrial fibrillation. Myocardial
infarction status post PTCA stent. Hypertension. Left total
hip.
MEDICATIONS ON ADMISSION: Coumadin 5 mg a day, atenolol 100
mg a day, Zestril 5 mg a day, aspirin 81 mg q.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Temperature 99.6, heart rate 114 in
atrial fibrillation, blood pressure 112/63, respiratory rate
18, pulse ox 93 percent on 2 liters nasal cannula. In
general, GCS 15. Pupils equally round and reactive to light
and accommodation. Head and neck exam showed a 4 cm
laceration on the posterior aspect of the scalp. Chest was
clear to auscultation bilaterally. Cardiac showed irregular
rate and rhythm. Abdomen soft, nondistended, nontender.
Extremities left upper extremity was tense with ecchymosis.
Radial pulse 2+. Sensation intact to light touch. Left hand
motor was [**6-18**] in radial, median and ulnar. Neuro exam was
within normal limits.
LABORATORY DATA: On admission sodium 139, potassium 5.1,
chloride 114, bicarb 24, BUN 35, creatinine 1.6, glucose 149.
White blood cell count 15.8, hematocrit 32.6, platelets 218.
INR 3.5. Lactate 1.5. Amylase 61. Serum tox was negative.
Urinalysis was negative. CT of the C-spine showed
degenerative changes and spinal stenosis at C6-C7. There was
retrolisthesis at C5-C6, anterolisthesis C1-C2-C3. Chest
x-ray showed no pneumo, showed an AC separation on the left
and acromial fracture and left rib fractures six through
eight and 11th rib. Pelvis showed right hip replacement,
degenerative changes of the left hip. CT of abdomen and
pelvis showed no free fluid, no free air. CT of the chest
showed left pulmonary contusion, vascular negative.
HOSPITAL COURSE: The patient was admitted to the intensive
care unit where he was placed there for observation.
Orthopaedic consult was obtained as the patient's left upper
extremity and shoulder region were tense. There was no
evidence of compartment syndrome. They recommended a sling
for comfort and follow up in orthopaedic trauma clinic. Ice
packs to the shoulder and pain control. Neurosurgical
consult was obtained for degenerative changes. The patient
obtained flexion extension views to clear his C-spine which
was done. Neurosurgery requested followup in their clinic in
one month for evaluation of spinal stenosis.
As mentioned, the patient was admitted to the ICU. For
details please see ICU notes in the chart. Essentially his
coumadinization was reversed using FFP and vitamin K. Upon
discharge his INR was approximately 1.3. The patient's
hematocrit gradually trended down into the high 20s. The
patient was transfused to obtain hematocrit greater than 30.
As his hematocrit continued to trend down, chest x-ray was
reobtained and it showed a large left effusion consistent
with hemothorax. This was after the patient had been
transferred to the floor.
On [**2160-1-22**], hospital day five, the patient received a chest
tube. The chest tube expressed 800 cc of blood initially.
Chest tube was left to wall suction. Sequential chest x-rays
showed resolution of the hemothorax. Chest tube was
eventually pulled and post chest tube removal showed
resolution of the hemothorax and no pneumothorax. While in
the ICU the patient also received an MRI of the C-spine
showing no acute cord changes and reiterated the severe
cervical spinal stenosis. While on the floor the patient's
hematocrit level remained stable in the low 30s. His primary
care physician was [**Name (NI) 653**] who suggested that we restart
him on Coumadin 5 mg a day starting on Monday, [**1-28**].
The patient had also received an additional abdominal CT
while on the unit as his hematocrit had been falling, as
previously stated. Both abdominal CTs did not show any
bleed. The patient was guaiac negative on admission and a
second exam was done. Prior to the day of discharge the
patient was seen by occupational therapy and physical
therapy. He was out of bed, walking around without
difficulty. His pain was well controlled with p.o.
medication. He was tolerating a regular diet. Occupational
therapy recommended outpatient services while at home for
left upper extremity exercises. The patient will be seen by
occupational therapy at home.
The patient's 4 cm laceration on the posterior aspect of his
scalp was stapled on the day of admission. The staples were
discontinued on the day of discharge.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS:
1. Coumadin 5 mg a day to start on [**1-28**].
2. Percocet for pain.
3. Colace for constipation.
4. Atenolol once a day as previously taking.
5. Lisinopril 5 mg a day as previously taking.
6. Iron once a day.
DISCHARGE INSTRUCTIONS: The patient will follow up in trauma
clinic in three weeks. The patient will follow up in
neurosurgery clinic in one month. The patient will follow up
in orthopaedic trauma clinic in two to three weeks. The
patient will follow up with his primary care physician [**Last Name (NamePattern4) **]
[**2-4**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], M.D. [**MD Number(1) 14131**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2160-1-25**] 09:13
T: [**2160-1-28**] 14:29
JOB#: [**Job Number 53707**]
|
[
"V45.82",
"811.01",
"412",
"860.2",
"V58.61",
"414.01",
"807.03",
"873.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"86.59",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
5323, 5539
|
994, 1116
|
2569, 5268
|
5564, 6150
|
254, 392
|
1139, 2551
|
157, 233
|
421, 843
|
866, 967
|
5293, 5300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,138
| 144,158
|
10667
|
Discharge summary
|
report
|
Admission Date: [**2142-11-20**] Discharge Date: [**2142-11-22**]
Date of Birth: [**2086-2-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Mental status changes
Hypoglycemia
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
56yo RH M h/o alcoholic cirrhosis, diabetes, chronic renal
insufficiency p/w hypoglycemia and AMS. Pt was in USOH till last
night. His wife heard him moaning at 2 am. EMS was called. His
FSG was 30. He recived D50 and FSG went up to 130. He was
confused and delirious and was taken to the ED.
.
In the ED he was founbd to have fever to 101 and was delirious
and agitated. His head CT was neg for acute IC process. He
underwent LP under conscious sedation. Neuro was consulted. He
received CTX 2g x 1 and acyclovir 750 mg x 1. UA was neg and CXR
showed LLL opacity concerning for PNA.
.
His wife reports that he had a episode of hypoglycemia at the
time of [**Holiday **] when he also had a seizure-like activity
with it. However at that time his MS [**Name13 (STitle) 34984**] to baseline
quickly. Also she notes that he has [**Last Name (un) **] coughing on and off for
past few days, sometimes bringing up mucus.
.
ROS (per his wife): No night sweats or recent weight loss or
gain. Denied 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.
Denied rash.
Past Medical History:
DM with unspecified complication type 2 - Type w many
complications
Retinopathy, Neuropathy
Diabetes Type: 2
Years w/ DM: 4 Age of Diag: 52 Year Diag: [**2137**]
How Diag: classic symptoms
Patient treats diabetes with: - Insulin. Patient is on the
sliding level insulin plan.
Alcoholic Cirrhosis of Liver
Hyperparathyroidism, secondary, of renal origin
Joint pain, shoulder
GI Bleeding
Alcohol Abuse
Psych Factors Associated with DM
Anemia of End Stage Renal Disease awaits renal-liver transplant
Impotence, organic origin
Hypofunction, testicular NEC
Chronic kidney disease, stage 3
Microalbuminuria
Hypertension, benign essential
Social History:
on disability. Quit etoh 4yrs ago. Wife does not know of any
illicit drug use.
Family History:
mother/father had diabetes
Physical Exam:
VS: 97.6 138/70 89 16 100%/RA
Gen Awake, NAD
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. Tympanic
Ext No C/C/E b/l
Skin no rashes or lesions noted
Pertinent Results:
[**2142-11-22**] 06:45AM BLOOD WBC-5.5 RBC-3.06* Hgb-8.8* Hct-27.1*
MCV-89 MCH-28.8 MCHC-32.5 RDW-13.5 Plt Ct-133*
[**2142-11-21**] 03:31AM BLOOD WBC-5.5 RBC-2.95* Hgb-8.6* Hct-26.1*
MCV-88 MCH-29.2 MCHC-33.1 RDW-13.6 Plt Ct-119*
[**2142-11-20**] 04:27AM BLOOD WBC-6.3# RBC-3.86* Hgb-11.0* Hct-33.9*
MCV-88 MCH-28.5 MCHC-32.5 RDW-14.0 Plt Ct-187
[**2142-11-20**] 10:20AM BLOOD Neuts-81.2* Bands-0 Lymphs-12.7*
Monos-5.4 Eos-0.6 Baso-0.1
[**2142-11-21**] 12:16PM BLOOD PT-14.7* PTT-37.2* INR(PT)-1.3*
[**2142-11-22**] 06:45AM BLOOD Glucose-111* UreaN-13 Creat-1.9* Na-138
K-4.1 Cl-105 HCO3-27 AnGap-10
[**2142-11-20**] 04:27AM BLOOD Glucose-110* UreaN-19 Creat-2.2* Na-137
K-4.3 Cl-101 HCO3-26 AnGap-14
[**2142-11-21**] 12:16PM BLOOD ALT-16 AST-33 LD(LDH)-152 AlkPhos-82
Amylase-124* TotBili-0.3
[**2142-11-20**] 04:27AM BLOOD ALT-23 AST-39 AlkPhos-118* Amylase-189*
TotBili-0.7
[**2142-11-22**] 06:45AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.1
[**2142-11-21**] 12:16PM BLOOD Albumin-3.4 Calcium-7.8* Phos-2.5*
Mg-3.6* Iron-66
[**2142-11-21**] 12:16PM BLOOD calTIBC-241* VitB12-354 Folate-GREATER TH
Ferritn-157 TRF-185*
[**2142-11-21**] 03:31AM BLOOD %HbA1c-5.8
[**2142-11-20**] 04:29AM BLOOD Ammonia-40
[**2142-11-20**] 04:27AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2142-11-20**] 06:14PM BLOOD Lactate-1.6
[**2142-11-20**] 10:24AM BLOOD Lactate-2.3*
[**2142-11-21**] 06:17PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.002
[**2142-11-21**] 06:17PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2142-11-20**] 10:18PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
[**2142-11-20**] 10:18PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2142-11-20**] 10:18PM URINE RBC-88* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1 /HPF
[**2142-11-20**] 10:18PM URINE Mucous-RARE
[**2142-11-20**] 05:50AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2142-11-20**] 05:50AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2142-11-20**] 05:50AM URINE
[**2142-11-20**] 05:50AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2142-11-20**] 10:00AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-76
Lymphs-8 Monos-16
[**2142-11-20**] 10:00AM CEREBROSPINAL FLUID (CSF) TotProt-30 Glucose-70
[**2142-11-20**] 10:00AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
Blood and urine culture neg to date. CSF cultures neg to date.
US FINDINGS: Limited survey of the four quadrants of the abdomen
demonstrates no intra-abdominal ascites. Incidental note is made
of an echogenic liver echotexture and cholelithiasis, which was
also present on previous study.
IMPRESSION: No intra-abdominal ascites.
CXR: FINDINGS: A single portable radiograph is available for
review. Lung volumes are slightly decreased when compared to
previous. Fullness within the hilar regions bilaterally is
believed secondary to low lung volumes and vascular crowding.
There is a subtle opacity within the left lung base. No effusion
or pneumothorax is identified.
IMPRESSION: Suble opacity in the left lung base which may
represent focal atelectasis however correlation with PA and
lateral radiographs recommended. Otherwise, no acute
cardiopulmonary process is detected.
NONCONTRAST HEAD CT: Multiple attempts were made, however, the
patient was not able lie still and various parts of scan are
limited by motion. Within the limitations, there is no evidence
of acute intracranial hemorrhage or major vascular territorial
infarct. The ventricles are normal in size and configuration.
There are no extra-axial fluid collections. No calvarial
fractures identified. There is complete opacification of the
right maxillary sinus with mild thickening of the underlying
bone, suggesting chronic sinusitis.
IMPRESSION:
1. Limited study due to motion. No evidence of acute
intracranial hemorrhage or major vascular territorial infarct.
2. Chronic right maxillary sinusitis.
CXR: FINDINGS: In comparison to the previous examination of
[**2142-11-20**], there is no relevant change. The pre-existing very
subtle parenchymal opacity at the left lateral lung base is
slightly smaller than on the previous examination. The lack of
contour loss of the left hemidiaphragm, not the left heart
border, makes an inflammatory opacity unlikely. No pleural
effusion. No signs of fluid overload, no other suspicious
pulmonary opacities. The size of the cardiac silhouette is
within the upper range of normal, with an accentuated left heart
border.
IMPRESSION: In comparison to [**2140-11-20**], there is slight
decrease in subtle left- sided opacity. Configuration and
morphology of this opacity, however, make an inflammatory
etiology unlikely. Accentuated left heart border.
Brief Hospital Course:
# H/o DM type 2 / Hypoglycemia: from poor po intake from missing
dentures. Now resolved as her started eating. [**Last Name (un) **] follow up
arranged/ Diabetic education provided by nutrition. Continue
lantus at 6 units at bedtime with humalog coverage only if
sugars>200. Discussed at length with patient about appropriate
meals and [**Last Name (un) **] education. VNA arranged for at home for continual
diabetic education.
# Delirium: resolved. Likely related to prolonged hypoglyemia.
No signs of infection on LP. Did well off antibiotics. Per wife,
patient's mentation is at baseline. Neuro folloed as well.
#Fever in ER: no recurrence. Negative culture data to date.
Antibiotics stopped.
# CKD stage : On list for kidney transplant. On renal
supplements - calcitriol and lisinopril.
# Alcoholic cirrhosis: on nadolol. On list for liver transplant.
D/w liver team - no indication of acute encephalopathy.
# Anemia: has a history of varices (banded) in past. Guiac neg
per ICU team.
Hematocrit stable in hospital. Plan hct check with PCP next
appt. Patient reports he stopped taking oral iron a few weeks
back which could be the reason he is now anemic.
# Post LP headache - resolved with conservative measures.
.
# Thrombocytopenia: dilutional vs hypersplenism. Has had low
platelets in past. Plan to check plts with PCP at next appt.
.
# Hematuria: repeat UA with PCP. [**Name10 (NameIs) **] from foley trauma. U
culture pending.
# Abnormal CXR: Opacity since [**2139**] - as above. Defer further
evaluation to PCP.
Medications on Admission:
Multivitamin once a day
Humalog sliding scale
nadolol 40 mg once a day
nortriptyline 25 mg once a day
lisinopril 20 mg once a day
Lantus insulin 10 units once a day
folic acid 1 mg daily
calcitriol 0.5 mg daily
Amoxicillin before dental work
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Insulin Glargine 100 unit/mL Solution Sig: 6 (six) Units
Subcutaneous at bedtime.
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Amoxicillin 500 mg Capsule Sig: Four (4) Capsule PO once: one
hour before dental work as recommended by the dentist.
10. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO once a
day.
11. Humalog 100 unit/mL Solution Sig: as per attached sliding
scale Subcutaneous four times a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Hypoglycemia, resolved
Diabetes mellitus type 1, uncontrolled with complications
Delirium, resolved
Alcoholic cirrhosis
Chronic kidney disease stage 3
Discharge Condition:
stable.
Discharge Instructions:
Your were admitted for confulsion likely related to very low
sugar levels. The low sugar was from missing a meal or eating
poorly (while being on insulin). It is very important that you
closely monitor your sugars and take regular meals especially
since you are on insulin.
Keep your appointments. You also are advised to follo wup with
[**Hospital **] clinic.
Nursing services have been set up for you at home (visiting
nurses) mainly for diabetic education.
Return to the hospital if you notice any bleeding, confusion,
sweating or other symptoms of concern to you. Your platelets and
hematocrit counts were low and so please discuss with your
primary doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] about getting a blood work done at your
visit with him. Also discuss with your primary doctor about
getting another urine test to look for blood.
Followup Instructions:
Primary care Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 815**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2142-12-6**] 2:30. Discuss with your primary doctor about
checking a bloot test for CBC at that time.
[**Hospital **] clinic:
1. With [**Doctor First Name **] ([**Telephone/Fax (1) 2378**]) on [**2142-11-29**] at 1430 hours
2. Dr [**Last Name (STitle) 10516**] on [**2142-12-24**] at 11AM
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2143-1-7**]
10:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2143-1-23**] 10:00
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2143-1-25**] 10:30
|
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icd9cm
|
[
[
[]
]
] |
[
"03.31"
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icd9pcs
|
[
[
[]
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] |
10487, 10545
|
7701, 9233
|
352, 370
|
10740, 10750
|
2832, 6202
|
11668, 12468
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2395, 2424
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9525, 10464
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6211, 7678
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,819
| 116,800
|
363
|
Discharge summary
|
report
|
Admission Date: [**2181-5-6**] Discharge Date: [**2181-5-11**]
Date of Birth: [**2103-9-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3266**]
Chief Complaint:
mental status change
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
77 M with pmhx of pulmonary fibrosis, CHF, presents with one
week history of altered mental status, increasing lethargy, and
confused speech. He was brought to his PCP (Dr. [**Last Name (STitle) 3267**] for
evaluation and was referred for a Head CT on 2 days PTA,
negative. On the DOA, he was found by his son to be slumped in
bed, minimally responsive, confused, with bowel incontinence,
and brought to the ED. No report of LOC, trauma, fevers, chills,
has had continued good PO intake, no diarrhea per report, or
cp/sob
In ED, VS 97.8 57 184/40 100% 2L, given levaquin, NS, lactulose,
head CT was negative. NGL was negative.
He was taken to MICU for closer monitoring. TBili was elevated
and ammonia was 114. RUQ U/S revealed chronic liver disease
changes and hepatology was consulted.
Upon improvement of mental status with lactulose, he was
transferred back to the floor. On the floor, he has no
compliants of pain. He denies any F/C/N/V, abd pain. He does
note feeling very thirsty.
Past Medical History:
Interstitial Fibrosis
CHF
Social History:
Lives with wife (with alzheimers), son lives 3 blocks away,
independant own ADLs, was driving up to 1 week ago, DC'd Etoh 5
yrs ago, was told to stop, o/w [**2-3**] drinks/day, quit smoking 25
yrs ago, but o/w 1-2ppd smoker.
Family History:
Brother died 40s, CAD
Father died 40s, CAD
1 Sister healthy
Physical Exam:
VS 98.9 98.9 154-187/71-76 68 18 99%2L
GEN: slightly agitated
HEENT: PERRL, EOMI, icteric sclera, dry MM, OP with thrush
CV: RRR, SEM III/VI, radiating R carotid
ABD: +BS, NT, distended, splenomegaly, no hepatomegaly, no
stigmata, trace guaiac positive
Neuro: awake, oriented X 3, no asterixis
Pertinent Results:
Head CT Head: neg
.
CXray [**2181-5-6**]
- New airspace opacities in left mid and both lower lungs, which
may be due to asymmetrical edema or aspiration pneumonia.
- Diffuse irregular interstitial opacities consistent with
patient's history of fibrosis.
- Multiple calcific densities projecting over the right upper
quadrant likely gallstones.
.
Abd USG [**2181-5-6**]
- findings consistent with chronic liver disease
- no evidence of ascites
- portal vein is patent with antegrade flow.
- Cholelithiasis without cholecystitis.
.
ECHO [**2181-5-7**]
- EF 55%
- left atrium is dilated
- mild symmetric LVH Right ventricular chamber
- mild aortic valve stenosis (area 1.2-1.9cm2)
- Mild (1+) aortic regurgitation
- Mild (1+) mitral regurgitation is seen.
- Mod pulmonary artery systolic hypertension
- no pericardial effusion
Endoscopy:
Erythema and mosaic appearance in the stomach body and fundus
compatible with portal gastropathy
Varices at the lower third of the esophagus and middle third of
the esophagus
Varices at the lower third of the esophagus and middle third of
the esophagus
Erythema in the gastroesophageal junction compatible with
esophagitis
Otherwise normal EGD to second part of the duodenum
Brief Hospital Course:
77 y/o M with pmhx of idiopathic pulmonary fibrosis, CHF p/w
altered MS and found to have hepatic encephalopathy
.
# Chronic liver disease: The etiology for his liver disease is
unclear. [**Name2 (NI) **] does drink alcohol but not excessively per patient
and family report. Hepatitis serologies, hemachromatosis, A1AT,
and [**Doctor First Name **] were sent and unremarkable. EGD revealed large varices,
and he was started on nadolol and [**Hospital1 **] PPI.
# Altered Mental Status: This was felt to be secondary to
hepatic encephalopathy as well as a UTI. His mental status
improved with lactulose and levaquin for UTI. It remained
unclear what precipitated the hepatic encephalopathy, but may be
infection. Patient remained afebrile, but with mild
leukocytosis. Ultrasound revealed no ascites and thus no SBP. He
continued lactulose, MVI, thiamine, folate.
# Infectious: Patient noted to have urinary tract infection and
possible radiographic evidence of PNA (although no cough,
fever). He was started on levaquin on [**2181-5-6**]. He should continue
for total of 14 day course.
# Anemia: Patient noted to have macrocytic anemia felt likely
from liver disease. B12 and folate were high. Although
haptoglobin low and LDH high and fibrinogen 100, he was not felt
to to be in DIC because no schistocytes on smear and he was
hemodynamically stable with stable hematocrit. Low haptoglobin
was attributed to cirrhosis. He did have guaiac positive stools
and will need outpatient GI follow-up. EGD revealed ulcerations
and Barrett's, and he was started on [**Hospital1 **] PPI.
# Thrombocytopenia: Baseline in [**2171**] was 150's. Now lower
possibly due to splenic sequestration. No evidence to suggest
TTP/HUS.
# Mild Coagulopathy: Felt likely from chronic liver failure.
# HTN: Patient was found hypertensive on admission with elevated
BP during MICU stay. He was initially on lopressor, but then
switched to nadolol given varices.
# Aspiration: NGT placed in MICU for possible aspiration and
inability to swallow [**2-2**] delirium. Speech and swallow eval
cleared him for ground solids. He will need further speech and
swallow therapy at rehab.
# CODE: Full
.
# Contacts: Son
[**Telephone/Fax (3) 3268**]
Medications on Admission:
1. Prednisone, 10 mg daily.
2. Spironolactone, 50 mg daily.
3. Atenolol, 50 mg daily.
4. Aspirin, 81 mg daily.
5. Ativan as needed for sleep.
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q2-3HRS ()
as needed for Titrate to 3 BMs/Day.
Disp:*2700 ML(s)* Refills:*5*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]
Discharge Diagnosis:
Primary:
cirrhosis
esophageal varices
urinary tract infection
Secondary:
idiopathic pulmonary fibrosis
Discharge Condition:
stable, mental status at baseline
Discharge Instructions:
You have several new diagnosis:
1) You have chronic liver disease of unclear cause. Your liver
disease may have contributed to your confusion.
2) You also have esophageal varices, which are distended blood
vessels inside your esophagus.
3) You had a urinary tract infection being treated with an
antibiotic
You will need to take several new medications due to your new
diagnosis:
1) Lactulose: You can adjust your daily dose until your have
three soft formed bowel movements every day. This medication is
very important and will help prevent your from becoming
confused.
2) Nadolol: This medication will help with your esophageal
varices
3) Please STOP taking your metoprolol
4) Protonix: This is an acid suppressors for your stomach.
Please take all medications as prescribed.
Please attend all follow-up appointments.
Please call your primary doctor or go to the emergency room if
you have any increased confusion, yellowish tinge to your eyes
or skin, increased itchyness, fever, chills, abdominal pain,
bloody vomit or stools, black and tarry stools, or any other
concerning symptoms.
Followup Instructions:
You have an appointment to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
your new liver doctor [**First Name (Titles) **] [**2181-5-29**] at 3:00 PM in the [**Hospital Unit Name 3269**] [**Location (un) **], Deth [**Country **] [**Hospital Ward Name 517**].
Please attend the following appointments:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2181-5-24**] 2:00
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2181-5-24**] 2:00
Provider: [**Name Initial (NameIs) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2181-5-24**] 3:00
|
[
"574.20",
"515",
"281.2",
"486",
"571.2",
"456.21",
"530.10",
"572.2",
"305.00",
"401.9",
"599.0",
"286.9",
"537.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6513, 6602
|
3313, 3785
|
334, 346
|
6750, 6786
|
2078, 2083
|
7927, 8659
|
1676, 1738
|
5727, 6490
|
6623, 6729
|
5561, 5704
|
6810, 7904
|
1753, 2059
|
274, 296
|
374, 1367
|
2092, 3290
|
3800, 5535
|
1389, 1417
|
1434, 1660
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,364
| 108,645
|
49486
|
Discharge summary
|
report
|
Admission Date: [**2162-9-29**] Discharge Date: [**2162-10-6**]
Date of Birth: [**2091-2-18**] Sex: M
Service: MEDICINE
Allergies:
Nsaids/Anti-Inflammatory Classifier / Vancomycin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
CC:[**CC Contact Info 103544**]
Major Surgical or Invasive Procedure:
Mesenteric angiograpm w/ coil embolization of bleeding vessel.
Sigmoidoscopy.
Colonoscopy.
History of Present Illness:
HPI: Pt is a 71 y/o male with h/o dm2, cad s/p cabg, DVT/PE on
long term anti-coagulation, ulcerative colitis on Asacol
presents with brbpr starting at 9am of the morning of admission.
He'd been having lower abdominal pain for approximately the past
week, a symptom for which he's been admitted in the past. His
PCP had recently started ciprofloxacin for a UTI. At 9am the
morning of admission he passed a large, bloody bowel movement
and came to the ED. There, his vitals were intially stable with
a hct of 36.7, though he was felt to be hypovolemic and this
hemoconcentrated; his previous hct was 39 about five months ago.
He refused an NG lavage. Although an initial DRE showed only
clot, he later passed a large, bloody bowel movement, and his bp
nadired to the low 90's but rested there only transiently and
easily rebounded to the 130's-140's with fluid; he then went to
angiography for a tagged RBC scan where they found and embolized
two vessels to the sigmoid colon. His HCT had dropped from 36.7
to 30.8 despite 2U PRBC and 3 U FFP.
.
Is called out of the [**Hospital Unit Name 153**] as has been been HD and stable HCT.
Currently denies CP, SOB, abd pain or continued BRBPR.
Past Medical History:
PMH:
1.)DM-2
2.)CAD s/p 3v-CABG [**2152**] and subsequent stenting of SVG and LIMA
3.)CHF with EF 30-35% on [**6-8**] echo
4.)Right parietal intracranial bleeding following [**2152**] cardiac
cath
5.)LBBB
6.)Sinus node dysfunction s/p pacemaker
7.)H/O DVT (right sided) and subsequent PE, put onto lifetime
warfarin
8.)Ulcerative colitis
PSH:
1.)C4-7 anterior discectomies
2.)CABG [**2152**]
3.)R intracerebral hemorrhage drainage
Social History:
SocHx: Mr [**Known lastname 103545**] generally lives with his wife but has spent a
great deal of time recently at rehab. He has no h/o ETOH/IVDA
but quit tob 15 years ago.
Family History:
Noncontributory.
Physical Exam:
VS 98.4, 62, 103/37, 15 97%2L
gen- lying in bed, NAD
heent- anicteric sclera, op clear with mmm
neck- jvd flat
cv- rrr, s1s2, no m/r/g
pul- CTAB without rales
abd- soft, minimally distended, nt, no rebound/guarding, nabs
extrm- trace edema at ankles, no cyanosis, warm/dry
Pertinent Results:
[**2162-9-29**] 05:47PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2162-9-29**] 05:47PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2162-9-29**] 05:47PM URINE RBC-21-50* WBC-0-2 BACTERIA-FEW
YEAST-NONE EPI-<1
[**2162-9-29**] 02:32PM LACTATE-1.8
[**2162-9-29**] 12:20PM GLUCOSE-197* UREA N-25* CREAT-0.8 SODIUM-141
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-22 ANION GAP-18
[**2162-9-29**] 12:20PM WBC-5.6 RBC-4.35* HGB-12.6* HCT-36.7* MCV-84
MCH-28.9 MCHC-34.3 RDW-15.7*
[**2162-9-29**] 12:20PM NEUTS-80.5* LYMPHS-13.1* MONOS-3.5 EOS-2.5
BASOS-0.4
[**2162-9-29**] 12:20PM POIKILOCY-1+ MICROCYT-1+
[**2162-9-29**] 12:20PM PLT COUNT-102*
[**2162-9-29**] 12:20PM PT-20.5* PTT-29.4 INR(PT)-3.0
GI BLEEDING STUDY [**2162-9-29**]
IMPRESSION: Increased tracer activity demonstrated within the
left lower
quadrant, most likely sigmoid colonic loops of bowel, consistent
with active
bleeding.
CT ABDOMEN W/CONTRAST [**2162-9-29**] 3:27 PM
IMPRESSION:
1. No evidence of colitis or other bowel pathology present to
explain the patient's bright red blood per rectum.
2. Stable appearance of left adrenal fat-containing lesion
consistent with a myelolipoma.
3. Stable appearance of hypodense lesion within the caudate lobe
of the liver, too small to fully characterize.
4. Subcentimeter attenuation lesion within the lower pole of the
right kidney, too small to characterize.
5. 3-mm noncalcified pulmonary nodule within the right lower
lobe. If the patient does not have a history of a primary
malignancy, followup CT of the chest in 1 year is recommended to
evaluate for stability of this finding.
Brief Hospital Course:
Initial A/P:
71 y/o male with dm2, cad, chf, uc presents with one week of
lower abdominal pain and 2 episodes of brpbr on the day of
admission.
.
#BRBPR -- The patient was in the intensive care unit given his
lower GI bleed. An angiography showed bleeding in two vessels
off of the [**Female First Name (un) 899**] supplying the sigmoid that were succesfully
embolized. The patient was transfused from a Hct 29 to 34 on the
day of discharge. His coumadin was held during his stay given
his acute bleed but restarted per his PCP with the guidance of
GI on the day of discharge.
- The patient underwent a flex sigmoidoscopy on Friday, [**10-1**],
which showed old blood in the rectal vault but no active source
of bleeding. Given this, it was advised that the patient have a
colonoscopy to rule out further bleeding.
- The patient had a colonoscopy on Monday [**10-4**] but
unfortunately, was unable to complete the study as his bowel
prep was inadequate. Therefore, he had a repeat colonoscopy on
[**10-5**] which showed expected mucosal signs of moderate ulcerative
colitis, no polyps, w/ 8 mm ulcer at junction of distal
descending colon and sigmoid colon.
.
- Biopsies were obtained during his colonoscopy and he should
follow up with gastroenterology for the results.
#Ulcerative colitis -- The patient's Asacol was originally held
but restarted the day prior to discharge per GI.
.
#CAD/CHF - The patient was restarted on his home regimen prior
to discharge as it was held temporarily given his acute GI
bleed. The exception is that per his PCP, [**Name10 (NameIs) **] aspirin will be
held for 2 weeks given that he was restarted on coumadin with
his risk of bleeding.
.
#DM-2 -- The patient was maintained on his home insulin regimen.
#h/o DVT/PE: Coumadin was initially held. It was unclear at
first as to why the patient required life-long anticoagulation.
After discussing this with his PCP, [**Name10 (NameIs) **] was clear that the
patient had had recurrent DVTs and ultimately a PE and his PCP
felt strongly that he required long-term anticoagulation. His
goal INR should be 1.6-2.0. If bleeding continues to occur,
consider [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter.
.
#Access -- 2 large bore PIV's
.
#Code -- full
Medications on Admission:
Meds on Admission:
1.)Spironolactone/hctz 25/25 daily
2.)Atenolol 12.5mg daily
3.)Insulin 45N/8R qAM and 33N qPM
4.)Furosemide 10mg every other day
5.)Aspirin 81mg daily
6.)Zoloft 40mg qAM
7.)Flomax
8.)Atorvastatin 40mg daily
9.)Ritalin 20mg daily
10.)Ramipril 2.5mg daily
11.)Asacol 400mg 3, TID
12.)Carafate 1gm [**Hospital1 **]
13.)Actos 15mg daily
14.)Folate 1mg daily
15.)Warfarin 2mg daily
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ramipril 1.25 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for DM.
11. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day) as
needed for ulcerative colitis w/o recent severe flares.
12. Insulin
45 NPH in am with 33 NPH at bedtime
Continue Sliding scale insulin as needed.
13. Sertraline 20 mg/mL Concentrate Sig: Two (2) PO at bedtime.
14. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Rectal bleeding from inferior mesenteric artery tributaries
supplying sigmoid colon.
Discharge Condition:
Good.
Discharge Instructions:
Please call physician if you develop shortness of breath,
weakness in your legs or arms, sudden blurry vision or slurred
speech, chest pain, faintness, or significant unexplained weight
loss.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2162-11-26**] 2:30
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2162-12-10**]
1:30
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2162-12-10**] 2:00
Please call [**Last Name (LF) **],[**First Name3 (LF) **] L. at [**Telephone/Fax (1) 2660**] to schedule an
appointment with him in 1 week.
Please call your gastroenterologist to schedule a follow up
appointment in 2 weeks.
|
[
"276.52",
"V58.61",
"250.00",
"V45.81",
"599.0",
"V45.01",
"556.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"99.07",
"39.79",
"99.04",
"45.24",
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
8248, 8325
|
4356, 6621
|
339, 432
|
8454, 8462
|
2636, 4333
|
8702, 9329
|
2310, 2328
|
7068, 8225
|
8346, 8433
|
6647, 6652
|
8486, 8679
|
2343, 2617
|
269, 301
|
460, 1648
|
6666, 7045
|
1670, 2104
|
2120, 2294
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,620
| 120,438
|
34183
|
Discharge summary
|
report
|
Admission Date: [**2199-5-20**] Discharge Date: [**2199-6-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Angiography
History of Present Illness:
Mr. [**Known lastname 78764**] is a [**Age over 90 **]M with history of atrial fibrillation c/b
iliac thrombus and chronic GIB who was admitted with right-sided
abdominal pain, swelling, and dyspnea. On admission, he was
found to have Hct of 16 and a rectus sheath hematoma. He had
been on levonox 60BID following recent admission for left iliac
thrombus. He was initially admitted to the vascular service and
required transfusion of 4 units PRBCs and 2 units FFP. He had an
angiography showing no evidence of active bleeding.
His hospital course was complicated by a troponin leak to 0.14
(in the setting of Cr elevation to 1.5). Cardiology consult was
called and recommended medical management. Upon transfer to the
medicine service, he had no complaints, denying CP, SOB,
abdominal pain, lightheadedness/dizziness, recent bleeding.
Past Medical History:
CHF systolic
--EF 40-45% [**2199-4-26**] mild global HK, 2+MR, 3+TR, RA moderately
dilated, mild LVH, mod-severe pulm HTN
--repeat echo [**2199-5-2**] with EF 60%
Hypertension
Hypercholesterolemia
Atrial fibrillation, on warfarin
Iliac thrombus s/p embolectomy
Chronic GIB
-negative colonoscopy [**2199-5-6**]
-negative EGD [**2199-4-26**]
-negative enteroscopy [**2199-4-30**]
-had capsule study [**5-7**] delayed transit from esophagus, capsule
did not reach esophagus
Duodenal ulcer
CAD
Colon CA s/p resection [**2171**]'s
Pleural effusion
Back Surgery
Social History:
Retired [**Location (un) 86**] policeman. Daughter lives upstairs. Non-smoker.
Rare EtOH (1-2 drinks/week). Wife currently lives at [**Hospital 100**]
Rehab.
Family History:
Non-contributory
Physical Exam:
T 96.8 P 81 BP 128/54 RR 19 O2 97% on RA
General Pale elderly man in no acute distress
HEENT sclera white, conjunctiva pink, MMM
Neck +JVD
Pulm Lungs with few wheezes, no rales
CV Regular S1 S2 II/VI HSM LLSB increased with inspiration
Abd Soft L side with hematoma palpable R side of abdomen, tender
on right, no rigidity guarding or rebound
Extrem LE with 2+ bilateral edema, feet cool but 1+ palpable DP
and PT pulses
Foley in place
Pertinent Results:
ADMISSION LABS:
[**2199-5-20**] 12:05PM WBC-11.6*# RBC-2.76* HGB-8.3* HCT-25.9*
MCV-94 MCH-30.3 MCHC-32.2 RDW-15.4
[**2199-5-20**] 12:05PM PLT COUNT-342
[**2199-5-20**] 12:05PM NEUTS-86.3* LYMPHS-7.4* MONOS-5.6 EOS-0.2
BASOS-0.4
[**2199-5-20**] 12:05PM PT-13.8* PTT-33.1 INR(PT)-1.2*
[**2199-5-20**] 12:05PM GLUCOSE-160* UREA N-25* CREAT-1.2 SODIUM-139
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-21* ANION GAP-18
[**2199-5-20**] 12:47PM LACTATE-2.8*
[**2199-5-20**] 04:20PM HGB-5.3*# HCT-16.3*#
[**2199-5-20**] 10:57PM FIBRINOGE-459*
LABS AT TIME OF DISCHARGE:
[**2199-6-10**] 06:55AM BLOOD WBC-6.1# RBC-4.17* Hgb-12.8* Hct-37.9*
MCV-91 MCH-30.6 MCHC-33.6 RDW-15.4 Plt Ct-346
[**2199-6-10**] 06:55AM BLOOD Glucose-95 UreaN-16 Creat-1.2 Na-142
K-3.5 Cl-103 HCO3-27 AnGap-16
[**2199-6-10**] 06:55AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.6
[**2199-5-20**] EKG:
Atrial fibrillation. Ventricular premature beats. Consider prior
anteroseptal myocardial infarction. Baseline artifact. Low QRS
voltage in the limb leads. Compared to the previous tracing of
[**2199-5-2**] the ventricular premature beats and artifact are new.
[**2199-5-20**] CXR IMPRESSION: Layering right pleural effusion.
[**2199-5-20**] CT ABD/PELVIS:
1. Large right rectus sheath hematoma as described with
posterior extension into the extraperitoneal and intraperitoneal
portions of the anterior pelvis. CT with contrast may be
performed to evaluate for active extravasation.
2. Large right pleural effusion with right lower lobe
compressive atelectasis.
3. Small amount of abdominal ascites.
4. Pancreatic calcifications, raising the possibility of chronic
pancreatitis.
5. Right renal hypodensities, likely represent cysts.
[**2199-5-22**] LE ULTRASOUNDS:
No evidence of DVT in either lower extremity.
[**2199-5-28**] TRANSTHORACIC ECHOCARDIOGRAM:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. 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 no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2199-5-2**],
left ventricular function appears similar.
Brief Hospital Course:
1. Rectus sheath hematoma
Mr. [**Name14 (STitle) 78765**] presented with abdominal pain and swelling and was
found to have a large right sided rectus sheath hematoma and
significant drop in his hematocrit. He underwent angiography
that showed no active bleeding. The vascular surgery service
evaluated the patient and felt that no operative intervention
was required and conservative management was most appropriate.
His abdominal discomfort and hematoma size were improved at time
of discharge.
2. Atrial fibrillation
Mr. [**Name14 (STitle) 78765**] on metoprolol 25 mg [**Hospital1 **] on admission for rate
control; it was titrated to 37.5 mg [**Hospital1 **] with HR in the 50 -
60's. He was changed to metoprolol XL 50 mg QD prior to
discharge with stable HR and BP. The risks vs. benefits were
discussed at length with the patient, and he decided to restart
warfarin given the stroke risk. A lower INR goal of 2.0 - 2.5
was chosen given his history of bleeding, and he was discharged
on warfarin 2 mg QHS.
3. Congestive heart failure, systolic, acute on chronic
Mr. [**Name14 (STitle) 78765**] was total body volume overloaded in the setting of
receiving blood products for his anemia. An echocardiogram was
obtained which showed a preserved ejection fraction with
moderate TR and MR as seen in prior studies. He was diuresed
with lasix with good effect. He was discharged on metoprolol and
lisinopril, as well as standing lasix 40 mg PO QD. He was
euvolemic upon discharge.
4. Coronary artery disease with demand ischemia
His troponin was mildly elevated to peak of 0.14, likely demand
ischemia due to anemia and poor rate control early in admission.
He will continue metoprolol, simvastatin, and lisinopril. He
was on aspirin prior to admission for a history of NSTEMI,
although this was held in house while the patient was bleeding
into his rectus shealth. Aspirin 81 mg should be restarted once
INR is stabilized and the rectus sheath hematoma is stable at
the therapeutic INR.
5. Hypertension
Mr. [**Name14 (STitle) 78765**] was started on lisinopril, metoprolol, and
amlodipine for blood pressure control with good effect; BP was
in the 110-120's/50-60's upon discharge.
INSTRUCTIONS GIVEN TO REHAB FACILITY FOR FOLLOW-UP:
(1) Mr. [**Known lastname 78764**] should have his INR measured for a goal of 2.0 -
2.5 (lower goal range given patient's history of bleeding).
Please measure on [**2199-6-12**] and adjust warfarin dose appropriately
(he was discharged on warfarin). Please check INR every two days
until stable.
(2) Please weigh patient daily and adjust lasix as appropriate
to keep weight stable.
(3) The patient was on aspirin prior to this hospital admission.
Please restart aspirin 81 mg QD by the end of the week once INR
is stable in range 2.0-2.5 and there is no evidence of worsening
of the rectus sheath hematoma with anticoagulation.
Medications on Admission:
Enoxaparin 60 mg SC bid, lisinopril 5, omeprazole 20,
simvastatin 40, Lopressor 25 [**Hospital1 **], aspirin 81, Lasix 20 daily,
Colace, oxycodone, Tylenol
Discharge Medications:
1. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed: to groin rash.
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-9**] Sprays Nasal
TID (3 times a day).
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please adjust as needed for INR 2.0 - 2.5.
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day:
PLEASE DO NOT START UNTIL INR IS STABLE AND NO EVIDENCE OF
ONGOING BLEEDING IN RECTUS SHEATH.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 533**] Centre for Extended Care
Discharge Diagnosis:
Primary
1. Rectus sheath hematoma
2. Coronary artery disease with demand ischemia
3. Atrial fibrillation
4. Hypertension
5. Congestive heart failure, acute on chronic, diastolic
Discharge Condition:
Fair, hemodynamically stable with no gross bleeding, pain under
control.
Discharge Instructions:
You came into the hospital because of bleeding in your abdominal
muscles (rectus sheath hematoma). This was likely due to the
blood thinners (lovenox) you were taking. You were evaluated by
the vascular surgeons who felt that this should be followed
closely but you did not need a surgical procedure.
Call your doctors and [**Name5 (PTitle) **] medical attention if you develop:
bloody or black tarry stools, nosebleeds or other bleeding,
chest discomfort, shortness of breath, weakness, numbness,
confusion, slurred speech, or any other symptoms that worry you
or your family.
Followup Instructions:
Please follow up with Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital3 **] [**7-25**] at 3pm. The office is on the
[**Hospital Ward Name 516**] of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] on the [**Location (un) **]. The
phone number is [**Telephone/Fax (1) 250**].
Your coumadin levels will now be followed at the [**Hospital **] at [**Hospital1 **] Hospital. They will call you to
set up your first appointment for checking your coumadin levels
after you leave [**Hospital 100**] Rehab.
|
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icd9cm
|
[
[
[]
]
] |
[
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
9352, 9431
|
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276, 290
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9653, 9728
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1965, 2402
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222, 238
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318, 1157
|
2437, 5111
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1179, 1736
|
1752, 1916
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,672
| 105,638
|
39091+58258+58259
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2174-5-16**] Discharge Date: [**2174-5-25**]
Date of Birth: [**2113-6-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
[**2174-5-16**] Coronary artery bypass grafting x1 ( SVG to
RAMUS)/Aortic valve replacement( [**Street Address(2) 17009**]. [**Male First Name (un) 923**] mechanical
valve)
History of Present Illness:
This 60 year old man, known to our
service, who has a history of hypertension, hyperlipidemia,
diabetes and prior smoking. He has been followed for at least
the
past ten years with serial echocardiograms for aortic valve
disease. Previously his testing had been at [**Hospital 86642**], but he has recently switched his medical care to the
[**Hospital1 **]. Referred for surgical evaluation after
cardiac cath on [**2174-3-3**] revealed severe aortic stenosis and
coronary artery disease.
Past Medical History:
Aortic Stenosis and Insufficiency
CAD
postop A Fib
HTN
Hyperlipidemia
DM
Chronic Leukocytosis
Mild diverticulitis noted on colonoscopy [**11/2173**]
Social History:
single, lives with his signficiant other; works for media
company making educational material. has past hx of tobacco
years ago; drinks only occasionally at social events
Family History:
non-contributory
Physical Exam:
Height: 5'7" Weight: 198#
General: well-developed male 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 3/6 systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema: trace
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: trans murmur Left: trans murmur
Pertinent Results:
PREBYPASS
A patent foramen ovale is present. A left-to-right shunt across
the interatrial septum is seen at rest. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The descending thoracic aorta is mildly dilated. The
aortic valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Moderate
(2+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen.
POSTBYPASS
Biventricular systolic function is preserved. There is a well
seated, well functiong bileaflet mechanical valve in the aortic
position. AI is present which is normal in quantity and location
for this type of prosthesis. The exam is otherwise unchanged
from the prebypass exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2174-5-16**] 12:53
[**2174-5-21**] 05:30AM BLOOD WBC-16.5* RBC-3.55* Hgb-10.5* Hct-30.0*
MCV-85 MCH-29.6 MCHC-35.0 RDW-15.0 Plt Ct-335
[**2174-5-21**] 05:30AM BLOOD PT-30.1* PTT-30.9 INR(PT)-3.0*
[**2174-5-21**] 05:30AM BLOOD Glucose-96 UreaN-21* Creat-0.9 Na-139
K-3.6 Cl-106 HCO3-27 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 3311**] was admitted on [**5-16**] and underwent surgery with Dr.
[**Last Name (STitle) **]. He was transferred to the CVICU in stable condition on
titrated propofol and insulin drips. He was extubated the
following morning. He went into A Fib and was treated with
amiodarone. Coumadin was started for a mechanical AVR. He was
transferred to the floor on POD #3 to begin increasing his
activity level. He was gently diuresed toward his preop weight.
He continued to progress and was cleared for discharge to home
with VNA by Dr. [**Last Name (STitle) 914**] on POD #five. His first blood draw will
be Monday [**5-23**] with results to the [**Hospital1 18**] [**Hospital 620**] [**Hospital **]. Target INR 2.0-3 for mechanical AVR/atrial fibrillation.
Medications on Admission:
Atenolol 75 mg [**Hospital1 **]
Lisinopril 60 mg daily
Metformin 1000 mg [**Hospital1 **]
Nifedipine SR 90 mg daily
Simvastatin 20 mg daily
Aspirin 81 mg daily
Mag. oxide 400 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] through [**5-26**]; then 200 mg [**Hospital1 **] [**Date range (1) 21202**]; then
200 mg daily ongoing.
Disp:*60 Tablet(s)* Refills:*1*
7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*28 Tablet(s)* Refills:*2*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day for 2
weeks.
Disp:*56 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
13. Outpatient Lab Work
Coumadin will be followed by the [**Hospital 18**] [**Hospital3 271**] in
[**Location (un) 1411**] ([**Telephone/Fax (1) 86643**]. INR to be drawn on [**5-23**]. INR goal for a
mechanical AVR/afib [**12-22**].
14. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses: Coumadin will be followed by the [**Hospital 18**]
[**Hospital3 271**] in [**Location (un) 1411**] ([**Telephone/Fax (1) 86643**]. INR to be drawn
on [**5-23**]. INR goal for a mechanical AVR/afib [**12-22**].
.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1376**] [**Location (un) **]
Discharge Diagnosis:
AS/AI/ CAD s/p AVR/cabg x1
postop A Fib
NIDDM
HTN
hyperlipidemia
mild diverticulitis ( on colonoscopy [**11-28**])
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema :
1+ throughout
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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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:
Coumadin will be followed by the [**Hospital 18**] [**Hospital3 271**] in
[**Location (un) 1411**] ([**Telephone/Fax (1) 86643**]. INR to be drawn on [**5-22**]. INR goal for a
mechanical AVR/afib 2-2.5.
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) **] Thursday [**6-23**] at 1:00 PM
Please call to schedule appointments with your:
Primary Care Dr.[**Last Name (STitle) **] in [**11-20**] weeks
Cardiologist Dr. [**Last Name (STitle) 86644**] in [**11-20**] 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 ?????? mechanical AVR/ A Fib
Goal INR 2.0-2.5
First draw Sunday [**5-22**]
Results to [**Hospital 18**] [**Hospital3 **]
phone [**Telephone/Fax (1) 10413**]
Completed by:[**2174-5-21**] Name: [**Known lastname 9894**],[**Known firstname 63**] H Unit No: [**Numeric Identifier 13706**]
Admission Date: [**2174-5-16**] Discharge Date: [**2174-5-25**]
Date of Birth: [**2113-6-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
On the day of discharge Mr. [**Known lastname **] was hypertensive, so his
lisinopril was increased above his home dose of 60mg daily to
80mg daily. His blood pressure resolved and he was discharged
home with the higher dose of lisinopril.
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) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
4. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] through [**5-26**]; then 200 mg [**Hospital1 **] [**Date range (1) 13707**]; then
200 mg daily ongoing.
Disp:*60 Tablet(s)* Refills:*1*
7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2
weeks.
Disp:*28 Tablet(s)* Refills:*2*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day for 2
weeks.
Disp:*56 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
12. Outpatient Lab Work
Coumadin will be followed by the [**Hospital 8**] [**Hospital3 **] in
[**Location (un) 1502**] ([**Telephone/Fax (1) 13708**]. INR to be drawn on [**5-23**]. INR goal for a
mechanical AVR/afib [**12-22**].
13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses: Coumadin will be followed by the [**Hospital 8**]
[**Hospital3 **] in [**Location (un) 1502**] ([**Telephone/Fax (1) 13708**]. INR to be drawn
on [**5-23**]. INR goal for a mechanical AVR/afib [**12-22**].
.
Disp:*40 Tablet(s)* Refills:*0*
14. Lisinopril 40 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3546**] [**Location (un) **]
Followup Instructions:
Coumadin will be followed by the [**Hospital 8**] [**Hospital3 **] in
[**Location (un) 1502**] ([**Telephone/Fax (1) 13708**]. INR to be drawn on [**5-23**]. INR goal for a
mechanical AVR/afib [**12-22**].
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) **] Thursday [**6-23**] at 1:00 PM
Please call to schedule appointments with your:
Primary Care Dr.[**Last Name (STitle) **] in [**11-20**] weeks [**Telephone/Fax (1) 13709**]
Cardiologist Dr. [**Last Name (STitle) 13710**] in [**11-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? mechanical AVR/ A Fib
Goal INR 2.0-3
First draw Sunday [**5-22**]
Results to [**Hospital 8**] [**Hospital3 1946**]
phone [**Telephone/Fax (1) 13711**] fax
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2174-5-21**] Name: [**Known lastname 9894**],[**Known firstname 63**] H Unit No: [**Numeric Identifier 13706**]
Admission Date: [**2174-5-16**] Discharge Date: [**2174-5-25**]
Date of Birth: [**2113-6-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
The patient developed a phlebitis of the right antecubital fossa
which was treated with Vancomycin and local care. This improved
dramatically and he was discharged subsequently on oral Keflex
to be seen in 48 hours after discharge.
Chief Complaint:
see summary
Major Surgical or Invasive Procedure:
[**2174-5-16**] Coronary artery bypass grafting x1 ( SVG to
RAMUS)/Aortic valve replacement( [**Street Address(2) 13712**]. [**Male First Name (un) 744**] mechanical
valve)
History of Present Illness:
see summary
Past Medical History:
Aortic Stenosis
aortic Insufficiency
coronary artery disease
hypertension
Hyperlipidemia
noninsulin dependent diabete mellitus
Chronic Leukocytosis
Social History:
single, lives with his signficiant other; works for media
company making educational material. has past hx of tobacco
years ago; drinks only occasionally at social events
Family History:
non-contributory
Physical Exam:
see summary
Pertinent Results:
[**2174-5-25**] 05:50AM BLOOD WBC-17.5* RBC-3.49* Hgb-10.2* Hct-28.9*
MCV-83 MCH-29.1 MCHC-35.2* RDW-15.1 Plt Ct-517*
[**2174-5-24**] 04:40AM BLOOD WBC-24.3* RBC-3.76* Hgb-11.0* Hct-31.8*
MCV-85 MCH-29.1 MCHC-34.5 RDW-15.3 Plt Ct-637*
[**2174-5-20**] 05:30AM BLOOD WBC-16.8* RBC-3.46* Hgb-10.2* Hct-29.6*
MCV-85 MCH-29.5 MCHC-34.6 RDW-14.7 Plt Ct-280
[**2174-5-25**] 05:50AM BLOOD Glucose-47* UreaN-18 Creat-1.1 Na-139
K-3.6 Cl-103 HCO3-23 AnGap-17
[**2174-5-24**] 04:40AM BLOOD Glucose-60* UreaN-16 Creat-1.0 Na-139
K-3.7 Cl-104 HCO3-21* AnGap-18
Brief Hospital Course:
see summary
Medications on Admission:
see summary
Discharge Medications:
1. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
2. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg [**Hospital1 **] through [**5-26**]; then 200 mg [**Hospital1 **] [**Date range (1) 13707**]; then
200 mg daily ongoing.
Disp:*60 Tablet(s)* Refills:*1*
5. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a day:
Coumadin will be followed by the [**Hospital 8**] [**Hospital3 **] in
[**Location (un) 1502**] ([**Telephone/Fax (1) 13711**]). INR goal is 2.5-3.5.
Disp:*100 Tablet(s)* Refills:*2*
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Aspirin, Buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**2-22**]
hours as needed for fever or pain.
11. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
13. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
14. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
15. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
16. Outpatient Lab Work
Please draw a PT/INR on [**5-26**] and 9 then prn and call results to
[**Hospital 8**] [**Hospital 1209**] Clinic in [**Location (un) 1502**] at [**Telephone/Fax (1) 13711**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3546**] [**Location (un) **]
Discharge Diagnosis:
aortic stenosis
aortic insufficiency
coronary artery disease
s/p aortic valve replacement and coronary artery bypass
noninsulin dependent diabetes mellitus
hypertension
hyperlipidemia
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - 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 until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 1477**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Coumadin will be followed by the [**Hospital 8**] [**Hospital3 **] in
[**Location (un) 1502**] ([**Telephone/Fax (1) 13708**]). INR to be drawn on [**5-26**] and 9. INR goal
is 2.5-3.5
have lab drawn at [**Hospital3 5717**] lab on [**5-26**] and 9. They will
cal results to [**Hospital1 8**] [**Hospital 1502**] [**Hospital 1209**] Clinic who will tell you
dose to take.
You are scheduled for the following appointments:
Surgeon:Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1477**]) 0n Thursday, [**6-23**] at 1:00 PM
Please call to schedule appointments with:
Primary Care: Dr.[**Last Name (STitle) **] in [**11-20**] weeks [**Telephone/Fax (1) 13709**]
Cardiologist: Dr. [**Last Name (STitle) 13710**] in [**11-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? mechanical AVR/ A Fib
Goal INR 2.5-3.5
First draw Thursday, [**5-26**]
Results to [**Hospital 8**] [**Hospital3 1946**]
phone [**Telephone/Fax (1) 13711**] fax
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2174-5-25**]
|
[
"427.31",
"272.4",
"250.00",
"276.6",
"997.1",
"V15.82",
"285.9",
"451.82",
"401.9",
"E878.2",
"288.60",
"424.1",
"414.01",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.11",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
16961, 17033
|
14794, 14807
|
13564, 13739
|
17261, 17486
|
14222, 14771
|
18246, 19504
|
14157, 14175
|
14869, 16938
|
17054, 17240
|
14833, 14846
|
17510, 18223
|
14190, 14203
|
13513, 13526
|
13767, 13780
|
13802, 13952
|
13968, 14141
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,621
| 177,462
|
31937
|
Discharge summary
|
report
|
Admission Date: [**2125-8-29**] Discharge Date: [**2125-9-10**]
Date of Birth: [**2102-1-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Tylenol overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 23 y/o male with a PMH significant for bipolar
disorder, past suicide attempts x 2, who initially presented on
[**2125-8-29**] s/p significant tylenol overdose of 100 tablets of
extra-stength tylenol on [**2125-8-28**] at 1 am. He then presented to
an OSH at [**2047**] and was found to have a tylenol level of
approximately 125 at that time. He was given a dose of NAC and
transferred to [**Hospital1 18**] MICU for further management.
In the MICU, he was followed by both hepatology and transplant
surgery. His peak transaminases were around 16,000 and peak INR
of 10.3. He was started on a NAC drip and continued until his
INR<2. He was taken off the transplant list given his improving
condition; however, while in the MICU he went into acute renal
failure, likely [**12-22**] ATN from tylenol toxicity. His creatinine
continued to rise, however he makes good urine of >100cc/hr and
electrolytes have been stable. Nephrology has been following.
He was never intubated and his mental status has been
appropriate. He has been having symptoms of epigastric
pain/discomfort while in the MICU, which has been attributed to
gastritis vs gastropathy [**12-22**] hepatic congestion. He has been
treated with PPI, GI cocktail, and carafate.
Currently, he only reports his epigastric symptoms. No f/c/s,
n/v/diarrhea. No dysuria, LE edema. No headaches.
Past Medical History:
- Bipolar disease with ?psychotic features - followed by a
psychiatrist in RI, has had prior suicidal attempts at psych
admissions in RI, with no medical consequences.
Social History:
Lives with his parents in RI. Smokes marijuana. No other ilicit
drugs. Has not drank ETOH in "long time." No current tobacco.
Family History:
CAD on mothers side of family; father has hypercholesterolemia;
no diagnosed psych illnesses.
Physical Exam:
VS: Tc 99.6, Tm 100.0, BP 120-140/60-80, HR 74-80, RR 18-27,
96%/RA, [**Telephone/Fax (1) 74864**], UOP 100-150cc/hr
General: pleasant, comfortable, NAD with flat affect
HEENT: PERLLA, EOMI, no scleral icterus, no sinus tenderness,
MMM, op without lesions
Neck: supple, no LAD or TMG
Chest: CTA-B, no w/r/r
CV: RRR s1 s2 normal, no m/g/r
Abd: soft, with slight TTP over epigastrum. NABS. Liver 3-4 cm
below costal margin, no tenderness. No splenomegaly.
Ext: no c/c/e, pulses 2+ b/l
Neuro: AO x 3, flat affect. CN II-XII intact. MS [**3-24**] throughout,
sensation to light touch intact.
Pertinent Results:
[**2125-8-28**] 11:58PM PT-32.7* PTT-35.6* INR(PT)-3.5*
[**2125-8-28**] 11:58PM PLT COUNT-172
[**2125-8-28**] 11:58PM NEUTS-89.5* LYMPHS-8.3* MONOS-1.9* EOS-0.2
BASOS-0.1
[**2125-8-28**] 11:58PM WBC-14.8* RBC-4.70 HGB-15.0 HCT-43.1 MCV-92
MCH-32.0 MCHC-34.9 RDW-13.4
[**2125-8-28**] 11:58PM ASA-NEG ETHANOL-NEG ACETMNPHN-94.6*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2125-8-28**] 11:58PM ACETONE-NEGATIVE
[**2125-8-28**] 11:58PM LIPASE-16
[**2125-8-28**] 11:58PM ALT(SGPT)-2623* AST(SGOT)-2265* LD(LDH)-1590*
ALK PHOS-116 AMYLASE-29 TOT BILI-4.2*
[**2125-8-28**] 11:58PM estGFR-Using this
[**2125-8-28**] 11:58PM GLUCOSE-132* UREA N-12 CREAT-0.9 SODIUM-139
POTASSIUM-3.2* CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
[**2125-8-29**] 03:17AM FIBRINOGE-104*
[**2125-8-29**] 03:17AM PT-40.5* PTT-38.4* INR(PT)-4.6*
[**2125-8-29**] 03:17AM PLT COUNT-158
[**2125-8-29**] 03:17AM HCV Ab-NEGATIVE
[**2125-8-29**] 03:17AM WBC-13.3* RBC-4.47* HGB-14.7 HCT-41.2 MCV-92
MCH-32.9* MCHC-35.7* RDW-13.4
[**2125-8-29**] 03:17AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-NEGATIVE
[**2125-8-29**] 03:17AM ALBUMIN-4.4 CALCIUM-8.7 PHOSPHATE-2.8
MAGNESIUM-2.5
[**2125-8-29**] 03:17AM LIPASE-16
[**2125-8-29**] 03:17AM ALT(SGPT)-5337* AST(SGOT)-4898* ALK PHOS-112
AMYLASE-27 TOT BILI-4.2* DIR BILI-1.5* INDIR BIL-2.7
[**2125-8-29**] 03:17AM GLUCOSE-146* UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-3.2* CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2125-8-29**] 08:15AM HIV Ab-NEGATIVE
[**2125-8-29**] 08:18AM FIBRINOGE-110*
[**2125-8-29**] 08:18AM PT-43.0* PTT-39.4* INR(PT)-4.9*
[**2125-8-29**] 08:18AM PLT COUNT-153
[**2125-8-29**] 08:18AM WBC-12.3* RBC-4.56* HGB-14.9 HCT-42.3 MCV-93
MCH-32.7* MCHC-35.3* RDW-13.1
[**2125-8-29**] 08:18AM ALBUMIN-4.3 CALCIUM-9.0 PHOSPHATE-2.3*
MAGNESIUM-2.4
[**2125-8-29**] 08:18AM LIPASE-18
[**2125-8-29**] 08:18AM ALT(SGPT)-7900* AST(SGOT)-6853* ALK PHOS-116
AMYLASE-30 TOT BILI-4.4*
[**2125-8-29**] 08:18AM GLUCOSE-92 UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-23 ANION GAP-17
[**2125-8-29**] 01:19PM FIBRINOGE-87*
[**2125-8-29**] 01:19PM PT-50.9* PTT-40.6* INR(PT)-6.0*
[**2125-8-29**] 01:19PM PLT COUNT-152
[**2125-8-29**] 01:19PM WBC-12.9* RBC-4.53* HGB-14.5 HCT-42.0 MCV-93
MCH-32.0 MCHC-34.5 RDW-13.1
[**2125-8-29**] 01:19PM TSH-0.13*
[**2125-8-29**] 01:19PM CALCIUM-8.5 PHOSPHATE-2.8 MAGNESIUM-2.2
[**2125-8-29**] 01:19PM LIPASE-18
[**2125-8-29**] 01:19PM ALT(SGPT)-[**Numeric Identifier 74865**]* AST(SGOT)-8651* ALK PHOS-115
AMYLASE-27 TOT BILI-4.6*
[**2125-8-29**] 01:19PM GLUCOSE-124* UREA N-20 CREAT-0.9 SODIUM-142
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-18
[**2125-8-29**] 08:01PM FIBRINOGE-79*
[**2125-8-29**] 08:01PM PT-67.4* PTT-42.8* INR(PT)-8.5*
[**2125-8-29**] 08:01PM PLT COUNT-107*
[**2125-8-29**] 08:01PM WBC-11.0 RBC-4.29* HGB-13.8* HCT-38.6* MCV-90
MCH-32.3* MCHC-35.8* RDW-13.2
[**2125-8-29**] 08:01PM CALCIUM-8.0* PHOSPHATE-2.6* MAGNESIUM-2.4
[**2125-8-29**] 08:01PM LIPASE-27
[**2125-8-29**] 08:01PM ALT(SGPT)-[**Numeric Identifier 74866**]* AST(SGOT)-[**Numeric Identifier **]* ALK
PHOS-118* AMYLASE-32 TOT BILI-3.7* DIR BILI-1.7* INDIR BIL-2.0
[**2125-8-29**] 08:01PM GLUCOSE-196* UREA N-23* CREAT-1.0 SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
Brief Hospital Course:
23 y/o male s/p tylenol OD with resulting hepatotoxicity now
improving, now with acute renal failure likely [**12-22**] ATN.
# s/p tylenol overdose - The patient was admitted after taking
50g of tylenol. His initial tylenol level was 125 (18 hours
after ingestion). Original AST 800/ALT 600/INR 3 at the OSH.
He was transferred to [**Hospital1 18**] for potential transplant. Over the
next few days his LFT's trended up to AST [**Numeric Identifier 20629**]/ALT [**Numeric Identifier **]/INR
10.3. Throughout this time, he never had mental status changes.
Fortunately, his LFT's and INR then began to trend down.
# Acute renal failure - The patient was admitted with a
creatinine of 0.9. It remained in the normal range until 3 days
after admission when it started to climb. Urine sediment was
consisent with ATN. This was thought most likely to be
secondary to direct acetaminophen toxicity. Throughout the
hospital course, the patient continued to make good urine and
electrlytes remained within normal limits. His creatinine
reached a peak of 7.6 on hospital day #7. It quickly started to
the trend down. At the time of transfer his creatinine was 1.6.
It was felt that he would have a complete recovery.
# SI - The patient was followed by psychiatry throughout his
hospital course. His seroquel was held during his medical stay
secondary to liver and renal failure. A 1:1 sitter was with the
patient at all times. He was transferred to the psychiatry team
on [**2125-9-10**].
Medications on Admission:
Risperidone q2 weeks
Seroquel 100 tid
Discharge Medications:
Pantoprazole 40mg PO BID
Ondansetron 4mg ODT PO q8 PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Tylenol Overdose
Liver Failure
Acute Renal Failure - Secondary to ATN
Secondary Diagnosis:
Bipolar
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital after a tylenol overdose.
This ingestion caused severe liver and kidney injury. You were
severely ill and almost required a liver transplant. Luckily,
your liver and kidney function improved.
Please avoid taking more than [**11-21**] tylenol at a time.
If you experience any thoughts of hurting yourself or others,
severe depression, or any other concerning symptoms please
contact your psychiatrist immediately or go directly to the ER.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 1 week of discharge.
Please see your psychiatrist within 1-2 days of discharge.
|
[
"V62.84",
"296.7",
"E950.0",
"276.0",
"295.90",
"570",
"584.5",
"965.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7835, 7841
|
6167, 7667
|
331, 337
|
8004, 8013
|
2801, 6144
|
8537, 8681
|
2081, 2176
|
7756, 7812
|
7862, 7862
|
7693, 7733
|
8037, 8514
|
2191, 2781
|
275, 293
|
365, 1727
|
7973, 7983
|
7881, 7952
|
1749, 1919
|
1935, 2065
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,815
| 154,936
|
22228
|
Discharge summary
|
report
|
Admission Date: [**2137-10-10**] Discharge Date: [**2137-11-1**]
Date of Birth: [**2063-1-4**] Sex: F
Service: MED
Allergies:
Penicillins
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
respiratory distress
fevers
Major Surgical or Invasive Procedure:
none
History of Present Illness:
74 yo female, transferred from [**Hospital1 1872**] rehab for recurrent
flash pulmonary edema. Pt recently admitted/hospital stay at
[**Hospital1 **] on [**9-8**] for DKA and NSTEMI. At this time, pt had a
long/complicated hospital course, determined not to be a
candidate for cardiac catheterization and MI managed medically.
She developed pulm edema, respiratory failure, was intubated,
developed vent-associated pna (MSSA), treated with levo until
[**10-7**]. She failed extubation and was eventually PEG/Trached,
sent to rehab on [**10-2**]. At rehab, pt had multiple episodes of
flash pulm edema that were managed with Morphine and lasix prn.
This morning, she had a similar episode with desat to 85%,
tachypnea to 30's, and SBP=78 with leukocytosis. At family's
request and with these symptoms, she was transferred back here.
On presentation, she received MSO4 for dyspnea, was febrile to
102.2, BP=90/41, WBC=19 with left shift. Pt with some new EKG
changes (t-wave inv v5-6, st elev v2-4), and elevated tnt. Pt
admitted to MICU at this time for management of respiratory
failure vs. pneumonia.
Past Medical History:
DM2 on insulin
Hypercholesterolemia
Dementia/[**Doctor Last Name 122**] disease (an inherited spinocerebellar ataxia:
progressive neurological disorder of ataxia, peripheral
neuropathy)
(No known HTN)
Vent-associated PNA
NSTEMI
CHF
Anemia
Social History:
Prior to admission the patient was living at home with her
daughter. The patient was bedridden and very dependent on family
members to care for her. She has a significant smoking history
of 50 pack years, though she quit smoking 10 years ago. Denies
EtOH or other drugs.
Family History:
[**Last Name (un) 32665**]-[**Doctor Last Name 11042**] disease.
Physical Exam:
102.2 85 90/41 18 99%
Gen: elderly appearing, lethargic, sedated
HEENT: PERRL, dry MM, tracheostomy c, d, i
CV: RRR, 2/6 SEM
Pulm: coarse BS, occasional rhonchi, no crackles
Abd: PEG-c,d,i; soft, NABS, nt
Extr: warm, no edema, good pulses, L PICC line-c, d, i
Neuro: non arousable
Pertinent Results:
[**2137-10-10**] 09:34PM TYPE-ART PO2-126* PCO2-42 PH-7.50* TOTAL
CO2-34* BASE XS-8
[**2137-10-10**] 09:34PM LACTATE-1.8
[**2137-10-10**] 04:44PM TYPE-ART PO2-144* PCO2-45 PH-7.50* TOTAL
CO2-36* BASE XS-10
[**2137-10-10**] 04:44PM LACTATE-2.2*
[**2137-10-10**] 03:21PM GLUCOSE-276* UREA N-47* CREAT-0.6 SODIUM-138
POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-33* ANION GAP-16
[**2137-10-10**] 03:21PM ALT(SGPT)-44* AST(SGOT)-38 LD(LDH)-278*
CK(CPK)-52 ALK PHOS-403* AMYLASE-65 TOT BILI-0.4
[**2137-10-10**] 03:21PM LIPASE-53
[**2137-10-10**] 03:21PM CK-MB-NotDone cTropnT-0.28*
[**2137-10-10**] 03:21PM ALBUMIN-3.5 CALCIUM-8.9 PHOSPHATE-3.8
MAGNESIUM-2.3
[**2137-10-10**] 03:21PM WBC-19.1*# RBC-3.65* HGB-11.5* HCT-35.5*
MCV-97 MCH-31.4 MCHC-32.4 RDW-13.9
[**2137-10-10**] 03:21PM NEUTS-88.5* LYMPHS-6.8* MONOS-4.0 EOS-0.4
BASOS-0.3
[**2137-10-10**] 03:21PM MACROCYT-1+
[**2137-10-10**] 03:21PM PLT COUNT-446*
[**2137-10-10**] 03:21PM PT-12.2 PTT-23.7 INR(PT)-0.9
[**2137-10-10**] 03:21PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2137-10-10**] 03:21PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
[**2137-10-10**] 03:21PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
Brief Hospital Course:
A/P: 74F s/p recent NSTEMI, VAP, with recurrent flash pulmonary
edema, presenting with respiratory distress, fever,
leukocytosis, in setting of likely more flash pulmonary edema.
1. Fever/leukocytosis - The patient was pan cultured and grew
out MSSA from her sputum for which she was treated with
clindimycin.
2. Respiratory Failure - likely multifactorial with
contributions from both PNA and CHF. The MSSA PNA was treated
with clindimycin for a 2 week course. The CHF team was
consulted regarding the patients CHF. A cardiac cath was
performed which demonstrated three vessel coronary artery
disease, moderate systolic ventricular dysfuction, and moderate
diastolic ventricular function. It was decided at this time that
the patients CAD was not amenable to PCI and that medical
management was the best option. Hence the patient was optimized
on a medical regimen which included hydralazine, clonidine,
captopril, metoprolol, amlodipine, isordil, plavix, and aspirin.
On this regimen, the patients BP's were maintained with
systolics in the 140's.
3. DM - The patient's blood sugars were controlled on an insulin
drip. At discharge the drip was converted to an equivalent dose
NPH/Regular.
4. Hypothyroidism - the patient was continued on her home dose
of synthroid.
5. Code Status - DNR. Given the patient's severe CAD/CHF the
patient's functional status is severely impaired and she is now
vent dependent. Her prognosis for any meningful recovery is
grim and this was discussed in detail with the family which ha
decided to make her DNR.
Medications on Admission:
Meds: lantus, ssi, asa, captopril, colace, laxis, sq heparin,
HCTZ, levothyroxine, lopressor, nystatin, senna
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
coronary artery disease
congestive heart failure / flash pulmonary edema
pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please take medications as directed.
Followup Instructions:
none
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
|
[
"250.00",
"584.5",
"410.72",
"244.9",
"518.84",
"482.41",
"414.01",
"V44.0",
"428.0",
"333.0",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.72",
"99.04",
"37.23",
"34.91",
"88.53",
"96.6",
"88.56",
"33.21",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5439, 5511
|
3719, 5278
|
294, 300
|
5638, 5646
|
2410, 3696
|
5731, 5830
|
2006, 2072
|
5532, 5617
|
5304, 5416
|
5670, 5708
|
2087, 2391
|
227, 256
|
328, 1439
|
1461, 1702
|
1718, 1990
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,081
| 132,889
|
38590
|
Discharge summary
|
report
|
Admission Date: [**2156-5-29**] Discharge Date: [**2156-6-8**]
Date of Birth: [**2090-4-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Cardiac arrest.
Major Surgical or Invasive Procedure:
Endotracheal intubation.
Central venous line placement.
Post-arrest hypothermia.
Cardiac catheterization.
History of Present Illness:
Mr. [**Known lastname 2716**] is a 66 YOM with no past medical history who has not
sought medical care, who was in his usual state of health until
this evening when he had an unwitnessed arrest. He was last
heard walking down the stairs to do some work in the basement
and about 5 minutes later, his wife heard moaning but no fall or
crash and found him lying on floor unresponsive. She called 911
and called her son and friend who provided CPR until the police
arrived and placed an AED on the patient (who may have been
pulseless at that time). The AED detected a shockable rhythm and
fired two shocks. Estimated time from arrest to shock was 10
minutes. EMS arrived and found that the patient had a pulse and
stable vital signs but he was breathing shallow breaths on his
own. An initial EKG showed ST elevations in the inferior leads,
most prominent in III and depressions in V1 through V6. The
patient was taken to [**Hospital3 **] and received 100 mg lidocane
in transport. At [**Hospital1 **] he was still unresponsive and had
posturing. He was intubated for airway protection. There were no
ST elevations seen on EKG at that time, but there were
depressions in V1 and V2 and evolving Q waves in III and AVf. He
had a positive CKMB of 8. He underwent head and neck CT which
were negative. He was given dilantin and ativan. He was then
med-flighted to [**Hospital1 18**].
.
Upon arrival to the ED he was hemodynamically stable with T 98.4
HR 99 and BP 117/70 100% O2sat intubated with fio2 100%. He was
intubated with peak 14, peep 5, on 100% fio2, and sedated on
benzodiazepines without pain medication. His EKG showed NSR, 88
bpm, no ST elevations and Q waves in III and aVF. He had a
bedside echo, which showed hypokinesis of the mid and basal
inferioseptal and inferolateral walls with EF 45%. Cardiology
did not feel that he needed an urgent cath given the resolution
of ST elevations and he was started on a heparin gtt and given
aspirin and plavix 300 mg. Blood pressure was found to be
elevated at 202/105. Neurological exam revealed cortical
posturing and lack of gag and pupilary reflexes.
.
ROS unable to be obtained due to unresponsiveness/ sedation/
intubation. But by report from his wife he has been feeling
fatigued today. Also has had ? left sided chest pain and
shortness of breath with exertion for a while, but never had it
checked out. Denied knowledge of fever, chills, HA.
Past Medical History:
- Does not seek medical care, not having seen doctor for some
years and last time for stiches after chain saw accident.
- Hypertension (known to have SBPs in the 150s at the grocery
store)
- Question of exertional angina, shortness of breath and
circumoral cyanosis per family - patient denies.
Social History:
Worked in construction for his working life and now continues to
do some odd-jobs and carpentry. Plays the guitar and writes his
own music. Married with children. All three children live nearby
and family is close.
-Tobacco history: quit 40 years ago
-ETOH: none
-Illicit drugs: none
Family History:
Brother had CABG, sister had breast cancer, mother had COPD.
Physical Exam:
GENERAL: intubated, sedated
HEENT: ETT in place, Sclera anicteric, pupils 1.5 mm and
reactive
NECK: Supple with no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**3-20**] HSM
LUNGS: CTAB, no rales or rhonchi.
ABDOMEN: Soft, ND, no abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: 2+ DP 2+ PT 2+
Left: 2+ DP 2+ PT 2+
On morning after admission:
Overweight man with no spontaneous behavior. Ventilated,
intubated. [**Location (un) 2848**]-J in place. Presently cooled.
Scleral edema.
Heart sounds dual, no murmur, no s3, s4 appreciated
Chest expansion symmetric without adventitious sounds laterally
Belly tense, but bowel sounds present
Trace peripheral edema
GCS 3, without response to pain ?????? no EEG desynchronization noted
on pain (nailbed compression) or very loud clap. CNs without
activity (s/p cessation of paralysis 3-4 hours earlier) ?????? no
papillary response, cannot evaluate doll??????s eye in [**Location (un) 2848**]-J.
Caloric testing not performed. Areflexic (brachial,
brachioradialis, plantar, snout). EEG (when connected with theta
and superimposed beta ?????? no changes to sounds, pain, other
environmental stimuli).
At discharge:
Pertinent Results:
Pertinent Labs at Admission
[**2156-5-29**] 10:40PM BLOOD WBC-13.4* RBC-4.65 Hgb-13.7* Hct-40.3
MCV-87 MCH-29.5 MCHC-34.0 RDW-13.2 Plt Ct-189
[**2156-5-29**] 10:40PM BLOOD Neuts-91.3* Lymphs-3.9* Monos-4.2 Eos-0.2
Baso-0.4
[**2156-5-29**] 10:40PM BLOOD PT-12.9 PTT-71.1* INR(PT)-1.1
[**2156-5-30**] 04:36AM BLOOD Glucose-158* UreaN-18 Creat-1.1 Na-143
K-3.8 Cl-111* HCO3-21* AnGap-15
[**2156-5-29**] 10:40PM BLOOD ALT-489* AST-365* CK(CPK)-756* AlkPhos-41
TotBili-0.3
[**2156-5-29**] 10:40PM BLOOD CK-MB-48* MB Indx-6.3*
[**2156-5-29**] 10:40PM BLOOD cTropnT-1.91*
[**2156-5-29**] 10:40PM BLOOD Albumin-4.0 Calcium-7.4* Phos-3.2 Mg-1.9
[**2156-5-29**] 10:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2156-5-29**] 10:56PM BLOOD Type-ART Temp-37.4 Tidal V-100 PEEP-5
pO2-340* pCO2-59* pH-7.21* calTCO2-25 Base XS--5
Intubat-INTUBATED Vent-CONTROLLED
[**2156-5-29**] 10:41PM BLOOD Glucose-114* Lactate-1.5 Na-145 K-4.2
Cl-104 calHCO3-23
[**2156-5-30**] 01:59PM BLOOD freeCa-1.06*
Pertinent Labs from the Admission
[**2156-5-29**] 10:40PM BLOOD CK-MB-48* MB Indx-6.3*
[**2156-5-29**] 10:40PM BLOOD cTropnT-1.91*
[**2156-5-30**] 04:36AM BLOOD cTropnT-1.22*
[**2156-5-30**] 03:38PM BLOOD CK-MB-93* MB Indx-3.9 cTropnT-0.77*
[**2156-5-31**] 04:12AM BLOOD CK-MB-76* MB Indx-4.1
[**2156-5-31**] 12:45PM BLOOD CK-MB-56* MB Indx-3.8 cTropnT-0.38*
[**2156-6-1**] 05:52AM BLOOD CK-MB-42* MB Indx-3.0 cTropnT-0.67*
[**2156-6-4**] 06:00AM BLOOD %HbA1c-5.3 eAG-105
[**2156-6-4**] 06:00AM BLOOD Triglyc-264* HDL-37 CHOL/HD-4.6
LDLcalc-81
Labs at Discharge:
[**2156-6-8**] 05:34AM BLOOD WBC-13.6* RBC-3.82* Hgb-10.9* Hct-32.5*
MCV-85 MCH-28.6 MCHC-33.6 RDW-14.0 Plt Ct-341
[**2156-6-8**] 05:34AM BLOOD Glucose-105* UreaN-13 Creat-0.9 Na-140
K-4.2 Cl-103 HCO3-27 AnGap-14
[**2156-6-8**] 05:34AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.4
[**2156-6-4**] 06:00AM BLOOD %HbA1c-5.3 eAG-105
[**2156-6-4**] 06:00AM BLOOD Triglyc-264* HDL-37 CHOL/HD-4.6
LDLcalc-81
Cardiac catheterization [**6-7**]:
COMMENTS:
1. Coronary angiography in this right dominant system revealed
significant three vessel coronary artery disease. The LMCA was
without
disease. The LAD had an 80% proximal stenosis, with an 80% mid
and 99%
distal stenosis, as well as a 70% stenosis of the second major
diagonal
branch. The LCX had a 60% stenosis at the origin, with a 70%
stenosis
of the OM1 branch and a 99% stenosis of the OM2 branch. The RCA
was
totally occluded after the mid-portion, with the distal vessel
filling
via collaterals from the left coronary artery. The acute
marginal
branch of RCA was a large vessel with 70% stenosis.
2. Left ventriculography revealed normal EF of 59% with
hypokinesis of
the mid inferobasal segment. There was no evidence of mitral
regurgitation.
3. Resting hemodynamics revealed severely elevated left-sided
filling
pressures with LVEDP of 41 mmHg. The systemic blood pressure
was
moderately elevated, with SBP of 178 mmHg. There was no aortic
stenosis
detected by left ventricular pullback technique.
.
ECHO [**5-29**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%) secondary to hypokinesis of the inferior septum,
inferior free wall, and posterior wall. The other walls of the
left ventricle are hyperdynamic. 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. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
CXR [**6-6**]:
FINDINGS: As compared to the previous radiograph, the
pre-existing
retrocardiac opacities have increased in extent and now extend
along the right lateral chest wall. Blunting of the left
costophrenic sinus makes the presence of a minimal left pleural
effusion likely. On this basis, the
possibility of developing pneumonia should be excluded by
short-term
radiological followup.
No evidence of other focal parenchymal opacities. No evidence of
pulmonary
edema. No pneumothorax.
Brief Hospital Course:
This 66-year-old man with possible angina, perioral cyanosis on
exertion, without past medical attention presents after
collapsing at home.
Sudden Cardiac Death R/T Ischemia and likely VF.
Given moaning and then likely VF on AED, and upon enzymes,
EKG, it seems likely that he suffered an AMI/ACS which resulted
in collapse and moaning before VF. Given that troponin had
already peaked at admission, it seems likely that there had been
an acute myocardial infarction some hours prior to presentation.
It is of course still possible that this enzyme leak was
produced by electrical cardioversion and chest compressions. CPR
was given at the scene by son. Cardiac cath showed severe threee
vessal disease involving the LAD, RCA (presumed culprit) and
LCX. Cardiac surgery spoke to patient at length and recommended
immediate surgery. Mr. [**Known lastname 2716**] refused surgery and said he
wanted to go home and consider his options before consenting to
what he felt was a risky surgery. The CCU attending, family and
CCu team all attempted to pursuade pt to consent to surgery
without success. He insisted on going home and was discharged
with close follow up appts and a Lifevest. We were not able to
determine a safe level of activity for this patient given his
history and anatomy. Patient was discharge on ASA, Plavix,
atorvastatin, metoprolol, and Imdur. An ACE inhibitor should be
started at his first appt.
Mental Status
Pt with some signs of neurologic injury at early presentation ??????
absent papillary reflexes and posturing. This was concerning for
poor prognosis, however spinal and brainstem reflexes reappeared
quickly over the following three days, along with some initially
concerning false localizing sign, likely due to sedation. He was
successfully extubated and showed good cognitive function
complicated by poor insight, jocular behavior (both apparently
somewhat near baseline) and delirium with hallucinations.
Delerium resolved over hospital stay and although pt was not
cooperative with psychiatric evaluation at discharge, there was
no evidence that pt was not competant or was suicidal. Memory
appears to be relatively intact for recent events, so prognosis
is excellent. Dr. [**Last Name (STitle) **] ask for f/u with Neurology (Dr.
[**First Name (STitle) **]. Patient refused this and was not planned at
discharge.
Pneumonia:
Initially intubated for airway protection. Drawing large tidal
volumes prior to paralysis. Fever and infiltrate on CXR likely
[**3-16**] aspiration. Completed 9 day course of vancomycin/Zosyn with
resolution of fever although WBC slightly elevated at discharge
to 13.9. Pt refused to stay the final day in hospital to
complete a 10 day course. On discharge, he had no cough, SOB and
O2 sat was mid 90's on RA.
Hypertension
Hypertension when agitated immediately after extubation. Blood
pressures subsequently were low after extubation and delerium
resolved. He was started on Metoprolol and Imdur for ant-anginal
effect. An ACE inhibitor should be started after discharge for
post MI care. His LVEDP was elevated in the cath lab possibly
indicating long standing hypertension.
Acute Renal Failure with urinary obstruction.
Foley was obstructed briefly (hypospadia and difficult urinary
tract to catheterize) while cooled and we think that renal
perfusion was likely poor peri-arrest. Urology replaced Foley.
He briefly developed ARF which was thus likely mild ATN versus
reversible obstructive nephropathy. Renal failure resolved.
Anemia
Hemodilution with warming and then positive fluid balance
produced apparently worsening anemia. No concern for losses or
hemolysis.
UTI
Moderate bacteria seen on UA. Covered with antibiotics for PNA.
No symptoms on discharge.
Medications on Admission:
None.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
take up to 3 tablets 5 minutes apart. Call 911 if you take this
medicine.
Disp:*25 Tablet, Sublingual(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
ST elevation Myocardial Infarction
Severe Coronary Artery Disease
Dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You collapsed and your heart stopped requiring CPR and a shock.
You had a large heart attack and you were in the ICU while your
heart recovered. You were quite confused after waking up and
your memory has slowly returned. A cardiac catheterization
showed severe muti- vessel blockages and a bypass operation was
recommended to be done immediately. You asked to go home and
think about this before consenting to the operation. We are
worried that your heart may stop again so we want you to wear a
Lifevest that would shock your heart back in to a regular rhythm
if needed. If you have any symptoms of chest pain, arm pain,
sweating or trouble breathing, you should call 911 and try
taking nitroglycerin.
.
Medication changes:
1. Plavix and aspirin, to prevent blood clots in the arteries
that are clogged.
2. Imdur: to keep the clogged arteries as open as possible
3. Atorvastatin: to lower your cholesterol as much as possible.
4. Nitroglycerin: to take if you have chest pain or pressure as
described above.
5. Metoprolol XL to keep your heart rate low and help your heart
recover from the heart attack.
.
Please keep all of the appts that we have scheduled for you. It
is critically important that you take all of your medicines.
Followup Instructions:
Cardiology:
Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **]
[**Hospital1 **] Healthcare - [**Location (un) **]
15 [**Name (NI) **] Brothers [**Name (NI) **]
[**Name (NI) **]
[**Location **], [**Numeric Identifier 18655**]
Phone: [**Telephone/Fax (1) 8725**]
Fax: [**Telephone/Fax (1) 8719**]
[**2156-7-8**] at 1:15 pm
.
Primary care:
[**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 6700**], MD
[**Hospital1 **] Healthcare - [**Location (un) 1475**]
[**Last Name (un) 85793**], [**Numeric Identifier 85794**]
Phone: [**Telephone/Fax (1) 6699**]
Fax: [**Telephone/Fax (1) 84090**]
Date/time: [**6-15**] at 2:45pm.
Completed by:[**2156-6-9**]
|
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"518.81"
] |
icd9cm
|
[
[
[]
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] |
[
"96.6",
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"38.91",
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icd9pcs
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[
[
[]
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] |
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,809
| 151,280
|
32583
|
Discharge summary
|
report
|
Admission Date: [**2117-10-6**] Discharge Date: [**2117-10-21**]
Date of Birth: [**2036-10-12**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
SDH found on CT scan from OSH
Major Surgical or Invasive Procedure:
Craniotomy with evacuation of SDH
bronchoscopy
History of Present Illness:
HPI: (obtained with assistance from his son and daughter-in-law)
80 year old male presents from OSH s/p fall at his [**Hospital3 12272**] earlier today. The patient also fell about 2 weeks ago.
He
was found to have a SDH on CT and was transferred to [**Hospital1 18**] for
further care. He does have Alzheimer's but is usually very
pleasant at baseline and has been extremely agitated while in
the
ER. The patient takes aspirin and plavix at home for CAD and h/o
CABG. He also has a-fib but does not take coumadin. The patient
is confused and has 4 point restraints on to keep him on the
stretcher. The patient does not seem to be in any pain.
Past Medical History:
PMHx: Alzheimer's Disease, CAD, s/p CABG x 4 7 years ago, s/p
bilateral "carotid artery surgery for plaques" about 7 years
ago,
A-fib, HTN, prostate CA, cortical stenosis
Social History:
Social Hx: lives at [**Hospital3 **] with wife
Family History:
Family Hx: non-contributory
Physical Exam:
PHYSICAL EXAM:
T:98.7 BP:142/71 HR:80 RR:20 O2Sats: 97% RA
Gen: Patient is very agitated.
HEENT: Pupils: 2mm bilaterally EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+, + abdominal scar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person only.
Language: No fluent, word salad, expressive aphasia
Cranial Nerves:
I: Not tested
II: Pupils 2 mm bilaterally, non-reactive. Appear surgical.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength appears full power [**4-10**] throughout, but patient
is not cooperative with exam. He will squeeze to command and
wiggle his toes. He required 4 point restraints to keep him in
the stretcher.
Sensation: Appears intact throughout
Toes downgoing bilaterally
Pertinent Results:
NON-CONTRAST HEAD CT: There is a large left subdural hematoma
measuring approximately 3 cm in greatest diameter with a
hematocrit level suggesting acute on chronic blood. There is
approximately 8 mm of rightward subfalcine herniation. The
ventricles are normal in size and configuration for the
patient's
age, with no intraventricular blood. There is moderate sulcal
effacement and mass effect on the subjacent left hemispheric
cortex. Old infarct/encephalomalacia is noted within the right
basal ganglia/centrum semiovale. The basal cisterns are well
visualized with no evidence of uncal
herniation.
Motion limits full evaluation of the osseous structures. There
is no calvarial fracture identified. The visualized paranasal
sinuses and mastoid air cells are clear.
IMPRESSION:
1. Large left subdural hemorrhage, with a hematocrit level
suggesting acute on chronic blood. There is moderate mass
effect
on the left hemisphere and 8 mm of rightward subfalcine
herniation.
2. Old right basal ganglia infarct.
Findings were discussed with the neurosurgery team at the time
of
the exam.
[**2117-10-19**] 07:00AM BLOOD WBC-13.4* RBC-3.13* Hgb-10.1* Hct-31.0*
MCV-99* MCH-32.3* MCHC-32.6 RDW-13.8 Plt Ct-816*
[**2117-10-20**] 12:40PM BLOOD WBC-13.6* RBC-3.40* Hgb-11.1* Hct-33.2*
MCV-98 MCH-32.7* MCHC-33.5 RDW-14.1 Plt Ct-752*
Brief Hospital Course:
Pt was admitted to the ICU for close monitoring. He was brought
to the OR where under general anesthesia he underwent craniotomy
with evacuation of SDH. Post op head CT was improved. He had
some right arm tremors and underwent EEG that showed
encephalopathy but no seizure activity. On [**10-7**] he
self-extubated but later aspirated tube feeds and required
re-intubation.
[**10-10**] - CT stable; sputum culture negative; no growth on bronch
lavage.
[**10-12**] - Exam improved, patient was extubated. Blood cultures
showed gram (+) cocci,
clindamyicn/levoquin started.
[**10-13**] - ID was consulted: they recommended starting vancomycin
and zosyn and stopping
clindamycin and levoquin.
[**10-15**] - Failed speech/swallow eval. Continued NPO. ID recs: d/c
vanco and continue
zosyn x 7-10 days total. Obtain blood cultures every
other day.
[**9-15**] - Patient removed his NGT, a new one was placed.
[**10-17**] - staples removed
[**10-19**] - Speech and swallowed eval. Passed video swallow -
started on ground solids
and thin liquids. He ate lunch and dinner with no
difficulty. PT evaluated
the patient and recommended rehab. He was safe to be
discharged from a
neurosurgical standpoint. He is awaiting a bed.
[**10-20**] - The patient is neurologically improved since admission.
He is full strength in his upper extremites and is slightly weak
in his lower extremities. He is oriented to himself only and is
confused. It appears that he is back to his baseline mental
status now. The patient is significantly improved compared to
admission and compared to his immediate post-op period.
Medications on Admission:
Medications prior to admission:
Exelon 1 mg PO daily
Norvasc 5 mg PO daily
Enteric coated aspirin 81 mg PO daily
Plavix 75 mg PO daily
Lipitor 10 mg PO at bedtime
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Senna 6.5 % Liquid Sig: One (1) PO BID (2 times a day).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Rivastigmine 3 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-8**]
Puffs Inhalation Q6H (every 6 hours) as needed.
11. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
12. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 7 days: Patient
is on day 7 of 14 on [**2117-10-20**].
16. Insulin Regular Human Subcutaneous
17. Insulin Sliding Scale order
Sliding scale per printout
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] Healthcare Center [**Location (un) 4047**]
Discharge Diagnosis:
SDH
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
??????Have a family member check your incision daily for signs of
infection
??????Take your pain medicine as prescribed
??????Exercise should be limited to walking; no lifting, straining,
excessive bending
??????You may wash your hair only after sutures and/or staples have
been removed
??????You may shower before this time with assistance and use of a
shower cap
??????Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
??????If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
??????Clearance to drive and return to work will be addressed at your
post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
??????New onset of tremors or seizures
??????Any confusion or change in mental status
??????Any numbness, tingling, weakness in your extremities
??????Pain or headache that is continually increasing or not relieved
by pain medication
??????Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
??????Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
|
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32,193
| 136,977
|
9447
|
Discharge summary
|
report
|
Admission Date: [**2165-9-3**] Discharge Date: [**2165-9-20**]
Date of Birth: [**2096-5-8**] Sex: F
Service: MEDICINE
Allergies:
Tetracycline Analogues / Atenolol / Tegaderm
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
CVVH
Diagnostic coronary angiography
Pulmonary Artery catheterization
Percutaneous angioplasty and stenting of SVG to RCA conduit and
OM1
hemodialysis
Tunneled hemodialysis line placement
arterial cannulization
central line placement
History of Present Illness:
Ms. [**Known lastname 32090**] is a 69 yo F with sig PMH for DM, CAD s/p CABG,
a.fib and CHF with LVEF of 20-25% presents to ED feeling weak
and fatigued. She started dialysis two weeks prior and since
then her BP has been low, she has been dizzy, LH with nausea.
She states that all of these symptoms are aggrevated with
movement. She also stated that since dialysis has started her
glucose levels have been low and her appetite has been
decreased. She has difficulty lying flat and uses 3 pillows at
night. She denies any new medications recently, she also denies
fever/chills, diarrhea, abdominal pain, syncope and rash. Her
last dialysis treatment was yesterday.
.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals/Trigger: trigger for hypotension
- EKG: ST elevations but unchanged from prior
- ASA taken in the AM
- troponin elevated to 0.3 in setting of elevated Cr
- BPs down to 80s with normal mentation -> 1 L bolus given
slowly and BP increased from 80s to 100s
- Dr. [**Last Name (STitle) **] alerted -> can scale back meds
- Hyperkalemia -> no ekg changes, 30 g kayelexate, 1 L fluids
.
On arrival to the CCU pt was mentating well, able to answer all
of my questions appropriately in NAD. She was denying symptoms
of CP, SOB, N/V, LH or dizziness.
.
On review of systems, she denies bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. All
of the other review of systems were negative.
Past Medical History:
- CAD s/p 4V CABG '[**51**] (LIMA to LAD, SVG to diag, SVG to Cx, SVG
to RCA), DES x3 to OM1 ([**2164-8-11**]), BMS to OM1 ([**2164-5-1**]), BMS x3
to LCX/OM ([**1-/2165**])
- TIA `97 or `98
- paroxysmal afib/flutter s/p multiple cardioversions '[**55**]/'[**56**];
d/c'd coumadin ~4yrs ago [**2-6**] GIB
- ESRD
- COPD on 3L home O2 (non compliant)
- Morbid obesity
- Hypertension
- Hyperlipidemia
- PVD s/p angioplasty of anterior tibial artery ([**9-11**]), s/p
angioplasty of right dorsal pedis ([**11-11**])
- s/p L5 amp & [**4-9**] metatarsal head resections
- GIB from PUD ~4 yrs ago
- OSA
- Chronic anemia (baseline ~ 32)
- C. diff colitis, toxin positive, in the absence of diarrhea
- Hypothyroidism
- Asthmatic bronchitis
- Sciatica
- Vertigo
- MRSA hx
Social History:
Lives in [**Location 86**], at home with her son, [**Name (NI) **]. She uses a
wheelchair at baseline and is on 2 liters O2. She formerly
worked as a homemaker and in meat wrapping.
-Tobacco history: quit smoking 30 years ago, smoked 2.5 ppd x
25yrs
-ETOH: no current alcohol use, none in past that she reports
-Illicit drugs: denies
Family History:
Mother died of breast cancer at age 60; sister died at 60 of
glioblastoma; father died of lung cancer at 73; and sister died
at 60 of heart disease; son died at [**Hospital1 18**], diabetic, of massive
MI in [**2160**]
Physical Exam:
ON ADDMISSION:
VS: T=97.3 BP=86/51 HR=88 RR=20 O2 sat= 97% 2 L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple no lymphadenopathy. JVP difficult to assess
secondary to body habitus.
CARDIAC: RR, 3/6 systolic murmur
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles present b/l at
bases
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: B/L LE 2+ edema to mid thigh
SKIN: multiple scars on LE from prior CABG
PULSES:
Right: Carotid 2+ radial 1+ DP 1+
Left: Carotid 2+ radial 1+ DP 1+
.
Discharge
GENERAL: NAD.aox3, sitting in bed comfortable
NECK: Supple JVD 15cm
CARDIAC: rrr, 3/6 systolic murmur across precordium radiating
to axilla.
LUNGS: ctab
ABDOMEN: Soft, obese
EXTREMITIES: B/L LE 2+ edema to mid thigh
SKIN: multiple scars on LE from prior CABG
Pertinent Results:
[**2165-9-3**] 04:30PM PT-14.3* PTT-27.6 INR(PT)-1.2*
[**2165-9-3**] 04:30PM NEUTS-69.0 LYMPHS-19.9 MONOS-7.7 EOS-2.4
BASOS-0.9
[**2165-9-3**] 04:30PM WBC-5.8 RBC-3.62* HGB-10.0* HCT-31.0* MCV-86
MCH-27.6 MCHC-32.3 RDW-18.0*
[**2165-9-3**] 04:30PM cTropnT-0.32*
[**2165-9-3**] 04:30PM CK-MB-4
[**2165-9-3**] 04:30PM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-1.9
[**2165-9-3**] 04:30PM CK(CPK)-250*
[**2165-9-3**] 04:30PM GLUCOSE-144* UREA N-29* CREAT-4.5*#
SODIUM-134 POTASSIUM-6.8* CHLORIDE-95* TOTAL CO2-30 ANION GAP-16
CPK ISOENZYMES CK-MB cTropnT proBNP
[**2165-9-5**] 04:09 2 0.26*1 [**Numeric Identifier 32222**]*2
PITUITARY TSH
[**2165-9-6**] 05:48 1.7
THYROID T4
[**2165-9-6**] 05:48 7.2
Cortsol
[**2165-9-4**] 03:29 22.4
EKG [**9-3**]: Rate PR QRS QT/QTc P QRS T
91 0 114 348/402 0 93 -125
Baseline artifact. Probably sinus rhythm with A-V nodal
Wenckebach.
Poor R wave progression. Cannot exclude an old anteroseptal
myocardial
infarction.
ECHO [**9-3**]:
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is milldy dilated. There is
akinesis of the septum, and moderate to severe hypokinesis of
the remaining left ventricular segments. LVEF (20-25%) .The
right ventricular cavity is dilated and hypokinetic. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. The study is inadequate to exclude
significant aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. Mild
to moderate ([**1-6**]+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild cavity dilation and severe
left ventricular systolic dysfunction as detailed above. Dilated
and hypokinetic right ventricle. Mild to moderate mitral
regurgitation.
Compared to the prior study (images reviewed) of [**2165-7-31**],
estimated pulmonary artery pressures are lower (may be
underestimated due to poor acoustic windows). The severity of
mitral regurgitation has increased.
CARDIAC CATH [**9-5**]:
1. Selective coronary angiography of this right dominant system
demonstrated 3-vessel coronary artery disease. The LMCA had mild
non-obstructive plaquing. The LAD is occluded proximally. There
was
severe in stent restenosis of the distal OM1 and a de [**Last Name (un) 11083**]
lesion more
distal to this. The RCA was not injected and is known to be
occluded.
2. Venous conduit angiography demonstrated an ostial/proximal
90%
stenosis in the SVG to RCA. The RCA system was free of
significant
disease. The SVG to OM was patent with new disease at the
anastamosis
and in the bypassed vessel.
3. Arterial conduit angiography demonstrated the LIMA to LAD to
be
patent.
4. Resting hemodynamics revealed elevated left and right heart
filling
pressures (RVEDP 24mmHg and LVEDP 27mmHg). There was moderate
pulmonary
artery hypertension (52/32mmHg). The SVR was low and was
significantly
elevated (500 dynes*sec*cm-5 and 186 dynes*sec*cm-5). The CO and
CI were
normal in the context of anemia (5.6L/min and 2.4 L/min/m2).
There was
no gradient across the aortic valve on careful pullback from the
LV to
the ascending aorta.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Occluded SVG to Diagonal and new stenosis of SVG to RCA.
3. Patent LIMA to LAD.
4. Significantly elevated left and right heart filling pressures
with
moderate secondary pulmonary artery hypertension.
5. Hypotension likely due to a combination of inappropriately
low SVR
and lower than expected CO in the context of anemia from her
known
systolic dysfunction.
[**2165-9-10**]:
ECHO: LV systolic function appears depressed. The right
ventricular cavity is dilated with depressed free wall
contractility. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2165-9-4**], the findings are similar.
.
[**2165-9-13**]
CT abd and pelvis with contrast
MPRESSION:
1. Mural wall thickening and adjacent fat stranding of the
ascending colon,
findings consistent with focal colitis. Differential includes
ischemic,
inflammatory and infectious etiologies, though infectious is
preferred given
the clinical history of septicemia. Abdominal arterial
vasculature is densely
calcified, though appears grossly patent. No drainable fluid
collection is
identified.
2. Small bilateral pleural effusions with compressive
atelectasis.
3. Dense atherosclerotic vascular calcifications. Stable
subcutaneous soft
tissue density posterior to the right iliac crest dating back to
[**2160**].
The study and the report were reviewed by the staff radiologist.
.
[**2165-9-10**]
CTA Chest:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Moderate bilateral pleural effusions, right greater than
left, increased
compared to [**2165-7-28**].
3. Unchanged small volume perihepatic ascites with a nodular
liver contour,
raising concern for cirrhosis.
.
.
[**2165-9-12**]
cardiac cath.
COMMENTS:
1. Limited resting hemodynamics revealed moderate pulmonary
hypertension
and elevated right- and left-sided filling pressures, with mean
PA
pressure of 40 mm Hg, mean RA pressure of 19 mm Hg, and mean
PCWP of 26
mm Hg.
FINAL DIAGNOSIS:
1. Left-sided congestive heart failure with elevated right- and
left-
sided filling pressures.
2. Hemodialysis and CRRT in the morning via a tunnelled line in
the left
internal jugular vein placed in the morning.
3. Left CVP catheter removed, and tip sent for culture.
4. Start PO amiodarone load for atrial fibrillation with RVR.
.
.
Discharge labs:
WBC 10.8 heme 8.6* hct 26.6* plt 180
BUN 42* Cr 4.5* Na 131* K 4.1 Cl 92* bicarb 27
Brief Hospital Course:
Ms. [**Known lastname 32090**] is a 69 yo F with sig PMH for DM, CAD s/p CABG,
a.fib and CHF with LVEF of 20-25% presents to ED feeling weak
and fatigued and found to be hypotensive.
.
# Hypotension-Patient's hypotension was felt to be related to
cardiogenic shock, though adrenal insufficency and sepsis were
ruled out. Pulmonary embolism and tamponade were ruled out with
CTA chest and echo, respectively. ECHO on admission showed
depressed EF of 20-25%, diffuse WMA and elevated RA pressures.
Echo was grossly unchanged from baseline (7/[**2165**]). EKG was also
unchanged from baseline. Patient was cathed which showed new
distal occlusions in the OM1 and 90% stenosis of the RCA-ACG
bypass, DES were placed in both. Patient's PCWP was elevated,
CI was depressed and surprisingly, SVR was noted to be 500
during the procedure. Despite depressed SVR, hemodynamics were
felt to be from fluid overload and increased preload. She was
diuresed with CVVH requring additonal pressure support with
phenylephrine. Phenylephrine was difficult to wean but
ultimately pt was started on midodrine, sudafed and
fludrocortisone to assist in raising SVR. Additionally, 20 L
were removed with CVVH and phenylephrine was and pt maintained
pressures with MAPs of 60-80. Dialysis was reinitiated and
after two sessions, pt was able to tolerate dialysis without any
drops in pressure. A new tunneled dialysis catheter was placed
and she will continue dialysis in rehab and ultimately resume
outpatient HD.
.
#Leukocytosis/infection- The patient developed a leukocytosis
during this admission. Her WBC rose to 18. She also became
febrile at that time as well. Her tunneled dialysis line on the
right was noted to be erythematous. Cultures were sent from the
line and 1 of 2 bottles grew gram positive rods, gram negative
rods and gram postive cocci in pairs and chains. She was started
on empiric Vancomycin and Zosyn antibiotic therapy. Also her
tunneled line was pulled as well as her left IJ central line. On
antibiotics her leukocytosis resolved. During her antibotic
course she developed diarrhea. She was then also started on
Flagyl as well and her stool was sent for C.Difficile toxin as
well as PCR which was negative. She completed a 10 day course of
Vancomycin and Zosyn. A temporary dialysis line was re-inserted
into her right IJ for continued CVVH while in the CCU. She was
restarted on HD and a new tunneled line was placed.
.
# [**Name (NI) 4964**] Pt has documented EF 20-25% on echo from [**2165-7-31**] with
severe regional left ventricular systolic dysfunction and severe
hypo to akinesis of the entire septum, anterior wall, and distal
[**2-7**] of the left ventricle. Cath showed new distal occlusions in
the OM1 and 90% stenosis of the RCA-ACG bypass, DES were placed
in both. Patient was aggressively diuressed with CVVH requiring
pressors as outlined above. At time of discharge pt's weight
had decreased from 143kilos to 119 kilos.
.
# A.[**Name (NI) 6233**] Pt had CHADS score of 4 and not anticoagulated given
history of recurrent GI bleeds, patient was monitored on
Telemetry while in the ICU. She was ultimately loaded with
amiodorone. afib converted to sinus after first day of
amiodorone loading. She was discharged on 400mg TID of
amiodarone for an additional 3 days of loading and will
transition to 200mg daily after loading.
.
# CAD- Patient had documented 4 vessel disease status post CABG,
underwent Cath and stenting of the ACG-RCA bypass and the OM1
while in the ICU. She was continued on asprin, statin and
plavix.
.
# [**Name (NI) 3672**] Pt was not wheezing on admission but developed cough and
wheezing approximately one week prior to discharge. She was
started on advair, ipratropium and albuterol nebs and given
short course of solumedrol, and a prednisone taper. O2 sats
were in low to mid 90's on RA at time of discharge.
.
# [**Name (NI) 1568**] Pt on insulin at home. Pt was managed on ISS. She was
discharge on home insulin regimen. Gabapentin was continued for
peripheral neuropathy.
.
# Hypothyroidism- TSH and free T4 were WNL. Pt was continued on
levothyroxine 100mcg.
.
Transitional:
- tolerate BPs in 80-90 systolic.
- needs HD on MWF
Medications on Admission:
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. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. torsemide 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
11. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
12. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) as needed for Constipation.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
17. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
19. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
20. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
21. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Thirty (30) units Subcutaneous every AM.
22. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous every PM.
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. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
10. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [**5-14**]
MLs PO Q6H (every 6 hours) as needed for cough.
14. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
15. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. tramadol 50 mg Tablet Sig: One (1) Tablet PO q8hr: PRN.
17. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation q6hr PRN as needed for
cough.
18. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) neb Inhalation once a day.
19. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Thirty (30) units Subcutaneous qAM.
20. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Twenty (20) units Subcutaneous qHS.
21. insulin lispro 100 unit/mL Solution Sig: 2-12 units
Subcutaneous QACHS: PRN as needed for hyperglycemia. BG>150: as
per insulin sliding scale regimen.
22. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
23. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day) for 4 days: please stop after [**9-24**].
24. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
To be started on [**9-25**].
25. prednisone 20 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses.
26. prednisone 5 mg Tablet Sig: Two (2) Tablet PO ONCE (Once)
for 1 doses.
27. pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO
every twelve (12) hours for 1 days: [**9-21**].
28. pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO once
a day for 1 days: [**9-22**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Cardiogenic shock
CHF exacerbation
ESRD
atrial fibrillation
sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname 32090**],
It was a pleasure taking care of you. You were admitted to the
hospital for a congestive heart failure exacerbation and
hypotension. This resulted in a condition called cardiogenic
shock. You were treated with IV medications to increase your
blood pressure and we used a type of dialysis called CVVH to
remove excess fluid from your body. Your blood pressures
improved and we restarted you on hemodialysis. You tolerated
the hemodialysis well and will continue with your
[**Known lastname **]-wednesday-friday dialysis routine. Your hospital course
was complicated by an infection in your blood. We treated you
with antibiotics and changed your dialysis catheter and you
improved.
.
We have made the following changes to your home medications:
START: Amiodorone 400mg tab by mouth three times daily until
[**2165-9-24**]. On [**2165-9-25**] start Amiodorone 200mg tab by mouth once
daily
START: Midodrine 10 mg by mouth three times daily
START: Fludricortisone acetate 0.2mg tab by mouth once daily
Continue pseudoephedrine taper: on [**9-21**] take 30mg by mouth every
12 hrs, on [**9-22**] take 30mg by mouth once and then discontinue
this medication.
START: albuterol 0.083% Neb solution 1 NEB IH q6hr:PRN for cough
START: fluticasone-solumedrol inh 250/50mcg/dose: one puf by
mouth twice daily
START: nephrocaps, one cap daily
DECREASE: atorvastatin from 80mg to 40mg daily
Continue: Prednisone taper: take 20mg by mouth on [**9-21**] and 10mg
by mouth on [**9-22**] and then stop this medication
STOP: metolazone, torsemide, metoprolol, lisinopril and
isosorbide mononitrate.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**]
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 7960**]
Appointment: Wednesday [**2165-10-9**] 2:30pm
.
You will be contact[**Name (NI) **] by nephrology to schedule outpatient
dialysis after you leave rehab.
|
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icd9cm
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"88.57",
"37.23",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19207, 19250
|
10381, 14578
|
315, 551
|
19361, 19361
|
4477, 7898
|
21279, 21766
|
3251, 3472
|
16590, 19184
|
19271, 19340
|
14604, 16567
|
9919, 10255
|
19537, 20309
|
10272, 10358
|
3487, 4458
|
20327, 21256
|
264, 277
|
579, 2095
|
19376, 19513
|
2117, 2883
|
2899, 3235
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,122
| 117,059
|
8422
|
Discharge summary
|
report
|
Admission Date: [**2172-3-9**] Discharge Date: [**2172-3-14**]
Date of Birth: [**2112-2-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
EGD [**2171-3-14**]
History of Present Illness:
60M with PMH of CAD s/p 3 vessel CABG, IDDM and anemia who
presents with one day of dizziness. The patient states that he
woke up at 4am to go to the bathroom this morning and felt
dizzy. He returned to bed and was persistenly dizzy with all
subsequent attempts to get out of bed. Patient notes that he had
a dark bowel movement this morning. He also vomited once this
orning. This afternoon, he came to dermatology clinic for
scheduled biopsy of an umbilic nodule. On [**2172-3-3**], the patient
had had a CT scan of his abdomen that revealed a 4.5cm
pancreatic mass with mesenteric and umbilical nodules concerning
for metastases. Following the derm appointment, the patient came
to the ED for further evaluation.
.
In the ED, initial vs were: T 97.6 P 106 BP 94/61 R 18 O2 100%
RA Patient did not take his insulin this am and had a blood
glucose of 707 in the ED for which he received 10 units of
insulin. Repeat FSBS was 489. The patient was also noted to have
a positive troponin of .27 and an index of 9.1. Cardiology was
contact[**Name (NI) **] and it was thought to be due to demand in the setting
of a hematocrit of 20. Cardiology recommended giving the patient
and aspiring, which was done. In addition, the patient received
2L NS. CXR showed no acute cardiopulmonary process. EKG showed T
wave inversions in inferior leads, ST elevation in [**Last Name (LF) 1105**], [**First Name3 (LF) **]
depression in V5 and V6.
.
On arrival to the ICU, vitals 98.5 102 101/55 12 95% on 2L. Pt
had no complaints. ROS as below. Pt received additional 10 units
of insulin for persistently elevated blood glucose.
.
Review of systems:
(+) Per HPI. In addition, constipation on Fe, dry cough, and
loss of appetite for the last few weeks. He also notes a 7 pound
intentional weight loss since [**Month (only) 956**].
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
Pancreatic Tumor with Abdominal Lymphadenopathy
Anemia
Insulin-Dependent Diabetes Mellitus
Chronic Renal Insufficiency [**1-13**] Diabetic Nephropathy
Bilateral Hernia Repair age 5
Congestive Heart Failure
Coronary Artery Disease s/p 3-vessel CABG
Hypertension
Hyperlipidemia
Atrial Septal Defect Repair
[**Doctor Last Name **] [**Location (un) **] Exposure in [**Country 3992**]
Diabetic Retinopathy
Social History:
Mr. [**Known lastname **] works as a data center manager for
[**Hospital1 **], has been quite stressed and busy at work in
the
past 5 years. He is married, has 3 children. He never smoked,
drinks only occasionally. He was exposed to [**Doctor Last Name 360**] [**Location (un) **] in
[**Country 3992**].
Family History:
His father died at the age of 84 from liver
cancer, had HTN. Mother is in her 80s and alive, had breast ca.
He has one brother who has asthma, his children are healthy.
Physical Exam:
Vitals: T: 97.1 BP: 130/80 P: 80 R: 18 O2: 100% 2L
General: NAD
HEENT: No oropharyngeal erythema or exudate.
Lungs: Decreased breath sounds, rales at basees.
CV: RRR. No m/r/g.
Abdomen: +BS. Soft. NTND. Palpable LN umbilicus s/p bx incision.
Rectal: Dark brown, guaiac positive stool.
Ext: No c/c/e.
Pertinent Results:
Images:
CT Abd - [**2172-3-3**] - 1. 4.5-cm spiculated mass centered in the
distal pancreas, highly concerning for malignancy. Mesenteric
nodule and umbilical nodules are compatible with metastatic
foci.
2. Splenomegaly.
3. Cholelithiasis, no evidence of acute cholecystitis.
4. Limited assessment of solid organs due to lack of IV
contrast.
.
CXR - [**2172-3-9**] - No acute cardiopulmonary process.
.
EKG: Regular rate and rhythm, Q waves in II with questionable ST
segment elevations. New T wave inversion in II, ST segment
depression in V5 and V6.
.
ECHO [**2171-11-15**] - The left atrium is mildly dilated. A possible
secundum type atrial septal defect is seen with left to right
flow (clips 43/46 - vs. prominent caval flow). There is mild
(non-obstructive) focal hypertrophy of the basal septum. The
left ventricular cavity size is normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe hypokinesis of the basal half of the inferior septum,
inferior, and inferolateral walls. The remaining segments
contract normally (LVEF = 35 %). Right ventricular chamber size
is normal. with mild global free wall hypokinesis. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are mildly thickened. Mild to moderate ([**12-13**]+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2169-4-3**],
the regional left ventricular systolic function is more
extensive and the severity of mitral regurgitation has
increased. A possible secundum type atrial septal defect is now
seen. If the clinical suspicion for an ASD is high, a TEE or
follow-up TTE with saline contrast is suggested.
Brief Hospital Course:
60M with h/o DM1, CAD s/p 3 vessel CABG and new pancreatic mass
and abdominal lymphadenopathy concerning for metastatic
presenting with symptomatic anemia.
# [**Name (NI) 3674**] Pt most likely GIB from mets to the GI tract from
known pancreatic mass. Other possibilities include
gastritis/duodenitis, PUD, AVMS, or colonic lesions. Pt received
a total of 8units PRBC, and stable to 32 [**Hospital 29715**] transferred to
the floor. EGD/[**Last Name (un) **] [**9-17**] revealed only gastritis/duodenitis and
coffee grounds in stomach. Capsule [**1-20**] with coffee grounds as
well. Pt had black loose stool, first BM since admission,
expected to pass old blood. Pt was continued on IV PPI and had
hct remained stable, and was sent out with close follow up.
# Elevated trop- demand ischemia vs. [**Name (NI) 7792**] - Pt has WMA on
echo, Discussed with cards, and since clinically stable, and
overall CE trending downward, and EKG not associated w/ new CP,
cardiology agrees w/ EGD tomorrow. Concerning troponin 2.0 from
1.7, overall trending down from peak 2.5, and reassuring that
CK, CKMB [**Last Name (un) 8636**]. Continued ASA, statin.
# Pancreatic mass- newly diagnosed with pancreatic cancer,
deferred treatment to outpatient.
# Congestive Heart Failure - Last EF 35%, got 2L NS in ED. NO O2
requirement. Pt remained euvolemic.
# [**Name (NI) 29716**] Pt was below baseline of 3.0 during admission.
Medications on Admission:
ATORVASTATIN [LIPITOR] - 80 mg po daily
CALCITRIOL - 0.5 mcg po daily
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - sliding scale
once a day as needed for sq injection dm
METOPROLOL TARTRATE - 12.5mg po bid
OMEPRAZOLE - 20 mg po bid
CYANOCOBALAMIN - 2,000 mcg po daily
FERROUS GLUCONATE - 325 mg po bid
INSULIN NPH HUMAN RECOMB [HUMULIN N] - 100 unit/mL Suspension -
inject ut dict for dm
NIACIN - 500 mg Tablet po daily
VITAMIN A-VIT C-VIT E-ZINC-CU [OCUVITE PRESERVISION] - 1 tablet
po daily
Senna
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. 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*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
8. Ocuvite PreserVision Tablet Sig: One (1) Tablet PO daily
().
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Insulin Regular Human 100 unit/mL Cartridge Sig: other
Injection once a day: per sliding scale as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- Upper GI bleed - gastric wall invasion vs. gastric varices
- Demand ischemia of the heart (while you had low blood counts)
Secondary diagnosis:
- metastatic pancreatic cancer
- chronic renal disease
- diabetes
- Coronary Artery Disease s/p 3-vessel CABG
- Hypertension
- Hyperlipidemia
- Atrial Septal Defect Repair
- Diabetic Retinopathy
Discharge Condition:
good, hematocrit stable
Discharge Instructions:
You had a GI bleed that may be due to metastasis from your
pancreatic cancer or from gastritis. You were hospitalized until
your blood counts remained stable. You may expect [**12-13**] more dark
stools while the remaining blood is passing through, but if you
have persistent black stools, or start feeling light-headed or
weak please return to the ED or contact Dr. [**First Name (STitle) 679**] immediately.
Also return if you have a fever >101, or new chest pain
Medication changes:
- start taking Omeprazole 40mg twice a day until you see Dr.
[**First Name (STitle) 679**]
- take Aspirin 81mg once per day
Followup Instructions:
After speaking with you, you said you prefer to make the
appointment with your primary care doctor, Dr. [**Last Name (STitle) 12872**], for
convenience of coordinating with your work. Please make sure to
follow up in [**12-13**] weeks.
You already have an appointment with Dr. [**First Name (STitle) 679**], your GI doctor [**First Name (Titles) **] [**Last Name (Titles) 7712**] at 12:45pm. At time of discharge the pathology report for
your skin biopsy was still pending, please have him follow up
with this.
You also mentioned you already have an appointment with your
cardiologist, Dr. [**Last Name (STitle) **].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2172-3-16**] 3:30
Provider: [**Name10 (NameIs) 11021**] [**Name11 (NameIs) 11022**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2172-3-16**] 3:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2172-4-1**]
|
[
"V58.66",
"403.90",
"285.1",
"362.01",
"V58.67",
"456.8",
"197.8",
"272.4",
"286.9",
"414.00",
"V45.81",
"585.9",
"250.50",
"198.2",
"578.9",
"157.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8586, 8592
|
5633, 7047
|
320, 342
|
8997, 9023
|
3774, 5610
|
9682, 10710
|
3266, 3437
|
7604, 8563
|
8613, 8613
|
7073, 7581
|
9047, 9514
|
3452, 3755
|
2000, 2503
|
9534, 9659
|
274, 282
|
370, 1981
|
8779, 8976
|
8632, 8758
|
2525, 2928
|
2944, 3250
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,976
| 196,624
|
50646
|
Discharge summary
|
report
|
Admission Date: [**2114-11-15**] Discharge Date: [**2114-11-19**]
Date of Birth: [**2034-6-29**] Sex: M
Service: MEDICINE
Allergies:
Cozaar / Ace Inhibitors / Morphine
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Incessant ventricular tachycardia
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a 80 year-old Male with a PMH significant for coronary
artery disease (s/p CABG in [**2083**], [**2088**]), infarct-related
cardiomyopathy (EF 20-25%), status-post biventricular ICD
placement (EPS revealed VT inducible with triple extra-stimuli
from the RVA), atrial flutter status-post ablation, multiple
atrial tachycardias status-post ablation, and AVNRT status-post
slow pathway modification who was recently admitted with
incessant VT and underwent ablation ([**2114-10-24**]) who presented
with chest pain.
.
The patient was feeling well until the evening of [**2114-11-14**], at
8PM, when he developed chest pressure. Shortly following this,
his ICD fired 4-times. EMS was called and an additional
10-shocks were witness by the EMS staff (overall 23-shocks
recorded from his device). He received 324 mg PO Aspirin and IV
Amiodarone 150 mg followed by a continuous infusion prior to
arrival at [**Hospital1 2025**]. In the [**Hospital1 2025**] ED, initial VS 97.1 160/79 71 18 95%
3L NC. His exam was notable for 1+ pitting edema. He was noted
to have recurrent, slow wide-complex tachycardia (at 150 bpm)
and was started on a Lidocaine gtt at 2 mg/min, which resulted
in reversion to a paced rhythm. His initial EKG showed VT @ 140,
upright in V1, II, III, aVF, negative in I, aVL; almost positive
concordance in the precordial leads. His Troponin was 0.07 and
0.26, CK-MB 4.3 to 8.8. Creatinine 1.8, magnesium 2.1 and
potassium 3.0 (repleted to 3.9). A CXR showed a patchy left
retrocardiac opacity, likely atelectasis. He had no symptoms of
chest pressure, shortness of breath, diaphoresis or nausea; no
palpitations. He remained hemodynamically stable and was
mentating at baseline following his last shock. He was
transferred to BIMDC for further management.
.
Of note, the patient was admitted to the CCU on [**2114-10-24**] with
chest pain associated with nausea and dyspnea and his ICD fired
around that time. In our ED, he developed incessant VT with
associated chest pain and his blood pressure was tenuous in the
SBP 90-100 mmHg range. Anti-tachycardia pacing was attempted and
would only break the VT for 2-3 beats with return to a
wide-complex rhythm. Electrophysiology was consulted and he was
taken to the EP lab from the ED where he underwent ablation of
an inducible focus of ventricular tachycardia which was the
presumed source. His VT-1 was a left-bundle type morphology with
a superior axis and negative throughout the precordial leads,
very similar to the EKG morphology during RV-pacing. Biosense
mapping revealed scar at the inferior wall and apex. The
earliest site of activation was located at the atrial septum. A
second site (VT-2) revealed a right-bundle branch morphology
with a right inferior axis, earliest activation site in the
basal inferolateral ventricle. A third site (VT-3) was a right
bundle-branch block with qR morphology in the inferior leads;
this was poorly tolerated and required pressor support with
Dopamine. A VT-4 site was noted as well, right bundle-branch
block morphology with an inferior right axis and positive
throughout the precordium. 40-seconds of ablation was applied to
the VT-1 site. Following this procedure, he was monitored in the
CCU following ablation and had no recurrent episodes of VT on
telemetry. He had stopped Amiodarone prior to discharge (on
[**2114-10-27**]).
.
Of note, he had a positive urinalysis and urine culture with
coagulase positive Staphylococcus last admission which was
treated with IV Ceftriaxone as an inpatient and 5-days of
Cefpodoxime.
.
On arrival to the CCU, the patient is mentating at baseline. He
is without chest discomfort, has no nausea, palpitations or
diaphoresis. He denies shortness of breath. He notes some
on-going urinary dribbling and stopping-starting, no dysuria.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or pre-syncope.
.
ROS: The patient denies a history of prior stroke/TIA, deep
venous thrombosis or pulmonary embolus. Denies headaches or
vision changes. No upper respiratory symptoms; mild, chronic
non-productive cough. Denies chest pain, dizziness or
lightheadedness; no palpitations. Denies shortness of breath. No
nausea or vomiting, denies abdominal pain. No dysuria or
hematuria. No change in bowel movements or bloody stools. Denies
muscle weakness, myalgias or neurologic complaints. No
exertional buttock or calf pain.
.
Past Medical History:
CARDIAC HISTORY: Hyperlipidemia, Hypertension, Diabetes mellitus
* CABG: [**2083**] (SVG-distal LAD, distal LCx, distal RCA), re-do in
[**2088**]
* PERCUTANEOUS CORONARY INTERVENTIONS: None
* PACING/ICD: [**Company 1543**] biventricular ICD (placed in [**2104**])
.
PAST MEDICAL & SURGICAL HISTORY
1. Paroxysmal atrial fibrillation
2. Infarct-related cardiomyopathy with significant coronary
disease, (EF 20-25%, left ventricular systolic dysfunction with
akinesis of the inferior septum, inferior wall, and
inferolateral wall)
3. Coronary artery disease
4. Ventricular tachycardia storm status-post biventricular ICD
placement in [**2104**] (Medtronig [**First Name9 (NamePattern2) **] [**Last Name (un) 24119**] generator replacement
in [**3-/2108**])
5. Atrial tachycardia status-post ablation ([**2104**], [**2105**]), atrial
flutter status-post ablation, and AVNRT status-post slow pathway
modification
6. Prior history of stroke post-CABG in [**2088**]; another stroke
([**2108**]) - mild residual visual disturbance and unsteady gait
7. Prostate cancer s/p TURP
8. Diet-controlled diabetes mellitus
9. Chronic renal insufficiency (baseline 2.0-2.3)
10. h/o nephrolithiasis
11. Intermittent vertigo history
12. Mild insomnia (sleeps 2-3 hours nightly)
13. s/p Tonsillectomy (at age 40 years)
14. s/p Mastoidectomy
Social History:
Patient lives at home alone in [**Hospital1 3494**], MA. Patient is
independent in his ADLs. Retired nurse. Denies tobacco use or
alcohol use; no recreational substance use.
Family History:
Patient is adopted. Unaware of biological family history.
Physical Exam:
ADMISSION EXAM:
VITALS: 97.8 / 97.8 70 135/65 24 94% 3L NC
BG: 272 mg/dL
GENERAL: Appears in no acute distress. Alert and interactive,
mentating at baseline. Ill-appearing male.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. No xanthalesma.
NECK: supple without lymphadenopathy. JVD 2-3 cm above clavicle
at 30-degrees.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. A-V paced rate and rhythm, [**12-31**] holosystolic murmur heard
best at apex, without rubs or gallops. S1 and S2 normal. No S3
or S4.
RESP: Respirations unlabored, no accessory muscle use. Decreased
breath sounds at bases bilaterally without adventitious sounds.
No wheezing, rhonchi or crackles. Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; 1+ peripheral edema, triphasic
dopplerable pulses; chronic venous stasis dermatitis up to
mid-shins bilaterally
DERM: Evidence of stasis dermatitis; but no ulcers, scars, or
xanthomas.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Sensation grossly intact. Gait deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP and PT dopplerable
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP and PT dopplerable
.
DISHCARGE EXAM:
VS 96.7 115/54, 70, 20, 93% on 2L
General Appearance: Well nourished, No acute distress,
Overweight / Obese
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal),
(Murmur: Systolic), 2/6 systolic murmur heard best at apex,
without rubs or gallops. S1 and S2 normal.
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Diminished), (Left DP pulse:
Diminished), triphasic dopplerable pulses
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : significant inspiratory crackles at bases
bilaterally)
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: 1+, Left lower
exremity edema: 1+, chronic venous stasis dermatitis up to
mid-shins bilaterally
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): self, time, location, Movement:
Purposeful, Tone: Normal
Skin: sebborheic dermatitis
Pertinent Results:
ADMISSION LABS:
[**2114-11-15**] 06:55PM BLOOD WBC-9.0 RBC-3.92* Hgb-11.5* Hct-34.2*
MCV-87 MCH-29.2 MCHC-33.5 RDW-15.8* Plt Ct-148*
[**2114-11-15**] 06:55PM BLOOD PT-12.4 PTT-30.6 INR(PT)-1.1
[**2114-11-15**] 06:55PM BLOOD Glucose-278* UreaN-38* Creat-1.7* Na-136
K-4.6 Cl-99 HCO3-27 AnGap-15
[**2114-11-15**] 06:55PM BLOOD ALT-25 AST-41* CK(CPK)-128 AlkPhos-95
TotBili-0.8
[**2114-11-15**] 06:55PM BLOOD CK-MB-5 cTropnT-0.26*
[**2114-11-15**] 06:55PM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.5*#
Mg-2.7*
.
PERTINENT RESULTS:
[**2114-11-16**] 03:08AM BLOOD WBC-8.9 RBC-3.87* Hgb-11.4* Hct-34.2*
MCV-88 MCH-29.5 MCHC-33.3 RDW-15.9* Plt Ct-143*
[**2114-11-16**] 03:08AM BLOOD PT-12.9* PTT-37.6* INR(PT)-1.2*
[**2114-11-15**] 06:55PM BLOOD TSH-1.4
.
DISCHARGE LABS:
[**2114-11-19**] 05:31AM BLOOD WBC-4.8 RBC-3.67* Hgb-10.7* Hct-31.8*
MCV-87 MCH-29.0 MCHC-33.6 RDW-15.8* Plt Ct-137*
[**2114-11-19**] 05:31AM BLOOD PT-12.5 PTT-39.3* INR(PT)-1.2*
[**2114-11-19**] 05:31AM BLOOD Glucose-159* UreaN-67* Creat-2.0* Na-140
K-3.5 Cl-101 HCO3-35* AnGap-8
[**2114-11-19**] 05:31AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
.
PREVIOUS DATA:
EKG (from [**2114-10-24**]): wide-complex tachycardia @ 158. Left
bundle-branch morphology with superior, anterior-to-posterior
axis. Negative throughout precordium.
.
2D-ECHO ([**2113-4-18**]): The left atrium is mildly dilated. The right
atrium is moderately dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is severe regional left ventricular
systolic dysfunction with akinesis of the inferior septum,
inferior wall, and inferolateral wall. There is also hypokinesis
of the distal third of the ventricle. The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is moderately dilated. The aortic valve leaflets
are moderately thickened. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is no pericardial
effusion. Moderate left ventricular dilation with regional
systolic dysfunction c/w multivessel CAD.
.
[**2114-10-24**] CHEST (PA & LAT) - The three ICD leads are in place
with unchanged position since prior radiograph on [**2114-6-21**],
extending to the expected positions of the right atrium, right
ventricle, and coronary sinus. The patient is status post median
sternotomy and coronary artery bypass surgery. The
cardiomediastinal silhouette is enlarged, unchanged from prior
chest x-ray. The lungs are clear. A calcified granuloma is noted
in the right lower lobe, unchanged. A more peripheral focal
opacity may represent an area of atelectasis.
.
CARDIAC CATH: None following [**2088**] record.
.
MICROBIOLOGY DATA:
[**2114-10-24**] Urine culture - coagulase negative Staphylococcus
(pan-sensitive, except Levofloxacin)
.
IMAGING FROM THIS ADMISSION:
[**2114-11-15**] CXR: Comparison is made with prior study [**2114-9-25**].
Moderate cardiomegaly has increased. Moderate-to-severe
pulmonary edema is new. Left transvenous pacemaker leads are in
standard positions. There is no pneumothorax or large pleural
effusion. The patient is status post CABG. Sternal wires are
aligned.
.
[**2114-11-16**] ECG: rate 69, A-V sequentially paced rhythm. Compared
to the previous tracing of [**2114-10-26**] there is no significant
diagnostic change.
Brief Hospital Course:
IMPRESSION: 80M with PMH significant for coronary artery disease
(s/p CABG in [**2083**], [**2088**]), infarct-related cardiomyopathy (EF
20-25%), status-post biventricular ICD placement (EPS revealed
VT inducible with triple extra-stimuli from the RVA), atrial
flutter status-post ablation, multiple atrial tachycardias
status-post ablation, and AVNRT status-post slow pathway
modification who was recently admitted with incessant VT and
underwent ablation ([**2114-10-24**]) who now presents with chest pain,
found to have incessant ventricular tachycardia.
.
# INCESSANT VENTRICULAR TACHYCARDIA, WIDE-COMPLEX TACHYCARDIA -
The patient underwent ablation of an inducible focus of
ventricular tachycardia which was the presumed source of
incessant VT on his prior admission ([**2114-10-24**]). At that time,
his EP study showed his VT-1 was a left-bundle type morphology
with a superior axis and negative throughout the precordial
leads, very similar to the EKG morphology during RV-pacing.
Biosense mapping revealed scar at the inferior wall and apex.
The earliest site of activation was located at the atrial
septum. A second site (VT-2) revealed a right-bundle branch
morphology with a right inferior axis, earliest activation site
in the basal inferolateral ventricle. A third site (VT-3) was a
right bundle-branch block with qR morphology in the inferior
leads; this was poorly tolerated and required pressor support
with Dopamine. A VT-4 site was noted as well, right
bundle-branch block morphology with an inferior right axis and
positive throughout the precordium. 40-seconds of ablation was
applied to the VT-1 site. He had stopped Amiodarone prior to
discharge. He now presented with VT storm (incessant VT) with
chest pain and multiple firings of his ICD (up to 23-shocks).
His EKG tracing from [**Hospital1 2025**] demonstrate a wide-complex tachycardia
with right bundle-branch morphology, right inferior axis, and
almost positive concordance. In terms of localization, a high
lateral position at the left ventricle from back-to-front would
create this effect. It's hard to determine if one of his prior
VT-2 through VT-4 sites are the precipitant (maybe VT-2); they
appeared to have right bundle morphology and originated from the
inferolateral ventricle. Following initiation of Amiodarone and
Lidocaine, his VT reverted to sinus rhythm and he remained
hemodynamically stable. In terms of etiology, we considered
metabolic derrangements (his electrolytes were K+ of 3.0 and Mag
2.1 on admission to [**Hospital1 2025**]) vs. ischemia would be a consideration
given his prior coronary disease (Troponin was 0.07 and 0.26,
CK-MB 4.3 to 8.8 at [**Hospital1 2025**]) vs. prior scarring (prior
infarct-related scarring has been noted on his biosense mapping
on his EPS recently) vs. anti-arrhythmic effect (on none
currently and stopped Amiodarone) vs. endocrinopathy (TSH 1.3 in
7/[**2113**]). On arrival to the [**Hospital1 18**] CCU, Lidocaine was initially
continued and then stopped. He was loaded with Mexiletine 150 mg
PO Q8H with good effect, however he had occasional runs of
asympomatic nonsustained vtach. His cardiac biomarker trend
revealed a mildly elevated Troponin with flat CK-MB and he was
without chest pain and received multiple prior shocks. LFTs on
admission were reassuring, as well as a normal TSH. We
aggressively repleted his electrolytes and monitored him via
telemetry. He will be maintained on Mexiletine, Quinidine
gluconate, and Metoprolol XL as an outpatient and should
follow-up for device interrogation to determine success of
medical management.
.
# CORONARY ARTERY DISEASE - Patient has a known history of
significant three-vessel coronary artery disease (s/p CABG in
[**2083**], with re-do in [**2088**] - SVG-distal LAD, distal LCx, distal
RCA) and no subsequent cardiac catheterizations following his
surgery in [**2088**]. He has been medically managed with Aspirin,
statin and nitrate, along with a beta-blocker. He denied chest
pain this admission, outside of his ventricular tachycardia
episodes. Sublingual nitroglycerin relieved this pain at [**Hospital1 2025**].
Recurrent VTs here have been asypmtomatic. His EKG was
unreliable for ischemic changes in the setting of VT. Cardiac
biomarkers at [**Hospital1 2025**] showed: Troponin was 0.07 and 0.26, CK-MB 4.3
to 8.8 at [**Hospital1 2025**]. We trended his cardiac biomarkers and they were
reassuring. His Aspirin was continued at 325 mg PO daily, his
statin was continued and his beta-blocker and nitrate were
continued. We aggressively repleted his electrolytes and
monitored him via telemetry. Serial EKGs were reassuring.
.
# INFARCT-RELATED CARDIOMYOPATHY, SYSTOLIC DYSFUNCTION - His
most recent 2D-Echo from [**3-/2113**] showed a left ventricular cavity
that was moderately dilated with severe regional LV systolic
dysfunction with akinesis of the inferior septum, inferior wall,
and inferolateral wall. There was also hypokinesis of the distal
third of the ventricle. The right ventricular cavity was mildly
dilated with mild global free wall hypokinesis. LVEF 20-25%. The
patient's heart failure regimen does not include an ACEI/[**Last Name (un) **]
given cough issues; he is on a beta-blocker, and Torsemide with
Metolazone. On his last admission, his exam revealed only mild
peripheral edema without oxygen requirement. NYHA class II-III.
We weaned his supplemental oxygen on admission and gave some
intermittent IV Lasix to promote diuresis. Clinically he
appeared slightly hypervolemic vs. euvolemic. We continued his
home Torsemide (increased to 40mg daily), beta-blocker
medications (changed to extended release metoprolol) and
monitored his daily weights, I/Os and aimed for a goal of even
to 0.5L negative for diuresis. On discharge, he appears slightly
hypervolemic with rales and so he was discharged with Torsemide
40 mg PO BID for three additional days. He is then to return to
Torsemide 40 mg daily. Additionally, Aldactone was started on
discharge at 25 mg daily.
.
# PAROXYSMAL ATRIAL FIBRILLATION - The patient has a history of
paroxysmal atrial fibrillation history; patient was previously
on chronic Amiodarone therapy for this. He is not anticoagulated
with Coumadin due to a history of recurrent hematuria. The
patient has been 100% atrially and [**Hospital1 **]-ventricularly paced,
rhythm control with Amiodarone was attempted in the past and was
not continued this admission. Of note, recent device
interrogation revealed an intrinsic atrial rhythm of 20bpm with
no ventricular response. Patient was changed to AV pacing
through the right lead only (LV lead close to area of scarring
and may have been contributing to arrythmias). We deferred
anticoagulation this admission.
.
# HYPOXIA - Patient presented without home oxygen requirement,
however, he was requiring several liters of oxygen for
desaturations to the 80s on ambulation. CXR [**11-15**] should
moderate to severe pulmonary edema. His Torsemide was increased
to 40 mg daily, and his oxygen requirement improved. Patient was
88% on RA when ambulating on the day prior to discharge,
requiring home oxygen which was set up prior to discharge.
.
# DIABETES MELLITUS, TYPE 2 - The patient has a history of
diet-controlled diabetes, home regimen includes Glipizide 5 mg
PO daily only (started last admission). He recently saw [**Hospital **]
Clinic and was started on Lantus insulin for management. His
blood sugars on his last admission were severely elevated in the
400-500 mg/dL range. He was maintained on an aggressive insulin
sliding scale and his HbA1c was 13%. [**Last Name (un) **]-Diabetes provided
fingerstick check teaching. We held his oral hypoglycemic [**Doctor Last Name 360**]
this admission, continued his home Lantus dosing and utilized a
moderate insulin sliding scale. His home insulin regimen was
restarted on discharge.
.
# CHRONIC RENAL INSUFFICIENCY - Patient has known history of
chronic renal insufficiency likely attributed to diabetic
nephropathy and on-going congestive heart failure history.
Baseline creatinine between 1.8 and 2.3 (based on prior
records). His creatinine appeared improved from his prior
admission and we therefore restarted his diuretics and monitored
him closely. HIs creatinine remained within baseline range over
admission. We avoided nephrotoxins and renally dosed all
medications.
.
TRANSITION OF CARE ISSUES:
1. Started patient on home oxygen therapy this admission.
2. Follow-up with cardiology for device interrogation to ensure
he is medically managed on anti-arryhthmics.
3. Code status: Patient was previously DNR/DNI, however
clarified that he would like to be resuscitated for a minimal
amount of time only. His code status was changed to FULL CODE.
Medications on Admission:
1. Atorvastatin 20 mg PO daily
2. Senna 8.6 mg 1 tablet PO BID
3. Metolazone 2.5 mg PO once weekly (Sundays)
4. Isosorbide dinitrate 20 mg PO TID
5. Aspirin 325 mg PO daily
6. Cholecalciferol (vitamin D3) [**2102**] units PO daily
7. Folic acid 0.5 mg PO daily
8. Miconazole nitrate 2% powder topical [**Hospital1 **] PRN rash
9. Glipizide 5 mg PO daily
10. Colace 100 mg PO BID
11. Metoprolol tartrate 75 mg PO BID
12. Ascorbic acid 1000 mg PO daily
13. Torsemide 20 mg PO Tuesday, Thursday; 40 mg PO every other
day of the week (held on last discharge)
14. Lantus 14 units SC daily (at bedtime)
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO on Sundays.
4. isosorbide dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. cholecalciferol (vitamin D3) 2,000 unit Tablet Sig: One (1)
Tablet PO once a day.
7. folic acid 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. miconazole nitrate 2 % Powder Sig: One (1) application
Topical twice a day as needed for rash.
9. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a
day.
12. insulin glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous at bedtime.
13. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
14. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Take 40mg tiwce daily for 3 days ([**Date range (1) 86962**]), then take 40mg
daily.
Disp:*66 Tablet(s)* Refills:*2*
15. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*2*
16. Supplemental Oxygen
Sig: Continuous home oxygen 2L with conserving device.
Disp: QS
Diagnosis: Pulmonary Toxicity (interstitial lung disease from
Amiodarone)
Oxygen saturation 88% on room air with ambulation.
Oxygen saturation 98% on 2L at rest.
17. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. quinidine gluconate 324 mg Tablet Extended Release Sig: One
(1) Tablet Extended Release PO three times a day.
Disp:*90 Tablet Extended Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
1. Incessant ventricular tachycardia
2. Hypoxia with ambulation
.
Secondary Diagnoses:
1. Paroxysmal atrial fibrillation
2. Infarct-related cardiomyopathy
3. Coronary artery disease
4. Ventricular tachycardia storm status-post biventricular ICD
placement in [**2104**]
5. Atrial tachycardia status-post ablation
6. Atrial flutter status-post ablation
7. AVNRT status-post slow pathway modification
8. Insulin dependent diabetes mellitus
9. Chronic renal insufficiency
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:
Patient Discharge Instructions:
.
You were admitted to the Cardiac Care Unit at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Medical Center on [**Hospital Ward Name 121**] 6 regarding management of your atypical
ventricular rhythm, ventricular tachycardia. This resulted in
multiple firings of your implantable cardioverter-defibrillator
(ICD) and you were initially seen at [**Hospital3 104358**] and treated with IV anti-arrhythmics. You were then
transferred to [**Hospital1 18**] and you were managed with IV
anti-arrhythmics.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Please START taking:
Metoprolol Extended Release 200mg by mouth once daily
Mexiletine 150mg by mouth three times a day
Quinidine Gluconate 324mg by mouth 3 times daily
Aldactone 25mg by mouth daily
.
* During your admission the following medication was CHANGED:
Torsemide: take 40mg by mouth twice daily for 3 days and then
every day after that (instead of taking 20mg some days and 40mg
other days)
.
* The following medications were DISCONTINUED on admission and
you should NOT resume:
Metoprolol Tartrate 75mg by mouth twice daily.
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above. You will also need
supplemental oxygen at home now, which is being set up for you.
Followup Instructions:
Please call your primary care doctor and cardiologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] and make an appointment to be seen by him within the next
1-2 weeks. His office number is: #[**Telephone/Fax (1) 6937**].
Department: CARDIAC SERVICES
When: MONDAY [**2115-2-25**] at 2:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2115-5-7**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2115-9-26**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
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31,861
| 139,853
|
31772+57764
|
Discharge summary
|
report+addendum
|
Admission Date: [**2141-8-7**] Discharge Date: [**2141-8-11**]
Date of Birth: [**2059-5-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
[**2141-8-7**] - CABGx3 (left internal mammary artery to the left
anterior descending coronary artery; reverse saphenous vein
single graft from aorta to the first obtuse marginal coronary
artery; reverse saphenous
vein single graft from the aorta to the posterior). Left atrial
appendage ligation.
History of Present Illness:
82 y/o male with doe and +ETT. He was referred for a cardiac
cath which revealed severe coronary artery disease. He was thus
referred for surgical revascularization.
Past Medical History:
CAD
Hyperlipidemia
HTN
AF
MR
[**First Name (Titles) 21593**]
[**Last Name (Titles) 74596**] degeneration
[**Last Name (Titles) 74597**]
PTSD
Social History:
Sales who lives with his wife. Quit smoking cigars 30 years ago.
Drinks 1 glass of wine daily.
Family History:
None noted
Physical Exam:
70 af bp: 150/90
Gen: Pleasant elderly man in NAD
SKIN: Mild bruising
HEENT: NCAT, PERRL, Anicteric sclera, OP benign. No cartoid
bruit
LUNGS:CTA
HEART: Irreg, ireeg, no M/R/G
ABD: Benign
EXT: Warm, well perfused, no edema. No Varicosities. Pulses [**11-15**]+
NEURO: Nonfocal
Pertinent Results:
[**2141-8-7**] ECHO
PRE-BYPASS:
1. The left atrium is markedly dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No thrombus
is seen in the left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. The coronary sinus is dilated
(diameter >15mm).
2. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. Mild aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral central regurgitation is seen.
7. There is no pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and AV
pacing.
1. LV systolic function is improved.
2. RV function is mildly depressed
3. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**]
4. Aorta is intact post decannulation
5. Other findings are [**Last Name (Titles) 1506**]
[**2141-8-8**] CXR
In comparison with the study of [**8-7**], there has been removal of
the endotracheal and nasogastric tubes. The Swan-Ganz catheter
appears to be pulled back to the right atrium. Enlargement of
the cardiac silhouette persists with minimal fullness of the
pulmonary vessels. Increased opacification is again seen in the
retrocardiac area with a thick band of atelectatic change
adjacent.
[**2141-8-10**] 09:35AM BLOOD WBC-15.7* RBC-3.51* Hgb-11.2* Hct-32.0*
MCV-91 MCH-32.0 MCHC-35.1* RDW-13.8 Plt Ct-221
[**2141-8-10**] 09:35AM BLOOD PT-13.5* PTT-30.1 INR(PT)-1.2*
[**2141-8-10**] 09:35AM BLOOD Glucose-130* UreaN-23* Creat-0.9 Na-134
K-4.5 Cl-98 HCO3-28 AnGap-13
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2141-8-7**] for surgical
management of his coronary artery disease. He was taken to the
operating room where he underwent coronary artery bypass
grafting to three vessels and a left atrial appendage ligation.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. By postoperative day one, Mr. [**Known lastname **]
had awoken neurologically intact and had been extubated. His
pressors were slowly weaned. Later on postoperative day one, he
was transferred to the step down unit for further recovery. He
was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. His foley was replaced for
urinary retention. His foley was d/c'd and he voided well. He
was discharged to rehab in stable condition on POD#4.
Medications on Admission:
Toprol XL 100'
Zocor 20'
Coumadin
Proscar 5'
Terazosin 10'
Cosopt
Aplhagan
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 5 days.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H
(every 12 hours).
8. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
11. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
mapleleaf
Discharge Diagnosis:
CAD s/p CABG
AF
Hyperlipidemia
MR
[**First Name (Titles) 21593**]
[**Last Name (Titles) **]
[**Last Name (Titles) 74596**] degeneration
PTSD
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 914**] in 1 month ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 39975**] in [**11-15**] weeks.
Follow-up with [**Doctor Last Name **] in 2 weeks. [**Telephone/Fax (1) 74598**]
Please call all providers for appointments.
Completed by:[**2141-8-11**] Name: [**Known lastname 12291**],[**Known firstname **] Unit No: [**Numeric Identifier 12292**]
Admission Date: [**2141-8-7**] Discharge Date: [**2141-8-11**]
Date of Birth: [**2059-5-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Pt. was also sent on Coumadon 5 mg PO daily for INR goal of
[**12-16**].5. Pt. will have INR daily until INR goal is reached.
Discharge Disposition:
Extended Care
Facility:
mapleleaf
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2141-8-11**]
|
[
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
[
[
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7286, 7481
|
3466, 4377
|
322, 622
|
5675, 5684
|
1436, 3443
|
6426, 7263
|
1109, 1121
|
4502, 5431
|
5511, 5654
|
4403, 4479
|
5708, 6403
|
1136, 1417
|
279, 284
|
650, 817
|
839, 981
|
997, 1093
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,702
| 120,962
|
25712
|
Discharge summary
|
report
|
Admission Date: [**2124-1-6**] Discharge Date: [**2124-1-17**]
Date of Birth: [**2043-11-27**] Sex: F
Service: MEDICINE
Allergies:
Effexor / Aricept / Zoloft / Augmentin / Wellbutrin / Rifabutin
/ Lactose Intolerance / Vancomycin / Ceftazidime
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Dizziness and falls, shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Pt is a 80f with interstitial lung disease, MALT lymphoma,
bilat breast ca s/p bilat mastectomies, cryptococall and
aspergillus pna's in [**2119**] and aspergillus in [**2123**], recent MRSA
pna currently on 6wk course of linezolid, recent sinusitis s/p 2
weeks levoflox (finished 1 wk ago), recent C. diff (finished
metronidazole 2-3days ago), hypoth presents with a 2 days of
diarrhea, decreased po intake, dizziness, weakness, and falls.
She says that the falls may have been related to fainting, but
she's not sure; she is unclear on much of the history, and per
prior notes, this appears to be her baseline. She denies f/c,
ha, chest pain, abd pain, n/v, dysuria/hematuria, change in
urine vol. She denies any pain in chest/back/abdomen or joints,
no pain from the fall, does not think she hit her head.
Past Medical History:
PMH:
1.)Interstitial lung disease
2.)Hypogammaglobulinemia
3.)MALT lymphoma, dx [**2119**]
4.)Breast cancer, bilat, s/p bilat mastectomies
5.)Cryptococcal and aspergillus pna [**2119**], aspergillus [**2123**]
6.)MRSA Pna [**2123**] by BAL
7.)C. diff (2wk course of flagyl-ended in late [**Month (only) **])
8.)Sinusitis, finished levoflox course [**2123-12-28**]
9.)Depression/anxiety
10.)Mild cognitive impairment
11.)Hypothyroidism
.
PSH:
1.)Bilateral mastectomies with implants
Social History:
SocHx: Pt currently at [**Hospital1 599**] in [**Location (un) **] after her recent
admission, though normally at [**Hospital3 **]. She
has 2 sons in [**Name2 (NI) **], involved in her care. She's divorced.
20pack yr hx, quit 20yrs ago. No etoh.
Family History:
Her sister has died of uterine cancer at the age of 75 years and
her brother is still living and reportedly in good health.
Physical Exam:
PE: t 98.4, bp 140/45, hr 97, rr 18, spo2 96%ra
gen- elderly, cachectic, chronically-ill appearing female, nad
heent- anicteric sclera, op very dry but clear
neck- no jvd/lad/thyromeg
cv- rr, s1s2, [**2-28**] systol murmur ursb
pul- fair air movement, decr bs rll, diffuse rhonchi
abd- soft, nd, mild [**Month/Day (4) **] tenderness, no rebound/guarding
back- no cva/vert tenderness
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, no pitting/color changes/indentations
neuro- awake, alert, oriented to person, place, not date, knows
she's currently living at [**Hospital1 **] but normally lives at another
facility. no focal cn/motor/sensory deficits
Pertinent Results:
CXR: Persistent infiltrate, possible incr left mid lung zone, no
major change
.
CT Chest: Unchanged
.
CT head: No hemorrhage, sinusitis unchanged (complete paranasal
opacities)
.
ECG: Sinus tach, nl axis, nl intervals, lvh, no q/st-t
changes/twi
.
Labs: hct 27.7 (baseline 26-29)
.
[**1-16**] CT head:
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Opacification of multiple sinuses, similar in appearance to
previous examination, with interval opacification of right
mastoid air cells.
3. MRI with DWI may be performed to exclude subtle abnormalities
as clinically warranted.
.
CT chest and abdomen:
IMPRESSION:
1. Right lower lobe consolidation, left lower lobe
consolidation, scattered bilateral ground-glass and nodular
opacities appear slightly worse in the interim. New right lower
lobe lateral aspect consolidation.
2. Increased pulmonary interstitial edema. Increased small
bilateral pleural effusions.
3. No evidence of retroperitoneal hematoma.
4. Anasarca.
5. Calcified lymphadenopathy in the chest, unchanged. Contrast
enhancement within the urinary collecting system and gallbladder
probably due to previous cardiac catheterization and poor renal
function.
Brief Hospital Course:
This 80 yo female with a h/o interstitial lung disease
(?miliary pattern), MALT lymphoma, bilat breast ca s/p bilat
mastectomies, cryptococcal and aspergillus pna's in [**2119**] and
aspergillus in [**2123**], recent MRSA pna currently on 6wk course of
linezolid (started [**12-6**]), recent sinusitis s/p 2 weeks levoflox
(finished 1 wk prior to admission)), recent C. diff (finished
metronidazole 5-6 days ago), who initially presented with a 2
days of diarrhea, decreased po intake, dizziness, weakness, and
falls. On the floor, she was initially treated with Flagyl for
possible C. diff (this was stopped on [**1-10**] with 1 neg C. diff
and the recommendation of ID. It was thought that her delta MS
may have been due to underlying infection, and source for this
was sought out. Given her h/o sinusitis, ENT was consulted; as
she had no clinical symptoms of sinusitis, decision was made to
treat with NS nasal spray. Pulmonary, ID, and thoracics were
consulted to evaluate her chronic lung process that appeared
unchanged on CT from this admission (pt still with RLL
consolidation with cavitary component, unchanged from prior
study despite 4 weeks of linezolid). Cultures have remained
negative, and pt has had only low-grade fevers.
Interdisciplinary family meeting on [**1-10**] was held, and it was
decided to proceed with CT-guided core biopsy when possible to
biopsy lung process and lymph nodes. Heme/onc was also
consulted with respect to hypogammoglobulinemia and recommended
IVIG (which she received on [**1-7**]).
She was transferred to the MICU on [**2124-1-10**], she became
tachypneic on the floor approximately 1 hour s/p PRBC
transfusion, with RR to 40's, with ABG of 7.17/76/217 (?baseline
CO2). She received 1 mg morphine initially CXR was difficult to
interpret given bilateral breast reconstructions but appeared
grossly unchanged.. She was placed on non-invasive ventilation
(CPAP/BiPAP), and ABG improved to 7.23/60/219. She received 20
mg IV lasix with only a small amount of concentrated urine
output . She became tachycardic (to 120s) and hypotensive (SBPs
in 70s from baseline of 150) in this setting. Upon arrival to
ICU, she was bolused with 250 cc NS with improvement in these
parameters. She had no specific complaints and stated her
breathing felt better. She was admitted to ICU for further
observation overnight and non-invasive ventilation as needed.
Her hypercarbic respiratory failure seemed to correlate
temporarily with blood transfusion (1hr s/p). X-ray did not
seem grossly volume overloaded, however, but BNP was elevated.
Her initial ABG was consistent with hypercarbia; this improved
with non-invasive ventilation and O2 sats have been stable. She
was continued on non-invasive ventialation as needed and wean
FiO2.
.
2. Hypotension: on floor, in setting of lasix, positive
pressure ventilation, responded to IVF while maintaining O2
Sats. Hypovolemia is most likely etiology
- bolus as necessary for bp; follow UO, goal even to 500 cc
positive
- will reck TTE in am; EKG without ischemic signs, no reason
to suspect cardiogenic shock
.
3. ?PNA/ILD: unclear what lung process represents; has had MRSA
in sputum that may be pathogen. Currently completing 6 week
course of linezolid and ID following closely
- send bld cx, Ucx, C. diff, sputum
- plan is for CT-guided biopsy--?lymphoma, bronchoalveolar
carcinoma, infection, fungal, ILD on differential for lung
process; touch base with thoracics and radiology (Dr. [**Last Name (STitle) 4401**]
in am
- Continue Linezolid for now
- low threshold to broaden abx coverage if decompensates
- f/u ID recs
- leukocytosis may be stress response although is concerning
for infection; will follow
- no empiric C. diff treatment for now
- no rx for ?sinusitis at this time, d/w ID
.
4. Hypogammoglobulinemia: s/p IVIG on [**1-7**], f/u onc recs;
would this affect ability to mount fever/response to ?infection.
.
5. CHF: signs of dCHF on TTE from [**11-27**]; BNP elevated but seems
intravascularly depleted, BP responed to IVF
- follow I/Os and lung exam
.
6. Anemia:
- S/p PRBC yesterday
- Getting pan CT to look for bleeding site, concern for RP bleed
vs. head bleed
- 1 unit PRBC today.
.
7. Hypothyroidism: on synthroid; may need adjustment of dose as
outpt
.
8. PPX: SQ hep, PPI while NPO
.
9. FEN: NPO for now, replete lytes as needed
.
10. Code: Full; discussed with 3 children on [**1-10**]; HCP is
[**Name (NI) **] [**Name (NI) **]
.
11. Communication: son [**Name (NI) **] is HCP ([**Telephone/Fax (1) 64100**])
.
12. Access: L PICC from [**1-10**], PIV; t/c A-line if needs closer
BP monitoring and frequent ABGs
.
13. Dispo: ICU care overnight and reevaluate in am
.
14 Neuro: New onset left sided weakness and blown pupil on
the left
- head CT todayP: 80f with hypogammaglobulinemia, interstitial
lung disease, multiple pna's, recent mrsa pna/sinusitis/c. diff,
h/o breast cancer presents with increasing confusion, weakness,
dizziness, and falls.
.
#Weakness/dizziness/falls -- Pt's neuro exam is non-focal,
making CVA seem unlikely. No fever, wbc to suspect acute
infectious process. This appears to be most likely severe
dehydration/hypovolemia related to diarrhea and decreased po
intake. Plan to check full infectious work-up (blood, urine,
cxr, sputum). and re-hydrate, dealing with diarrhea as below.
Check tsh.
.
#Diarrhea -- With multiple antibiotics and recent C. diff
infection, this is highly probable. Will send off 3 C. diff
cx's and begin empiric treatment tonight.
.
#Pna -- Continue linezolid for now. Send off sputum, blood cx,
legionella urinary ag, galactomannan With
hypogammaglobulinemia, will likely need heme and id consults for
question of IVIg and abx tailoring, respectively. Pt's o2 sats
stable (somewhat improved from results at rehab).
-id has been consulted, regarding chronic infiltrate, and
current antibx therapy both for MRSA infiltrate and chronic
sinusitis
-heme consulted, regarding hypogammaglobulinemia
.
#Hypogammaglobulinemia -- [**2123-11-19**]: IgG 207 ([**Telephone/Fax (1) 39637**]), IgA 50
(70-400), IgM 167 (40-230)
Heme consult as above for ? IVIg. Sending of UPEP,SPEP,
kappa/gamma light chains
.
#Sinusitis -- Persistent sx and CT findings, ENT consulted for
drainage/cx. Pt was on levo, but possibly not therapeutic due to
pt taking Iron-will restart again and await ID requests.
.
#Abd pain -- very mild, no evidence of acute abd. As localized
to [**Last Name (LF) **], [**First Name3 (LF) **] check lft's.
.
#Anemia -- baseline at 30, current hct 27.7, recent labs show no
fe [**Last Name (LF) 64101**], [**First Name3 (LF) **] check b12/fol
.
#Hypothyroid -- TSH mildly elevated (5.1) 1 mo ago, con't dose,
recheck tsh
.
#FEN -- reg diet, vol +1-2l tonight
.
#PPx -- sc heparin
.
#Code -- became dnr/i then cmo [**1-17**]
Following above, a family meeting was held on [**1-17**]. Family
decided that given poor prognosis for recovery, pt would not
want above continued aggressive measures and requested that
comfort be made the only goal of care. Comfort plan initiated
at 12:30AM included morphine gtt titrated to comfort, propofol
gtt to control anxiety, scopolamin PRN secretions, regular
comfort assessments. Patient died @ 1AM, comfortable and
w/family at the bedside.
Medications on Admission:
1.)Linezolid 600mg [**Hospital1 **] x 6 weeks (started [**2123-12-18**])
2.)Coltrimazole 10mg tid
3.)Ritalin 5mg [**Hospital1 **]
4.)Ambien 5mg qHS
5.)FeSo4 325 qAM
6.)Pantoprazole 40mg daily
7.)Levothyroxine 75mcg daily
8.)Tiotropium 18mcg daily
9.)Advair 250/50 [**Hospital1 **]
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
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"285.9",
"473.9",
"518.81",
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"V09.0",
"V10.3",
"428.0"
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icd9cm
|
[
[
[]
]
] |
[
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"96.04",
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"88.53",
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icd9pcs
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[
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11772, 11781
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4088, 11413
|
414, 420
|
11833, 11843
|
2874, 2976
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11895, 11901
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2054, 2180
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11802, 11812
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11439, 11721
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11867, 11872
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2195, 2855
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334, 376
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448, 1266
|
3176, 4062
|
1288, 1771
|
1787, 2038
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,293
| 170,668
|
21325
|
Discharge summary
|
report
|
Admission Date: [**2175-7-12**] Discharge Date: [**2175-8-1**]
Date of Birth: [**2101-10-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Transfer for elective L superficial femoral artery stenting
Major Surgical or Invasive Procedure:
Anterior cervical discectomy and fusion C3/C4 -- [**2175-7-13**]
Emergent Intubation -- [**2175-7-19**]
History of Present Illness:
PT is a 73 yo man with a long history of PVD, HTN, CRI,
dementia, hyperhomocyteinemia, poorly controlled DMII, 80+ pack
year history, and L4 disc herniation who was transered here for
stenting of his left superficial femoral artery by Dr. [**Last Name (STitle) **]. On
admission he was febrile to 101.8 and found to have signs of
upper motor neuron lesions, ataxia, and incontinence. His
history is notable for a progressive decline in functioning over
the past several months. He has new unsteadiness but was working
at a Shaws retreiving shopping carts from the parking lot until
a few days before admission. Now he cannot walk. His dementia
has also been becoming worse by report from his daughters. [**Name (NI) **]
has developed trouble using utensils and reports new dribbling
from the side of his mouth when he drinks. He has also had
increasing trouble walking. It is unclear how much of this is
due to his PVD and how much to his neurologic decline. Also of
note is dyspnea of exertion with activities such as gardening.
.
He has a past history of peripheral vascular disease in the
context of HTN, hyperlipidemia, DM, and hyperhomocysteinemia s/p
left [**Name (NI) 1793**] stent in [**2170**], s/p stent to LRA and atherectomy of
right common femoral artery and s/p PTA of the left [**Year (4 digits) 1793**] for
instent restenosis in [**2173**]. He has been complaining of
claudication and underwent duplex studies recently which
indicated left lower extremity stenosis.
.
He was admitted to OSH with a near syncopal episode on [**2175-7-11**]
with a fall to the ground but is unclear if he loss
conciousness. He was at his sister's funeral just prior to the
episode and experienced unsteadiness at the funeral itself. He
had non-contrast head CT which was negative for acute process.
He also had an abdominal CT and a chest CT which were
essentially negative for any new findings. He reportedly has a
tremor but no etiology is noted.
.
OSH course: Presented to the ED with 2 episodes of near syncope
on [**2175-7-10**]. He has been more confused of late and incontinent of
urine per his daughters/records. His sister recently died and he
nearly passed out at her funeral. Upon arrival, his temp was
103.5 and was given tylenol. BCx and UCx were sent. Lactate was
normal. Abdominal CT W/ contrast was performed which was
unrevealing. Head CT was negative. CEs were sent and were
negative x 2. No further fevers.
Past Medical History:
CAD: s/p STEMI with overlapping stents to RCA in [**6-/2171**]
IDDM
CHF (EF 40-45% [**6-25**] TTE)
HTN
s/p C3-4 laminectomy c/b dysphagia
hyperlipidemia
PVD: s/p left [**Month/Year (2) 1793**] stent in [**2170**]
s/p stent to LRA and atherectomy of right CFA in [**9-23**]
s/p PTA of left [**Date Range 1793**] in [**11-23**]
GERD
Asbestosis
CRI b/l Cr ~1.2
Anemia
PUD s/p remote partial gastrectomy
Depression
Dementia
Social History:
Patient is a widower and works as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] at Stop and Shop. He
does not current smoke tobacco, but he had an 80+ pack year
history with asbestos exposure. Patient denies EtOH or illicit
drug use.
Family History:
There is no history of alcohol abuse. There is no family history
of premature coronary artery disease or sudden death. All four
of his sisters died of cancer.
Physical Exam:
VS - 101.5 130/62 81 18 95%RA
Gen: Somewhat disheveled but pleasant, NAD, A&Ox3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple no JVD. No carotid bruits
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. II/VI SEM. No r/g. No thrills, lifts. No S3
or S4.
Chest: No chest wall deformities, scoliosis or kyphosis.
Resp were unlabored, no accessory muscle use. Crackles on the R
in all fields, no wheezes or rhonchi, no dullness to percussion
Abd: BS+, somewhat distended, fluid level and shifting dullness
on percussion. Nontender. No HSM but limited exam. Abd aorta not
palpable. No abdominial bruits.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Limbs: No pedal edema
Pulese: Carotids 2+, radials 2+
Neuro: CNII-XII WNL, mild R pronator drift and weakness of the
upper limb. Symmetric hyperreflexia of the upper limbs. Babinsky
positive, symmetric hyperreflexia of the lower limbs, atactic
gait with scissoring, Romberg positive.
Pertinent Results:
ADMISSION LABS:
[**2175-7-12**] 08:08PM BLOOD WBC-6.9 RBC-3.50* Hgb-10.9* Hct-30.8*
MCV-88 MCH-31.1 MCHC-35.3* RDW-14.5 Plt Ct-154
[**2175-7-13**] 06:10AM BLOOD Neuts-82* Bands-6* Lymphs-6* Monos-5
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2175-7-13**] 06:10AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2175-7-12**] 08:08PM BLOOD PT-14.2* PTT-28.6 INR(PT)-1.2*
[**2175-7-13**] 06:10AM BLOOD ESR-56*
[**2175-7-12**] 08:08PM BLOOD Glucose-236* UreaN-30* Creat-1.7* Na-134
K-4.1 Cl-100 HCO3-24 AnGap-14
[**2175-7-12**] 08:08PM BLOOD CK(CPK)-115
[**2175-7-12**] 08:08PM BLOOD CK-MB-4 cTropnT-<0.01
[**2175-7-12**] 08:08PM BLOOD Calcium-8.7 Phos-2.2* Mg-2.0
[**2175-7-13**] 06:10AM BLOOD VitB12-1008*
[**2175-7-13**] 06:10AM BLOOD %HbA1c-7.9*
[**2175-7-13**] 06:10AM BLOOD TSH-0.50
[**2175-7-13**] 06:10AM BLOOD CRP-130.7*
[**2175-7-13**] 06:10AM BLOOD PEP-NO SPECIFI
PERTINENT LABS/STUDIES:
Hct: Ranged from 27.9 to 35.9 on this hospital admission
ESR: 56
Cr: 1.6 ([**7-13**]) -> 1.2 ([**7-20**]) -> 1.3 ([**8-1**])
Troponin: <0.01 x4
Vit B12: 1008
HbA1c: 7.9%
TSH: 0.50
CRP: 130.7
Blood Cultures: Negative x4
Urine Culture: Negative x2
CDiff: Negative
BAL Culture: GRAM STAIN (Final [**2175-7-19**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2175-7-21**]): ~6OOO/ML
OROPHARYNGEAL FLORA.
ACID FAST SMEAR (Final [**2175-7-20**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Final [**2175-8-4**]):
YEAST.
ECHO ([**7-13**]): Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. Mild
to moderate ([**1-18**]+) mitral regurgitation is seen. Tricuspid
regurgitation is present but cannot be quantified. No regionall
wall motion abnormality is seen EF 40-45%.Small PFO is seen.No
vegetations are seen on the mitral and aortic valve .Tricuspid
valve not well visualised .
MR [**Name13 (STitle) 430**] ([**7-13**]): No hemorrhage, edema, or evidence of ischemia.
Chronic small vessel ischemic disease and mild age-related
parenchymal atrophy.
MR [**Name13 (STitle) **] ([**7-13**]): Severe spinal stenosis and foraminal
narrowing at C3-4 level with extrinsic indentation on the spinal
cord and increased signal within the spinal cord due to
myelomalacia/cord edema. Mild multilevel degenerative changes
with foraminal changes as described
above.
MR [**Name13 (STitle) **] ([**7-13**]): Multilevel degenerative changes in the
thoracic region with disc bulging at T9-10 level in contact with
the anterior aspect of the spinal cord without deformity of the
cord.
MR [**Name13 (STitle) **] ([**7-13**]): Multilevel degenerative changes with
moderate-to-severe right and mild-to-moderate left-sided
foraminal narrowing at L4-5 level.
Video Oropharyngeal Swallow ([**7-14**]): Moderate oropharyngeal
dysphagia, with penetration and aspiration with various
consistency liquids. Aspiration was largely silent, though cued
cough was effective.
MR [**Name13 (STitle) **] ([**7-15**]): Interbody fusion device at C4-5 appears
normal. C3-4 appears normal. Diffuse discogenic disease with
secondary degenerative changes with severe right-sided
uncovertebral hypertrophy at C4-5.
CXR ([**7-15**]): Developing patchy opacity at right middle lobe.
This could represent aspiration.
CXR ([**7-26**]): Unchanged aspect of the partly calcified pleural
plaques. No
evidence of focal parenchymal opacity suggestive of pneumonia.
Video Oropharyngeal Swallow ([**7-24**]): Continued laryngeal
penetration and aspiration throughout all consistencies with
silent aspiration and partially effective cued cough.
Video Oropharyngeal Swallow ([**7-27**]): Penetration with multiple
consistencies and aspiration with thin liquid.
DISCHARGE LABS:
[**2175-7-31**] 05:10AM BLOOD WBC-7.0 RBC-3.55* Hgb-10.8* Hct-31.6*
MCV-89 MCH-30.5 MCHC-34.3 RDW-15.0 Plt Ct-253
[**2175-7-22**] 05:55AM BLOOD Neuts-81* Bands-0 Lymphs-10* Monos-1*
Eos-2 Baso-0 Atyps-0 Metas-2* Myelos-4*
[**2175-7-31**] 05:10AM BLOOD Plt Ct-253
[**2175-8-1**] 05:25AM BLOOD Glucose-179* UreaN-19 Creat-1.3* Na-136
K-4.3 Cl-101 HCO3-27 AnGap-12
[**2175-7-31**] 05:10AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.9
Brief Hospital Course:
Patient is 73 y/o M s/p cervical spine decompression and
laminectomy for cord compromise, whose hospital course has been
complicated by aspiration pneumonia, difficulty swallowing, and
intubation. Patient is clinically much improved.
.
#. Spinal Cord Compression: Patient presented to OSH with
urinary retention, muscle fasciculations, mental status changes,
and ataxia consistent with spinal cord compression. Patient had
a MR of his C-Spine performed on [**7-13**], which showed degenerative
disc disease and spinal cord compression at C3/C4. That day,
patient had an anterior cervical diskectomy, anterior cervical
arthrodesis, and insertion of interbody device at C3-4. Patient
recovered from this surgery well and was followed by the
neurology service after this surgery. His mental status
returned to baseline, he recovered 5/5 strength in his
extremities, and his gait returned to [**Location 213**] prior to discharge.
Patient will be seen in clinic by Dr. [**Last Name (STitle) 548**] four weeks after
discharge.
.
#. Dysphagia: The patient developed significant dysphagia s/p
anterior cervical diskectomy. On [**7-15**], patient began to develop
copious upper airway secretions. Patient had an NG tube placed
by IR for nutrition twice. However, both of these were pulled
out by the patient during his hospital stay. The patient was
followed by speech pathology, who evaluated the patient's
swallowing on [**7-12**], and [**7-27**]. His swallowing progressed as
his post-surgical edema resolved. At the time of discharge, the
patient was able to swallow an adequate caloric intake of thick
liquids. He will be followed by the speech pathology department
after discharge.
.
#. Respiratory Distress: On [**7-15**], the patient began to develop
copious upper airway secretions. A CXR was performed, which
showed a potential right middle lobe infiltrate. Patient was
started on levofloxacin for aspiration pneumonia. On [**2175-7-18**],
patient developed severe respiratory distress and was found to
be stridorous with an ABG of 7.44/64/34. He was emergently
intubated in the OR on [**7-19**] and transferred to the MICU. Patient
remained intubated for 24 hours. The patient had a repeat CXR
on [**7-21**], which did not show a right middle lobe infiltrate.
Patient's course of levofloxacin was discontinued. He was
extubated on [**2175-7-20**], and his respiratory status continued to
improve. The patient's upper airway secretions decreased as his
post-surgical edema resolved.
.
#. HTN: Patient developed hypertension during his stay in the
MICU. His blood pressure regimen was increased at this time.
When he returned to the floor, the patient experienced
orthostatic hypotension. This was thought to be secondary to
poor PO intake as well as his increased BP meds. Patient was
placed back on his outpatient blood pressure regiment, and he
remained stable throughout the remainder of his hospital course.
.
#. Code: Full
.
#. Communication: Daughter [**Name (NI) **], [**Telephone/Fax (1) 56361**]
.
Medications on Admission:
NOTE Pt noncompliant with medication due to ecomonic contraints.
He takes them when he can get samples or can [**Last Name (un) 56362**] them
Celebrex 200 mg 1 tab daily
Cymbalta 60 mg 1 tab daily
ASA 325 mg 1 tab daily
Nexium 40 mg 1 tab q 6 (only takes [**Hospital1 **])
Aricept 5 mg 1 tab daily
Levemir 24 Units qd (does not take)
Zocor 40 mg 1 tab dialy
Colace 100 mg PRN
MVI 1 tab daily
Discharge Medications:
1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Nexium 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*
4. Aricept 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
Disp:*500 mL* Refills:*2*
7. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*2*
9. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day.
Disp:*1 inhaler* Refills:*2*
10. Levemir Flexpen 100 unit/mL Insulin Pen Sig: Twenty Four
(24) Units Subcutaneous once a day: Please take 24 Units every
day.
Disp:*8 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary:
Cervical disc herniation
Dysphagia
Respiratory Distress
Secondary:
Hypertension
Diabetes
Discharge Condition:
Good. Patient's vital signs are stable, and he is able to
ambulate to the bathroom.
Discharge Instructions:
You were admitted to the hospital because you were going to be
evaluated for a femoral artery graft. On admission, it was
found that you had difficulty walking, urinary incontinence, and
weakness in your upper extremities. You were seen by
neurosurgery, and your were found to have a bulging disc in your
neck, which was causing your symptoms. You had surgery to
repair this disc on [**7-13**]. After the surgery, you had
significant swelling in your throat. You had difficulty
swallowing, and you had a significant amount of upper airway
secretions, which were unfortunately going down into your lungs.
On [**7-19**], you had an episode where you were unable to breath well
on your own. You were taken to the MICU, and they put a tube
down your airway to make it easier for you to breathe, which
remained in place for approximately one day. You then came back
to the floor, where you still experienced significant problems
swallowing. After a few days, you were able to swallow very
thick liquids. This past weekend, you were able to swallow
pureed foods without danger of aspirating, and you have gained a
significant amount of strength over the past few days. You can
continue this diet at home, with close follow-up with Dr. [**Last Name (STitle) **]
and the speech pathologists at [**Hospital1 18**].
While you were here, we made the following changes to your
medications:
1. We increased your Simvastatin to 40 mg daily for your
cholesterol
2. We discontinued your Celebrex.
Please take all medications as prescribed.
Please keep all previously scheduled appointments.
Please return to the ED or your healthcare provider immediately
if you experience shortness of breath, chest pain, difficulty
swallowing, pain not relieved by pain medications, fevers,
chills, upper extremity weakness, a change in your urination, or
any other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5456**], MD (PCP): Monday, [**2175-8-14**] at [**Location (un) 56363**].
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (Cardiology): Monday [**2175-8-7**] at 1:[**Location (un) 56364**].
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 548**]. Please call [**Telephone/Fax (1) **] to schedule a
follow-up appointment with Dr. [**Last Name (STitle) 548**] in 4 weeks. XRays will be
needed prior to this appointment.
Completed by:[**2175-8-27**]
|
[
"722.71",
"250.00",
"585.9",
"507.0",
"518.5",
"403.90",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"77.79",
"81.02",
"96.04",
"96.6",
"81.62",
"33.24",
"84.51"
] |
icd9pcs
|
[
[
[]
]
] |
14245, 14300
|
9492, 12530
|
375, 481
|
14443, 14530
|
4965, 4965
|
16452, 17027
|
3662, 3822
|
12974, 14222
|
14321, 14422
|
12556, 12951
|
14554, 16429
|
9048, 9469
|
3837, 4946
|
6570, 9031
|
276, 337
|
509, 2934
|
4982, 6534
|
2956, 3377
|
3393, 3646
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,210
| 115,091
|
20696
|
Discharge summary
|
report
|
Admission Date: [**2139-3-9**] Discharge Date: [**2139-3-16**]
Date of Birth: [**2065-2-4**] Sex: M
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 74 year old
male with known history of aortic stenosis and hypertension.
He was admitted to the [**Hospital3 3583**] on [**2139-3-7**]
with 10 out of 10 chest pain. The patient was transferred to
[**Hospital6 256**] for further evaluation
and treatment.
PAST MEDICAL HISTORY: 1. Hypertension; 2. Aortic stenosis.
PAST SURGICAL HISTORY: Unremarkable.
MEDICATIONS ON ADMISSION:
1. Maxzide [**1-9**] tablet p.o. q. day
2. Captopril 12.5 mg p.o. t.i.d.
3. Isobutyl 400 mg p.o. q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient quit smoking in [**2095**]. Drinks
occasionally, approximately one beer per day.
PHYSICAL EXAMINATION: On physical examination the patient
was afebrile with vital signs stable. Head was
normocephalic, atraumatic, no scleral icterus noted. Neck
was soft and supple. No carotid bruits. Heart was regular
rate and rhythm, Grade IV/VI systolic ejection murmur. Chest
was clear to auscultation bilaterally. Abdomen was soft,
nontender, nondistended with positive bowel sounds.
Extremity examination was significant for trace bilateral
pedal edema with palpable pulses.
LABORATORY DATA: Admission laboratory data were white count
9.6, hematocrit 46.0, platelets 205. Sodium 140, potassium
3.5, chloride 99, bicarbonate 31, BUN 24, creatinine 1.2, and
glucose 102. INR 1.3.
HOSPITAL COURSE: The patient is a 74 year old male with
aortic stenosis and known history of hypertension,
transferred to [**Hospital6 256**] from the
outside hospital for further assessment and treatment of 10
out of 10 chest pain. On [**2139-3-9**], the patient was
taken to the Cardiac Catheterization Laboratory which
demonstrated moderate to severe aortic stenosis, three vessel
coronary artery disease, with severe left anterior descending
stenosis arising from a complex aneurysm. Left ventricular
function was normal. Immediately following cardiac
catheterization, Cardiac Surgery was consulted, and the
patient was evaluated and assessed by Dr. [**Last Name (STitle) 1537**] and thought to
be a good candidate for coronary artery bypass graft surgery
and aortic valve repair. On [**2139-3-10**], the patient was
taken to the Operating Room where coronary artery bypass
graft times four was performed and an aortic valve
replacement with a Porcine valve. For more details, please
see operative report. Postoperatively, the patient was
transferred to the Cardiac Surgery Recovery Unit. The
patient was extubated at 8 PM on postoperative day #0. The
patient was on an Amiodarone drip for brief ventricular
fibrillation coming off pump and Neo-Synephrine at .2 for
blood pressure. On postoperative day #2, the patient
required atrioventricular pacing to maintain a heart rate in
the 80s and blood pressure 115/59. Electrophysiology was
consulted. Electrophysiology had no new recommendations.
The patient was back into sinus rhythm and was later
transferred to the floor on postoperative day #2. On
postoperative day #3, the patient was doing well, 79 in
sinus. Chest tubes were discontinued on postoperative day
#3. The patient was started on Metoprolol 12.5 mg b.i.d.
Post chest tube pull, chest x-ray demonstrated a .5 cm apical
pneumothorax on the right and 1 cm apical pneumothorax on the
left. Chest x-ray following initial chest x-ray showed that
these pneumothoraces were not changing.
On postoperative day #4, Toprol was increased to 25 mg b.i.d.
Pacing wires were discontinued and repeat chest x-ray showed
no evolution of the pneumothorax. On postoperative day #5,
another repeat chest x-ray showed no evolution of
pneumothoraces. Lopressor was increased to 50 mg b.i.d. The
patient was able to achieve physical therapy level 5. On
postoperative day #6, the patient was doing well, physical
therapy level 5 and another repeat chest x-ray showed no
evolution of the pneumothorax. The patient was deemed well
enough to go home.
DISCHARGE DISPOSITION: To home.
CONDITION ON DISCHARGE: Good.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Hypertension.
3. Aortic stenosis.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q. 12 hours times 10 days.
2. Potassium chloride 20 mEq p.o. q. 12 hours times 10 days.
3. Colace 100 mg p.o. b.i.d. and prn for constipation.
4. Aspirin 325 mg p.o. q. day.
5. Percocet 1 to 2 tablets p.o. q. 4-6 hours prn for pain.
6. Metoprolol 75 mg p.o. b.i.d.
FOLLOW UP: The patient is to follow up with the Wound Care
Clinic in one week, primary care physician and cardiologist
in two to four weeks and Dr. [**Last Name (STitle) 1537**] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2139-3-16**] 09:26
T: [**2139-3-16**] 09:40
JOB#: [**Job Number 55261**]
|
[
"041.7",
"427.41",
"414.01",
"599.0",
"424.1",
"997.1",
"401.9",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"35.21",
"36.13",
"37.23",
"88.56",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4122, 4132
|
4277, 4569
|
4185, 4254
|
576, 723
|
1551, 4098
|
535, 550
|
4581, 5030
|
858, 1533
|
175, 448
|
471, 511
|
740, 835
|
4157, 4164
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,588
| 153,334
|
43941
|
Discharge summary
|
report
|
Admission Date: [**2110-5-5**] Discharge Date: [**2110-5-23**]
Date of Birth: [**2073-1-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
shortness of breath, cough, fever, chills
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
37M alpha-1-trypsin deficiency and IVDU (reportedly injected
cocaine 2 days ago) who presented to the ED w/ subjective F/C
and productive cough x 3 days. (+)SOB, No CP. Reportedly BS
500's x 2 days which he attempted to cover with RISS.
.
Above hx per ED note, on initial presentation to MICU team, pt
was intubated and unable to provide further history.
.
In [**Name (NI) **], pt with significant respirtory distress, breathing RR
30-40, HR 130s, Pox 90s on NRB. Initial gas on NRB was
7.47/25/64/19. Said he felt a little better after antibiotics
(ceftriaxone 1 g x 1, vancomycin 1 mg IV x 1), steroids
(solumedrol 100 mg IV x 1), regular insulin 12 units ?IV x 1.
Subsequent gas showed 7.37/33/104/20. Was eventually intubated
[**2-5**] septic shock.
.
After intubation, pt continued with RR 40 (? decreased BS on L)
and SBP decreased to 70s with increased sedation (was given
propofol). Given above findings and agitation, was given
vecuronium 10 mg (paralyzed him despite steroids). He was then
placed on SIMV 700 x 14, PEEP 5, Fio2 100%. SBP dropped,
started on dopa, then subsequently given neo. Femoral placed,
levophed given. Foley placed.
.
Temperature finally taken 102.4. HR 140s. SBP 90s on levophed
(other pressors stopped).
.
In the MICU, pt was treated for sepsis [**2-5**] nectrotizing MSSA PNA
with MSSA bacteremia. He initially required pressors for BP
support, but was quickly weaned off once ABX were initiated and
he was HD stable. He received vanco/CTX/azithro for his
PNA/bacteremia, changed to Flagyl/oxacillin/ceftaz when
sensitivities came back. His MICU course was notable for
agitation, making him difficult to wean off the vent and labile
blood glucose levels, requiring insulin gtt. His agitation was
initially thought [**2-5**] ETT; however, he continued to have
episodes of agitation upon extubation, which resolved with
increasing fentanyl and methadone doses. Given pt's agitation
and periods of hypoxia, pt had an MRI to r/o structural/acute
brain injury and EEG to evaluate for hypoxic encephalopathy. MRI
showed no abnormalities and an EEG which showed abnormal bursts
of generalized slowing and a relatively low voltage monotonous,
unresponsive background suggestive of a widespread
encephalopathy. Medications appeared to be the most likely
etiology of these findings. His agitation resolved and fentanyl
gtt was switched to oxycontin and fentanyl patch. As his acute
issues had resolved and he was stable form HD and respiratory
standpoints, he was transferred to the floor for further
management.
Past Medical History:
Alpha 1 antitrypsin deficiency
Type 1 DM
IVDU - cocaine
Liver disease - since at least [**2097**] in our records. at that
time, Hep B and C neg, thought to be due to ETOH.
Hypothyroidism - s/p XRT to thyroid
Depression
Social History:
Tobacco and IVDU abuse
Family History:
NC
Physical Exam:
Initial presentation:VS: HR 130s BP 90 - 110/50 - 60; RR 30 -
40; 92 - 96% NRB
Gen: intubated, paralyzed, NAD
HEENT: anicteric, pink conjunctiva
NEck: supple
CV; tachy, RR. No murmur
Lungs: bronchial BS at R base, no wheezes
Abd: + BS, soft, NT/ND
Ext: warm, no edema
Neuro: paralyzed, pupils [**6-8**]
On transfer to the medicine service:
97.9 93/46-101/50 100s 95%2L 1590/2920; LOS +[**Numeric Identifier 40496**]
Gen: Sitting up in chair without O2, pleasantly conversant,
comfortable, NAD
HEENT: PERRL, OP clear
Neck: supple, no LAD, no JVP
CVS; RRR, distant heart sounds, no M/R/G
Chest: decreased b/s R base; o/w CTA
Abd: soft Nt/ND NABD, no rebound/guarding
Ext: no c/c/e
Skin: several red patches with excoriation over neck/face, at
site of tape placement; chest with red papules in
folliculocentric distribution
Neuro: A&O x3; strength 5/5 B U/LE
Pertinent Results:
Admission Labs:
[**2110-5-5**] 04:15PM BLOOD WBC-6.1 RBC-4.59* Hgb-15.1 Hct-43.7
MCV-95 MCH-32.9* MCHC-34.6 RDW-14.4 Plt Ct-263
[**2110-5-5**] 04:15PM BLOOD Neuts-52 Bands-11* Lymphs-11* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-19* Myelos-1*
[**2110-5-5**] 09:15PM BLOOD PT-16.7* PTT-62.8* INR(PT)-1.8
[**2110-5-5**] 04:15PM BLOOD Glucose-430* UreaN-29* Creat-1.1 Na-129*
K-4.2 Cl-95* HCO3-18* AnGap-20
[**2110-5-5**] 09:15PM BLOOD ALT-104* AST-53* LD(LDH)-177 AlkPhos-89
TotBili-0.4
[**2110-5-5**] 04:15PM BLOOD Calcium-9.0 Phos-1.1* Mg-1.3*
[**2110-5-5**] 04:15PM BLOOD Cortsol-115.1*
Studies:
CHEST (PORTABLE AP) [**2110-5-5**] 6:35 PM
CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN
Reason: r/o PTX
[**Hospital 93**] MEDICAL CONDITION:
37 year old man s/p tube placement
REASON FOR THIS EXAMINATION:
r/o PTX
INDICATION: 37-year-old status post tube placement, evaluate for
pneumothorax.
AP CHEST: The endotracheal tube is unchanged in position. There
is no pneumothorax. Essentially unchanged appearance of right
midlung zone and right lower lobe alveolar opacification. The
left lung zone remains unaffected. The left CP angle is excluded
from this film. No other interval change.
IMPRESSION: Persisting right middle lung zone and right lower
lobe alveolar opacification, unchanged from prior film. No other
interval change.
ECHO:
Conclusions:
Left ventricular wall thicknesses and cavity size are normal.
There is
moderate global left ventricular hypokinesis. Right ventricular
chamber size
is normal with moderate global free wall hypokinesis. The mitral
valve appears
structurally normal with trivial mitral regurgitation. There is
a
trivial/physiologic anterior pericardial effusion.
CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST
Reason: eval for ? cavitations seen on CXR
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
37 y/o M w/alpha-1 antitripsyn deficiency, type 1 DM, and IVDU,
who was admitted with pna. Now with worsening pna, fevers, and
new cavitary lesions seen on CXR (or possible bullae [**2-5**] alpha
1?). Also look for effusion.
REASON FOR THIS EXAMINATION:
eval for ? cavitations seen on CXR
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Alpha-1 antitrypsin deficiency. Worsening pneumonia
and fever.
Helical CT of the chest was performed following intravenous
administration of 100 cc of Optiray. Nonionic contrast was
administered due to the patient's limited respiratory status.
Comparison is made to multiple prior portable chest radiographs
dating between [**2110-5-8**], and [**2110-5-5**].
The lungs demonstrate multifocal consolidation throughout the
right lung, affecting the right lower lobe to a greater degree
than the right upper and right middle lobes. This is
superimposed upon underlying extensive emphysema. Multifocal
ground-glass opacities are also noted, adjacent to areas of
consolidation in the right lung and scattered within the left
lung. Some consolidative changes are noted in the left lower
lobe, but most of consolidation is within the right lung.
Multiple small cystic lucencies are seen throughout the right
lung, consistent with underlying emphysema. However, within some
of the areas of consolidation, there are larger lucent areas,
particularly within the right upper lobe on image 22, with an
appearance suggestive of cavitary necrotic pneumonia. Similarly,
within the right lower lobe, within areas of otherwise dense
consolidation, there are areas of rounded lucency suggesting
cavitation which do not communicate with bronchi. The appearance
of the consolidation within the right lower lobe also appears
heterogeneous with low-attenuation areas consistent with
necrosis. No frank abscess is identified at this time. There is
a small dependent left pleural effusion and a moderate dependent
right pleural effusion present. There are mildly enlarged
bilateral hilar and mediastinal nodes, likely reactive in the
setting of an acute pneumonia.
Within the imaged portion of the upper abdomen, the adrenal
glands are normal in appearance. No focal abnormalities are
observed within the liver, spleen, or imaged portions of the
kidneys. There is a small amount of ascites, and note is also
made of body wall edema within the chest and abdominal walls.
The heart size is normal, and there is no evidence of
pericardial effusion.
Note is made of the presence of an endotracheal tube, central
venous catheter, and nasogastric tube, which appear unchanged in
position compared to the recent chest x-ray of [**2110-5-8**],
earlier the same date.
Skeletal structures demonstrate no significant skeletal
findings. Finally, note is made of multiple thick-walled cystic
spaces predominantly within the right upper and right middle
lobe, which are thought to represent areas of bullous emphysema
with associated infection. Finally, note is made of a small 4-mm
diameter diverticulum arising from the lateral wall of the
bronchus intermedius.
IMPRESSION:
1) Extensive multifocal pneumonia predominantly involving the
right lung with lesser degree of involvement in the left lung,
superimposed upon extensive underlying changes of emphysema.
There are areas of necrosis and cavitation within the right
lower and right upper lobe consolidative areas.
2) Moderate right and small left pleural effusions.
3) Thoracic lymphadenopathy, likely reactive in this patient
with pneumonia.
4) Small amount of ascites and anasarca.
EEG:
FINDINGS:
ABNORMALITY #1: Throughout the recording there were frequent
bursts and
runs of 2 Hz delta slowing with a bifrontal emphasis.
BACKGROUND: Was often of very low voltage and usually a faster
frequency background. The background did not appear responsive
to
external stimuli.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: No normal waking or sleeping morphologies were seen
although
some portions of the tracing suggested drowsiness.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Abnormal portable EEG due to the bursts of
generalized
slowing and due to the relatively low voltage monotonous
unresponsive
background. These findings suggest a widespread encephalopathy.
Medications, metabolic disturbances, and infection are among the
most
common causes. In this patient, medications appear prominent.
There
were no areas of persistent focal slowing although
encephalopathies can
obscure focal findings. There were no epileptiform features
MRA BRAIN W/O CONTRAST [**2110-5-16**] 1:44 AM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: MS CHANGES, INCREASING AGITATION, NOT ALERT.
[**Hospital 93**] MEDICAL CONDITION:
37 year old man with alpha-1 antitrypsin def, type 1 DM, IVDU,
admitted with necrotizing pna, now off the ventilator and
increasing agitated, not alert
REASON FOR THIS EXAMINATION:
r/o ischemic event
INDICATION: 37-year-old male with alpha-1 antitrypsin
deficiency, type 1 deficiency and IV drug user, admitted with
necrotizing pneumonia. Now off the ventilator and increasingly
agitated, not alert. Question ischemic event.
TECHNIQUE: Multiplanar T1 and T2-weighted images of the brain
according to standard departmental protocol. No prior studies
for comparison.
FINDINGS: There are no diffusion abnormalities. No white matter
lesions are identified. No areas of susceptibility are noted.
Posterior fossa structures are unremarkable. There is increased
T2 signal within the bilateral mastoid air cells which could
represent mucosal thickening versus fluid. There is minimal
mucosal thickening involving bilateral maxillary and ethmoid
sinuses.
IMPRESSION: No acute stroke. No white matter lesions. No
intracranial hemorrhage. Bilateral mastoiditis.
MR ANGIOGRAM OF THE BRAIN.
TECHNIQUE: 3D time-of-flight imaging of the anterior and
posterior cerebral circulations was obtained. There are no prior
studies for comparison.
FINDINGS: There is no hemodynamically significant stenosis or
aneurysmal dilatation of the visualized vasculature.
IMPRESSION: Normal brain MR angiogram.
CHEST (PORTABLE AP) [**2110-5-18**] 2:10 AM
CHEST (PORTABLE AP)
Reason: eval for NGT placement
[**Hospital 93**] MEDICAL CONDITION:
37 y/o M w/lobar pna sepsis, now resolved. Now with NGT
REASON FOR THIS EXAMINATION:
eval for NGT placement
INDICATION: NGT placement.
FINDINGS:
The tip of the NGT extends over the left upper quadrant of the
abdomen. The right apex and right lateral aspect of the chest
were cut off from view. There is a right CVL seen with the tip
in the SVC. Some residual airspace disease is seen in the right
lower lobe but appears improved compared to prior study. The
left lung remains clear.
Brief Hospital Course:
A/P: 37M alpha-1-antitrypsin and DM1 with h/o IVDU admitted for
septic shock [**2-5**] MSSA PNA
.
# Sepsis/bacteremia: After intubation, pt became hypotensive in
the ED. BCx later came back positive for MSSA, presumanly from
his necrotizing PNA. In the [**Name (NI) **], pt's hypotension did not resolve
with switching from propofol to versed/fent. Dopa and neo were
started in ED then switched to Levo on floor. APACHE score of 15
on admission. He was treated with massive fluid resuscitation,
steroids, and antibiotics and became HD stable soon after
admission to the MICU. TEE here showed no endocarditis.
.
# Resp failure: [**2-5**] MSSA PNA involving RML and RLL. The patient
had one Bcx positve for MSSA and MSSA in sputum. He was treated
with ceftriaxone, oxacillin (was on vancomycin but switched once
[**Last Name (un) 36**] came back) and flagyl. It was noted on the 3rd hospital day
that his CXR showed pneumatoceles forming. Chest CT confirmed
this. Thoracic surgery was consulted about the utility of a
chest tube. No surgical intervention was needed and the patient
recovered well from his PNA. He will need to f/u with his
pulmonologist at [**Hospital1 112**] and likely need a repeat chest CT in [**2-6**]
months.
.
# Agitation: Extreme agitation was a barrier to extubation in
this patient. FOr several days after extuabtion, he was
extremely agitated requiring many sedating medications and
drips. He was reintubatd for an LP and MRI, both of which were
normal. He was then slowly weaned from Fentanyl, and Versed
drips. He was palced on both Seroquel and Zyprexa and his home
amitripylene. This combination allowed his delerium to clear
over a period of 4 days. The Zyprexa and Seroquel were then
D/ced and he was left on his home dose of methadone, duragesic
tp, and oxycodone prn ( the patient has chronic pain and back
pain at baseline).
.
# DM: Was in DKA on admission which quickly resolved. Startd
back on SC insulin on [**5-20**].
.
# Alpha-1-antrypsin def: The patient normally takes Aralast q
week. THis was held when he was acutly ill, but restarted on
Monday [**5-19**].
.
# Coagulopathy: Initially had an elevatd INR on admission
possibly due to liver disease - ?Heb B/C, alpha antitrypsin def,
ETOH - or malnutrition. He wasgiven VIt K and has corrected.
.
# IVDU - Continue methadone
.
# Comm: [**Name (NI) 4134**] (mother) [**Telephone/Fax (1) 94334**]
.
# Depression: Celexa was restarted once pt was extubated.
.
# Dispo: Pt was discharged home after he was transferred to the
floor, stable and afebrile for >72 hours, with O2 sats 94-95%.
He had completed a 19 day course of IV antibiotics and his PNA
had resoolved clinically. After a discussion with ID, the
initially planned remaining 2 days of his 3 week course of
antibiotic treatment were held, b/c of his recovery.
Medications on Admission:
Aralast infusion (for alpha-1-antitrypsin)
Protonix
Methadone 20 mg PO TID
Fentanyl patch 30
NPH 30 units PO Qam/pm
Celexa 60 mg PO QD
Synthroid 125 mcg PO QD
Amitryptylline 75-150 mg po qd
HISS
Flonase
Colace
Albuterol
Combivent
Lidoderm patch 5%
Xanax 0.5 ml po prn panic attacks
Ambien 10 mg PO qhs prn
Discharge Medications:
1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Methadone HCl 10 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
4. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed.
5. Amitriptyline HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Oxycodone HCl 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for back pain.
7. Aralast Intravenous
8. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Insulin NPH Human Recomb Subcutaneous
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Albuterol Inhalation
13. Atrovent Inhalation
Discharge Disposition:
Home
Discharge Diagnosis:
Necrotizing MSSA PNA
sepsis [**2-5**] MSSA bacteremia
Discharge Condition:
Stable. O2 sats 94-96% on room air. Ambulatory O2 sats 96%.
Discharge Instructions:
Please call your doctor and return to the hospital if you are
having any difficulty breathing, fever, chills, night sweats,
increasingly productive cough, feeling lighthaeded/dizzy or for
any other concerning symptoms you may have.
.
Please follow-up with your Pulmonary doctor [**First Name (Titles) **] [**Last Name (Titles) 3390**] next week.
Followup Instructions:
Please follow-up with Dr.[**Last Name (STitle) 8446**] next week. Please call for
appointment.
.
Please follow-up with your Pulmonologist next week. Please call
for appointment.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"293.0",
"513.0",
"518.81",
"303.90",
"995.92",
"286.7",
"038.11",
"305.60",
"273.4",
"482.41",
"564.00",
"571.2",
"250.11",
"785.52",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"99.15",
"38.93",
"03.31",
"96.6",
"88.72",
"00.17",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
16864, 16870
|
12784, 15594
|
355, 367
|
16968, 17029
|
4143, 4143
|
17423, 17724
|
3244, 3248
|
15950, 16841
|
12275, 12331
|
16891, 16947
|
15620, 15927
|
17053, 17400
|
3263, 4124
|
274, 317
|
12360, 12761
|
395, 2946
|
4160, 4841
|
2968, 3188
|
3204, 3228
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,711
| 135,137
|
30853
|
Discharge summary
|
report
|
Admission Date: [**2190-5-28**] Discharge Date: [**2190-6-14**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2190-6-3**] - Coronary artery bypass grafting x4 with the left
internal mammary artery to the left anterior descending artery,
and reverse saphenous vein grafts to the posterior descending
artery, obtuse marginal artery and the ramus intermedius artery.
[**2190-6-1**] - Thoracentesis
History of Present Illness:
This is an 85 year old female with multiple cardiac risk
factors. She recently experienced chest discomfort while
undergoing dialysis, associated with hypotension and
bradyarrhythmia. Cardiac catheterization was significant for
three vessel coronary artery disease and she was transferred to
the [**Hospital1 18**] for cardiac surgical intervention.
Past Medical History:
Cerebrovascular Disease - History of Stroke
Hyperlipidemia
Hypertension
Diabetes Mellitus Type II
End Stage Renal Disease - on Hemodialysis
Osteoporosis
Appendectomy
Tubal Ligation
Cataract Surgery
Social History:
Denies history of tobacco and ETOH. Currently lives with her
daughter and son.
Family History:
Brother with coronary artery disease ?age of diagnosis
Physical Exam:
Admission PE
Vitals: T 99.7, BP 112/52, HR 76, RR 22, SAT 98% on 3L
General: elderly female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, transmitted murmurs noted
Heart: regular rate, normal s1s2, 3/6 systolic ejection murmur
Lungs: bibasilar rales
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2190-5-28**] 07:40PM BLOOD WBC-9.1 RBC-3.02* Hgb-10.2* Hct-32.4*
MCV-107* MCH-33.8* MCHC-31.4 RDW-17.9* Plt Ct-347
[**2190-5-28**] 07:40PM BLOOD PT-11.2 PTT-28.9 INR(PT)-0.9
[**2190-5-28**] 07:40PM BLOOD Glucose-90 UreaN-15 Creat-4.1* Na-139
K-4.2 Cl-103 HCO3-25 AnGap-15
[**2190-5-28**] 07:40PM BLOOD ALT-7 AST-7 LD(LDH)-148 AlkPhos-71
Amylase-98 TotBili-0.2
[**2190-5-28**] 07:40PM BLOOD Albumin-3.5 Calcium-8.8 Phos-4.3 Mg-2.0
[**2190-5-28**] 07:40PM BLOOD %HbA1c-5.6
[**2190-5-28**] Chest x-ray: 1. Cardiomegaly. 2. Bilateral pleural
effusions, right greater than left. 3. Large opacity in the
right lung base could be due to pleural effusion; however,
cannot rule out air space consolidation.
[**2190-5-31**] Carotid Ultrasound: Minimal plaque with bilateral less
than 40% carotid stenosis.
[**2190-5-31**] Echocardiogram: The left atrium is elongated. The
estimated right atrial pressure is 0-5mmHg. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). There is a mild resting left
ventricular outflow tract obstruction. Right ventricular chamber
size and free wall motion are normal. The aortic arch is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is within normal limits. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
[**2190-6-1**] Chest CT scan: 1. The right lower lobe mass suspected on
chest radiograph is relaxation atelectasis due to moderate right
pleural effusion. No mass or inhomogeneity within the
atelectasis is demonstrated.
2. Small left pleural effusion. 3. Coronary calcifications.
Fusiform aortic dilatation to 3.7 cm at the level of the
diaphragm.
[**2190-6-8**] Ultrasound: Uncomplicated ultrasound and
fluoroscopically guided single lumen PICC line placement via the
left basilic venous approach. Final internal length is 38 cm,
with the tip positioned in the SVC. The line is ready for use.
[**2190-6-10**] Head CT scan: 1. Ill-defined area of hypodensity within
the left frontal lobe could represent a focus of edema and thus
a subacute or chronic area of infarction. If clinically
indicated, MRI is recommended to further assess this finding. 2.
There is extensive periventricular white matter and subcortical
small vessel disease.
Brief Hospital Course:
Mrs. [**Known lastname 1005**] was admitted under cardiac surgery and underwent
routine preoperative evaluation in addition to echocardiogram,
and carotid ultraound(see result section). The renal service was
consulted to assist in the pre and postoperative management of
her end stage renal disease. She continued on her routine
hemodialysis schedule. Due to a significant right sided pleural
effusion, she underwent successful thoracentesis on [**6-1**].
she otherwise remained stable on medical therapy and was
eventually cleared for surgery. On [**6-3**], Dr. [**Last Name (STitle) **]
performed coronary artery bypass grafting surgery. For surgical
details, please see seperate dictated operative note. She
remained intubated for several days secondary to requiring
hemodialysis d/t metabolic acidosis and fluid overload from her
renal disease. On post-op day three she was weaned from
sedation, awoke neurologically intact and extubated. Chest tubes
and epicardial pacing wires were removed per protocol. She was
weaned off of any pressors by post-op day three and started on
beta blockers. On post-op day four she required blood
transfusion secondary to low hematocrit. She remained in the CSR
for several more days requiring aggreesive pulmonary toilet. On
post-op day six a PICC line was placed for definitive
intravenous access. She was later transferred to the SDU for
further care. On post-op day seven patient had some right-sided
weakness and CT followed by an MRI were performed. And neurology
was consulted as well. CT showed possible subacute or chronic
infarct. MRI then showed a new left frontal infarct. She has
remained stable hemodynamically. She has had increasing
strength of her right arm, and neurology has not recommended any
further treatment for this except for physical and occupational
therapy. She is ready to be discharged to a rehab facility to
begin with her therapy to increase strength and mobility.
Medications on Admission:
Lopressor 50 [**Hospital1 **], Trazadone 25 qd, Colace 100 [**Hospital1 **], Reglan 10
tid, Protonix 40 qd, Aggrenox, Zocor 20 qd, Fosrenol, Albuterol
prn
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day). Tablet(s)
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12
hr Sig: One (1) Cap PO BID (2 times a day).
12. 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.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Pleural effusions s/p Thoracentesis
Cerebrovascular Disease - History of Stroke
Hyperlipidemia
Hypertension
Diabetes Mellitus Type II
End Stage Renal Disease - on Hemodialysis
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist Dr.
[**Last Name (STitle) **] with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 29065**] in 2 weeks. ([**Telephone/Fax (1) 73003**]
Completed by:[**2190-6-14**]
|
[
"414.01",
"250.00",
"585.6",
"733.00",
"V17.3",
"272.4",
"V45.61",
"997.02",
"403.91",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"99.04",
"38.93",
"39.61",
"34.91",
"89.60",
"36.13",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7750, 7798
|
4343, 6282
|
279, 569
|
8053, 8061
|
1771, 4320
|
8775, 9066
|
1282, 1338
|
6487, 7727
|
7819, 8032
|
6308, 6464
|
8085, 8752
|
1353, 1752
|
229, 241
|
597, 948
|
970, 1170
|
1186, 1266
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,736
| 190,985
|
41170
|
Discharge summary
|
report
|
Admission Date: [**2171-12-31**] Discharge Date: [**2172-1-8**]
Date of Birth: [**2111-6-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
black stools per rectum
Major Surgical or Invasive Procedure:
Upper endoscopy [**12-31**] with endoclip to duodenal ulcer
Upper endoscopy [**1-2**] with epi injection to duodenum
IR Embolization [**1-3**] of distal gastroduodenal arcade
History of Present Illness:
This is 60 year old male with PMH anxiety and insomnia,
presented initially to [**Hospital6 17032**] with melena
and transferred to [**Hospital1 18**] for management of continued melanotic
stools.
Patient reports that he has had epigastric pain for the last
month. Mild in nature, [**1-30**], slightly improved with food. He
reports that secondary to this pain he has been taking ibuprofen
[**Hospital1 **] for the last several weeks. Also endorses [**1-24**] alcoholic
drinks daily for years. Upon presentation to OSH, reported 2
day history of black stools. On the day of presentation, was
with lightheadedness and fatigue. He denies any nausea,
vomiting, diarrhea, cough, fever, or chest pain. He also
endorses to a high amount of stress secondary to his new job.
OSH initial vital signs were stable; T: 97.7, BP: 99/70, HR: 72,
RR: 18, O2sat: 100%RA. Initial hematocrit was 31.5 but found to
drop to 19.1 the following day. Protonix gtt administered. ECG
was without ischemic symptoms. EGD on [**12-29**] demonstrated post
bulbar duodenal ulceration with a clean base. Repeat endoscopy
on [**12-30**] demonstrated duodenal ulcer with no active bleeding and
a bright red clot. No visible vessels. No intervention was
performed. Was admitted to the ICU, found to have systolic
blood pressures in the 80s and required 10 units of prbcs and 2
units of FFP over three days.
Transferred to [**Hospital1 **] for further evaluation of GI bleed. Also
noted to have a low grade temperature to 101.4 on the AM of
transfer.
Past Medical History:
- anxiety
- insomnia
Social History:
Patient is married, lives with wife. Was unemployed for several
months but now with new occupation. Denies any smoking, drugs,
consumes 4 drinks of alcohol each day. No IVDU.
Family History:
Non-contributory. Mother: stroke.
Physical Exam:
Admission Exam:
VS: Temp: 98.6, BP: 113/59 HR: 70 RR: 16 O2sat: 99%RA
GEN: comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
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
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
RECTAL: maroon stools
Discharge Exam:
VS: 96.6 124/76 71 16 98RA
GEN: comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
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
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.
Pertinent Results:
Admission labs:
[**2171-12-31**] 01:02PM GLUCOSE-99 UREA N-22* CREAT-1.0 SODIUM-140
POTASSIUM-3.5 CHLORIDE-111* TOTAL CO2-25 ANION GAP-8
[**2171-12-31**] 01:02PM ALT(SGPT)-14 AST(SGOT)-17 LD(LDH)-117 ALK
PHOS-25* TOT BILI-1.3
[**2171-12-31**] 01:02PM CALCIUM-6.5* PHOSPHATE-2.6* MAGNESIUM-1.4*
[**2171-12-31**] 01:02PM WBC-11.6* RBC-3.16* HGB-9.4* HCT-26.6* MCV-84
MCH-29.7 MCHC-35.3* RDW-14.6
[**2171-12-31**] 01:02PM PLT SMR-LOW PLT COUNT-81*
[**2171-12-31**] 01:07PM PT-15.1* PTT-31.9 INR(PT)-1.3*
[**2171-12-31**] 10:22PM HCT-27.4*
Discharge Labs:
[**2172-1-8**] 06:12AM BLOOD WBC-6.6 RBC-3.27* Hgb-10.2* Hct-28.7*
MCV-88 MCH-31.2 MCHC-35.5* RDW-15.6* Plt Ct-357
[**2172-1-8**] 06:12AM BLOOD Glucose-101* UreaN-5* Creat-1.1 Na-141
K-4.1 Cl-107 HCO3-27 AnGap-11
EKG: At OSH -> NSR with no ST depressions or T wave inversions
concerning for ischemia.
Imaging:
Chest radiograph (OSH: [**2171-12-30**]): no acute cardiopulmonary
process
CT (OSH: [**2170-12-30**]): No report attached in paperwork.
EGD findings (OSH: [**2171-12-29**] and [**2171-12-30**]) as per HPI.
.
EGD at [**Hospital1 18**] [**12-31**]:
Impression: NG tube trauma in esophagus. Superficial
non-bleeding duodenal ulcers (endoclip)
Duodenitis. Otherwise normal EGD to third part of the duodenum
EGD [**1-2**]:
Impression: Fresh red blood in the second part of the duodenum
(injection) Duodenitis. During the procedure the patient had
bradycardia (HR 30s) and significant retching with abdominal
distension and tension, requiring decompression of the stomach
several times during the procedure. After the procedure, the pt
complained of significant new upper abdominal pain and continued
to have upper abdominal distension and tension, although to a
smaller degree than during the procedure. Fresh clotted blood in
the stomach cardia Ulcers in the duodenum Otherwise normal EGD
to third part of the duodenum
MESENTERIC ARTERIOGRAM [**2172-1-2**]:
1. Mesenteric arteriography showing no active extravasation or
lesion, however, knowing today's endoscopy findings, elective
embolization of GDA was planned, but because of takeoff of
hepatic flexure arterial supply as described, more selective
embolization was performed as described above. 2. Right hepatic
artery replaced to superior mesenteric artery.
Brief Hospital Course:
Mr. [**Known lastname 29819**] is a 60 year old male with PMH anxiety and
insomnia, presented initially to [**Hospital6 17032**]
with melena and transferred to [**Hospital1 18**] for management of large
volume GI bleed, who later achieved hemostasis after selective
embolization of his gastroduodenal arcade.
ACUTE PROBLEMS:
1. UPPER GI BLEED: He was admitted for an upper GI bleed given
his history of melena. GI performed urgent EGD which confirmed
presence of duodenal ulcer - likely NSAID induced given the
patient's history. this was endoclipped. Patient was transfused
2 units pRBCs initially without an appropriate bump in his
hematocrit and then transfused another 2 units with appropriate
rise. He was monitored overnight in the ICU and remained
hemodynamically stable with stable hematocrits, however the
morning of [**1-2**] his Hct dropped from 30 -> 24.1. GI did a
repeat EGD and saw blood at the distal esophagus as they were
coming out of the stomach and he started having acute abdominal
pain during the procedure concerning for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear.
Stat KUB and CXR were negative for free air. Surgery was
urgently consult, however they did not think he had an
esophageal perforation. He was transfused a total of 3 units
PRBC and taken to IR for embolization of the gastroduodenal
artery (GDA). A proximal embolization of the GDA was not
possible because the vasculature feeding the hepatic flexure
arose proximally, and therefore a proximal embolization would
risk bowel ischemia. A more distal embolization was therefore
performed. His abdominal pain had improved by the time he was
back on the floor from IR. He was kept NPO overnight and his
Hct's were trended. He lost peripheral access and a central
line was placed on [**1-3**]. He required a total of 10 units of
PRBC since admission. His last transfusion was on [**1-4**]. Since
that transfusion his Hct has remained stable around 30's. H.
pylori returned negative. GI and IR were clear that If he were
to bleed again his options would be to go to surgery versus to
IR for embolization of the proximal GDA, despite the ischemic
risk. These options have been explained to him. He was
transferred to the general medicine floor in stable condition.
His hematocrit was trended and remained stable around 28-30.
Total transfusion requirement was 20 units between the two
hospitals. Discharge hematocrit was 28.7. He was observed on
the medical floor for 48 hours. He tolerated full advancement
of his diet without further bleeding episodes. He was
transitioned to PO PPI and will require 8 weeks of therapy. The
relationship between his bleed and NSAIDs was explained. He was
advised to abstain from alcohol in the short term as well. He
has follow up with the GI physicians next month, and may require
repeat EGD as an outpatient. He knows to seek evaluation for
further bleeding, nausea, vomiting, dizziness, fatigue, or
weakness.
2. AT-RISK DRINKING: Patient admitted to [**1-24**] alcoholic
beverages nightly, mainly beer. He met with social work to
assess for possible abuse. He occasionally drinks hard liquor.
The relationship between alcohol and ulceration was explained to
the patient. He has gone through extended periods of abstinence
in the past to prove that he does not have an addiction. He
does not currently appear to demonstrate an abuse pattern. He
was advised to abstain as his gut heals.
INACTIVE ISSUES:
3. ANXIETY: continued his home-dose ativan with good effect.
PENDING LABS AT DISCHARGE: none
TRANSITIONAL CARE ISSUES:
1. Will need PO PPI for 8 weeks
2. Will need GI follow-up
Medications on Admission:
Medications at home:
- ibuprofen prn
- ativan
- claritin 10mg PO daily
Meds on transfer:
- ativan 0.5mg PO q6h
- protonix 40mg IV BID
- morphine sulfate 2mg q6h
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
8 weeks.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
3. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding duodenal ulcer s/p endoclip, epi injection, and IR
embolization procedure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 29819**],
You were recently transferred to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center from an Outside Hospital for further evaluation and
management of an upper gastrointestinal bleed. During your
hospitalization two upper GI endoscopies were performed which
revealed a duodenal ulcer as the source of your bleeding;
however, attempts to stop the bleeding were unsuccessful. Due
to continued bleeding, Interventional Radiology performed a
Mesenteric Arteriogram in order to block the blood supply to the
problem[**Name (NI) 115**] portion of your gut. Since this procedure, you have
remained stable with no clinical indication of continued
bleeding.
.
During your hospitalization, you were admitted to the MICU.
While there you received ten units of packed red blood cells to
maintain adequate levels within your blood. Following, the
embolization procedure you required three additional units. The
last transfusion was administered on the morning of [**1-4**]. You
have not required subsequent infusions.
Your bleed may have been precipitated by ibuprofen use- please
avoid ibuprofen (advil, motrin), naproxen (aleve), and other
"non-steroidal anti-inflammatory drugs" in the future. You may
use tylenol safely for your aches and pains. Also, alcohol is
known to increase your risk of bleeding. Please abstain over
the next several weeks until your duodenum heals.
The following changes have been made to your medications:
1. START PANTOPRAZOLE 40mg orally twice a day for 8 weeks
Please continue all other meds as previously prescribed
Followup Instructions:
You have the following appointments with your primary care
doctor and a GI specialist:
Department: Primary Medicine
Name: Dr. [**Last Name (STitle) 78062**] [**Name (STitle) 9183**]
When: Thursday [**2172-1-16**] at 12 PM
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Location (un) 21638**], [**Location (un) **],[**Numeric Identifier 21639**]
Phone: [**Telephone/Fax (1) 21640**]
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2172-1-21**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 10314**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"287.5",
"300.00",
"780.52",
"285.1",
"532.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"38.93",
"44.44",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
10193, 10199
|
5886, 9378
|
329, 506
|
10326, 10326
|
3567, 3567
|
12153, 12900
|
2327, 2364
|
9793, 10170
|
10220, 10305
|
9606, 9606
|
10477, 12130
|
4135, 5863
|
9627, 9678
|
2379, 3020
|
3036, 3548
|
265, 291
|
9518, 9580
|
9486, 9492
|
534, 2070
|
9395, 9467
|
3584, 4119
|
10341, 10453
|
2092, 2115
|
2131, 2311
|
9696, 9770
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,510
| 132,368
|
34631
|
Discharge summary
|
report
|
Admission Date: [**2101-6-1**] Discharge Date: [**2101-6-5**]
Date of Birth: [**2076-1-8**] Sex: F
Service: PLASTIC
Allergies:
Cefaclor
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
facial fracture
Major Surgical or Invasive Procedure:
ORIF Lefort 1 fracture, repair lip laceration, repair dental
alveolar fx
History of Present Illness:
25F s/p MVA w/ hx of anxiety unrestrained driver in MVA [**6-1**] PM,
[**Location (un) **] to [**Hospital1 18**] for care. Pt w/ visible mouth deformity, no
other acute medical or surgical issues on admission.
Past Medical History:
Anxiety
Social History:
1PPD x 10 years, social EtOH
Family History:
n/a
Physical Exam:
Gen: normocephalic, AOx3
CV: sinus tachy [**12-18**] pain, reg rhythm, nl s1/s2, no m/r/g
Pulm: CTAB
Abd: Soft, NT/ND, +bs,
skin: b/l knee abrasions
HEENT: PERRLA, CN II-XII intact; 3/4 cm full thickness vertical
incision on central lip; mobile upper maxilla with grossly
missing teeth; difficult to assess lefort fracture and facial
bone mobility [**12-18**] pain; mouth filled with dry blood, pt
protecting airway
Pertinent Results:
[**2101-6-1**] 06:20PM PH-7.42 COMMENTS-GREEN TOP
[**2101-6-1**] 06:20PM GLUCOSE-106* LACTATE-2.1* NA+-146 K+-3.6
CL--110 TCO2-20*
[**2101-6-1**] 06:20PM HGB-16.4* calcHCT-49
[**2101-6-1**] 06:20PM freeCa-1.03*
[**2101-6-1**] 06:15PM UREA N-6 CREAT-0.6
[**2101-6-1**] 06:15PM estGFR-Using this
[**2101-6-1**] 06:15PM AMYLASE-30
[**2101-6-1**] 06:15PM ASA-NEG ETHANOL-68* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2101-6-1**] 06:15PM URINE HOURS-RANDOM
[**2101-6-1**] 06:15PM URINE HOURS-RANDOM
[**2101-6-1**] 06:15PM URINE GR HOLD-HOLD
[**2101-6-1**] 06:15PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2101-6-1**] 06:15PM WBC-15.6* RBC-4.91 HGB-15.0 HCT-44.8 MCV-91
MCH-30.4 MCHC-33.4 RDW-13.7
[**2101-6-1**] 06:15PM PLT COUNT-411
[**2101-6-1**] 06:15PM PT-14.6* PTT-27.0 INR(PT)-1.3*
[**2101-6-1**] 06:15PM FIBRINOGE-195
[**2101-6-1**] 06:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2101-6-1**] 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2101-6-3**] 02:00AM BLOOD WBC-19.0*# RBC-3.91* Hgb-12.2 Hct-35.7*
MCV-91 MCH-31.1 MCHC-34.1 RDW-13.6 Plt Ct-307
[**2101-6-2**] 04:16AM BLOOD WBC-11.5* RBC-4.25 Hgb-13.0 Hct-38.7
MCV-91 MCH-30.7 MCHC-33.7 RDW-13.7 Plt Ct-309
[**2101-6-3**] 02:00AM BLOOD Plt Ct-307
[**2101-6-2**] 04:16AM BLOOD Plt Ct-309
[**2101-6-2**] 04:16AM BLOOD PT-13.4 PTT-25.8 INR(PT)-1.1
[**2101-6-3**] 02:00AM BLOOD Plt Ct-307
[**2101-6-3**] 02:00AM BLOOD Glucose-143* UreaN-11 Creat-0.5 Na-139
K-4.1 Cl-105 HCO3-25 AnGap-13
[**2101-6-1**] 06:15PM BLOOD Amylase-30
[**2101-6-3**] 02:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.8
[**2101-6-2**] 04:16AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
[**2101-6-1**] 06:15PM BLOOD ASA-NEG Ethanol-68* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2101-6-1**] 06:20PM BLOOD pH-7.42 Comment-GREEN TOP
Brief Hospital Course:
Pt was admitted to T/SICU overnight s/p MVA for observation. Pt
did not necessitate pressors or ventilatory support. She was
deemed stable for d/c to floor by T/SICU team with no other
issues than facial fractures.
Pt went to OR on [**6-2**] for fixation of Lefort fracture, dental
alveolar fracture, and maxillary fractures; pt was stable in the
PACU, oxygenating well, with good urine output and pain control.
Pt was extubated in PACU when completely awake.
Pt brought to floor in stable condition on [**6-4**] in AM. Pt had
some mild bouts of anxiety throughout her stay necessitating
small doses of IV Ativan (which the patient, by report, also
takes at home). Pt was on IV dexamethasone until d/c to minimize
potential airway swelling. Also on Abx (clindamycin).
Pt stable on floor, with minimal pain and doing well with family
at bedside. Ready to d/c with good support at home, oral abx,
peridex, and anxiety medication.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*200 ML(s)* Refills:*1*
2. Peridex 0.12 % Mouthwash Sig: One (1) mouthfull Mucous
membrane three times a day as needed.
Disp:*1 Bottle* Refills:*1*
3. Clindamycin Palmitate 75 mg/5 mL Recon Soln Sig: Four (4)
teaspoons (5cc) PO four times a day for 10 days.
Disp:*800 mL* Refills:*0*
4. Lorazepam Intensol 2 mg/mL Concentrate Sig: [**11-17**] 0.5cc
droplets PO twice a day as needed for anxiety: hold for
excessive sedation.
Disp:*1 bottle* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Dental alveolar fracture, maxillary fracture, Lefort 1 fracture,
lip laceration
Discharge Condition:
Good
Discharge Instructions:
Take antibiotics as prescribed, take pain medications as needed.
Take anti-anxiety medications as needed. If you experience
significant nausea and need to vomit, go to the ER as your jaw
is wired shut and vomiting could be a potential serious problem.
If you develop significant bleeding, fever, or anything else
that concerns you, call Dr.[**Name (NI) 27488**] office or go to the emergency
room.
Elevate head of bed while sleeping, no brushing your teeth.
Use mouthwash as needed. For diet, please drink ensure shakes
for nutrition.
Followup Instructions:
Plastic surgery clinic 1 week, please call to schedule an
appointment ([**Telephone/Fax (1) 7138**]
Completed by:[**2101-6-5**]
|
[
"802.20",
"300.00",
"599.0",
"E816.0",
"802.8",
"802.4",
"873.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"76.74",
"76.76",
"27.57",
"21.88",
"76.77"
] |
icd9pcs
|
[
[
[]
]
] |
4650, 4656
|
3105, 4037
|
281, 356
|
4780, 4787
|
1145, 3082
|
5371, 5501
|
688, 693
|
4060, 4627
|
4677, 4759
|
4811, 5348
|
708, 1126
|
226, 243
|
384, 595
|
617, 626
|
642, 672
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,835
| 159,375
|
40992
|
Discharge summary
|
report
|
Admission Date: [**2179-5-20**] Discharge Date: [**2179-5-25**]
Service: MEDICINE
Allergies:
Cardizem
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
pacemaker lead infection
Major Surgical or Invasive Procedure:
Pacemaker wire and device removal
History of Present Illness:
Ms. [**Known lastname 89428**] is a [**Age over 90 **] year-old woman with a history of atrial
fibrillation adn tachy-brady syndrome s/p PPM in 08/[**2176**]. RV
lead was malfunctioning and was replaced on [**2178-2-27**]. She did
well until [**2179-4-1**]. At that time she had increasing malaise
and chills. Shee was admitted with evidence of a pacemaker
pocket infection and MSSA bacteremia. A trial of prolonged
antibiotics rather than extraction was attempted due to her
advanced age. She received 4 weeks of oxacillin via PICC. Her
systemic symptoms improved. However, the localized infection
persisted and she was referred for lead extraction
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY:
- PACING/ICD: tachy-brady syndrome, s/p PPM [**2177-8-7**]. The RV
lead was malfunctioning and a new ventricular lead was placed on
[**2178-2-27**].
- diastolic congestive heart failure
- chronic atrial fibrillation. Not on anticoagulation due to
gait instability...
- moderate AS, [**Location (un) 109**] .9 cm2, mean gradient 11 mmHg
- moderate AI
- moderate MR
3. OTHER PAST MEDICAL HISTORY:
- osteoporosis
- pseudogout
Social History:
Patient is widowed and currently living in an [**Hospital3 **]:
[**Location 58939**] at Farm Pond in [**Location (un) 47**], since her bacteremia in
04/[**2178**]. Previously ambulatory with a walker but has been
wheelchair bound since [**71**]/[**2178**]. Receives physical therapy
several days a week. She does not smoke or drink.
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
Gen: A/O x3, sitting in chair, NAD
HEENT: supple, no JVD
CV: irreg irreg, 2/6 Systolic murmur at right upper sternal
border. Pacer drsg [**Name5 (PTitle) 151**] [**Name5 (PTitle) **] [**Name5 (PTitle) **] on dressing. Wound is 3x4
cm, 0.25 cm deep with bloody drainage. Not tender. Noted mod
edema and redness around site that correlates with pocket area.
RESP: CTAB post, no wheezes
ABD: soft, protuberant, pos BS
EXTR: no edema
NEURO: A/O x3, MAE
Extremeties:
Pulses:
Right: DP 2+ PT 1+
Left: DP 2+ PT 1+
Skin: see above
Access: PIV
Tubes: none
Pertinent Results:
[**2179-5-20**] 10:20AM [**Month/Day/Year 3143**] WBC-5.5 RBC-3.70* Hgb-10.8* Hct-32.9*
MCV-89 MCH-29.1 MCHC-32.8 RDW-15.9* Plt Ct-244
[**2179-5-25**] 07:15AM [**Month/Day/Year 3143**] WBC-5.5 RBC-2.93* Hgb-8.6* Hct-25.8*
MCV-88 MCH-29.4 MCHC-33.4 RDW-16.0* Plt Ct-209
[**2179-5-20**] 10:20AM [**Month/Day/Year 3143**] PT-12.7 PTT-26.6 INR(PT)-1.0
[**2179-5-20**] 10:20AM [**Month/Day/Year 3143**] Glucose-82 UreaN-26* Creat-1.3* Na-133
K-6.0* Cl-102 HCO3-24 AnGap-13
[**2179-5-25**] 07:15AM [**Month/Day/Year 3143**] Glucose-94 UreaN-13 Creat-0.7 Na-136
K-4.0 Cl-104 HCO3-25 AnGap-11
[**2179-5-20**] 07:06PM [**Month/Day/Year 3143**] Calcium-9.7 Phos-3.1 Mg-2.0
[**2179-5-24**] 06:45AM [**Month/Day/Year 3143**] Calcium-8.5 Phos-2.1* Mg-1.9
[**2179-5-21**] 06:53AM [**Month/Day/Year 3143**] Cortsol-22.7*
[**2179-5-21**] 06:53AM [**Month/Day/Year 3143**] Digoxin-0.7*
.
ECG [**5-20**]: Atrial flutter with variable block. Left bundle-branch
block pattern which appears to be related to paced beats in lead
V2. No previous tracing available for comparison.
.
ECG [**5-21**]: Patient now appears to be in atrial fibrillation.
Leftward axis. No other diagnostic abnormality.
.
BCx [**5-21**]: pending x2
.
ECHO [**5-21**]: The left atrium is elongated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no pericardial effusion. There is an anterior space which
most likely represents a prominent fat pad. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
Ms. [**Known lastname 89428**] is a [**Age over 90 **] year-old woman with tachy-brady syndrome,
now s/p PPM lead removal for pocket infection.
.
# lead infection: now s/p removal of infected foreign body with
open wound. This should facilitate wound healing. She has
completed four weeks of nafcillin after MSSA bacteremia ([**4-1**] at
[**Hospital1 **]). ID consulted and touched base with outpt infectious
disease specialist. Agreed to 2wk course of dicloxacillin
starting from day of lead removal as pt without evidence of
endocarditis (though only had TTE not TEE). Last day [**6-3**]. Pt
will follow-up with outpt ID for further management.
.
# afib/tachy-brady syndrome: currently afib/flutter with
ventricular response in the 70s and normal BP, although she was
reportedly pacer dependent prior to removal of device. No pacer
wire needed at present. Continue to hold digoxin and atenolol.
She was initially started on dopamine gtt with hypotension but
was able to come off of dopamine gtt with intravenous fluids.
She was continued on aspirin 325 mg po qdaily for
anticoagulation. Pt will follow up with outpt cards for further
management.
.
# Hypotension: She was noted to have SBP in 70s post pacemaker
lead explantation. TTE showed normal cardiac output and no
cardiac tamponade physiology. She did not appear to be in
distributive or septic shock with clinical presentation or
physical exam. AM cortisol was appropriate. Thought to be be
likely hypovolemic. She was started on dopamine gtt which was
weaned off with intravenous fluids. Hydralazine, atenolol and
digoxin were held on discharge.
.
# CHF: history of diastolic dysfunction on TTE but no clinical
history of heart failure per patient's daughter. [**Name (NI) **] pressure
controlled as above.
.
# Wound care: Pt will have a VNA as an outpatient.
Left upper chest:
1. Commercial wound cleanser to irrigate/cleanse open wound.
2. Pat the tissue dry with dry gauze.
3. Apply no sting barrier film to the periwound tissue with
each
drg change and air dry for 30 secs.
4. Apply [**12-20**] of Aquacel AG 4 x 4" gauze (antimicrobial to
decrease local bacterial bioburden and promote hemostatis)
5. Cover with dry gauze
6. Secure with Medipore tape.
7. Change dressing daily.
Upon removal of the Aquacel AG dressing, moisten with
commercial
wound cleanser or normal saline to obtain a gel effect and
nontraumatic removal of the dressing.
Medications on Admission:
atenolol 75 mg [**Hospital1 **]
digoxin 125 mcg qod
hydralazine 10 mg tid
lisinopril 40 mg daily
potassium chloride 40 mEq daily
Bactrim DS [**Hospital1 **]
ASA 325 mg daily
Ca/D
MVI
omega-3 fatty acid
Discharge Medications:
1. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO three times a day
as needed for pain.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
3. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Calcium 500 With D Oral
6. Fish Oil Concentrate Oral
7. multivitamin Tablet Sig: One (1) Tablet PO once a day.
8. dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
9. Outpatient Lab Work
Please check CBC and Chem-7 on [**2179-5-27**] with results to Dr.
[**Last Name (STitle) 5051**] at Phone: [**Telephone/Fax (1) 6256**]
Fax: [**Telephone/Fax (1) 33001**]
Discharge Disposition:
Home With Service
Facility:
Excella Health and Home care
Discharge Diagnosis:
Pacemaker wire infection
Hypertension
Atrial fibrillation
Acute on Chronic Diastolic Congestive Heart Failure
Aortic Stenosis
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 had an infection on your pacemaker and wires and we removed
them here. You will continue on your antibiotics for the next 10
days. While you were in the hospital, you were on vancomycin
intravenously. You will need to change the dressing at the
former pacemaker site daily. You should tell Dr [**Last Name (STitle) 5051**] if the
site looks more red, tender or is bleeding. The visiting nurses
will help you with this. Your kidneys were not working correctly
for a few days, they are now functioning normally. Weigh
yourself every morning, call Dr. [**First Name (STitle) 6164**] if weight goes up more
than 3 lbs in 1 day or 5 pounds in 3 days.
.
WE made the following changes to your medicines:
1. Start taking dicloxicillin to treat the infection at the old
pacemaker site and in your [**First Name (STitle) **]
2. STOP taking Hydralazine, atenolol and digoxin
Continue your other medicines as before.
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2179-6-1**] at 2:00PM AM
With:[**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 6256**]
Will check wound at the same time
.
Name: [**First Name11 (Name Pattern1) 5147**] [**Last Name (NamePattern4) 89429**], MD
Specialty: Internal Medicine
Location: [**Hospital **] MEDICAL GROUP-[**Location (un) **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 59119**]
Phone: [**Telephone/Fax (1) 8036**]
We are working on a follow up appointment with Dr. [**First Name (STitle) 6164**] within
the next week. You will be called at home with the appointment.
If you have not heard or have questions, please call the number
above.
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 89430**], MD
Specialty: Infectious Disease
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 59599**]
Phone: [**Telephone/Fax (1) 44428**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) 37454**] in
the next week. You will be called at home with the appointment.
If you have not heard or have questions, please call the number
above.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,810
| 147,734
|
42986
|
Discharge summary
|
report
|
Admission Date: [**2145-2-17**] Discharge Date: [**2145-2-21**]
Service: MEDICINE
Allergies:
Nitroglycerin / Aspirin / Penicillins / Levaquin /
Hydrochlorothiazide
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 10166**] is a [**Age over 90 **] year-old woman with a history of SBO and
hyponatremia who presents with LLQ pain, found to have
hyponatremia.
.
Recently admitted ([**Date range (1) 75462**]) with SBO and pulmonary edema and
aspiration. Also noted to have new afib during this admission
with aspirin started. Iron was also started for a diagnosis of
iron deficiency anemia. Both lisinopril and HCTZ were stopped
and her metoprolol dose was increased.
.
Since discharge she has generally been feeling well. Was seen by
her PCP who restarted both lisinopril and HCTZ given LE edema;
metoprolol was also decreased in dose and ASA was stopped. Given
new "severe depression", her outpatient psychiatrist started
sertraline on [**2-12**].
.
On the day of admission she experienced burning in her left
inner thigh; this resolved in 1 hour. Soon thereafter she
experienced LLQ pain not associated with nausea or vomiting.
Given that this did not resolve, she was taken to the ED. By the
time she arrived the pain had resolved (lasted ~1 hour total).
.
In the ED, T 97.8, BP 184/112, HR 92, RR 14, 98% on room air.
She was given metoprolol 25mg, potassium and IVF.
Past Medical History:
1. Coronary artery disease, s/p MI x 2
2. Hypertrophic cardiomyopathy
3. Severe AS ([**Location (un) 109**] = 0.7 cm2); mild (1+) AR
4. Moderate (2+) MR
5. Atrial fibrillation, diagnosed [**1-29**]. Anticoagulation
discussion with ASA started.
6. Hypertension
7. Graves' disease, s/p treatment with radioactive iodine
8. Osteoporosis with known vertebral fractures
9. Chronic obstructive pulmonary disease
10. Melanoma of the foot
11. Cervical cancer status post radiation therapy and radium
implant
12. Radiation proctitis with chronic diarrhea related to
treatment from cervical cancer
11. History of hyponatremia and SIADH
12. Gastric lesion: polypoid lesion seen posterior to stomach on
CT abdomen ([**1-29**])
13. Cystic pancreatic head lesion
14. Anemia
Social History:
No alcohol. 30 pack-year history of tobacco; quit 40 yrs ago. No
drug use. Previously worked as a manager of a clothing shop.
Currently living w/ her son [**Name (NI) **] who is her HCP. Ambulatory at
baseline.
Family History:
Father and sister deceased due to lung CA, brother w/ h/o MM
Physical Exam:
VITALS: T 98.6, BP 140/80, HR 82, 95% on room air, Wt: 84.6 lbs
GEN: Thin and frail female, lying in bed. No distress but feels
"frozen" and in pain.
HEENT: PERRLA, EOMI with fast right-beating nystagmus on left
gaze. Hearing difficulty with finger rub bilaterally. Mucous
membranes somewhat dry, no oral lesions or exudates. Neck
supple, no LAD or thyromegaly. No JVP visible.
CV: Irregular. IV/VI harsh systolic murmur apparent loss of S2
radiating to clavicles. Prominent non-displaced PMI.
PULM: Good air movement bilaterally, bibasilar crackles
ABD: Soft, non-tender no HSM, liver tip barely palpable below
costal margin. Wearing adult diaper.
EXT: Thin with 2+ DP pulses and no edema
SKIN: Herpetic rash with erythematous crusted papules on left
side of lower back, does not cross midline. Similar rash present
on medial sie of left thigh.
NEURO: AOx3, conversant and appropriate. Muscle bulk diffusely
atrophic, normal tone. Strength 4+/5 in UE, [**5-25**] in LE. Reflexes
1+ bilaterally.
Pertinent Results:
[**2145-2-17**] 07:45PM BLOOD WBC-9.1 RBC-3.71* Hgb-11.8* Hct-32.1*
MCV-86 MCH-31.8 MCHC-36.8* RDW-18.0* Plt Ct-168
[**2145-2-19**] 06:10AM BLOOD WBC-7.5 RBC-3.65* Hgb-11.8* Hct-32.8*
MCV-90 MCH-32.5* MCHC-36.1* RDW-18.0* Plt Ct-212
[**2145-2-17**] 07:45PM BLOOD Glucose-87 UreaN-19 Creat-0.9 Na-117*
K-2.7* Cl-76* HCO3-35* AnGap-9
[**2145-2-19**] 06:10AM BLOOD Glucose-69* UreaN-17 Creat-0.7 Na-121*
K-3.7 Cl-83* HCO3-33* AnGap-9
[**2145-2-17**] 07:45PM BLOOD ALT-15 AST-34 CK(CPK)-53 AlkPhos-74
TotBili-0.7
[**2145-2-17**] 07:45PM BLOOD Lipase-23
[**2145-2-17**] 07:45PM BLOOD cTropnT-0.02*
[**2145-2-19**] 06:10AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.6
[**2145-2-18**] 04:40AM BLOOD VitB12-1250*
[**2145-2-18**] 12:44AM BLOOD Osmolal-254*
[**2145-2-18**] 12:44AM BLOOD TSH-12*
[**2145-2-18**] 12:44AM BLOOD Free T4-1.2
[**2-17**] KUB
IMPRESSION: Non-obstructive bowel gas pattern. Left pleural
effusion.
[**2145-2-18**] 04:40AM BLOOD WBC-8.1 RBC-3.95* Hgb-12.8 Hct-35.3*
MCV-89 MCH-32.3* MCHC-36.2* RDW-17.9* Plt Ct-155
[**2145-2-21**] 08:10AM BLOOD WBC-8.9 RBC-3.52* Hgb-11.2* Hct-32.0*
MCV-91 MCH-31.9 MCHC-35.1* RDW-17.9* Plt Ct-201
[**2145-2-17**] 07:45PM BLOOD Glucose-87 UreaN-19 Creat-0.9 Na-117*
K-2.7* Cl-76* HCO3-35* AnGap-9
[**2145-2-18**] 04:40AM BLOOD Glucose-81 UreaN-14 Creat-0.6 Na-122*
K-3.9 Cl-86* HCO3-30 AnGap-10
[**2145-2-18**] 04:02PM BLOOD Glucose-72 UreaN-17 Creat-0.8 Na-119*
K-3.6 Cl-82* HCO3-31 AnGap-10
[**2145-2-19**] 12:50PM BLOOD Glucose-80 UreaN-19 Creat-0.7 Na-125*
K-3.9 Cl-82* HCO3-33* AnGap-14
[**2145-2-21**] 08:10AM BLOOD Glucose-63* UreaN-24* Creat-0.7 Na-126*
K-4.4 Cl-88* HCO3-30 AnGap-12
[**2145-2-17**] 07:45PM BLOOD ALT-15 AST-34 CK(CPK)-53 AlkPhos-74
TotBili-0.7
[**2145-2-17**] 07:45PM BLOOD Lipase-23
[**2145-2-17**] 07:45PM BLOOD cTropnT-0.02*
[**2145-2-18**] 04:40AM BLOOD VitB12-1250*
[**2145-2-19**] 12:50PM BLOOD Osmolal-260*
[**2145-2-18**] 12:44AM BLOOD TSH-12*
[**2145-2-18**] 12:44AM BLOOD Free T4-1.2
[**2145-2-18**] 05:00AM URINE Hours-RANDOM Creat-17 Na-122
[**2145-2-19**] 12:53PM URINE Osmolal-361
Urine culture
**FINAL REPORT [**2145-2-21**]**
URINE CULTURE (Final [**2145-2-21**]):
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
Brief Hospital Course:
[**Age over 90 **]F with history of SBO and SIADH, presented with abdominal pain
and hyponatremia.
.
1. Hyponatremia. PMH indicates prior history of SIADH with
sodium values as low as 115 in the past. Urine sodiums have been
elevated during some of these episodes which is consistent with
SIADH ([**9-24**]) though it also appears that she has had episodes
which improve with IVF ([**2-27**]). Has history of hypothyroidism
which could also contribute. TSH and T4 are not markedly outside
of normal limits. Also of note, sertraline was started 5 days
prior to admission. HCTZ was also recently restarted. She has an
outbreak of Zoster, and complains of severe pain. She did
improve slightly with IVF in the ED. Serum and urine osms
consistent with SIADH. Patient remains asymptomatic without
mental status changes.
Sertraline and HCTZ were discontinued, and patient was kept on a
750cc fluid restriction. Pain was controlled with standing
tylenol and tramadol. On discharge, sodium was 126. She was
instructed to have this rechecked 2 days after discharge at her
appointment with her PCP.
.
2. Abdominal pain, resolved on arrival to the floor. Patient
with history of SBO, felt to be secondary to radiation therapy.
This episode was short-lived and is now resolved. KUB did not
show obstruction. + BMs. Pain was mainly LLQ. Of note, Zoster
extends over left lower back and extends into L groin. This may
be the source of her pain.
.
3. Herpes Zoster: Patient has painful zoster over L lower back,
wrapping around into L medial thigh. This could certainly be
contributing to SIADH. Was taking tylenol, tramadol, and
capsaicin cream at home. This regimen was continued in the
hospital
.
4. Urinary tract infection: Urine culture grew >[**Numeric Identifier 4856**] gram
positive bacteria. Patient was asymptomatic, however this may
have contributed to her initial abdominal pain. She was
discharged with a 7 day course of Bactrim.
.
5. Normocytic anemia. HCT 35, which is about her baseline. Felt
to be iron deficient on last admit though ferritin >200.
Currently above prior value. No active signs of bleeding.
.
6. Atrial fibrillation. Rate controlled. Not on aspirin as
history of GI bleed.
Medications on Admission:
1. Aspirin 81 mg daily (not taking)
2. Lisinopril 20 mg daily (restarted [**2-9**])
3. HCTZ 12.5 mg daily (restarted [**2-9**])
4. Metoprolol Tartrate 25 mg [**Hospital1 **]
5. Levothyroxine 150 mcg daily
6. Sertaline 50 mg daily (started [**2-12**])
7. Risedronate 35 mg QWeek
8. Calcium Carbonate 500 mg TID
9. Ergocalciferol 50,000 unit QMonday
10. Vitamin B-12 1,000 QMonth
11. Tramadol 50 mg Q6H PRN
12. Lorazepam 0.5 mg QHS
13. Acetaminophen 500 mg PRN
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QMON (every Monday).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Risedronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
8. Cyanocobalamin 1,000 mcg/mL Solution Sig: 1000 (1000)
micrograms Injection once a month: intramuscular.
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
10. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3
times a day).
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
13. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO once a
day for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
Hyponatremia/SIADH
Herpes Zoster (shingles)
Hypothyroidism
Urinary tract infection
Depression
Discharge Condition:
Stable. Na 126.
Discharge Instructions:
You were admitted to the hospital due to a dangerously low
sodium level. Your sodium improved slightly with stopping your
hydrochlorothiazide (HCTZ) and sertraline (Zoloft). We
restricted your fluid intake. Please do not take more than
1500mL a day of fluids.
To help keep your sodium level in a safe range, please stop
taking your hydrochlorothiazide (HCTZ). For now, please also
stop taking your sertraline (Zoloft); please follow up with Dr.
[**Last Name (STitle) 17446**] about whether or not it is safe to resume the sertraline
in the future.
Also, to help control your sodium level, you should restrict
your oral fluid intake to 1500 mL per day.
We have contact[**Name (NI) **] your Visiting Nurse service, and they will
resume seeing you on Tuesday [**2145-2-23**].
Our blood tests indicated that your thyroid hormone replacement
(Synthroid) dose is too low. We are therefore recommending that
you increase your dose from 150 mcg per day to 175 mcg per day.
Please follow up with Dr. [**Last Name (STitle) **] regarding your thyroid
function.
If you experience chest pain, shortness of breath, loss of
consciousness, seizures, or any other concerning symptoms, then
you need to seek immediate medical attention.
The following changes have been made to your medications:
- Please STOP taking your hydrochlorothiazide HCTZ (you may
continue your lisinopril).
- Please INCREASE your dose of levothyroxine (Synthroid) to 175
mcg per day.
We are giving you a 7 day course of Bactrim for urinary tract
infection.
Followup Instructions:
We have arranged for you to see Dr. [**Last Name (STitle) 141**] [**2-23**] at
4pm. His office is on the [**Location (un) **] of the [**Hospital Unit Name **] ([**Hospital Unit Name **]) so that you can have your sodium rechecked.
Completed by:[**2145-2-23**]
|
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13,644
| 109,705
|
29512
|
Discharge summary
|
report
|
Admission Date: [**2132-11-26**] Discharge Date: [**2132-12-11**]
Date of Birth: [**2087-12-17**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal Pain
Severe Necrotizing Pancreatitis
Pancreatic Retroperitoneal Abscesses
Post-op Anemia
Major Surgical or Invasive Procedure:
Exploratory Laparotomy
Drainage of Pancreatic Pseudocysts
Placement of Jejunostomy Tube
History of Present Illness:
This is a 44 year old male admitted with fevers, increased INR
and malaise to [**Hospital 8641**] Hospital on [**2132-11-25**]. He was initially
admitted in [**6-29**] with severe pancreatitis and was transfered to
[**Hospital1 2025**]. He was treated for 1 month for severe necrotizing
pancreatitis. A CT at the time showed multiple pancreatic
pseudocyst. On [**2132-10-10**] he underwent an exploratory laparotomy,
LOA, excision of pancreatic pseudocyst, US guided pseudocyst
aspiration x 2. He had an unremarkable course. Approximately 10
days ago, he developed malaise, fevers and was admitted on
[**2132-11-25**] with fevers to 101. A CT showed multiple retroperitoneal
abscesses and inflammation over the transverse colon.
Additionally, the patient was on Coumadin for a previous DVT and
had an INR of 8.8 on admission.
He reports fever over the last several weeks and also abdominal
soreness. He has had intermittent N/V, decreased PO intake (pain
was worse with food), diarrhea x 3days. He denies HA, CP, SOB,
change in bladder function.
Past Medical History:
Hyperlipidimia
Pancreatitis
Colon Polyps
anemia
HTN
Obesity
Social History:
Nonsmoker
Physical Exam:
99.7, 93, 120/64, 18, 935 RA
Gen: NAD
HEENT: PERRL, EOMI, oralpharynx clear
CV: RRR
Chest: slightly decreased at base RLL
Abd: soft, slightly distended, TTP to epigastric and LUQ
Ext: warm, +2 DP/PT
Pertinent Results:
[**2132-11-27**] 01:48AM BLOOD WBC-5.2 RBC-3.53* Hgb-9.9* Hct-29.4*
MCV-83 MCH-28.1 MCHC-33.8 RDW-15.1 Plt Ct-335
[**2132-11-27**] 01:48AM BLOOD Glucose-104 UreaN-4* Creat-0.6 Na-139
K-4.0 Cl-102 HCO3-26 AnGap-15
[**2132-11-28**] 03:03AM BLOOD Glucose-137* UreaN-3* Creat-0.4* Na-137
K-3.5 Cl-102 HCO3-27 AnGap-12
[**2132-11-27**] 01:48AM BLOOD ALT-11 AST-13 AlkPhos-119* Amylase-92
TotBili-0.5
[**2132-11-27**] 01:48AM BLOOD Albumin-2.9* Calcium-8.1* Phos-3.0 Mg-2.1
CHEST (PA & LAT) [**2132-11-27**] 3:39 PM
INDICATION: Pancreatic pseudocyst. Fever.
IMPRESSION:
1. Bilateral pleural effusions, small on the right, and
small-to-moderate on the left. The left effusion may have a
subpulmonic component.
2. Patchy left basilar opacity, likely atelectasis, although
early focus of pneumonia is not excluded.
3. Possible ascites.
[**2132-12-7**] 06:15AM BLOOD WBC-4.3 RBC-3.08* Hgb-9.2* Hct-26.3*
MCV-85 MCH-29.7 MCHC-34.8 RDW-15.4 Plt Ct-234
[**2132-12-10**] 06:58AM BLOOD Glucose-98 UreaN-19 Creat-0.6 Na-138
K-3.8 Cl-101 HCO3-30 AnGap-11
[**2132-12-7**] 06:15AM BLOOD Amylase-14
[**2132-11-28**] 03:22PM BLOOD ALT-13 AST-19 AlkPhos-90 Amylase-58
TotBili-1.2
[**2132-12-10**] 06:58AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.1
[**2132-12-9**] 10:20AM BLOOD calTIBC-248* TRF-191*
CT ABDOMEN W/O CONTRAST [**2132-12-8**] 9:40 AM
[**Hospital 93**] MEDICAL CONDITION:
44 year old man s/p pancreatic abscess resection
REASON FOR THIS EXAMINATION:
*PLEASE NO IV CONTRAST* please eval the pancreatic bed for
undrained collection.
CONTRAINDICATIONS for IV CONTRAST: anaphylaxis
HISTORY: 44-year-old man status post pancreatic abscess
resection. Evaluate for undrained collections.
IMPRESSION: Near complete resolution of the pancreatic
collection. Three well positioned drainage catheters. The only
residual small amounts of fluid are in direct contiguity with
the drainage catheters.
[**2132-11-28**] 1:16 pm SWAB R. RETRO PERITONEAL ABSCESS.
**FINAL REPORT [**2132-12-2**]**
GRAM STAIN (Final [**2132-11-28**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2132-12-1**]):
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
ANAEROBIC CULTURE (Final [**2132-12-2**]):
PRESUMPTIVE CLOSTRIDIUM PERFRINGENS. RARE GROWTH
[**2132-11-28**] 12:40 pm TISSUE DEAD PANCREAS.
GRAM STAIN (Final [**2132-11-28**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN SHORT
CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) **] 1649 ON [**2132-11-28**].
TISSUE (Final [**2132-12-1**]):
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
PRESUMPTIVE STREPTOCOCCUS BOVIS. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2132-12-2**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED
[**2132-11-28**] 6:46 pm MRSA SCREEN Site: RECTAL
Source: Rectal swab.
**FINAL REPORT [**2132-12-2**]**
MRSA SCREEN (Final [**2132-12-2**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2132-12-5**] 9:20 am PERITONEAL FLUID JP #1.
GRAM STAIN (Final [**2132-12-5**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2132-12-8**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2132-12-11**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
He was admitted on [**2131-11-27**] and was NPO with IVF. A review of his
CT from the OSH revealed multiple retroperitoneal abcesses from
his Necrotizing pancreatitis. There was no way that these would
resolve without surgery.
Pre-operatively he was on Imipenem and Fluconazole. He was
hemodynamically stable and had a fever to 102.6.
He went to the OR on [**2131-11-29**].
In OR, he received 2000ml crystalloid, 2U pRBCs, 3U FFP, drained
approx 1 L purulent material from abscesses. Post-operatively,
he went to the ICU. He remained intubated for 5 days post-op. He
was transferred to the floor on POD 6.
Pulmonary Edema: He remained intubated post-operatively. His
lungs were coarse. CXR ([**2132-11-28**]): Effusion, perihilar edema
suggesting some failure CXR ([**11-29**]): B/l layering eff R>L,
worsening pulm edema CXR x2 ([**11-30**]): Minimal improvement in pulm
edema. CXR ([**12-2**]): slight improvement in b/l pleural effusions.
He was extubated POD 5 and tolerated extubation.
CV: On POD 2, he had symptomatic post-op A-fib with a reate to
150's and a SBP to 88. He received Lopressor IV and converted
back to NSR. He continued on Lopressor for rate control.
GI: He had a NGT to medium suction. The J tube was to gravity.
He was ordered for Octreotide. He abdomen was soft and
nondistended. KUB ([**12-1**]): No dilated loops of small bowel are
seen.
Abd: He has 4 JP drains in place and a feeding J-tube. He had a
midline abdominal incision.
POD 10, he had 2 of his drains removed. The other 2 drains will
remain in place. The staples will remain in place until
follow-up.
ID: He continued on Meropenum, Fluconazole and Flagyl was added.
Antibiotics were D/C'd on POD 10.
Pain: After extubation, he was on a PCA for pain control. He was
eventually transitioned to PO meds and had good control.
Heme: He had moderate anemia post-op. This was followed closely.
His HCT on POD 3 was 23.9, he received 2 Uints of PRBC. His INR
was also elevated and began to drift down. His Coumadin was not
restarted.
Renal: He received a 1 liter bolus x 2 for post-op low urine
output (Oliguria/hypovolemia). The urine output improved as he
began to auto-diuresis. He was then started on Lasix and Diamox
for diuresis and peripheral edema. He had good response to these
medications. His weight decreased and the last Lasix was on POD
11.
FEN: He was started on J-tube feedings on POD. He was advanced
to goal. He was then started on a PO diet on POD 10 and advanced
to a regular diet. His tube feedings were cycled at night. TPN
was also started and continued for 9 days post-op. He will
continue with Tube feedings until follow-up.
Depression: Psych was consulted for depression. He did not want
to start any medications at this time.
Micro: [**12-2**] MRSA screen+; [**11-28**] OR tissueCx GPbact +Strep v.,
Ucx(-), Bld cx pending; [**11-27**] BCx:p UCx
[**11-28**] OR fluid - strep viridans, Strep bovis
[**11-28**] Or tissue: strep viridans (sparse), gram(+) bacteria
(sparse)
Medications on Admission:
tricor 145', nexium 40', lopressor 25''', Creon-20 2 tabs''',
coumadin 5', abl prn, colace prn
Discharge Medications:
1. Tube Feeding
Replete with Fiber 3/4 strength.
Rate 150cc/hr.
Cycle for 14 hours at night.
Flush tubing before and after infusion.
2. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA and Hospice
Discharge Diagnosis:
Severe necrotizing pancreatitis with multiple retroperitoneal
abscesses.
Post-op Anemia
Pulmonary Effusion
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
.
Please resume all of your regular medications and take any new
meds as ordered.
.
Continue to ambulate several times per day.
.
You will go home with 2 drains in place. Continue with drain
care as instructed by your nurse.
.
Continue tube feedings at night. Continue with J-tube care.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] on [**2132-12-22**]. Call ([**Telephone/Fax (1) 27730**] to schedule an appointment. You will need a CT prior to
your appointment. PO contrast only. The secretary will help you
set this up.
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2132-12-22**]
11:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2132-12-22**] 10:00
Completed by:[**2132-12-11**]
|
[
"518.5",
"286.9",
"V12.51",
"577.0",
"272.4",
"309.0",
"567.38",
"428.0",
"511.9",
"278.00",
"788.5",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"46.32",
"99.04",
"96.6",
"99.07",
"52.22",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
9558, 9629
|
5830, 8821
|
416, 506
|
9780, 9786
|
1926, 3250
|
10279, 10802
|
8967, 9535
|
3287, 3336
|
9650, 9759
|
8848, 8944
|
9810, 10256
|
1706, 1906
|
5785, 5807
|
277, 378
|
3365, 5033
|
534, 1581
|
1603, 1664
|
1680, 1691
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,530
| 179,582
|
42299
|
Discharge summary
|
report
|
Admission Date: [**2106-10-23**] Discharge Date: [**2106-10-27**]
Date of Birth: [**2052-3-29**] Sex: M
Service: MEDICINE
Allergies:
Tylenol-Codeine #3
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
- Percutaneous Coronary Intervention w/ Drug-Eluting Stent
Placement (x2) in Right Coronary Artery.
History of Present Illness:
54 year old male with PMH of hypercholesterolemia admitted with
chief complaint of chest pain. Pt reports that this afternoon
he had substernal chest pain and diaphoresis. Previously he was
in good health and denies any h/o angina.
.
In the ED EKG revealed STE in inferior leads and in V5/V6. Pt
was loaded with 600mg of plavix, given 325 ASA and given heparin
bolus.
.
Cath revealed 70% mid-RCA lesion and occlusion of PDA.
Thrombectomy of RCA and PCI placed in RCA and PDA lesions. Was
given fentanyl for CP.
.
On transfer to CCU pt was in sinus rhythm, SBP 160 and vitals
were otherwise unremarkable. Venous sheath was still in place.
Pt still complaining of chest pain and STE have not yet
resolved, but improved.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia.
2. CARDIAC HISTORY: Unremarkable.
3. OTHER PAST MEDICAL HISTORY: Left Inguinal Hernia.
Social History:
Works as skilled metal worker. Lives with fiance in [**Location (un) 6151**] but
stays every night with his mother in [**Name (NI) 86**]. Primary caretaker
of mother, has limited support from siblings.
- Tobacco history: no
- ETOH: no
- Illicit drugs: no
Family History:
Father died of MI
Mother s/p quadruple bypass
Physical Exam:
VS: T=afebrile (Tmax=99.7, Range=97-99.7 x 24 hrs)
BP=91-114/59-79
HR=80-104
RR=16-20 O2-Sat= 95-97%
GENERAL: NAD. Oriented x3.
HEENT: Sclera anicteric, non-injected. PERRL, EOMI.
NECK: Supple. No lymphadenopathy or asymmetry noted.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No m/r/g or S3/S4
noted. No thrills, lifts.
LUNGS: 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. Venous sheath in place
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Exam at Discharge:
GENERAL:54 yo M in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive. Pos
hernia.
EXT: wwp, no edema. DPs, PTs 2+.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. Gait
WNL.
SKIN: no rash
PSYCH: A/O , calm, appropriate
Pertinent Results:
ADMISSION AND HOSPITAL COURSE LABS
[**2106-10-23**] 10:22PM PLT COUNT-227
[**2106-10-23**] 10:22PM NEUTS-55.7 LYMPHS-37.0 MONOS-5.2 EOS-1.4
BASOS-0.7
[**2106-10-23**] 10:22PM WBC-8.3 RBC-5.00 HGB-15.5 HCT-42.0 MCV-84
MCH-31.0 MCHC-36.8* RDW-13.5
[**2106-10-23**] 10:22PM CALCIUM-8.6 PHOSPHATE-3.3 MAGNESIUM-2.1
[**2106-10-23**] 10:22PM GLUCOSE-160* UREA N-15 CREAT-0.7 SODIUM-142
POTASSIUM-3.1* CHLORIDE-109* TOTAL CO2-19* ANION GAP-17
[**2106-10-23**] 10:30PM PT-17.9* INR(PT)-1.6*
[**2106-10-23**] 10:22PM BLOOD cTropnT-<0.01
[**2106-10-24**] 04:51AM BLOOD CK-MB-261* MB Indx-8.1* cTropnT-7.56*
[**2106-10-24**] 01:22PM BLOOD CK-MB-209* MB Indx-7.2*
[**2106-10-25**] 05:12AM BLOOD CK-MB-83* MB Indx-5.1
[**2106-10-23**] 10:22PM BLOOD CK(CPK)-106
[**2106-10-24**] 04:51AM BLOOD CK(CPK)-3224*
[**2106-10-24**] 01:22PM BLOOD CK(CPK)-2917*
[**2106-10-25**] 05:12AM BLOOD CK(CPK)-1614*
[**2106-10-24**] 04:51AM BLOOD Triglyc-155* HDL-34 CHOL/HD-6.3
LDLcalc-150*
.
DISCHARGE LABS
[**2106-10-27**] 07:15AM BLOOD WBC-8.0 RBC-4.70 Hgb-14.6 Hct-40.6 MCV-86
MCH-31.0 MCHC-35.9* RDW-13.4 Plt Ct-201
[**2106-10-25**] 05:12AM BLOOD PT-14.9* PTT-36.4* INR(PT)-1.3*
[**2106-10-27**] 07:15AM BLOOD Glucose-134* UreaN-19 Creat-0.8 Na-141
K-4.1 Cl-104 HCO3-28 AnGap-13
.
IMAGING
[**2106-10-23**] Cardiac Cath:
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated two vessel coronary artery disease. The LMCA was
normal.
The LAD was patent. The LCx had less than 50% stenosis. The RCA
had a
70% mid-vessel lesion and a subtotal occlusion before the
bifurcation
with complete occlusion of the PDA.
2. Limited resting hemodynamics revealed systolic and diastolic
arterial
hypertension.
3. Successful aspiration thrombectomy, PTCA and stenting of the
distal
RCA into the PDA with a 3.0 x 18 mm Promus DES (see PTCA
comments).
4. Successful direct stenting of the mid RCA with a 3.5 x 28 mm
Promus
DES (see PTCA comments).
5. Successful RFA AngioSeal (see PTCA comments)
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Normal ventricular function.
3. Successful aspiration thrombectomy and PCI fo the distal RCA
into the
PDA with a 3.0 x 18 mm Promus DES.
4. Successful PCI of the mid RCA with a 3.5 x 28 mm Promus DES.
[**2106-10-24**] TTE:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate regional left ventricular systolic
dysfunction with severe hypokinesis of the basal 2/3rds of the
inferior and inferolateral walls. The remaining segments
contract normally (LVEF = 40-45 %). Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size is normal with focal basal free wall
hypokinesis. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal left ventricular cavity size with regional
biventricular systolic dysfunction c/w CAD (prox/mid RCA
distribution). Mild pulmonary artery systolic hypertension.
Brief Hospital Course:
Mr. [**Known lastname **] is a 54 yo male with PMH of hyperlipidemia who
presented with chest pain and found to have STEMI s/p 2
drug-eluting stent placement.
.
# Acute Inferior Myocardial Infarction (STEMI): Initial EKG
showed ST elevation in II, III, aVF, V5 and V6, as well as ST
depression in I, aVL, aVR, V1 and V2. Pt underwent emergent
catheterization, which revealed 70% stenosis of RCA, and 100%
occlusion of PDA. Aspiration thrombectomy was performed, and 2
Drug-Eluting Stents were placed (distal-RCA into PDA, mid-RCA).
Post-PCI echocardiogram performed on HD 2 was notable for mild
LV dysfunction, w/ EF of 40-45%, and severe hypokinesis of basal
[**3-4**] inferior/inferolateral walls and mild pulmonary
hypertension. His post-cath course was complicated by right
groin hematoma at the site of access on HD 2, but resolved
without intervention. He also developed low-grade temps to Tmax
of 100.5, but was without other concerning signs or symptoms for
infection or acute thromboembolic event. He was started Aspirin,
Plavix, Atorvastatin, Lisinopril, and Metoprolol. He tolerated
these medications well, and at time of discharge, pt had
experienced no observed arrhythmias on telemetry, and was
asymptomatic, feeling well and ready to go home.
.
# Hypertension: Pt was previously on HCTZ/lisinopril, stopped
secondary to side-effects (lightheadedness). He was started on
Metropolol and Lisinopril for long-term improved cardiac
outcome.
.
# Hyperlipidemia: At time of admission, pt was not on any
lipid-lowering medications, and lipid panel on this admission
revealed LDL of 150, borderline low HDL and TG 155. As pt is
status-post acute myocardial infarction, he was started on
atorvastatin, which will require long-term continuation.
.
TRANSITIONAL ISSUES:
- Will have follow-up with NP [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 67876**] on [**2106-11-4**],
previous outpatient Cardiology (Dr. [**Last Name (STitle) **] on [**2106-11-23**], and Dr.
[**Last Name (STitle) **] on [**2106-12-21**]
- Will recommend CBC + BMP check-up at first outpatient
consultation.
- Dry weight estimated at 89kg. Will aim for healthy weight
reduction via low-salt/low-fat cardiac diet.
Medications on Admission:
None.
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation myocardial infarction
Acute Systolic dysfunction
Dyslipidemia
Discharge Condition:
Medically Stable.
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 during your hospitalization
at [**Hospital1 69**]. You were admitted
because you had a heart attack. Images of your heart
(catheterization) showed that critical vessels that supply blood
to your heart were blocked, and so 2 stents (drug-eluting) were
placed in order to keep the blood vessels open. Echocardiogram
(which is an ultrasound of your heart) after the catheterization
procedure showed impaired heart function. These findings
predispose you to future heart problems, including fluid backup
in your lower extremities and lungs.
Please START taking the following medications in addition to
your home medications:
1. Metoprolol - to lower your heart rate, control your blood
pressure and help your heart pump better.
2. Atorvastatin - to lower your cholesterol and prevent future
plaque build-up in your heart's arteries.
3. Plavix - to prevent re-occlusion of your stented arteries or
blockage of the drug-eluting stent that was placed.
4. Aspirin - to prevent platelet blockage of the drug-eluting
stent that was placed.
5. Lisinopril - to control your blood pressure and help your
heart pump better.
6. Nitroglycerin - to alleviate heart-related chest pain. Please
take this medication if you have chest pain at home that is
similar to the chest pain that brought you to the hospital. Take
one tablet, wait 5 minutes, then take another tablet. Please
call 911 if you still have chest pain after 2 tablets, and
please call Dr. [**Last Name (STitle) **] if you use nitroglyerin at all.
It is very important that you are compliant with these
medications, especially Plavix (Clopidogrel) and Aspirin.
Skipping or changing doses of these medications can result in
life-threatening blockage of the arteries that were blocked
during this heart attack. Do not stop unless your cardiologist,
Dr. [**Last Name (STitle) **], tells you that it is ok.
In addition, please:
1. Weigh yourself every morning, and call your primary care
physician if your weight goes up by more than 3 lbs (total).
2. Continue the exercise plan that the physical therapist
discussed with you during this admission.
3. Involve your family and friends in your lifestyle
modifications (including low-salt/low-fat diet, aerobic exercise
and new medication regimen) in order to facilitate the long-term
maintenance of this care.
Thank you for entrusting your health to our staff. Please
contact the [**Name (NI) 91659**] ([**Telephone/Fax (1) 10339**]) if you have chest pain
again or any other concerning symptoms.
Followup Instructions:
Name: [**Last Name (LF) **], [**Name8 (MD) **] NP
Location: [**Hospital **] MEDICAL ASSOCIATES, P.C.
Address: [**Street Address(2) 75807**], STES 3A, B, [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 54268**]
Appointment: THURSDAY [**11-4**] AT 10:45AM
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) 640**] [**Last Name (NamePattern1) **] MD
Specialty: CARDIOLOGY
Address: [**Street Address(2) 75807**],STE 2C, [**Location (un) **],[**Numeric Identifier 23881**]
Phone: [**Telephone/Fax (1) 44655**]
Appointment: TUESDAY [**11-23**] AT 10:30AM
Department: CARDIAC SERVICES
When: TUESDAY [**2106-12-21**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2106-10-27**]
|
[
"410.41",
"429.9",
"414.01",
"401.9",
"998.12",
"272.0",
"E879.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"36.07",
"37.22",
"00.41",
"99.20",
"88.56",
"00.46"
] |
icd9pcs
|
[
[
[]
]
] |
9892, 9898
|
6930, 8682
|
293, 395
|
10017, 10036
|
3456, 5453
|
12772, 13718
|
2105, 2152
|
9196, 9869
|
9919, 9996
|
9166, 9173
|
5470, 6907
|
10187, 10861
|
2167, 2956
|
1747, 1761
|
10879, 12749
|
2970, 3437
|
8703, 9140
|
242, 255
|
423, 1666
|
10051, 10163
|
1792, 1815
|
1688, 1727
|
1831, 2089
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,113
| 166,878
|
4724
|
Discharge summary
|
report
|
Admission Date: [**2139-11-17**] Discharge Date: [**2139-12-5**]
Service: VSU
CHIEF COMPLAINT: Left hallux infection.
HISTORY OF PRESENT ILLNESS: This is an 81 year-old gentleman
known to Dr. [**Last Name (STitle) **] with left common iliac aneurysm which is
occluded and a left AT which is occluded, now with a left
hallux infection which has been treated by his podiatrist
with Levaquin and Flagyl was added by his primary care
physician 1 week ago. Initially the foot was purplish with
new blackish lesions for 2 days. He denies any claudication
or rest pain, fever. He does admit to purulent discharge x1
week from the wound and chills. Patient was initially
evaluated in the emergency room. He had desaturated. He was
given Lasix and nebulizers with improvement in his oxygen
saturation.
ALLERGIES: Augmentin and penicillin.
MEDICATIONS ON ADMISSION: Include aspirin 325 mg daily,
atenolol 25 mg daily, Flomax 0.4 mg daily, Glyburide 5 mg
b.i.d., Lasix 10 mg daily, Lipitor 10 mg daily,
nitroglycerine sublingual p.r.n., Zestril 2.5 mg daily,
Tylenol #3 p.r.n.
PAST MEDICAL HISTORY: History of hypertension, history of
osteoarthritis, history of hyperlipidemia, history of type 2
diabetes, history of benign prostatic hypertrophy, history of
chronic back pain, history of coronary artery disease with
ejection fraction of 60 to 70% in [**2134-12-27**]. History of
allergic rhinitis. History of endocarditis. History of
supraventricular tachycardia. History of anemia.
PAST SURGICAL HISTORY: Status post inguinal herniorrhaphy
x2, status post left spigelian herniorrhaphy, status post
left common iliac artery aneurysm repair, status post right
total repair. History of tonsillectomy, remote.
PHYSICAL EXAMINATION: Vital signs: Temperature 102.1, pulse
102, respirations 18, O2 saturation 95% on 6 liters. Blood
pressure 170/80. General appearance: A gentleman in no acute
distress. Head, eyes, ears, nose and throat examination is
negative for bruits with palpable carotid pulses bilaterally,
the left greater than right. Chest is clear to auscultation.
Heart is regular with tachycardia. Abdominal examination
shows bilateral hernias, a soft, nondistended, nontender
obese abdomen. Extremity examination shows palpable radials
bilaterally, palpable femoral 1+ with a monophasic signal for
left femoral. The popliteals are monophasic signals
bilaterally. The right dorsal pedis is palpable 2+ and the
posterior tibial is palpable 2+. The left dorsalis pedis is
absent and the left posterior tibial is a monophasic
Dopplerable signal. The left hallux with blackened to the
forefoot with mild erythema of the forefoot.
HOSPITAL COURSE: The patient was initially assessed in the
emergency room and admitted to the service for IV antibiotics
and vascular evaluation. His white count was 14.9, hematocrit
39.5. BUN 31, creatinine 1.5. Chest x-ray showed mild
cardiomegaly, no acute infiltrate. The foot x-ray was without
erosions or cortical destruction. Patient was placed on broad
spectrum antibiotics and heparinized. The patient underwent a
left common iliac stenting with intraoperative arteriogram
and left superficial femoral artery to posterior tibial
bypass with in situ saphenous vein angioscopy and valve lysis
on [**2139-11-24**] after being cleared by cardiology. The
patient's surgery was preceded by a diagnostic arteriogram of
the abdominal and pelvic vessels with left lower extremity
run off via the right common femoral artery on [**2139-11-30**]. The [**Hospital 228**] hospital course was unremarkable. He did
require debridement of the left foot and first metatarsal
head ray amputation and placement of VAC dressing on [**2139-12-1**]. The patient was continued on his antibiotics and at
discharge was discharged on Vancomycin 1 gram q 12 hours for
a total of 2 weeks. A PICC line was placed prior to patient's
discharge and x-ray confirmation was obtained of placement.
At the time of discharge the VAC dressing will be
discontinued and normal saline wet to dry dressing will begin
b.i.d. VNA services will come in to do VAC dressing on Sunday
morning and antibiotic therapy initiation will begin on
Saturday afternoon. Patient should follow up with Dr. [**Last Name (STitle) **]
in two weeks. She should call for an appointment at [**Telephone/Fax (1) 19879**]. The VAC dressing should be changed every 3 days with
continuous -120 cm of suction. Patient should have a
vancomycin trough and CBC done weekly while patient is on
antibiotics along with BUN and creatinine.
DISCHARGE MEDICATIONS: Include acetaminophen 325 mg tablets
1 to 2 q 4 hours p.r.n. for pain, arvostatin 10 mg q.d.,
aspirin 325 mg q.d., Flomax 0.4 mg q.d., metoprolol 25 mg
b.i.d., lisinopril 2.5 mg daily, oxycodone/acetaminophen
5/325 tablets 1 to 2 q 4 to 6 hours p.r.n. for pain, Colace
100 mg b.i.d. This can be purchased over the counter,
Glyburide 2.5 mg daily, Plavix 75 mg daily, Vancomycin 1 gram
q 12 hours for a total of 14 days.
Patient may ambulate as tolerated. He should maintain his
foot elevated when not ambulating, should ambulate essential
distances only. He should not shower or get the foot or leg
wet.
DISCHARGE DIAGNOSES: Left toe gangrene secondary to
peripheral vascular disease.
History of peripheral vascular disease, status post iliac
stenting on the left.
Status post iliac stenting with left femoral posterior tibial
bypass graft, angioscopy valve lysis on [**2139-11-24**].
Status post diagnostic arteriogram on [**2139-11-26**].
Status post debridement of the left foot with first
metatarsal head ray amputation and VAC placement on [**2139-12-1**].
Status post PICC placement.
Postoperative blood loss anemia, transfused.
History of congestive heart failure, compensated.
History of smoking, discontinued x1 year.
History of type 2 diabetes mellitus with neuropathy.
History of benign prostatic hypertrophy.
History of coronary artery disease.
History of supraventricular tachycardia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7258**], [**MD Number(1) 7263**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2139-12-4**] 15:21:39
T: [**2139-12-4**] 16:25:36
Job#: [**Job Number 19880**]
|
[
"707.15",
"272.4",
"428.0",
"357.2",
"682.7",
"041.11",
"730.07",
"447.1",
"V45.82",
"440.24",
"401.9",
"998.11",
"442.2",
"427.89",
"458.9",
"731.8",
"250.60",
"285.1",
"428.30",
"414.01",
"250.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.90",
"99.04",
"38.93",
"93.56",
"39.50",
"88.48",
"86.22",
"84.11",
"00.41",
"00.47",
"00.17",
"39.56",
"88.42",
"00.40",
"39.29",
"00.45",
"77.69"
] |
icd9pcs
|
[
[
[]
]
] |
5174, 6219
|
4546, 5152
|
875, 1086
|
2666, 4522
|
1519, 1721
|
1744, 2648
|
108, 132
|
161, 848
|
1109, 1495
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,928
| 172,770
|
50865
|
Discharge summary
|
report
|
Admission Date: [**2159-11-16**] Discharge Date: [**2159-11-23**]
Date of Birth: [**2086-6-5**] Sex: M
Service: C-MED
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old man
with long cardiac history, hypertension,
hypercholesterolemia, hepatitis B, who was admitted for
shortness of breath. Patient's cardiac history began back in
[**2128**] when he had an anterior MI at age 46 complicated by
v-fib arrest and subsequently he underwent CABG at [**Hospital1 2025**] with
SVG times two to the LAD. In [**2132**] he had an inferior MI and
at [**Hospital1 2025**] had repeat CABG times two SVGs to RCA and first
diagonal. In [**2145**] he underwent catheterization and PTCA
times two vessels in [**Location (un) **]. He also had PTCA times two
vessels at [**Hospital1 2025**] in [**2145**]. He reportedly did well since then
until [**2159-7-16**] when he developed chest pain and dyspnea on
exertion. Catheterization on [**8-10**] showed severe left main
coronary artery disease. Left main had a 90% distal lesion
with thrombus involving the origins of both the LAD and the
left circumflex. The LAD was totally occluded in the
mid-vessel after the take-off D2. The left circumflex had a
50% proximal lesion that was subtotally occluded after OM1
with faint filling of the small OM2 and OM3 branches. There
was 90% distal LAD stenosis to SVG. Circumflex was 100%
midstenosis. SVG to LAD had 60% ostial stenosis, 80% distal
before the anastomoses. Occluded SVG to D1 and RCA. He
underwent CABG times six with LIMA to LAD, left radial to
PDA, SVG to D1, SVG to D2, SVG to OM1 and OM2. Post-op
course complicated by fever and ventilator dependence. He
was eventually stabilized and weaned off the ventilator.
Cath showed EF of 30% pre-op and 20% post-op. There was no
mitral regurgitation. In [**2159-9-16**] patient was admitted
again on transfer from [**Hospital1 1774**]. Echo showed depressed ejection
fraction 15% to 20%, 4+ MR [**First Name8 (NamePattern2) **] [**Last Name (Titles) 1774**]. Echo here revealed
dilated LV with 2+ MR. [**Name13 (STitle) **] underwent repeat cath with
delay in intervention due to hemodynamic instability
secondary to elevated LV and diastolic pressures. Pressures
then RA 8, RV 40 and 9, PA 46/40, PCWP 26, cardiac output
4.8, cardiac index 2.8, PA sat 67%. He then underwent PTCA
of 80% stenosis of SVG to the jump graft at the touch-down
site of OM2. Of note, he had a six beat run of MSVT. Since
then patient has had daily chest pain with dyspnea. He was
admitted in early [**Month (only) 359**] with CHF and chest pain, diuresed
and now returns with the same symptoms. Patient states that
he has never felt well since the CABG mainly complains of
dyspnea with daily chest pain. He has also had decreased
weight, loss of appetite, PND and orthopnea.
PAST MEDICAL HISTORY: Coronary artery disease and CHF as
mentioned above. Left bundle branch block. MR 2+.
Hypertension. Hepatitis B. Radiculopathy. Lumbar sciatica.
MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d., Coreg
6.25 mg b.i.d., Lasix 60 mg p.o. q.d., Lipitor 20 mg p.o.
q.d., sublingual nitroglycerin p.r.n.
ALLERGIES: Penicillin causes a rash. Morphine causes
hypotension. Sulfa, iodine, codeine and Benadryl.
REVIEW OF SYSTEMS: Decreased weight. Decreased energy and
appetite. Question of depression. No thyroid symptoms. No
skin changes. No GU, GI or diabetic symptoms.
FAMILY HISTORY: Positive for coronary artery disease.
SOCIAL HISTORY: Positive previous tobacco history.
PHYSICAL EXAMINATION: The patient was afebrile temperature
97.6, heart rate 101, blood pressure 92/62, respiratory rate
18, 96% on 2 liters. Patient in no acute distress. Head and
neck exams were normal. No JVD. Supple neck. He had a
displaced PMI. He had a summation gallop, systolic murmur.
Bibasilar decreased breath sounds with rales on chest exam.
He had some right upper quadrant tenderness, hepatomegaly.
No peripheral edema.
LABORATORY DATA: EKG showed old left bundle branch block.
Hematocrit 34.4. Chemistries were essentially normal with
BUN and creatinine of 31 and 1.0.
HOSPITAL COURSE: The patient was admitted, diuresed with IV
Lasix. He was started on digoxin 0.125 mg p.o. q.d. and
Aldactone 12.5 mg p.o. q.d. as per the recommendations of
heart failure service. He was given one dose of Zaroxolyn
2.5 mg p.o. q.d. He was transferred to the CCU when a bed
became available for [**Location (un) **] therapy. Patient was swaned.
The Swan showed CVP of 2, [**MD Number(3) 105751**] 15, wedge pressure 9,
cardiac output 4.7. Numbers revealed intravascular dryness.
he received some fluid, was optimized hemodynamically. There
was a question of whether he had some pulmonary process in
view of the fact that he had continued dyspnea and abnormal
chest x-ray despite aggressive diuresis with decreased
pulmonary capillary wedge pressure. Chest CT was obtained
showing signs of CHF. Pulmonary consult was called who
evaluated patient and attributed the shortness of breath to
cardiac causes and recommended either monitoring the pleural
effusion, which would like resorb with time, versus tapping
the pleural effusion. It was decided, since the pleural
effusions were relatively small, to just watch the pleural
effusion and let it resorb on its own.
The patient was then transferred back to C-Med service
without chest pain, with improvement in his respiratory
status on the following regimen: aspirin 325 mg p.o. q.d.,
Lipitor 20 mg p.o. q.d., carvedilol 3.125 mg p.o. b.i.d. that
was halved from his home regimen, Lasix 80 mg IV b.i.d.,
digoxin 0.125 mg p.o. q.d., Aldactone 12.5 mg p.o. q.d.,
Protonix 40 mg p.o. q.d. Lasix was switched from 80 mg IV
b.i.d. to 80 mg p.o. q.a.m. and 40 mg p.o. q.p.m. Captopril
6.25 mg p.o. t.i.d. was restarted. Patient tolerated his
regimen well, remained relatively symptom-free and was
discharged in stable condition.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Coronary artery disease.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Lipitor 20 mg p.o. q.d.
3. Carvedilol 3.125 mg p.o. b.i.d.
4. Lasix 80 mg p.o. q.a.m., 40 mg p.o. q.p.m.
5. Digoxin 0.125 mg p.o. q.d.
6. Aldactone 12.5 mg p.o. q.d.
7. Protonix 40 mg p.o. q.d.
8. Ambien p.r.n. at night.
9. Captopril 6.25 mg p.o. t.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**]
Dictated By:[**Doctor Last Name 229**]
MEDQUIST36
D: [**2159-11-23**] 14:01
T: [**2159-11-23**] 14:00
JOB#: [**Job Number 105752**]
|
[
"428.0",
"272.0",
"412",
"401.9",
"414.8",
"414.01",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
3464, 3503
|
5972, 6032
|
6055, 6625
|
3042, 3278
|
4168, 5951
|
3579, 4150
|
3298, 3447
|
168, 2842
|
2865, 3015
|
3520, 3556
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,576
| 121,382
|
28082
|
Discharge summary
|
report
|
Admission Date: [**2173-11-12**] Discharge Date: [**2173-11-23**]
Date of Birth: [**2120-10-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
New onset seizure
Major Surgical or Invasive Procedure:
craniotomy
History of Present Illness:
53M limo driver was driving this am and apparently drove into
parked car and had approx 20 minute LOC, ?seizure. He has no
recollection of event. He does c/o headache. He does have h/o
htn and takes toprol (sporadically). Denies visual changes or
weakness/numbness/tingling.
Past Medical History:
HTN
Social History:
Married
Family History:
Non contributory
Physical Exam:
O: BP:210 / 100 HR:112 R30
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:3 to 2 EOMs full
Neck: Supple.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, "[**Hospital6 **]", and
"[**2173**]" but could not name month or date. After told 27th he did
comment that it was 20 days after his birthday.
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, 3to2
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-21**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Pertinent Results:
[**2173-11-12**] 11:45AM FIBRINOGE-386
[**2173-11-12**] 11:45AM PT-13.0 PTT-24.4 INR(PT)-1.1
[**2173-11-12**] 11:45AM PLT COUNT-339
[**2173-11-12**] 11:45AM WBC-16.5* RBC-5.72 HGB-16.1 HCT-48.8 MCV-85
MCH-28.2 MCHC-33.0 RDW-14.3
[**2173-11-12**] 11:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2173-11-12**] 11:45AM CK-MB-5 cTropnT-<0.01
[**2173-11-12**] 11:45AM CK(CPK)-272* AMYLASE-131*
[**2173-11-22**] 06:20AM BLOOD WBC-25.9* RBC-4.46* Hgb-12.3* Hct-37.8*
MCV-85 MCH-27.6 MCHC-32.6 RDW-15.0 Plt Ct-327
[**2173-11-21**] 07:45AM BLOOD WBC-19.8* RBC-4.31* Hgb-12.4* Hct-36.2*
MCV-84 MCH-28.9 MCHC-34.4 RDW-14.8 Plt Ct-256
[**2173-11-20**] 04:15AM BLOOD WBC-18.7* RBC-4.10* Hgb-11.8* Hct-33.4*
MCV-82 MCH-28.7 MCHC-35.2* RDW-14.8 Plt Ct-246
[**2173-11-19**] 04:12AM BLOOD WBC-23.3*# RBC-4.26* Hgb-11.9* Hct-35.9*
MCV-84 MCH-28.0 MCHC-33.3 RDW-14.9 Plt Ct-264
[**2173-11-18**] 12:01PM BLOOD WBC-12.6* RBC-4.73 Hgb-13.6* Hct-39.4*
MCV-83 MCH-28.7 MCHC-34.5 RDW-14.5 Plt Ct-265
Brief Hospital Course:
Mr [**Name13 (STitle) 518**] was admitted to the Neurosurgery service he had a
MRI with gadolinium that showed a large left parietal
meningioma, measuring about 5 cm in diameter.
He was preparred for surgery part of that work up included CT of
the torso, which showed numerous cysts in liver and enlarged
bilateral kidneys, most likely representing polycystic kidney
disease. No evidence of major organ injury. 3 mm left lower lobe
nodule, followup in 1 year is recommended.
He was found to have elevated creatinine which decreased from
2.0 to 1.7 on discharge.
On he underwent a Left neural navigation guided craniotomy for
resection of a meningioma. The surgery went without
complications and post operatively he spent the night in the
PACU for BP monitoring. He began a decadron taper on POD#1 and
was transferred to the surgical floor. On discharge he was
tolerating a regular diet,ambulating without difficulty.
Neurologically he remained stable without deficits he was
continued on Dilantin.
He was told to follow up with a PCP regarding his blood pressure
and elevated creatinine.
Medications on Admission:
None infrequently taking BP medication
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(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. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*1*
4. Nifedipine 10 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
Disp:*90 Capsule(s)* Refills:*2*
5. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p craniotomy for meningioma
Discharge Condition:
stable
Discharge Instructions:
please call the office if you have any concerns or questions,
call if you have fever, nausea, vomiting, chnage in mental
status, worsening headache, seizure or increased lethargy.
Followup Instructions:
please call the office for an appointment to be seen in [**4-22**]
weeks with a CT of the brain. Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) **].
YOU NEED TO COME INTO THE OFFICE TO HAVE YOUR STAPLES REMOVED ON
[**2173-12-2**]
as always after any hospitalization - please call your medical
doctor for an evaluation. Your blood pressure has been a little
high here in the hospital and he/she may want to make some
changes. ALSO THERE IS A SAMLL NODULE ON THE LEFT LOWER LOBE OF
YOUR LUNG - THIS WILL NEED TO BE FOLLOWED UP WITH RE- IMAGING IN
ABOUT 1 YEAR - YOUR DOCTOR NEEDS TO BE MADE AWARE OF THIS BY YOU
SO THAT YOU CAN HAVE APPROPRIATE FOLLOW UP.
YOU OR YOUR WIFE NEEDS TO CALL BRAIN [**Hospital **] CLINIC AT
[**Telephone/Fax (1) **] TO FINISH REGISTRATION - YOU HAVE AN APPOINTMENT AT
THE BRAIN [**Hospital **] CLINIC ON [**Hospital1 18**] [**Hospital Ward Name **] [**Location (un) **] [**Hospital Ward Name **]
BUILDING - [**12-20**] AT 2PM.
Completed by:[**2173-12-1**]
|
[
"E812.0",
"401.9",
"780.39",
"225.2",
"780.2",
"753.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
4889, 4895
|
3054, 4149
|
340, 353
|
4969, 4978
|
2004, 3031
|
5206, 6194
|
726, 744
|
4238, 4866
|
4916, 4948
|
4175, 4215
|
5002, 5183
|
759, 911
|
283, 302
|
381, 658
|
1288, 1985
|
926, 1272
|
680, 685
|
701, 710
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,797
| 147,082
|
23820
|
Discharge summary
|
report
|
Admission Date: [**2124-2-4**] Discharge Date: [**2124-2-15**]
Date of Birth: [**2065-8-21**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 58 year old gentleman with
a known history of coronary artery disease had a cardiac
catheterization prior to his admission on [**2124-2-4**]. He
was shown to have 3 vessel disease. Catheterization revealed
an ejection fraction of 64%, normal valves and 80% RCA lesion
and 80% LAD lesion and a proximal circumflex lesion of 80%.
He was referred to Dr. [**Last Name (STitle) 70**] for coronary artery bypass
grafting.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Elevated lipids.
3. Osteoarthritis.
4. Status post PTCA in [**2108**] and [**2116**] with known CAD.
LABORATORY DATA: Preoperative chest x-ray showed no evidence
of acute cardiopulmonary process.
Preoperative labs showed a white count of 9.0, hematocrit
38.5, platelet count 270,000. PT 12.5, PTT 23.1, INR 1.0.
Glucose 99, BUN 17, creatinine 0.8, sodium 136, potassium
4.0, chloride 105, bicarb 21, anion gap 14, ALT 39, AST 27,
alkaline phosphatase 92, amylase 49, total bilirubin 0.3,
albumin 4.1, cholesterol 226. Vitamin B12 171 and HB A1C was
5.5%. Triglycerides were also dramatically elevated at 552
with cholesterol HD ratio of 3.1.
Urinalysis was negative.
HOSPITAL COURSE: On [**2-4**], the day of admission, the
patient underwent coronary artery bypass grafting x3 with a
LIMA to the LAD, a vein graft to OM and a vein graft to the
RCA by Dr. [**Last Name (STitle) 70**]. He was transferred to the
cardiothoracic ICU in stable condition on a Propofol drip of
20 mcg per kilograms per minute and a Neo-Synephrine drip of
0.7 mcg per kilograms per minute.
On postoperative day 1 his hematocrit was stable at 30 with a
white count of 8.9 and a creatinine 0.9. His Ativan was
discontinued as an Ativan drip had been started and the
patient was given permission to drink beer with meals. He had
been extubated. He started his Lopressor beta blockade, as
well as Lasix diuresis. His PA catheter was discontinued. His
chest tubes remained in place over the day for slightly
elevated output.
On postoperative day 2 his chest tubes were discontinued. He
increased his beta blockade and continued the Lasix diuresis.
He was hemodynamically stable with a heart rate of 76 and a
blood pressure of 124/65. He was seen and evaluated by
physical therapy when he was transferred out to the floor on
postoperative day 2 to begin working with his activity
tolerance, increasing his ambulation. He was switched over to
po Percocet for chest discomfort.
On postoperative day 3 he had scattered inspiratory wheezes
and diminished breath sounds at the bases. He had a small
amount of serosanguineous drainage at the lower edge of his
sternal incision without any erythema. His pacing wires were
discontinued and he was encouraged to increase his activity
level. Central venous line had already been removed. The
patient also continued with aspirin therapy and was restarted
on Lipitor.
On postoperative day 4 he continued to have a small amount of
serosanguineous sternal drainage at the distal inferior one
fifth of his incision. He was in sinus rhythm and
hemodynamically stable. He had a saturation of 97% on 1 liter
nasal cannula. He was started on Cefazolin 2 grams IV q.8h to
empirically cover the sternal drainage. He had faint
expiratory wheezes. He was much more relaxed and far less
anxious than he had been the day prior. His Lorazepam 1 mg
was switched to po p.r.n. He continued to use albuterol and
fluticasone inhalers and had a repeat chest x-ray. As soon as
his drainage was decreased or stopped, he would be deemed
stable for discharge.
On postoperative day 5 he still had some serous drainage at
the lower pole of his incision. He continued on IV Cefazolin
and continued with Lasix diuresis. The drainage looked to be
a very small amount of purulent drainage at the distal pole.
He continued on antibiotic therapy and continued to work on
increasing his activity level. His left leg incision was
clean, dry and intact. He continued to receive Percocet for
pain management and was given Ativan p.r.n. for anxiety. Sero
drainage continued. A small amount of serosanguineous
drainage was found at the inferior pole. There was no
erythema and the sternum was stable. He continued with
dressing changes and strict sternal precautions were
discussed with the patient. He continued to ambulate on the
floor under observation. He was also seen by case management
and continued work every day with physical therapy on
increasing his activity level.
Sternal drainage had decreased on postoperative day 7. His
dressing changes were done twice a day. He was also seen by
social worker about possible addressing the issue of ETOH
abuse. The patient continued to be monitored for his sternal
drainage while he remained on the floor.
This continued on postoperative day 8 with a plan to return
him to the OR if it did not stop in the next couple of days.
On postoperative day 9 he continued to be afebrile. He was on
sliding scale insulin for tighter blood sugar control as
fingersticks drawn through the day were 190 and 160. The
sternum was stable with no clicks or erythema, as he did
continue to have some drainage from the sternal wound that
day.
On postoperative day 10 he continued to have a small amount
of drainage the day prior, but no erythema. He finished his
course of Cefazolin and the plan was to monitor him, and if
he had no drainage over the next 24 to 48 hours to let him go
home. On the 28th he did have no drainage. He also had a
clinical nutrition visit.
On postoperative day 11 he had no sternal drainage again and
he was discharged to home with visiting nurses. He was also
instructed to return to floor 2 on the following [**Last Name (STitle) 2974**] for a
wound check. On the day of discharge his blood pressure was
108/67 and sinus rhythm at 72 with saturation of 94% on room
air. His white count was 10.7, hematocrit 28.2, platelet
count 629,000. He was alert and oriented and with an
otherwise unremarkable physical exam.
On the 29th he was discharged to home with VNA services.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x3.
2. Coronary artery disease status post PTCA in [**2108**] and [**2116**].
3. Hypertension.
4. Elevated lipids.
5. History of ethyl alcohol abuse.
DISCHARGE INSTRUCTIONS: The patient was given the following
discharge follow up instructions: He was told to make an
appointment with Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **], his primary care in
approximately 1 to 2 weeks post-discharge. He is to make an
appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**], his surgeon, for his
postoperative surgical visit in 6 weeks. Make an appointment
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**], his cardiologist, approximately 2 to
3 weeks post-discharge. He was also instructed to return to
floor 2 on [**Last Name (LF) 2974**], [**2124-2-18**] for a wound check to
evaluate his sternal incision.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg po twice a day.
2. Colace 100 mg po twice a day.
3. Enteric coated aspirin 81 mg po once a day.
4. Percocet 5/325 one to 2 tablets po p.r.n. q.4h for pain.
5. Lipitor 10 mg po once daily.
6. Nicotine 14 mg 24 hour transdermal patch, 1 transdermal
patch a day for 10 days.
7. Nicotine 7 mg 24 hour patch, 1 patch transdermal once a
day for 14 days.
8. Lasix 20 mg po twice a day for 7 days.
9. Keflex 500 mg po 4 times a day for 7 days.
10. Potassium chloride 20 mEq po once a day for 7 days.
DISPOSITION: The patient was discharged home with VNA
services on [**2124-2-15**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2124-3-6**] 16:28:33
T: [**2124-3-7**] 10:47:40
Job#: [**Job Number 60795**]
|
[
"414.01",
"305.1",
"272.4",
"401.9",
"V45.82",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"89.68",
"39.61",
"36.12",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
6170, 6369
|
7137, 8013
|
1319, 6149
|
6394, 7114
|
164, 586
|
608, 1301
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,039
| 178,677
|
30671
|
Discharge summary
|
report
|
Admission Date: [**2172-6-1**] Discharge Date: [**2172-6-25**]
Date of Birth: [**2102-11-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vytorin
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
increasing SOB; hypoxia intubation at cath
Major Surgical or Invasive Procedure:
s/p cabg x 3 /MV repair/aortic endarterectomy and pericardial
patch [**2172-6-5**] (LIMA to LAD, SVG to OM and PDA with Y graft, 28
mm [**Company 1543**] annuloplasty ring)
History of Present Illness:
69 yo male with history of CAD presented to [**Hospital 1474**] Hospital
with increasing SOB. Noted to have inferior ST elevations and
taken to cath. Emergently intubated there for hypoxia. Cath
revealed 100% RCA, 70% CX/OM, 90-95% prox. LAD. Echo showed EF
55% and transferred here for surgery.
Past Medical History:
NSTEMI
PVD with AAA 4.7 cm
chronic A fib
CAD
HTN
elev. chol.
elevated PSA
Social History:
married, lives with wife
[**Name (NI) **]. ETOH
100 pack-year history- quit 2 yrs. ago
Family History:
CAD present prematurely
Physical Exam:
sedated , intubated on ventilator
CTAB anteriorly
RRR, no murmur noted
abd benign
extrems cool; + distal pulses
68" 75 kg
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2172-6-24**] 03:36AM 11.7* 2.88* 9.2* 27.4* 95 31.8 33.4 16.3*
340
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2172-6-16**] 03:09AM 76.8* 11.9* 4.7 5.9* 0.8
Source: Line-aline
RED CELL MORPHOLOGY Hypochr Macrocy
[**2172-6-16**] 03:09AM 1+ 1+
Source: Line-aline
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2172-6-24**] 03:36AM 340
[**2172-6-24**] 03:36AM 20.2* 63.0* 1.9*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2172-6-24**] 03:36AM 117* 42* 1.3* 141 3.8 108 27 10
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2172-6-24**] 7:41 AM
CHEST (PORTABLE AP)
Reason: evaluate effusion - page [**Numeric Identifier 72690**] with concerns
[**Hospital 93**] MEDICAL CONDITION:
69 year old man with history of cad awaiting CABG
REASON FOR THIS EXAMINATION:
evaluate effusion - page [**Numeric Identifier 72690**] with concerns
AP CHEST 8:27 A.M. ON [**6-24**]
HISTORY: Awaiting CABG.
IMPRESSION: AP chest compared to [**6-19**] through 14:
Moderately severe pulmonary edema which improved on [**6-22**] has
recurred accompanied by small bilateral pleural effusions. Heart
size is normal and unchanged. No pneumothorax. Tracheostomy tube
in standard placement. Findings were discussed by telephone with
Dr. [**Last Name (STitle) 72691**] at the time of dictation.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Cardiology Report ECHO Study Date of [**2172-6-5**]
*** Report not finalized ***
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: Congestive heart failure. Coronary artery disease.
Hypertension. Left ventricular function. Mitral valve disease.
Murmur. Myocardial infarction. Shortness of breath. Valvular
heart disease.
Status: Inpatient
Date/Time: [**2172-6-5**] at 08:41
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW5-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.8 cm (nl <= 3.4 cm)
INTERPRETATION:
Findings:
LEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection
velocity. No
thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function
(LVEF>55%). Overall normal LVEF (>55%).
LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;
mid inferoseptal - normal; basal inferior - normal; mid inferior
- normal;
basal inferolateral - normal; mid inferolateral - normal; basal
anterolateral
- normal; mid anterolateral - normal; anterior apex - normal;
septal apex -
normal; inferior apex - normal; lateral apex - normal; apex -
normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in ascending aorta. Complex (mobile)
atheroma in the
ascending aorta. Simple atheroma in aortic arch. Normal
descending aorta
diameter. Complex (>4mm) atheroma in the descending thoracic
aorta. Complex
(mobile) atheroma in the descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Moderate (2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
for the
patient.
Conclusions:
Prebypass:
1. The left atrium is normal in size. No thrombus is seen in the
left atrial
appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thickness, cavity size, and systolic
function are
normal (LVEF>55%). Overall left ventricular systolic function is
normal
(LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the aortic arch. There are
complex (>4mm),
mobile atheroma in the descending thoracic aorta. Given degree
of descending
disease an epiaortic scan was performed. There are simple
atheroma in the
ascending aorta. There is a single complex (mobile) atheroma 0.5
cm on the
posterior surface of the prox ascending aorta on epiaortic scan.
There are
simple atheroma in the aortic arch. There are complex (>4mm),
mobile atheroma
in the descending thoracic aorta. Aortic canullation and cross
clamping were
guided by the epiaortic scan
6. The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation. 7. The mitral valve
leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. (3+) was
evoked with
provacative maneuvers (fluid, elevated BP, Trendelenberg) Vena
contracta
measured as 0.6 cm.
8. There is no pericardial effusion.
Postbypass (on Phenylphrine ggt):
1. Preserved biventricular systolic function
2. There is a ring prosthesis in the mitral position. MR is now
trace/mild
eccentric valvular MR.
3. Study otherwise unchanged from prebypass.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 72692**])
Brief Hospital Course:
Admitted [**6-1**] and pre-op workup completed with cardiology
consult obtained. Carotid US was negative and plavix washout
continued for a few days.Extubated on [**6-2**]. Heparin continued
while enzymes peaked. Diuresis for CHF also done prior to CABG x
3/MV repair/aortic endarterectomy on [**6-5**] with Dr. [**First Name (STitle) **].
Transferred to the CSRU in stable condition on a titrated
porpofol drip. Extubated that evening and reintubated within 30
minutes for respiratory distress/ hypoxia. Dobutamine drip
continued for low cardiac output. Amiodarone loaded for
recurrent A fib with DC cardioversion to sinus brady on POD #2.
Heparin also restarted. Dermatology consult done for evaluation
of warts on hands and feet. He may follow up with derm. as an
outpt. Extubated again on [**6-9**], but reintubated again the next
morning for hypoxic resp. failure with bilat. infiltrates.
Bronchoscopy done [**6-10**] for bloody mucus plugs right lung. CT
chest showed CHF, infiltrates, and ? PNA vs. pneumonitis. Vanco
and zosyn started. He failed to wean from vent and underwent
trach and PEG on [**6-16**]. He continued to diurese and wean from
vent slowly. He had intermittent AF and was comadinized. He
developed diarrhea and was found to be c. diff positive on [**6-23**]
and was started on Flagyl. On POD#18 he stayed on trach mask for
8 hours and did well with a Passey-Muir valve. He passed a
swallowing study. On POD# 20 he was discharged to rehab in
stable condition.
Medications on Admission:
ASA 81 mg daily
plavix 75 mg daily (300 mg given [**6-1**])
crestor 5 mg daily
atenolol 50 mg daily
coumadin daily
cardizem CD 120 mg daily
lisinopril/HCTZ daily
cartia daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for temperature >38.0.
2. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol [**Month/Year (2) **]: One
(1) Inhalation [**Hospital1 **] (2 times a day).
3. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
Inhalation Q4H (every 4 hours) as needed.
5. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Rosuvastatin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2
times a day).
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H (every
8 hours) as needed.
11. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Diltiazem HCl 90 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day).
14. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [**Last Name (STitle) **]: Five
(5) ML PO DAILY (Daily).
15. Hydralazine 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every 6
hours).
16. Carvedilol 6.25 mg Tablet [**Last Name (STitle) **]: Six (6) Tablet PO BID (2
times a day).
17. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
18. Potassium Chloride 40 mEq Packet [**Last Name (STitle) **]: One (2) PO twice a
day for 10 days.
19. Lasix 80 mg Tablet [**Last Name (STitle) **]: One (2) Tablet PO twice a day for 10
days.
20. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3
times a day).
21. Sertraline 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
22. Coumadin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime: INR
goal 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
s/p cabg x 3 /MV repair/aortic endarterectomy and pericardial
patch repair
AAA
PVD
A fib
HTN
elev. chol.
right fem. stent
Discharge Condition:
stable
Discharge Instructions:
may shower over incisions and pat dry
no lotions, creams or powders on any incision
no driving for one month or until visit with surgeon
no lfting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 72693**] in [**2-11**] weeks
see Dr. [**Last Name (STitle) **] in [**3-14**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
see dermatology as an outpt.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2172-6-25**]
|
[
"078.10",
"276.52",
"414.01",
"443.9",
"110.1",
"486",
"V17.3",
"786.3",
"427.31",
"410.41",
"272.4",
"428.0",
"441.7",
"V58.61",
"518.5",
"584.5",
"008.45",
"424.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13",
"39.61",
"33.24",
"43.11",
"00.40",
"96.72",
"36.15",
"88.72",
"36.12",
"38.93",
"31.1",
"35.12",
"38.14",
"96.6",
"96.05"
] |
icd9pcs
|
[
[
[]
]
] |
10995, 11067
|
6929, 8418
|
316, 493
|
11233, 11242
|
1220, 2030
|
11528, 11867
|
1036, 1061
|
8645, 10972
|
2067, 2117
|
11088, 11212
|
8444, 8622
|
11266, 11505
|
2892, 6833
|
1076, 1201
|
234, 278
|
2146, 2866
|
521, 818
|
6868, 6906
|
840, 916
|
932, 1020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,979
| 101,824
|
7770
|
Discharge summary
|
report
|
Admission Date: [**2140-7-22**] Discharge Date: [**2140-8-29**]
Date of Birth: [**2082-7-22**] Sex: F
Service: SURGERY
Allergies:
Amoxicillin / Wellbutrin
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
SOB, hypoxia
Major Surgical or Invasive Procedure:
paracentesis, thoracentesis
History of Present Illness:
58F w/Alcoholic cirrhosis with consequent diuretic-refractory
ascites, edema, hyponatremia, and pleural effusions presents
from the IR outpatient clinic for admission because of fever to
101.7. Pt has known alcoholic liver disease with ascites
worsening over the past 6 months. She is being worked up for
liver [**First Name3 (LF) **] here. Over the past week she has been
increasingly fatigued walking across a room. Needs to sleep
nearly-upright with multiple pillows because of breathing
difficulty when lying down. Having daily fevers at nighttime. No
chills, no nausea/vomiting/abdominal pain. Some non-productive
cough. No sick contacts or contact with children. No dysuria or
hematuria. No bloody stools, but does always have black stools,
which she attributes to occasional lactulose use. When asked
about weight changes she states she hasn't been able to
recognize her body for 6 months.
.
This morning she presented to previously-scheduled outpatient
session with IR for therapeutic thoracentesis and paracentesis
to offload her ascites and pleural effusions, all thought to be
secondary to decompensated cirrhosis. First such session was
last week; at her last taps 1.75L of pleural fluid was removed
from her chest, she did not require post-procedure albumin, and
was able to go home the same day. Plan was not to be drained so
soon thereafter, but increase in dyspnea this week prompted a
return visit in just 1 week. At IR VS were 101.7 107/56 108
82%/3L. Because of the fever, she had just a diagnostic
paracentesis, but she did have 1L straw-colored drained by
thoracentesis due to O2 desaturation. O2 sat resolved to 90%/RA
by the end of the procedure, and post-procedure CXR show some
interval improvement of her R hydrothorax. Pleural and
peritoneal fluid sent for analysis and culture, blood cultures
also sent. Admitted for IV albumin, antibiotics for possible RUL
PNA seen on CXR, and fluid optimization.
Past Medical History:
Papillary Thyroid Carcinoma s/p resection
Alcohol Abuse
Alcoholic Cirrhosis c/b ascites and edema no hepatic
encephalopathy
Celiac Sprue
Psoriasis
HTN (prior to diuretic therapy; not an active issue off
diuretics now)
Rosacea
Hx Depression
Social History:
Hx alcohol abuse and daily smoking; stopped both recently.
Family History:
CVA, depression, alcohol abuse.
Physical Exam:
Admission Exam:
Vitals: 101.3 99/44 69 18 96/3LxNC
General: well-appearing pleasant woman sitting upright in bed
w/2 pillows, frequently coughing, jaundiced. Walking around
floor earlier tonight.
[**First Name3 (LF) 4459**]: NCAT EOMI PERRL icteric sclera
Neck: supple, no thyromegaly, JVD nondistended
Heart: RRR 3/6 holosystolic murmur throughout precordium loudest
LLSB
L Lung: slightly diminished lung field w diffuse rales,
base>apex
R Lung: absent breath sounds except above 4th rib posteriorly;
clear breath sounds above that level, with percussible air/fluid
level. Bandaged site c/d/i, nontender.
Abdomen: soft nontended +distended, tympanic superiorly but
w/also w/persussible air/fluid level, bulging flanks. Bandage
c/d/i, site nontender.
Extremities: pitting edema to groin, psoriatic plaques R elbow L
dorsal forearm, no spider angiomatas
Neurological: AOX3, no asterixis
.
MICU Admission Exam:
General: Alert, oriented, increased work of breathing,
moderately uncomfortable
[**First Name3 (LF) 4459**]: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP ~10cm, no LAD
Lungs: Clear to auscultation on left, right side with wheeze,
particularly in the lower lung zone, with some crackle
CV: Tachycardic Regular rhythm, 4/6 SEM, no rubs, gallops
Abdomen: soft, non-tender, mildly distended, + ascites, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: foley
Ext: warm, well perfused, 3+ edema to mid thigh, no clubbing,
cyanosis
Pertinent Results:
Admission labs:
[**2140-7-23**] 05:40AM BLOOD Glucose-84 UreaN-20 Creat-1.2* Na-122*
K-4.4 Cl-88* HCO3-27 AnGap-11
[**2140-7-23**] 05:40AM BLOOD WBC-8.1 RBC-2.20* Hgb-8.5* Hct-23.9*
MCV-109* MCH-38.5* MCHC-35.4* RDW-15.8* Plt Ct-112*
[**2140-7-23**] 05:40AM BLOOD PT-21.3* PTT-47.5* INR(PT)-2.0*
[**2140-7-23**] 05:40AM BLOOD ALT-26 AST-66* LD(LDH)-253* AlkPhos-90
TotBili-6.4*
[**2140-7-23**] 05:40AM BLOOD Albumin-2.5* Calcium-7.8* Phos-3.4 Mg-2.1
.
[**2140-7-25**] 04:40PM BLOOD Type-ART pO2-90 pCO2-38 pH-7.43
calTCO2-26 Base XS-0
[**2140-7-25**] 04:40PM BLOOD Lactate-2.2*
Brief Hospital Course:
57 F w/decompensated alcoholic cirrhosis and worsening ascites
and R-sided pleural effusions initially admitted to the Liver
service with fever for therapeutic [**Female First Name (un) 576**] and paracentesis. On
[**2140-7-25**], she developed hypoxia post thoracentesis requiring NRB
and was transferred to the MICU. Hypoxia was felt to be
re-expansion pulmonary edema, potentially complicated by
pneumonia given her fevers, worsening shortness of breath and
hypoxia. In the MICU, she initially required 100% face mask. IP
placed a pigtail catheter to drain re-accumulated right pleural
effusion [**2140-7-26**]. Initially, 600cc of serosanguinous fluid was
drained. The next day, 2L were drained. She was able to be
weaned to 3L NC and went back to the medical floor for
management of hyponatremia and worsening renal function.
Creatinine increased from baseline of 1.0. It was felt that she
was developing hepatorenal syndrome.
On [**8-9**], a liver donor became available and patient accepted
offer. She underwent ABO (A) incompatible liver (she was blood
type O) with splenectomy on [**2140-8-9**]. Three JPs were placed.
Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Pheresis was done just prior
to [**Last Name (NamePattern4) **] for Anti A titer of 512. CVVHD was done intraop.
Postop, she was transferred to the SICU intubated for
management. She required blood products in the immediate postop
period, but remained hemodynamically stable. LFTs increased
initially as expected then trended down daily. Liver duplex on
postop day 1 was normal. JP outputs were non-bilious. The JP in
the splenic bed had the highest output and appeared bloody.
Plasmapheresis continued daily based on Anti A antibody titers.
Titers decreased to 4. A total of 13 treatments were done. ATG
was given daily for a total of 7 doses (75mg each). Platelets
were administered prior to ATG in the immediate postop period.
Immunosuppression consisted of steroid taper per protocol,
CellCept [**Hospital1 **], ATG and Prograf which was started on postop day 1.
Doses were adjusted per trough levels. Goal prograf level was
10.
CVVHD was continued for hepatorenal syndrome. CVVHD was switched
to HD via temporary HD line. Nephrology followed her throughout
the hospital stay. Urine output increased around postop day 7
and dialysis was stopped ([**8-19**]). Urine output was approximately 2
liters, however, creatinine and BUN continued to increase up to
105. Dialysis was resumed on [**8-24**], and continued daily on [**8-25**] and
[**8-26**]. This was repeated on [**8-29**]. The plan was for her to continue
on hemodialysis at least twice weekly on Mondays and Fridays. On
[**8-25**], the temporary dialysis line was exchanged for a tunnelled
HD line in interventional radiology. A right-sided 23-cm
tip-to-cuff hemodialysis line with tip was seen in the right
atrium, ready for use.
She was transferred out of the SICU on [**8-20**] to the medical
surgical floor where diet was advanced and tolerated, but intake
was insufficient. Therefore, a feeding tube was placed and tube
feeds were started. Nutren 2.0 at 40cc/hour continuous was
recommended by the dietician. This was well tolerated. She
required intermittent sliding scale insulin for hyperglycemia
due to steroids.
Medial and lateral JPs were removed. The splenic bed JP drain
output appeared milky. Fluid was sent for amylase. On [**8-13**],
amylase was 537. This decreased to 76 on [**8-24**]. Drain output
volume decreased from 900ml/day to 300ml/day. JP was removed on
[**8-26**]. Incision was intact with staples.
Lower extremity non-invasives were done on [**8-25**] for asymmetrical
lower extremity swelling (Left>right). This was negative for
DVT. Teds were applied. Lower legs appeared erythematous with
puffiness of left dorsum.
Physical therapy worked with her noting improved strength and
balance. Medication teaching went well. A bed became available
at [**Hospital1 **] in [**Location (un) 86**] and she transferred there on
[**8-29**].
Medications on Admission:
(discharge meds [**2140-7-3**], confirmed with patient):
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. tolvaptan 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lactulose (takes occasionally)
Discharge Medications:
1. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
follow printed taper schedule
17.5 start [**8-30**].
3. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(MO,TH): Monday and Thursday.
8. ranitidine HCl 150 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
10. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
13. insulin regular human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
14. Outpatient Lab Work
every Monday and Thursday w results fax'd to [**Telephone/Fax (1) 697**] ([**Hospital 18**]
[**Hospital 1326**] Clinic)
cbc, chem 10, ast, alt, alk phos, t.bili, albumin and trough
prograf level
15. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
16. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
17. FreeStyle Lancets Misc Sig: One (1) Miscellaneous four
times a day.
Disp:*1 box* Refills:*2*
18. FreeStyle Lite Strips Strip Sig: One (1) Miscellaneous
four times a day.
Disp:*1 box* Refills:*2*
19. FreeStyle Lite Meter Kit Sig: One (1) kit Miscellaneous
once a day.
Disp:*1 kit* Refills:*2*
20. Insulin Syringes
U100 Low dose with 25-26 gauge needle
supply:1 box
refill: 2
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] - at [**Hospital 1263**] Hospital - [**Location (un) 686**]
Discharge Diagnosis:
etoh cirrhosis
hepatorenal syndrome
malnutrition
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 will be transferring to [**Hospital1 **] Rehab in [**Location (un) 86**]
Please call the [**Location (un) 1326**] Office [**Telephone/Fax (1) 673**] if you have any
of the following:
fever, shaking chills, nausea, vomiting, inability to take any
of your medications, jaundice, increased abdominal pain,
incision redness/drainage/bleeding, increased urine
output,constipation/diarrhea, malfunction of dialysis catheter
or any concerns
You will need to have blood drawn for lab monitoring every
Monday and Thursday
You will require hemodialysis at least twice weekly (Monday and
Friday)
You may shower, but must keep the tunnelled dialysis line dry
No straining/heavy lifting (nothing greater than 10 pounds)
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-8-31**] 2:00
Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-8-31**] 2:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2140-9-7**] 10:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2140-8-29**]
|
[
"427.1",
"V49.83",
"579.0",
"567.23",
"486",
"790.29",
"311",
"348.30",
"789.59",
"285.29",
"584.9",
"276.1",
"416.8",
"695.3",
"572.4",
"585.9",
"E932.0",
"403.90",
"511.9",
"780.09",
"193",
"263.9",
"244.9",
"276.2",
"696.1",
"276.69",
"458.29",
"303.93",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95",
"54.91",
"41.5",
"96.6",
"96.72",
"34.04",
"99.71",
"38.91",
"00.93",
"34.91",
"99.15",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
11451, 11554
|
4785, 8857
|
297, 326
|
11647, 11647
|
4183, 4183
|
12566, 13178
|
2639, 2672
|
9488, 11428
|
11575, 11626
|
8883, 9465
|
11830, 12543
|
2687, 4164
|
244, 259
|
354, 2283
|
4199, 4762
|
11662, 11806
|
2305, 2547
|
2563, 2623
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,761
| 165,422
|
21990
|
Discharge summary
|
report
|
Admission Date: [**2143-8-23**] Discharge Date: [**2143-9-19**]
Date of Birth: [**2093-10-30**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14385**]
Chief Complaint:
49F h/o probable alcoholic liver disease presents c/o abdominal
distention, diarrhea/abdominal cramps, and jaundice.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
For the past several weeks the pt has experienced diarrhea, a
gassy/bloated sensation, and abdominal distention. She usually
has diarrhea approximately 1 hr after eating. The sensation of
being bloated increases during the course of the day. The
symptoms are not relieved by passing stool. The distention has
increased progressively over the past weeks. She localizes the
feelings of distension to her lower abdomen. She also now notes
that the proximal portion of her lower extremities are also
swollen and there are increased visible spider veins. She now
eats very little because eating makes the diarrhea and symptoms
worse. Nothing has made her symptoms better. She has never
experienced anything like this before.
.
During the past 5 years the pt has increased her alcohol
consumption. She had previously been a social drinker, which to
her meant drinking 1-2 drinks at social events 1-2 times per
week. At age 45 the patient experienced multiple stressors in
her life started drinking 2 glasses of wine per evening. By
[**2140**], she was drinking 4 glasses of wine per evening. In
[**2141-10-22**] her LFTs were elevated at an annual doctor's
appointment. Over the past year and a half she has been in
several detox/rehab programs. During her detox programs she
never experienced withdrawal symptoms, including no seizures or
DTs. At the end of [**2143-6-23**] she noticed that her liver felt
hard. At this time her sister also noted that her eyes looked
yellow. The pt also experienced some nausea and itchy skin. In
early [**Month (only) **] she entered a detox program and says that she
has not had any alcohol since this time. Since then she has been
in an intense outpatient program in [**Hospital1 1562**], as well as
involved in an AA group.
.
Relevant ROS include no fevers, chills, or night sweats. Pt
reports a weight gain from 105 (her nl wt) to 112. She denies
melena or vomiting. Her urine has been dark and she has been
urinating smaller amounts more frequently. Pt reports no h/o
blood transfusions or travel to places endemic w/ hepatitis
virus. No hepatitis vaccination. No long-term of high-dose use
of hepatotoxic drugs. No recent trauma or abd/pelvic operations.
She denies changes of mental status. She has had trouble
sleeping, which she attributes to both her symptoms and anxiety,
but she does not get tired during the day.
.
ROS (In addition to those above): Pt notes occasional
palpitations. She said that an ECG has been done previously to
evaluate this and she was not aware of any abnormalities. She
has also had shallow, dry, and nonproductive cough for several
weeks. No history of bleeding or hypercoagulation problems.
Past Medical History:
Probable alcoholic liver disease
s/p appendectomy as a child.
.
Pt receives regular health care. She has had no abnormal
mammograms or pap smears. She had a normal colonoscopy 3-4 years
ago.
Social History:
Married. 2 children (ages 21 and 23). Lives in [**Location 52455**], MA and
[**Location (un) 20338**], FL. Works at home as a writer for the literature and
arts section of a newspaper. She smoked cigarettes for several
years in her 20s. Alcohol history as per HPI. No past or
current drug use. She eats a diet consisting of mostly
vegetables, chicken, and fish. She used to exercise several days
a week, but does so less often now.
Family History:
Father died at age 75 of CHF. He had Hodgkin's disease earlier
in his life. Pt thinks he may have had trouble w/ alcohol.
Mother alive at age 77 s/p 3 MI/angioplasties. Grandfather had a
stroke in his 60s and alcoholic? Grandfather and brother
alcoholics? [**Name2 (NI) **] family history of liver disease or bleeding
disease.
Physical Exam:
--Vitals: Tc 98.4 HR 88 and irreg irreg 90/60 RR 18
--General: Small woman lying comfortably in bed in NAD.
--Skin: Skin warm and dry. Nails without clubbing or cyanosis.
Hair of average texture. No suspicious nevi. No rash,
petechiae, or ecchymoses.
--HEENT: Head NC/AT. Sclerae slightly jaundiced. PERRLA, EOMs
intact. Fundoscopic and TM exams not performed. Hearing intact
to whispered voice. Oropharynx clear and nonerythematous. Mucous
membranes moist. Slight jaundice under tongue. Trachea midline.
Neck supple. No LAD. Thyroid not enlarged and without nodules.
--Cardiac: JVP not elevated. Carotid pulses 2+ bilaterally;
upstrokes brisk; without bruits. S1 & S2 normal. Rhythm
irregular. No murmurs, rubs, or gallops.
--Pulmonary: CTAP bilaterally. No wheezes, rales or ronchi.
--Abdomen: Appendectomy scar. Slight jaundice of abdominal skin.
Distended and resonant to percussion. Soft. Diffuse tenderness,
most localized in the lower abdomen. BS present in all 4
quadrants. Liver span 8-9 cm in the mid-clavicular line. Liver
palpable and firm. It seems to extend across the midline. Flank
dullness, shifting dullness, and fluid wave are present. No
rebound tenderness. Splenomegaly not appreciated. No CVA
tenderness. Rectal not performed.
--Extremities: Radial (2+) , post tib (1+) , and DP (1+) pulses
intact bilaterally. Good capillary refill bilaterally. No LE
edema. Red spider-like vascular markings on her upper LE.
--MSK: Good joint ROM. No evidence of swelling or deformity.
--Neuro:
No asterixis.
MMSE: AOx3. The rest of MMSE not performed.
CNs: II-XII intact to direct testing.
Sensory: Light touch intact in UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**].
Motor: Tone normal. Strength 4+/5 throughout.
DTRs and coordination not directly assessed.
Pertinent Results:
[**2143-8-23**] 09:45PM GLUCOSE-61* UREA N-6 CREAT-0.3* SODIUM-135
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-26 ANION GAP-13
[**2143-8-23**] 09:45PM ALT(SGPT)-72* AST(SGOT)-176* LD(LDH)-144 ALK
PHOS-111 AMYLASE-20 TOT BILI-8.1* DIR BILI-4.9* INDIR BIL-3.2
LIPASE-23
[**2143-8-23**] 09:45PM ALBUMIN-2.7* CALCIUM-8.1* PHOSPHATE-3.2
MAGNESIUM-1.8 IRON-54
[**2143-8-23**] 09:45PM calTIBC-127* FERRITIN-391* TRF-98*
[**2143-8-23**] 09:45PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
[**2143-8-23**] 09:45PM AMA-NEGATIVE
[**2143-8-23**] 09:45PM [**Doctor First Name **]-POSITIVE TITER-1:1280
[**2143-8-23**] 09:45PM HCV Ab-NEGATIVE
[**2143-8-23**] 09:45PM WBC-12.3* RBC-2.89* HGB-10.1* HCT-29.9*
MCV-103* MCH-34.8* MCHC-33.6 RDW-13.7
[**2143-8-23**] 09:45PM PLT COUNT-245
[**2143-8-23**] 09:45PM PT-16.6* PTT-37.7* INR(PT)-1.7
Brief Hospital Course:
A/P: 49yo women with significant alcohol use presents with
diffuse abdominal pain, diarrhea, abdominal distension and
jaundice.
.
1) Liver disease:
Alcoholic liver disease was the presumptive diagnosis due to
history while awaiting other labs. AST/ALT ratio is 2:1. The
possibility of an autoimmune etiology contributing to her liver
disease was initially unclear. Autoimmune serologies done before
this hospitalization were not conclusive. During this
hospitalization [**Doctor First Name **] was 1:1200 with IgG >150% of nml, however,
liver biopsy showed no evidence of autoimmune hepatitis.
.
Her discriminant function ([**Last Name (un) 26460**]??????s score) was >32 by HD2-3.
[**Last Name (un) 57563**] 400 mg PO TID started on HD4. Seroids not started
at this time due to pt's pulmonary infection and unclear benefit
in addition to [**Name (NI) 57563**]. Nutrition and alcohol abstinence
have been stressed to pt througout hospitalization. A
post-pyloric feeding tube was placed on HD 5 for nutritional
support.
.
Transjugular bx on HD7 showed: 1) Moderate lobular predominantly
neutrophilic infiltrate with numerous intracytoplasmic hyaline
and mild fatty change; 2)Trichrome stain shows marked sinusoidal
fibrosis with architectural distortion. No definite cirrhosis
seen. Reticulin stain evaluated; 3) No features of autoimmune
hepatitis are seen; 4) No iron seen on special stain; Note: The
findings are consistent with toxic metabolic injury.
.
Prednisone 20mg PO daily started HD 12 (pt not responding to
[**Name (NI) 57563**]). After 7 days at 20mg, the a taper was begun.
However, due to increased ALT and AST on HD20, Prednisone 20mg
was reinstituted.
.
Coags increased to 2.9. Patient received vitamin K. Albumin was
low, but was stable during hospitalization. Total bilirubin
increased steadily during admission from 8.1 to 21. ALT reached
165 and AST reached 256.
.
Ascites: Very small volume ascites on HD1. Dx paracentesis on
HD2 showed no SPB (WBC 81) and portal-hypertension etiology
(SAAG > 1.1). Furosemide and Spironolactone started on HD2.
Diuretics later held due to hyponatremia. The patient
experienced increased distention over several days and she
remained distended throughout hospitalization. Dx paracentesis
on HD9 showed no SBP(WBC 76). Tx paracentesis on HD 10. Tx
paracentesis on HD16 (WBC 5). Tx paracentesis on HD19 (WBC 6).
.
Encephalopathy: The patient had Grade I throughout most of the
hospitalization (subtle asterixis, drowsiness, agitation, and
mild confusion). She was initially treated w/ Lactulose and
Metronidazole. Metronidazole d/cd due to pt's frequent diarrhea.
Lactulose was used intermittently, depending on how many stools
she had per day (titrated to [**1-25**] BM/day. On HD 18 lactulose was
discontinued due to increasing abdominal distention with
tympanitic bowel and diarrhea with > 5 BM per day. Lactulose was
re-considered HD20-22 due to improving diarrhea. Patient
developed increasing somnolence and confusion on HD 25.
Lactulose reinstituted. Encephalopathy worsened during her time
in the MICU.
.
Esophageal Varices: 3 cords of grade I-II varices in the lower
[**11-24**] of esophagus. No stigmata of bleeding. Friability, erythema,
and congestion in the stomach body and antrum compatible with
moderate portal hypertensive gastropathy.
.
2) Renal Failure
BUN and Cr always WNL on admission. Decreased urine output
starting on HD8, concerning for hepatorenal. Foley catheter
placed to better monitor urine output. She responded well to IVF
w/ increased urine output. Considered using Octreotide,
Midodrine, and Albumin in MICU if urine output dropped lower.
Patient responded to fluid challege and diuretics; her urine
output increased by HD14-15. However, the patient continued to
be hyponatremic, with a sodium that declined to 119, therefore
diuretics were held on HD 19. On HD21-22 her urine output
started to decline again and she began to have significant
volume overload. Her BUN and Cr began to rise. On HD 23 the
patient became more somnolent and UOP declined to 45 cc over 8
hours. MICU was called to evaluate the patient and she was
transferred to the unit. In the MICU she continued to have
minimal urine output. Patient was given fluid in the form of
PRBC and 80 IV lasix, but did not respond. Renal was consulted
and felt urine sediment was consistent with
pre-renal/hepatorenal, rather than ATN. They did not recommend
hemodialysis due to the overall poor prognosis.
.
3) Hypoxemia
On HD26 patient developed hypoxic respiratory distress with
oxygen saturation that decreased to 86% off nasal cannula and
increasing respiratory rate. CXR showed pulmonary edema likely
due to volume overload from renal failure. Oxygenation improved
to 96% with 6L NC and 15 L shovel mask. ABG was within normal
limits, however, the patient was transferred to the intensive
care unit for more aggressive monitoring due to her respiratory
status and decreased UOP with possible need for hemodialysis.
.
4) Pneumonia
Presumed pneumonia on admission treated with levofloxacin and
metronidazole. Later in hospitalization, the patient was treated
for a possible nosocomial pneumonia with 10 days of levofloxacin
and zosyn. CXR with infiltrates suggesting PNA. As patient
remained afebrile, antibiotics were discontinued at the end of
this course on HD18. Pt had high WBC throughout hospitalization.
.
5) Clostridium Difficile colitis
Patient had three negative C diff toxins from [**Date range (1) 57564**].
Diarrhea seemed to be improving by HD20. However, she was having
large volume diarrhea prior to transfer to the MICU on HD26. Her
WBC was rising rapidly up to 25 with bandemia. She was started
on Metronidazole for emipiric C diff treatment and stool
cultures were obtained which came back positive for C diff. Her
CXR showed significant bowel distention. CT scan was deferred as
care was redirected to comfort measures only.
.
6) FEN
Pt has had intermittent hyponatremia, most likely caused by
increased ADH as a result of decreased effective intravascular
volume, as well as body stressors (N/V, pain). This was treated
with holding the diuretics and fluid restriction. Patient's
hyponatremia continued to worsen with Na of 119. In the MICU she
was started on hypertonic saline which improved her serum sodium
slightly. A post pyloric feeding tube was placed on HD5 for
aggressive tube feeds due to poor PO intake.
.
7) Prophylaxis: Pt did not receive DVT prophylaxis due to INR
>2.0.
.
8) Code Status: On HD 26 patient was transferred to the
intensive care unit due to respiratory distress and anuria. A
family meeting was arranged with her husband, brother, the liver
attending, MICU attending and renal attending. The family was in
favor of comfort measures as prognosis was grave and the patient
had expressed discomfort, pain, and a wish to die. The patient's
care was then refocused on comfort measures. A morphine drip was
started. The patient expired on [**9-19**] at . An autopsy was
deferred by the family. The patient was comfortable at the time
of death.
Medications on Admission:
Lexapro 10mg
Trazadone 100mg
Nexium 40 mg
Nordette
MVI
Discharge Disposition:
Expired
Discharge Diagnosis:
Alcoholic Hepatitis
Liver failure
Acute renal failure
Hepatorenal syndrome
Clostridium difficile colitis
Malnutrition
Pneumonia
Anemia
Discharge Condition:
Patient died
Discharge Instructions:
Patient died
Followup Instructions:
Patient died
|
[
"572.2",
"518.0",
"785.0",
"276.1",
"572.4",
"599.0",
"281.9",
"303.91",
"041.89",
"799.0",
"456.21",
"995.92",
"263.9",
"266.2",
"571.1",
"286.7",
"486",
"572.3",
"112.0",
"038.9",
"789.5",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"45.13",
"99.04",
"54.91",
"50.11",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
13989, 13998
|
6843, 13884
|
430, 436
|
14176, 14190
|
5978, 6820
|
14251, 14266
|
3808, 4136
|
14019, 14155
|
13910, 13966
|
14214, 14228
|
4151, 5959
|
273, 392
|
464, 3126
|
3148, 3341
|
3357, 3792
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,427
| 177,066
|
28217
|
Discharge summary
|
report
|
Admission Date: [**2190-10-5**] Discharge Date: [**2190-10-6**]
Date of Birth: [**2123-4-5**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
mesenteric ischemia
Major Surgical or Invasive Procedure:
ex lap
History of Present Illness:
67M acute abdominal pain x 8 hours, transferred from OSH with
diagnosis of mesenteric ischemia.
Past Medical History:
h/o etoh abuse
PVD
Social History:
etoh abuse
+IVDA
h/o cigs
Family History:
estranged from family
Physical Exam:
intubated
tense distended abdomen
Pertinent Results:
refer to carevue
Brief Hospital Course:
Taken emergently to OR, discovered to have diffusely ischemic
small bowels.
Transferred to SICU, where he quickly passed away without pain
Medications on Admission:
coumadin
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
ischemic bowel
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2190-10-6**]
|
[
"557.0",
"443.9",
"070.54",
"276.2",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
930, 939
|
701, 842
|
333, 342
|
998, 1009
|
660, 678
|
1061, 1224
|
568, 591
|
902, 907
|
960, 977
|
868, 879
|
1033, 1038
|
606, 641
|
274, 295
|
370, 467
|
489, 509
|
525, 552
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,375
| 177,581
|
34802
|
Discharge summary
|
report
|
Admission Date: [**2110-8-23**] Discharge Date: [**2110-8-29**]
Service: NEUROLOGY
Allergies:
Codeine
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Sudden onset right hemiplegia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 83 year old woman without significant prior
medical history who presents with sudden onset right hemiplegia
in the context of a left frontal intraparenchymal hemorrhage.
She
was admitted to the SICU on [**8-23**]. The patient was intubated
for airway protection.
Past Medical History:
Diverticulitis
Social History:
lives with her husband in the [**Location (un) **], she raised her two
daughters (one lives in the area), both daughters are here in
town at present, she does the bills in the house, she never
smoked, she does not drink, no illicit drug use.
Family History:
no history of stroke or bleeding diathesis.
Physical Exam:
PHYSICAL EXAMINATION:
Vitals: T 98.3, HR 68, BP 154/78, R 18, on O2 2l NC
Gen: lethargic.
HEENT: NCAT, MMM, anicteric sclera, OP clear
Neck- no carotid bruits
Pulm- CTA B
Abd- Soft, nt, nd, BS+
Extrem- no CCE
Neurologic Examination:
MS: unresponsive. Mobilizes the left hemibody with noxious
stimuli.
Left gaze conjugated deviation.
PERRL 4-->2mm on the left, sluggish on the right, no facial
asymmetry.
Motor- R leg externally rotated, no adventitious movements,
normal bulk, increased tone in R hemibody with hemiparesis.
Coordination: npt possible to examine.
Sensory: unresponsive not examined.
Toes- bilaterally upgoing.
Gait- unable to test.
Pertinent Results:
[**2110-8-23**] 02:30PM GLUCOSE-141* UREA N-20 CREAT-0.7 SODIUM-144
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-24 ANION GAP-19
[**2110-8-23**] 02:30PM estGFR-Using this
[**2110-8-23**] 02:30PM CK(CPK)-107
[**2110-8-23**] 02:30PM cTropnT-<0.01
[**2110-8-23**] 02:30PM CK-MB-4
[**2110-8-23**] 02:30PM WBC-13.7* RBC-4.63 HGB-14.8 HCT-41.7 MCV-90
MCH-32.0 MCHC-35.6* RDW-12.9
[**2110-8-23**] 02:30PM NEUTS-91.1* BANDS-0 LYMPHS-5.9* MONOS-2.4
EOS-0.3 BASOS-0.2
[**2110-8-23**] 02:30PM PLT COUNT-166
[**2110-8-23**] 02:30PM PT-12.0 PTT-20.5* INR(PT)-1.0
CT CNS w/o Contrast: 08/ 02/ 08
Large left frontoparietal intraparenchymal hemorrhage with no
significant mass effect, and grossly unchanged compared to the
outside
hospital CT performed three hours prior. Given the lobar
distribution, the
differential diagnosis includes amyloid angiopathy, underlying
mass of AVM, or
aneurysm. Comparison with concurrent CTA demonstrates no
evidence of these
entities at this time. An MRI and repeat CTA could be obtained
when the
hemorrhage has resolved to evaluate for amyloid angiopathy,
underlying mass or vascular malformation.
CT CNS w/ wo contrast: 08/ 02/ 08: No AVM aneurysm underlying
the left frontoparietal
intraparenchymal hematoma.
There is, however, suggestion of an incidental 4.6 mm aneurysm
probably
arising from the left cavernous carotid artery extending to the
suprasellar
cistern. Evaluation of this area on CT is limited due to
artifact from bone.
MRI CNS: 08 / [**3-29**]:
Stable left frontoparietal hemorrhage with enhancement of the
hematoma wall and hyperemia. No underlying AVM or mass seen on
the current
study but cannot be excluded due to the large amount of
hemorrhage.
CT CNS w/o contrast: 08 / 05/ 08:
here is new blood within the lateral ventricles bilaterally.
However, there is no evidence of increased bleeding associated
with the large
hematoma previously noted. It is possible this represents
rupture of the
existing hematoma into the ventricles. There is slight
dilatation of the
ventricles since the study of [**2110-8-25**]. Edema surrounding the
hematoma appears
stable.
Brief Hospital Course:
The patient had an episode of twitching her left arm and
hemiface. She was
loaded on fosphenytoin 1000 mg iv.
The prognosis was discussed with the family in a meeting on 08 /
06/ 08 at 11:00 am. They agreed with a change to DNR status. By
the time she had been on hypertonic saline that was stopped
given the Na and osmolality levels. She did not improve
clinically. A new family meeting was held. The palliative are
team was involved and the family decided to make her CMO on 08/
07/ 08.
Once the therapeutic measures were removed and she just received
comfort measures only she passed away.
Medications on Admission:
None
Discharge Medications:
Ms [**Known lastname **] [**Last Name (Titles) **].
Discharge Disposition:
[**Last Name (Titles) **]
Discharge Diagnosis:
Left frontal intraparenchimal hemorrhage
Discharge Condition:
[**Last Name (Titles) **]
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"780.6",
"431",
"342.00",
"530.81",
"276.0",
"276.3",
"V10.3",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.91",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
4501, 4528
|
3774, 4370
|
254, 260
|
4612, 4639
|
1634, 3751
|
4691, 4697
|
900, 945
|
4425, 4478
|
4549, 4591
|
4396, 4402
|
4663, 4668
|
960, 960
|
982, 1170
|
185, 216
|
288, 585
|
1194, 1615
|
607, 624
|
640, 884
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,000
| 138,171
|
5307
|
Discharge summary
|
report
|
Admission Date: [**2119-8-4**] Discharge Date: [**2119-8-15**]
Service: Medicine
ADMISSION DIAGNOSES:
1. Shortness of breath.
2. Increasing extremity edema.
HISTORY OF PRESENT ILLNESS: The patient presented on
[**2119-8-4**] for increasing extremity edema and shortness of
breath despite being on peritoneal dialysis for the past five
weeks for end-stage renal disease.
REVIEW OF SYSTEMS: Otherwise negative.
LABORATORY DATA: Complete blood count and chemistry panel
including creatinine were at baseline on admission. Cardiac
etiology ruled out via CK and EKG.
The patient was admitted for conversion to hemodialysis in
stable condition.
HOSPITAL COURSE: 1. End-stage renal disease: Peritoneal
dialysis catheter was removed and a tunnel catheter was
placed. The patient underwent hemodialysis on [**2119-8-5**]. The
patient remained stable until [**2119-8-7**] when the patient
became hypoxic, developed rigors, tachycardia and temperature
of 101. The patient transferred to the intensive care unit.
Intensive care unit course will be dictated separately by the
intensive care unit team. The patient was transferred back
to the floor on [**2119-8-10**]. The patient's course has been
stable since transfer. Systolic blood pressure is back at
baseline ranging in the 90s per primary care physician;
afebrile and saturating greater than 91% on room air. In
preparation for discharge the patient was evaluated by PT as
well as nutrition for albumin of 2.4. The patient underwent
another session of hemodialysis before discharge to ensure
that the patient could tolerate the procedure. The patient's
blood pressure remained at baseline and the patient is
asymptomatic status post dialysis.
2. Fever: Etiology unclear. The patient had been started on
vancomycin, levofloxacin, and metronidazole per vascular
surgery at admission for nonhealing left foot ulcer. The
patient does not appear infectious on examination but
osteomyelitis could not be ruled out. The wound remained
stable throughout examination. However, urine was noted to
be purulent at collection, and urosepsis became the working
diagnosis during the patient's intensive care unit stay.
Indocin, gentamicin, and vancomycin were started in the
intensive care unit. Metronidazole and levofloxacin were
discontinued. Panculture remained negative throughout
hospital course. Infectious disease consultation recommended
cessation of all antibiotics except Zosyn to be continued for
a 10-day total duration upon discharge.
3. Congestive heart failure: No indication of decompensation
during this admission.
4. Pleural effusion: Diagnostic thoracentesis was consistent
with transudate. No organisms were isolated. Further taps
were deferred as the patient was asymptomatic.
5. Physical therapy: The patient was evaluated by both
occupational therapy and physical therapy. It was deemed
that the patient would need rehabilitation placement upon
discharge. The patient was discharged in stable condition on
[**2119-8-15**].
PHYSICAL EXAMINATION AT DISCHARGE: General: Awake, alert,
sitting up, lucid, appropriate. Cardiovascular: Regular
rhythm, mild tachycardia. Respiratory: Clear to
auscultation bilaterally except lower one-fourth lung field
that showed decreased breath sounds but no crackles.
Abdomen: Soft, distended, but nontender to palpation.
Dressing removed from PD catheter site. The site is now
clean, no discharge, no erythema, and no edema. Extremities:
2+ pitting edema bilaterally. Left foot dressing is in
place, dry, pressure boot in place.
LABORATORY DATA: Complete blood count showed a white blood
cell count of 8.6, hemoglobin and hematocrit 9.9/31/7,
platelet count 164, physical therapy 13.7, PTT 30.7,
interrupted 1.3. Chemistry panel was sodium 140, potassium
4.3, chloride 104, bicarbonate 26, BUN 25, creatinine 4.2,
glucose 111.
IMAGING: Echocardiogram from [**2119-8-9**]: "Compared with the
findings of the prior study, tape reviewed of [**2119-5-1**], the
left ventricle was not dilated with similar systolic
dysfunction. The aortic valve gradient is now higher and
calculated valve area is now marginally smaller. Estimated
pulmonary artery systolic pressure is now higher. Ejection
fraction is now less than 15%."
Chest x-ray of [**2119-8-12**] shows: "Continual bilateral pleural
effusion at bases."
CONDITION ON DISCHARGE: Stable.
PROCEDURES:
1. Removal of peritoneal dialysis catheter from the abdomen.
2. Placement of tunnel catheter for dialysis.
3. Diagnostic thoracentesis.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE DIAGNOSES: End-stage renal disease.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Paroxetine 10 mg q.d.
3. Simvastatin 20 mg q.d.
4. Sevelamer 800 mg, two tablets p.o. t.i.d.
5. Collagenase 250 units per gram of ointment applied q.d. to
affected area of ulcer.
6. Digoxin 125 mcg, 0.5 tablet q.o.d.
7. Heparin sodium 5,000 units per mL, one injection q. 12.
8. Metoprolol 50 mg b.i.d.
9. Trazodone 50 mg, 0.5 tablet q.h.s. p.r.n.
FOLLOW UP: The patient is to be followed up with primary
care physician. [**Name10 (NameIs) **] patient is also scheduled for follow up
with Dr. [**Last Name (STitle) **] of podiatry within one week of discharge.
[**Name6 (MD) 251**] [**Known firstname 11865**], M.D. [**MD Number(1) 11866**]
Dictated By:[**Last Name (NamePattern1) 21646**]
MEDQUIST36
D: [**2119-8-14**] 10:39
T: [**2119-8-14**] 10:55
JOB#: [**Job Number 21647**]
|
[
"486",
"285.21",
"250.40",
"511.9",
"996.56",
"599.0",
"585",
"428.0",
"440.24"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.82",
"39.95",
"54.98",
"38.95",
"86.28",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
4615, 4641
|
4664, 5039
|
678, 2779
|
2798, 3049
|
5051, 5514
|
114, 170
|
3064, 4362
|
405, 660
|
199, 385
|
4387, 4593
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,780
| 115,064
|
31190
|
Discharge summary
|
report
|
Admission Date: [**2195-5-19**] Discharge Date: [**2195-5-23**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
decreased responsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]yo woman with history of breast cancer s/p rigth mastectomy on
arimidex, hypertension, presents with aphasia and right sided
weakness. She was in her USOH the night prior to presentation,
which is when she was last seen well. Her family found her this
morning, not speaking and not responding to them.
EMS was called and she was brought to [**Hospital1 18**] ED.
Past Medical History:
breast cancer s/p right mastectomy, on arimidex
hypertension
Social History:
per OMR, no tobacco or EtOH, retired teacher, son in [**Name (NI) **].
Family History:
not elicited
Physical Exam:
VS: T 100.4, HR 69, BP 162/90, RR 29, saO2 96%/RA, FS 116
Genl: sitting in bed, rhonchorous
HEENT: NCAT
Neck: supple
CV: RRR, nl S1, S2, but difficult to auscultate over rhonchi
Chest: diffusely rhonchorous
Abd: soft, NTND, BS+
Ext: warm and dry
Neurologic examination:
MS: Regards examiner on left, does not track past midline to
right. Does not follow commands. Does not speak.
CN: Pupils equal and reactive, 4->2, no blink to threat on
right,
left gaze deviation, does not pass midline, b/l corneals
present,
nasal tickle present b/l but R facial palsy.
Motor: Antigravity spontaneously in RUE, moves less than LUE;
RUE
drifts down immediately, LUE without drift. RLE triple flexes to
noxious, no antigravity movement but moves with gravity on the
bed. LLE antigravity.
Sensory: responds to noxious in all extremities
DTRs: hyperreflexic on right; not elicited in achilles b/l;
right
plantarstim -> triple flexion, left downgoing.
Pertinent Results:
143 107 26
------------< 117
4.3 25 1.7
estGFR: 28/34 (click for details)
CK: 72 MB: Notdone Trop-T: 0.02
Ca: 9.9 Mg: 2.0 P: 3.5
9.6 > 41.0 < 201
N:71.6 L:20.4 M:5.5 E:1.8 Bas:0.6
PT: 12.3 PTT: 27.8 INR: 1.0
U/A negative
CXR: Limited study demonstrating no evidence of pneumonia or
CHF.
<br>
Head CT [**5-19**]:
IMPRESSION:
1. Findings concerning for early infarct in the left frontal
lobe. MRI may be performed for further evaluation. No
hemorrhage.
2. Hyperdense appearance of the left ACA, worrisome for
thrombosis.
3. Chronic small vessel ischemic disease.
4. Age-related parenchymal atrophy.
<br>
Head CT [**5-20**]:
FINDINGS: Evolving hypodensity and associated cortical sulcal
effacement is noted of the left frontal lobe in the left middle
cerebral artery territory consistent with new infarction. Also
noted is a small area of developing hypodensity involving the
genu of the left internal capsule consistent with infarction.
There is no evidence of intracranial hemorrhage, mass effect,
shift of normally midline structures or hydrocephalus. There is
mild hypodensity of the periventricular white matter consistent
with chronic small vessel infarction. Mucosal thickening and a
fluid level is noted within the left maxillary sinus. Bilateral
lens replacements are present. There are age-related
involutional changes.
IMPRESSION:
1. Evolving infarction of the left middle cerebral artery
territory, including a portion of the left frontal lobe and genu
of the left internal capsule. No evidence of intracranial
hemorrhage or significant mass effect.
2. Fluid level within the left maxillary sinus.
Brief Hospital Course:
Ms. [**Known lastname 73624**] was admitted to the Neuro ICU for close monitoring
following her large Left MCA stroke. She continued to have a
dense aphasia, right side neglect, and right hemeplegia. She was
kept euthermic with Tylenol and euglycemic with an insulin
sliding scale.
On her first night in the ICU, she was found to go into rapid
atrial fibrillation. This was previously unknown and is the
likely mechanism for her stroke. Her rapid ventricular rate
caused some hemodynamic instability with hypotension; she was
rate controlled with a diltiazem drip. This was turned off the
next night when she converted back to sinus and had bradycardia
to the 50s.
Echo was not obtained as her family did not feel she would want
to have been anticoagulated.
After two days in the ICU, based on clinical findings and
imaging results, it was clear that she was not going to have a
significant recovery and in the long-term would need a PEG for
feeding and round-the-clock care. Her family were all in
agreement that this is not something she would want at the end
of her life, especially the PEG. Therefore, all involved agreed
that it was appropriate to make her code status CMO (Comfort
Measures Only). She was placed on a morphine drip and
transferred to the floor. Two days later, she passed comfortably
and quietly with family at the bedside.
Medications on Admission:
lisinopril
metoprolol
HCTZ
KCl
arimidex
ASA
All: NKDA
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cerebral Infarct (Stroke)
Discharge Condition:
Expired.
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2195-5-23**]
|
[
"427.89",
"V66.7",
"401.9",
"V10.3",
"780.01",
"507.0",
"784.3",
"434.01",
"427.31",
"342.90",
"781.94",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5009, 5018
|
3523, 4874
|
289, 295
|
5087, 5097
|
1881, 3500
|
5149, 5294
|
896, 910
|
4980, 4986
|
5039, 5066
|
4900, 4957
|
5121, 5126
|
925, 1172
|
224, 251
|
323, 706
|
1196, 1862
|
728, 791
|
807, 880
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,206
| 132,106
|
9613
|
Discharge summary
|
report
|
Admission Date: [**2104-2-22**] Discharge Date: [**2104-2-24**]
Date of Birth: [**2047-7-13**] Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 32581**]
Chief Complaint:
renal [**Hospital3 32582**] distress
Major Surgical or Invasive Procedure:
open R partial nephrectomy, [**2104-2-22**], Dr. [**Last Name (STitle) **]
History of Present Illness:
59yo M w/hx 5cm upper pole mass of the right kidney. Pt had
elective nephrectomy on [**2104-2-21**]. Had 1L EBL and was transfused
unit post op. Patient was difficult intubation originally
requiring a bougie. Pt extubated in PACU but went into resp
distress requiring glidescope intubation after multiple
attempts. Pt extubated this AM but serially ABGs revealed
increasing CO2 up to the 70s. BIPAP was started and on 15/5, CO2
down to 60s. ABG on tx was 7.37/63/74 on 50% FIO2. Pt tx to the
ICU for anesthesia back up which is not available at [**Hospital1 882**]
over the weekend.
Pt accepted by Urology service, [**Doctor Last Name **].
Past Medical History:
PMH: OSA, arthritis, HTN
PSH: none
Social History:
noncontributory
Family History:
noncontributory
Physical Exam:
avss, satting mid-90s on RA
no resp distress
abd obese, nontender, nondistended, R flank incision c/d/i with
staples to air
Pertinent Results:
[**2104-2-23**] 02:50AM BLOOD WBC-16.7* RBC-3.60* Hgb-10.9* Hct-32.8*
MCV-91 MCH-30.3 MCHC-33.2 RDW-14.4 Plt Ct-204
[**2104-2-23**] 02:50AM BLOOD Plt Ct-204
[**2104-2-23**] 02:50AM BLOOD Glucose-109* UreaN-20 Creat-1.0 Na-138
K-4.2 Cl-99 HCO3-33* AnGap-10
[**2104-2-23**] 02:50AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.0
Brief Hospital Course:
Pt was transferred from [**Hospital 882**] Hospital for ICU status care
after episode of respiratory distress at FH (see FH records for
details of admission and operative note). In the T/SICU he
remained stable on bipap and had no other active issues. On HD2
he was deemed safe for transfer to the floor. He tolerated a
diet prior to discharge. His pain was well-controlled without
PO narcotics. He passed a voiding trial. Respiratory therapy
fit him with cpap on the floor and he verbally contracted with
the MD to wear his cpap at home and follow-up with his PCP for [**Name Initial (PRE) **]
new sleep study, cpap mask fitting, and review of this
admission/ICU admission. He will call with any
questions/concerns in the interval.
Medications on Admission:
Vicodin 7.5mg q6hrs, metoprolol 50', ASA 324', Finasteride 5mg
qhs, tamsulosin 0.4mg qhs, lasix 20', KCl 20', Lisinopril 20',
pravastatin 20', multivit, patanol
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/fever.
Disp:*60 Tablet(s)* Refills:*0*
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
renal mass
Discharge Condition:
good
ambulating
voiding
tolerating diet
pain controlled without narcotic pain medications
Discharge Instructions:
Do not lift more than 10 pounds for next two weeks.
Please call or go to ED if you have new bright red blood in
urine.
Use a stool softener to avoid constipation.
Followup Instructions:
Call Dr.[**Name (NI) 32583**] office for a staple removal appointment.
**Call your PCP's office for a visit within the next 7 days to
followup on your admission, ideally within 4 days.** Please
bring any paperwork from your admission with you to the visit.
Items for PCP to address:
-Need for new sleep study per Respiratory therapy at [**Hospital1 18**]
-Fit of CPAP mask
-Calibration of CPAP machine
-Restarting lisinopril
|
[
"401.9",
"327.23",
"374.30",
"379.93",
"189.0",
"E878.6",
"278.01",
"518.52"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3503, 3509
|
1711, 2452
|
341, 418
|
3564, 3656
|
1372, 1688
|
3869, 4300
|
1195, 1212
|
2663, 3480
|
3530, 3543
|
2478, 2640
|
3680, 3846
|
1227, 1353
|
265, 303
|
446, 1087
|
1109, 1146
|
1162, 1179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,620
| 186,781
|
2165
|
Discharge summary
|
report
|
Admission Date: [**2116-2-13**] Discharge Date: [**2116-2-18**]
Date of Birth: [**2069-10-28**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Heparin Agents
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
hypotension at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
46 F h/o Juvenile DM I s/p renal tx [**2106**] and pancreatic tx [**2113**]
(explanted for necrosis) presented to the ED c/o hypotension,
malaise and fever at home and transferred to MICU for managment
of septic shock. Pt treated for pyelonephritis in [**11/2115**] and
just finished course of valcyte for herpes zoster of left flank.
Recent UTI treated with ciprofloxacin ending 1 wk prior. Fever
to 102.7 at home yesterday. No dysuria, tenderness of tx kidney,
cough, frequency, suprapubic discomfort. Had a headache this
morning during her fevers. Some neck pain put this was
transient. No photophobia. This morning she collapsed into her
husbands grasp on two occasions but did not lose consciousness
or hit her head; this happened when she got up to go to the
bathroom from her bed. She had three episodes of nonbilious
nonbloody nausea and vomiting. No belly pain. No diarrhea. Last
bm 36 hrs prior and brown/solid. Has been able to take po
fluids, not much solid food.
.
.
In the ED, initial VS were: t 100.4, bp 85/50, hr 112, rr14, sat
100% RA. Triggered for hypotension 78/51. SBP recovered to 100s
after 5L ivf resuscitation. Recieved iv zosyn 4.5g, iv vanc 1g,
hydrocort 50mg iv. Renal transplant u/s showed no abscess/hydro.
Transplant surgery evaluated, no intervention. Transplant
nephrology evaluated pt. [**Last Name (un) **] evaluated and wrote recs for her
continuous insulin pump.
.
Upon transfer to the micu, vitals 99.8, 103/54, hr 97, 97RA. On
arrival to the MICU, no acute complaints.
Past Medical History:
#. Type 1 diabetes mellitus since age 7
#. End-stage renal disease.
#. Status post renal transplant in [**2106-1-26**].
#. Status post failed pancreatic transplant on [**2113-9-30**], explanted
on [**2113-10-1**] in setting of necrotic and thrombotic graft
#. C section [**2097**]
#. Bilateral tubal ligation.
#. ankle fracture s/p repair with plate in [**2104**]
Social History:
Lives with husband, has a daughter. Denies alcohol, cigarettes,
illicit drugs.
Family History:
No history of CAD or cancer
Physical Exam:
Discharge exam
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
Admission Labs
[**2116-2-13**] 12:15PM PT-13.9* PTT-29.6 INR(PT)-1.3*
[**2116-2-13**] 12:15PM PLT SMR-NORMAL PLT COUNT-214
[**2116-2-13**] 12:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2116-2-13**] 12:15PM WBC-30.8*# RBC-4.44 HGB-12.3 HCT-35.9*
MCV-81* MCH-27.7 MCHC-34.1 RDW-15.4
[**2116-2-13**] 12:15PM CALCIUM-9.6 PHOSPHATE-4.6*# MAGNESIUM-1.8
[**2116-2-13**] 12:15PM estGFR-Using this
[**2116-2-13**] 12:15PM GLUCOSE-226* UREA N-49* CREAT-3.1*#
SODIUM-130* POTASSIUM-4.0 CHLORIDE-91* TOTAL CO2-23 ANION GAP-20
[**2116-2-13**] 12:35PM GLUCOSE-218* LACTATE-1.9 K+-4.2
[**2116-2-13**] 12:35PM COMMENTS-GREEN TOP
[**2116-2-13**] 03:00PM URINE RBC-4* WBC-107* BACTERIA-MOD YEAST-NONE
EPI-<1
[**2116-2-13**] 03:00PM URINE RBC-4* WBC-107* BACTERIA-MOD YEAST-NONE
EPI-<1
[**2116-2-13**] 03:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2116-2-13**] 03:00PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
[**2116-2-13**] 03:00PM URINE UCG-NEGATIVE
[**2116-2-13**] 03:00PM URINE HOURS-RANDOM
[**2116-2-13**] 06:09PM PLT COUNT-170
[**2116-2-13**] 06:09PM ALBUMIN-3.2* CALCIUM-7.9* PHOSPHATE-3.4
MAGNESIUM-1.6
[**2116-2-13**] 06:09PM ALBUMIN-3.2* CALCIUM-7.9* PHOSPHATE-3.4
MAGNESIUM-1.6
[**2116-2-13**] 06:09PM ALT(SGPT)-26 AST(SGOT)-35 LD(LDH)-141 ALK
PHOS-38 TOT BILI-0.7
.
TACROLIMUS LEVELS:
[**2116-2-13**] 01:51PM BLOOD tacroFK-11.1
[**2116-2-14**] 03:29AM BLOOD tacroFK-3.9*
[**2116-2-15**] 04:03AM BLOOD tacroFK-5.3
[**2116-2-16**] 05:35AM BLOOD tacroFK-7.7
[**2116-2-17**] 05:55AM BLOOD tacroFK-9.0
[**2116-2-18**] 06:15AM BLOOD tacroFK-7.0
DISCHARGE LABS:
[**2116-2-18**] 06:15AM BLOOD WBC-8.6 RBC-3.68* Hgb-9.8* Hct-29.9*
MCV-81* MCH-26.7* MCHC-32.8 RDW-15.7* Plt Ct-177
[**2116-2-18**] 06:15AM BLOOD Glucose-135* UreaN-28* Creat-1.4* Na-139
K-3.5 Cl-99 HCO3-30 AnGap-14
.
URINE CULTURE (Final [**2116-2-15**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
.
RENAL TRANSPLANT ULTRASOUND: The transplanted kidney is
demonstrated within
the right lower quadrant and measures 14.8 cm. Corticomedullary
differentiation is preserved. No renal calculi, renal masses, or
hydronephrosis is demonstrated. Tiny amount of simple free fluid
is
demonstrated superior to the upper pole of the transplant kidney
as well as inferior and medial to the lower pole.
Normal color flow and vascularity is demonstrated throughout the
transplanted kidney. The main renal artery and main renal vein
are widely patent and demonstrate normal arterial and venous
waveforms. Resistive indices within the upper pole, interpolar,
and lower pole intrarenal arteries are 0.76, 0.80, and 0.77
respectively. Previously, the resistive indices were 0.78, 0.73,
and 0.71, respectively.
The urinary bladder is collapsed.
IMPRESSION:
1. No evidence of hydronephrosis or abscess.
2. Resistive indices range from 0.76 to 0.80 on the current
study, which is minimally elevated within the interpolar region
when compared to the prior study. Otherwise, vascularity appears
unremarkable.
.
MRI:
IMPRESSION:
Unremarkable MR of the renal transplant kidney with a
subcentimeter
hemorrhagic / proteinaceous cyst noted in the lower pole. No
evidence for
hydronephrosis or hydroureter or evidence for peri-renal abscess
or
collection.
Brief Hospital Course:
46F h/o Juvenile DM s/p renal and pancreas transplants on
prednisone, cellcept, and tacrolimus presented with septic shock
from UTI.
.
#septic shock/UTI: Presented with hypotension and urinary tract
infection from klebsiella and was admitted to the MICU. She was
treated with IVF and vancomycin and meropenem. She was also
briefly treated with stress dose steroids given her chronic
steriod use. Her MMF was briefly held as well. Her Hypotension
improved and she was transferred to the floor. SHe received an
US of her transplanted to kidney to eval for causes of her
recurrent UTIs which was unrevealing. She then went on to an MRI
which also did not show any abscesses or predisposing
abnormalities. She was evaluated by ID who recommended a
prolonged course of ciprofloxacin per culture sensitivities as
well as ID and urology follow up.
.
#Acute on Chronic Kidney Disease: She is several years from her
kidney transplant on tacro, mmf and prednisone. Her graft had
been doing well until she presented with hypotension and [**Last Name (un) **]
from hypoperfusion leading to ATN. Her MMF was held in the
setting of infection. During her admission she began to
auto-diurese and her creatinine improved everyday until
discharge. Later her tacrolimus level was noted to be high and
her dose was decreased to 1.5mg [**Hospital1 **].
.
# Type 1 DM - Well controlled with insulin pump. Diagnosed when
the patient was 7 years old. She is on an insulin pump and
manages her sugars closely. The patient's fingersticks were
mildly elevated on admission, requiring small changes as [**First Name8 (NamePattern2) **]
[**Last Name (un) **].
.
# Dyslipidemia - Chronic. The patient was continued on home
pravastatin.
Medications on Admission:
alendronate 70mg qweek
gabapentin 300mg tid (started recently has taken only 1 dose)
humalog via continuous pump
mycophenolate mofetil/cellcept 500mg daily
prednisone 5mg daily
tmp/smx ss mwf
tacrolimus (PROGRAF)-brand name only; 2mg [**Hospital1 **]
mv
vitamin d/ca
.
Allergies:
heparin
morphine
Discharge Medications:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
2. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
3. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
5. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO bid ().
Disp:*180 Capsule(s)* Refills:*2*
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever and pain.
7. Insulin Pump
Humalog Insulin
Basal Rates:
Midnight - 3am: 1 Units/Hr
3am - 11am: 1.2 Units/Hr
11am - 10PM: 1 Units/Hr
10PM - 12am: 1 Units/Hr
Meal Bolus Rates:
Breakfast = 1:12
Lunch = 1:11
Dinner = 1:9
Snacks = 1:9
High Bolus:
Correction Factor = 1:
Correct To 120 mg/dL
8. pravastatin 20 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
11. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
12. cranberry 500 mg Capsule Sig: One (1) Capsule PO once a day.
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 16 days: Last dose [**2116-3-5**] at night.
Disp:*32 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
Please [**Last Name (un) 11550**] Chemistry 10, CBC and tacrolimus level Friday
[**2116-2-21**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Complicated urinary tract infection
Sepsis
.
Secondary Diagnosis:
Renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. [**Known lastname 11551**],
Thank you for coming to the [**Hospital1 1170**]. You were in the hospital because you had a urinary tract
infection, decreased renal function and low blood pressure. You
have been receiving antibiotics for your infection and you have
been doing much better. Your blood pressure was low because of
the infection. The antibiotics and IV fluids improved yuor blood
pressure and it has been stable for several days. The low blood
pressure caused the decrease in your kidney fucntion but we are
glad that this has been improving everyday after your blood
pressure improved. The fluid that you retained will continue to
resolve as your kidneys get better. We also did an MRI to
evaluate why you have had repeated urinary tract infections. The
MRI was normal and did not show any cause for the repeated
infections. We also set up an appointment with a urologist to
further evaluate for any structural abnormality. You will need
to continue antibiotics for a total of three weeks from the
start of antibiotics. We also decreased your tacrolimus dose
becasue your level was high. You will need to get labs at the
transplant center on Friday to confirm continued improvement in
your kidney function and appropriate tacrolimus level.
.
Summary of Medication Recommendations:
Please START ciprofloxacin for
Please DECREASE Tacrolimus to 1.5 mg twice daily
Please CONTINUE all other medications as you have been
Followup Instructions:
Department: TRANSPLANT CENTER
When: MONDAY [**2116-3-2**] at 3:40 PM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2116-3-6**] at 11:30 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: FRIDAY [**2116-8-7**] at 10:30 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
|
[
"276.2",
"584.5",
"V45.85",
"357.2",
"995.92",
"038.2",
"785.52",
"250.61",
"583.81",
"362.01",
"250.41",
"401.1",
"272.4",
"250.51",
"V58.67",
"V42.0",
"599.0",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10699, 10705
|
7158, 8869
|
308, 315
|
10851, 10851
|
3029, 4748
|
12460, 13478
|
2356, 2385
|
9217, 10676
|
10726, 10790
|
8895, 9194
|
11002, 12437
|
4764, 7135
|
2400, 3010
|
248, 270
|
343, 1854
|
10811, 10830
|
10866, 10978
|
1876, 2243
|
2259, 2340
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,842
| 122,439
|
54059
|
Discharge summary
|
report
|
Admission Date: [**2156-1-13**] Discharge Date: [**2156-1-20**]
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 1631**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
(HPI taken through a translator) Ms. [**Known lastname **] is a [**Age over 90 **]yo Russian
female with a PMH of CAD s/p multiple MIs and PCIs, CRI, afirb,
CHF, and chronic anemia who is admitted after developing chest
pain at [**Hospital 100**] Rehab. However, she states that she believes the
reason for her admission is for persistent abd pain/inflammation
that she acquired during her last admission. Her biggest
complaint currently is that she has a lot of hiccups, burping,
and nausea, and as a result, has not been eating. She feels that
she ends up vomiting after every time she eats solid foods, but
that she can tolerate liquids. Regardless, she feels like she
does not have an appetite. She feels like she has thick mucus in
her throat/esophagus that makes it difficult for her to swallow.
She feels like she has had this sore throat since her last
intubation. Because she has not been eating as much, she feels
weak and like she is losing strength. In further ROS, she does
note that she had an episode of CP yesterday that left her SOB,
but states that she has had CP regularly ever since her MI. She
describes the chest pain as being localized to the lateral
aspect of her left breast but exactly like her anginal pain,
only "lighter". It radiated around her ribs to her back. The
chest pain lasts no longer than 5 minutes and goes away on its
own. She does get SOB and dizzy w/ the CP, but she was told not
to take nitro because it makes her BP too low. She currently
denies feeling SOB. She states she has not had diarrhea today,
that her last episode of diarrhea was yesterday and was caused
by the contrast that she drank for the CT scan. Her stools are
black, nonbloody, but have been black for a while b/c of her
iron supplementation. She denies any dysuria or hematuria but
does note that she has to push to begin urinating. She also
notes that she feels that her abdomen is bloated
Past Medical History:
Coronary artery disease s/p multiple MI's, 3-VD s/p multiple
PCI's
Diastolic CHF
A-V pacer for sick sinus syndrome
h/o atrial fibrillation
Hypertension
Hypercholesterolemia
GERD
CRI baseline 2.2
Anemia [**1-22**] CRI
Constipation
Hypothyroidism
Gout
h/o colon adenocarcinoma s/p resection
Social History:
The patient previously lived alone and was highly functional.
Since then, she has been at [**Hospital 100**] Rehab since her prior
admission. Her daughter is involved with her care. She is
widowed, but was the primary caregiver for her husband. She
denies EtOH, illicits, tobacco.
Family History:
NC
Physical Exam:
VS: 97.8 157/68 64 20 100% 1L
Gen- alert, pleasant, elderly female in NAD, oriented x 3
[**Hospital 4459**]- NC, AT, PERRL, no scleral icterus
NECK - supple, no LAD, no thyromegaly, JVP is not elevated
Cardiac- regualar, nl SaS2, no M/R/G
Pulm- scattered creckles
Abdomen- + BS, soft, slightly distended, mildly tender to
palpation diffusely but more in RLQ, no rebound, no guarding
Extremities- no edema
Pertinent Results:
[**2156-1-13**] 01:00PM BLOOD WBC-7.4 RBC-3.14* Hgb-10.2* Hct-28.5*
MCV-91 MCH-32.6* MCHC-35.9* RDW-16.7* Plt Ct-460*
[**2156-1-20**] 07:50AM BLOOD WBC-8.9 RBC-3.52* Hgb-10.6* Hct-31.6*
MCV-90 MCH-30.2 MCHC-33.7 RDW-16.4* Plt Ct-251
[**2156-1-13**] 01:00PM BLOOD PT-21.2* PTT-28.8 INR(PT)-3.2
[**2156-1-13**] 01:00PM BLOOD Glucose-116* UreaN-24* Creat-2.0* Na-139
K-3.1* Cl-104 HCO3-23 AnGap-15
[**2156-1-20**] 07:50AM BLOOD Glucose-104 UreaN-24* Creat-1.6* Na-140
K-3.8 Cl-108 HCO3-24 AnGap-12
[**2156-1-13**] 01:00PM BLOOD Calcium-8.5 Phos-2.3* Mg-2.0
[**2156-1-20**] 07:50AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.3
[**2156-1-17**] 05:44PM BLOOD calTIBC-96* Ferritn-423* TRF-74*
[**2156-1-16**] 07:37AM BLOOD Hapto-228*
.
CXR [**2156-1-18**]: Single portable chest radiograph demonstrates no
change in the cardiomediastinal silhouette when compared to
[**2156-1-16**]. Prominent pulmonary vasculature and bilateral
airspace opacities are similar in appearance when compared to
the previous study and represent pulmonary edema. There may be
a tiny right-sided pleural effusion. Left chest cardiac
pacemaker obscures the left costophrenic angle. Cardiac leads
are unchanged in position. The aorta is calcified and tortuous.
Deviation of the trachea from the midline to the right is
attributable to the tortuous aorta. Oral contrast within the
colon is seen to project over the left upper quadrant.
IMPRESSION: CHF, unchanged.
Brief Hospital Course:
[**Age over 90 **]F w/ significant cardiac history recently admitted [**1-13**] for
chest pain, shortness of breath, and abdominal pain, transferred
from the floor for hypoxia. She had been doing well on the floor
with resolution of her chest pain and nausea, when she was noted
around 4am to have an acute onset of desaturation to 75% on room
air. She was placed on 10L face mask with improvement to 95%,
although she remained tachypneic to the 40s even on a NRB. A
chest x-ray was limited but showed new bilateral opacities
(including right upper zone and left lower zone) and congestive
heart failure. She was given a nebulizer treatment and lasix
20mg IV x 1 without significant improvement. She was written for
levofloxacin 250mg x 1. She was determined to be DNR/DNI,
confirmed with the patient. She was transferred to the ICU for
mask ventilation, frequent neb treatment, and closer monitoring.
.
On return to the floor, the patient had several problems as
below:
.
1. hypoxia/respiratory distress - The patient had CXR findings
c/w PNA and CHF. She was treated w/ vanco/zosyn and became
afebrile w/ a normal WBC on this regimen. Her cultures were
never positive. Her home lasix was restarted and she responded
well to this. She was maintained on nebulizer treatments
throughout her stay and was stable on 2L prior to d/c.
.
2. CV:
A. Coronaries: The pt has known CAD with 3vd s/p multiple
interventions. Although there are no ECG changes to explain this
acute decompensation, it would be difficult to interpret in the
setting of paced rhythm. CE were cycled 3 times, trop max of
0.16, likely due to demand ischemia, CK and MB were negative.
She was continued on cont. ASA 325mg once daily, plavix 75mg
once daily, lipitor 80mg QHS and metoprolol 12.5mg [**Hospital1 **]
.
b. Pump: The acute decompensation as well as the CXR finding is
consistent with some degree of CHF. Given the concomitant
opacities noted on CXR and concern for infectious process, we
aimed for modest diuresis 500cc-1L initially. She was given IV
lasix which she responded well to. She was also continued on
imdur/hydral and metoprolol as above. Her BP and urine output
decreased which was thought to be secondary to her
antihypertensives so hydral and imdur was discontinued. She
should eventually be started on [**Last Name (un) **] (ACE allergy) for afterload
reduction but because her BP was running from 100-110 systolic
this decision was deferred to the outpatient setting.
.
c. Rhythm: The pt has a hx of sick sinus node dysfunction and is
s/p PPM. In addition, she has a history of afib and is on
coumadin anticoagulation and Amiodarone HCl 200mg po daily.
Amiodarone was continued. Coumadin was held initially given
concern for bleeding (see below) but restarted once the hct was
stable.
.
3. Anemia with acute drop in hematocrit - pt w/ Hct drop of 9
points, now stable. This was thought to be not likely a true
drop - 33 likely a spurious value. Pt received 2 units PRBCs,
and hct remained stable ~29 thereafter. She has a h/o chronic
anemia secondary to CRI.
.
4. CRI: elevation of creatinine on admission but trending down
to baseline at the time of d/c.
.
5. C diff - she has a history of recent c diff that has
resolved. HOwever, given that antibiotics were restarted, will
continue flagyl while abx are being used, stop it when other abx
are d/c'd.
.
6. Hypothyroidism - continued levothyroxine
.
Communication - daughter [**Telephone/Fax (1) 110810**] (H), [**Telephone/Fax (1) 110811**](W),
[**Telephone/Fax (1) 110812**](C)
.
Code status - DNR/DNI, confirmed w/ pt through interpreter.
Medications on Admission:
Medications on admission:
1. ASA 325 mg daily
2. Plavix 75 mg daily
3. Levothyroxine 25 mcg daily
4. Simvastatin 80 mg daily
5. Metoprolol Tartrate 12.5 mg twice daily
6. Multivitamin 1 tab daily
7. Amiodarone 200mg daily
8. Iron sulfate daily
9. Epoetin Alfa 4,000U qMo/We/Fri- Discontinued at [**Hospital1 5595**]
10. Aranesp 40mcg qWeek
11. Hydralazine 25 mg q6h
12. Protonix 40 mg daily
13. Trazodone 25 mg Tablet QHS PRN
14. Isosorbide Mononitrate 60 mg daily
15. Tylenol prn
16. Dulcolax prn
17. Furosemide 20 mg daily
18. Warfarin 1 mg daily
19. Flagyl 500 mg po tid (started [**2156-1-1**])
20. NTG prn
21. Prochlorperazine prn
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. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) Nebulizer
Treatment Inhalation Q3H (every 3 hours).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
16. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
17. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours) for 7 days.
18. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Pneumonia
CHF
Reactive Airway Disease.
AFib
CAD
Discharge Condition:
Fair- the patient still needs assistance with ADLs. She needs
several breathing treatments per day.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: to less than 1.5 Liters per day.
Followup Instructions:
Please follow up with Physicians at [**Hospital 100**] Rehab.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 5376**] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2156-1-27**]
3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2156-2-13**] 9:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1636**]
Completed by:[**2156-1-20**]
|
[
"427.31",
"428.0",
"428.30",
"274.9",
"272.0",
"401.9",
"285.9",
"593.9",
"414.01",
"530.81",
"486",
"244.9",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10534, 10599
|
4701, 8298
|
236, 243
|
10691, 10794
|
3249, 4678
|
10994, 11524
|
2804, 2808
|
8985, 10511
|
10620, 10670
|
8350, 8962
|
10818, 10971
|
2823, 3230
|
185, 198
|
271, 2177
|
2199, 2489
|
2505, 2788
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,312
| 108,767
|
47660
|
Discharge summary
|
report
|
Admission Date: [**2168-8-28**] Discharge Date: [**2168-8-30**]
Date of Birth: [**2109-11-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
ETOH intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58M h/o SVT, CAD s/p stent, chronic EtOH abuse, depression and
anxiety presenting with EtOH intoxication. The patient reports
his was brought in after passing out after drinking [**12-1**] a bottle
of bourbon. He reports that he has been not drinking very
frequently because he is in a detox program but he was nervous
this week after seeing Dr [**Last Name (STitle) 724**] regarding a brain tumor that was
identified on his last admission. He was scheduled to have an
MRI next week to further evaluate the lesion and he was very
nervous about that. He reports prior to the day of admission,
he last drank 2 weeks ago. He does not get tremulous when he
does not drink. Denies SI/HI. + depression.
ROS: Denies headache, chest pain, palpitations, shortness of
breath, abdominal pain, urinary symptoms. + constipation today.
In the ED, the patient was found to be intoxicated and expressed
suicidal ideations to the resident. Inital vitals were 99.0 82
136/76 18 95%RA. Upon sobering up, the patient was seen by
psychiatry and denied SI's. He was persistently tachycardic and
hypertensive and required valium 5mg x 3, ativan 2mg x 2, and
metoprolol 50mg PO x 1. His HR remained elevated in the 130's
to 140's. He also received a MVI/thiamine 100mg/folic acid 1mg.
He was transfered to the ICU for closer monitoring for ETOH
withdrawal.
Past Medical History:
-- HTN
-- CAD s/p RCA stent in [**8-/2164**]
-- s/p closed fract tib/fib
-- SVT (AVRT v. AVNRT)
-- Chronic EtOH abuse (no h/o seizures; s/p detox 3 years ago,
referred to [**Hospital1 1680**] house partial hospitalization program [**5-5**])
-- Depression/anxiety ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 66064**] [**Numeric Identifier 100681**] @ [**Hospital1 1680**] JP;
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12528**] [**Telephone/Fax (1) 5260**])
-- Neurofibromatosis - dx on last admission
Social History:
Unemployed, living alone in [**Location (un) **] MA. Graduated from [**University/College 72402**]with a major in business, most recent work was as a
security guard. Originally from [**Hospital1 40198**] MA. No siblings or other
family. Denies illicit drugs. The patient has been drinking
chronically since the mid [**2150**]'s. He was sober from [**2157**]-[**2160**].
In addition, he was sober from [**Month (only) 116**] to [**2167-10-30**], but
relapsed after losing his job. He has had multiple blackouts,
but denies history of w/d seizure or DT's. He denies any
history of illicit drug use. He quit smoking 20 years ago, and
smoked [**4-3**] cigs/day at that time.
Family History:
Mother with depression and CAD.
Physical Exam:
T 97.2 BP 138/117 HR 121 RR19 O2 95%RA
General: comfortable, lying in bed, appears slightly dissheveled
HEENT: PERRL, poor dentition
Neck: soft, NT/ND
Cardiac: tachycardic
Pulmonary: CTA B/L
Abdomen: soft non-tender, non-distended, + bowel sounds
Extremities: no edema, mild tremor of the hands
Skin: numerous small subcutaneous nodules
Pertinent Results:
None
Brief Hospital Course:
The patient is a 58M h/o SVT, CAD s/p stent, chronic EtOH abuse,
depression and anxiety presenting with EtOH intoxication.
# EtOH intoxication/withdrawl: The patient is a chronic ETOH
abuser but has been in an outpatient treatment program. Prior
to the day of admission he had not had a drink in 2 weeks. He
was nervous about an upcoming MRI and drank heavily on the day
of admission. He was admitted to the ICU for concern of ETOH
withdrawl. The patient was tachycardic at the time of
admission, but after being placed on his home dose BB his rate
was well controlled. He was placed on valium TID and PRN based
on CIWA scale. He received MVI/thiamine and folic acid daily.
During his hospital course he did not require any CIWA coverage
and did not show any signs of withdrawl. His valium was quickly
tapered to [**Hospital1 **] and then daily. He was not discharged with any
benzos. Social work met with the patient to coordinate his
continued outpatient care. The patient was discharged directly
from the ICU.
# Tachycardia: The patient has a history of h/o SVT (AVRT vs.
AVNRT). His HR was in the 130s in ED, but was well controlled
in the ICU after being placed back on his home dose beta blocker
(metoprolol 50 TID). He was discharged on atenolol 100mg daily.
# Neurofibromatosis: The patient was diagnosed with
neurofibromatosis on his last admission earlier this month. He
was scheduled for an MRI [**8-30**] (day of discharge) on the [**Hospital Ward Name **] as part of a study protocol. The person in charge of the
protcol ended up canceling that appointment and they will call
the patient to reschedule. He will follow with Dr [**Last Name (STitle) 724**] in
clinic.
# Anxiety/Depression: He was continued on celexa.
Medications on Admission:
ASA 81 mg [**Last Name (un) **]
Celexa 20 mg qday
Atenolol
Lisinopril
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day:
Please take one pill daily. .
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
ETOH intoxication
ETOH withdrawl
Secondary Diagnosis:
Chronic EtOH abuse
HTN
CAD s/p RCA stent in [**8-/2164**]
s/p closed fract tib/fib
SVT (AVRT v. AVNRT)
Depression/anxiety
Neurofibromatosis
Discharge Condition:
Stable - Patient was ambulating, tolerating oral intake, and has
returned to his baseline condition.
Discharge Instructions:
You were admitted to the hospital with alcohol withdrawal. It
will be important for you to abstain from further alcohol use
and continue your program at [**Hospital1 1680**] House.
When you were in the hospital, we also increased your heart rate
medication to atenolol 100mg daily.
Followup Instructions:
Please follow-up with the following appointments:
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2168-8-31**]
1:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 815**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2168-9-1**]
2:30
|
[
"414.01",
"V45.82",
"300.4",
"291.0",
"427.89",
"237.70",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5768, 5774
|
3425, 5174
|
333, 339
|
6031, 6134
|
3396, 3402
|
6466, 6786
|
2991, 3024
|
5294, 5745
|
5795, 5795
|
5200, 5271
|
6158, 6443
|
3039, 3377
|
276, 295
|
367, 1720
|
5869, 6010
|
5814, 5848
|
1742, 2282
|
2298, 2975
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,370
| 151,399
|
21378
|
Discharge summary
|
report
|
Admission Date: [**2182-6-10**] Discharge Date: [**2182-6-10**]
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Found Down
Major Surgical or Invasive Procedure:
Femoral CVL line placement
Endotracheal intubation
History of Present Illness:
This is a [**Age over 90 **] year old female with history of insulin dependent
DM, HTN, and cerebrovascular disease who presented after being
found unresponsive at her home and having had a PEA arrest. The
patient was last seen three days prior to presentation when she
reported feeling somewhat unwell but had no particular
localizing symptoms. She was not seen in the ensuing days over
the weekend and then today her paperboy noted multiple papers
piled up on the porch. He called the police who broke into the
house and discovered the patient breathing but minimally
reponsive. EMS was then called and arrived on the scene found
her in rapid AF with hypotension, intubated the patient in the
field, and brought her to the ED. En route to the ED the
patient did have a PEA arrest and received epinephrine and
atropine before arriving in the ED where converted to VF,
received one defibrillation attempt, and then another round of
epi/atropine before return of spontaneous circulation though she
was quite hypotensive. She also received one amp bicarbonate,
six liters of fluid, and was started on phenylephrine. ET tube
was replaced in ED due to noted abdominal distension and concern
field intubation was esophageal. PIV placed in the field noted
to be infiltrated with surrounding arm cold. Labs revealed
leukocytosis to 19.1, lactate of 6.6 and ABG 7.13/65/38. CT
scan head showed hypoattenuation of the entire left parietal
lobe, CT chest with bilateral pleural effusions/ consolidations
and multiple pulmonary emboli with clot in the left atrial
appendage. She received vancomycin and pipercillin-tazobactam
for undifferentiated shock. Cardiology was consulted regarding
atrial fibrillation and recommended against rate control given
it was felt high rate was needed to compensate for poor
contractility post arrest.
Past Medical History:
- insulin dependent diabetes
- CVA earlier this year causing hallucinations per report
- afib on ASA
- Hypertension
Social History:
Lives independently in [**Location (un) 1411**].
Family History:
Unknown.
Physical Exam:
Vitals: 33 C 154 105/91 33 100%
General: Intubated, not sedated, posturing
HEENT: Pupils 4 mm, non-reactive
Neck: supple, JVP not assessed, no LAD
Lungs: Diffuse crackles bilaterally
CV: Irreg irreg, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: Cold, left arm with marked cyanosis distal to site of field
IV
Neuro: Unresponsive off sedation, no withdraw to pain/noxious
stimuli, + posturing, pupils fixed, dilated, non-reactive
bilaterally
Pertinent Results:
===================
LABORATORY RESULTS
===================
WBC-19.1* RBC-4.50 Hgb-14.0 Hct-43.2 MCV-96 RDW-14.1 Plt Ct-145*
---Neuts-79* Bands-1 Lymphs-11* Monos-9
Hypochr-NORMAL Anisocy-1+ Poiklo-2+ Macrocy-1+ Microcy-NORMAL
Polychr-OCCASIONAL Burr-2+
PT-16.1* PTT-40.7* INR(PT)-1.4*
Glucose-276* UreaN-58* Creat-1.1 Na-141 K-4.3 Cl-106 HCO3-16*
Calcium-12.8* Phos-6.8* Mg-2.4
ALT-35 AST-62* CK(CPK)-708* AlkPhos-58 TotBili-0.4
cTropnT-0.49* CK-MB-26* MB Indx-3.7
VBG at presentation 7.13/ 65/ 38 / 23 Lactate-5.8*
==============
OTHER RESULTS
==============
Images:
CT spine: No acute fracture or malalignment.
.
CT abdoman/ pelvis:
1. Segmental pulmonary emboli - right and left lower lobes.
2. Bilateral pleural effusion, pulmonary edema, and right middle
and lower lobe opacities (infection, atelectasis, aspiration).
3. Cardiomegaly and [**Hospital1 **]-atrial enlargement
4. Clot in left atrial appendage
5. Multiple bilateral rib fractures.
6. Periportal edema and gallstones.
.
CT head:
-Large confluent areas of hypoattenuation involving the entire
left parietal lobe, the left temporal lobe and the right
posterior parietal region -- concerning for diffuse ischemia.
-Local mass effect and sulcal effacemnt - No midline shift or
signs of herniation.
-No ICH or fracture.
.
EKG: afib with RVR
Brief Hospital Course:
[**Age over 90 **] y/oF with insulin dependent DM, afib not coumadin, recent CVA
w/o residual neurologic deficits found unresponsive at home,
likely down time 2-3 days, in afib with RVR c/b PEA arrest en
route to hospital, now intubated, with massive MCA infarcts, LV
thrombus, bilateral PE.
At presentation it was unclear how long the patient had been
immobilized though her lactic acidosis, high CK, and story of
missing multiple papers would suggest a prolonged
incapacitation. Unclear what was the primary lesion though
given PE, embolic strokes, and clot in left atrial appendage
would suspect widespread embolism from atrial clot with CVA
causing profound alteration in mental status and obtundation.
Patient likely then with secondary rhabdomyolysis and lactic
acidosis from muscle breakdown, poor perfusion, and likely
hypoventilation/poor perfusion.
At time of her arrival patient with no purposeful neurological
activity, posturing and large areas of ischemia from emboli.
She was in severe shock with two pressors required to maintain
blood pressures likely from components of obstructive (secondary
to PE) and distributive (due to acidosis, SIRS) pathology.
Given these factors prognosis was considered to be extremely
poor. After arrival of the family and discussion of very poor
prognosis they agreed to make the patient DNR/DNI and withdraw
pressors and life sustaining treatments. She was started on
morphine drip for comfort, extubated, and vasopressors were
stopped. She passed away < 30 minutes later. Family refused
autopsy.
Medications on Admission:
ASA
Discharge Medications:
None, pt deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Pt deceased
Discharge Condition:
Pt deceased
Discharge Instructions:
Pt deceased
Followup Instructions:
Pt deceased
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
"V58.67",
"785.59",
"401.9",
"427.31",
"728.88",
"415.19",
"276.2",
"250.00",
"434.11",
"410.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.09"
] |
icd9pcs
|
[
[
[]
]
] |
5998, 6007
|
4348, 5902
|
264, 316
|
6062, 6075
|
3018, 4007
|
6135, 6241
|
2403, 2413
|
5956, 5975
|
6028, 6041
|
5928, 5933
|
6099, 6112
|
2428, 2999
|
214, 226
|
344, 2182
|
4016, 4325
|
2204, 2321
|
2337, 2387
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,416
| 164,225
|
10454
|
Discharge summary
|
report
|
Admission Date: [**2167-4-21**] Discharge Date: [**2167-4-30**]
Date of Birth: [**2107-9-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
MVA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The 59 yo male, h/o CAD s/p CABG in [**2161**], DM1, HTN, CRI (b/l
creat=2.6-2.8), transferred to MICU service for increasing SOB.
Pt was originally transferred from LGH on [**2167-4-21**]. He was
reportedly restrained driver of a motorvehicle; Car was T-boned
by another vehicle, collision at about 40 mph. He was found to
have multiple rib fractures (right 6-9th) and fractures of
transverse processes of right sided L1-3. He was also noted to
have a small left apical pneumothorax, liver lacerations, with a
moderate perihepatic hematoma. He was transferred to [**Hospital1 18**] on
[**4-21**] for further monitoring. Throughout hospital course, he has
been hemodynamically stable. Creatinine was noted to be elevated
(to as high as 5), and a temporary HD [**Last Name (un) **] was placed on
[**2167-4-24**] (R IJ) for initiation of HD; prior to this, pt had been
managed without dialysis. [**Last Name (un) **] was consulted for management of
his diabetes. Dermatology is also following for ?rash/blistering
area on posterior cervical area. TTE on admit showed moderately
depressed EF with some anterior/inferior HK (anterior HK is
new).
On the morning of [**4-24**], he was acutely SOB when returning from
IR suite (where HD catheter had been placed). He was given lasix
(20mg, then 40 mg, IV lopressor), EKG demonstrated TWI/ST depre
in anterolateral distribution (similar to admit EKG). He
reported diaphoresis and right rib pain but denied any other sx.
He was seen by cardiology on [**4-24**] for ?SOB and EKG changes
(anginal equivalent in the past had been chest and shoulder
discomfort). Cardiac enzymes have been repeatedly negative.
Cardiology recommended optimizing medical mgt with beta
blockade, ASA, statin, plavix when hct stable (ddx NSTEMI vs.
cardiac contusion from trauma). Repeat TTE and diuresis (lasix
and nitro gtt) were also recommended. Pt was transferred to MICU
on [**4-24**] for management of his multiple medical issues and for
SOB following transfusion of PRBC.
Currently, he states his breathing is improved (s/p lasix 60 mg,
HD with 2 kg removed). He continues to report right sided rib
pain but denies new CP/jaw pain/shoulder pain. He states that he
was diaphoretic at time of SOB but denied n/v. He reports
occasional LE edema at home; he sleeps on 1 pillow and states he
does wake up sob at times in the night. No other complaints
currently.
Past Medical History:
1. Type 1 DM, on insulin pump
2. CRI, b/l creatinine 2.6-2.8, was not previously on HD;
nephrologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 34543**] ([**Telephone/Fax (1) 34544**]), PCP [**Name Initial (PRE) 34545**] ([**Telephone/Fax (1) 34546**])
3. CAD (3vd-60% LMCA, 90% mid LAD, 100% mid lcx, 100% prox RCA)
s/p CABG in [**2161**] with LIMA to LAD, SVG to PDA, SVG to ramus
intermedius, EF was 50% at this time
4. PVD, s/p bilateral fem-[**Doctor Last Name **] bypasses
5. HTN
6. Hypercholesterolemia
7. Gout
Social History:
Lives at home with family, quit smoking 7 yrs prior, drinks a
6-pack beer/day
Family History:
Seizures, brother with ESRD on HD (with DM)
Physical Exam:
Gen: NAD, pleasant male, lying in bed, able to speak in full
sentences
HEENT: PERRL, OP clear
Neck: no JVD appreciated although difficult exam with neck and
breathing pattern
Lungs: diffuse rhonchi and crackles, no wheezing, no focality
CV: HS obscured by BS; nl s1/s2, no m/r/g appreciated
ABD: soft, with midline and right sided surgical scars;
ecchymotic region under right nipple; some TTP in this area. No
HSM appreciated, NABS
Extr: s/p amputation of left 5th toe, with dry, crusty ulcers on
LE, dry skin, no erythema
Skin: blistering area on back of neck (with dry bandages in
place); hyperpigmentation of skin diffusely, esp in
intertriginous areas
Pertinent Results:
[**2167-4-21**] 12:45PM BLOOD WBC-11.2* RBC-3.78* Hgb-11.4* Hct-33.4*
MCV-88 MCH-30.1 MCHC-34.1 RDW-18.0* Plt Ct-179
[**2167-4-21**] 12:45PM BLOOD PT-12.6 PTT-22.6 INR(PT)-1.1
[**2167-4-21**] 12:45PM BLOOD Fibrino-386
[**2167-4-24**] 01:40PM BLOOD Fibrino-653*#
[**2167-4-21**] 12:45PM BLOOD UreaN-132* Creat-4.5*
[**2167-4-21**] 12:45PM BLOOD CK(CPK)-987*
[**2167-4-21**] 06:19PM BLOOD ALT-66* AST-72* LD(LDH)-356*
CK(CPK)-1056* AlkPhos-33* Amylase-91 TotBili-0.3
[**2167-4-27**] 06:00AM BLOOD CK(CPK)-277*
[**2167-4-21**] 12:45PM BLOOD CK-MB-30* MB Indx-3.0 cTropnT-0.20*
[**2167-4-23**] 05:00PM BLOOD CK-MB-38* MB Indx-5.2 cTropnT-0.34*
[**2167-4-26**] 07:28AM BLOOD CK-MB-6 cTropnT-0.97*
[**2167-4-27**] 06:00AM BLOOD CK-MB-7 cTropnT-1.20*
[**2167-4-23**] 11:20AM BLOOD %HbA1c-8.6* [Hgb]-DONE [A1c]-DONE
[**2167-4-21**] 12:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2167-4-24**] 01:57PM BLOOD Type-[**Last Name (un) **] pO2-33* pCO2-60* pH-7.32*
calHCO3-32* Base XS-2
[**2167-4-21**] 12:46PM BLOOD Glucose-72 Lactate-1.4 Na-146 K-3.0*
Cl-99* calHCO3-35*
[**2167-4-21**] 12:45PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2167-4-21**] 12:45PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2167-4-21**] 12:45PM URINE Hours-RANDOM UreaN-384 Creat-41 Na-69
[**2167-4-21**] 12:45PM URINE Osmolal-370
[**2167-4-21**] 12:45PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
MRSA and VRE screens negative
[**2167-4-21**] CT Spine - No evidence for fracture, there is small left
apical pneumothorax with possible contusion/hemorrhage. Please
see torso CT from today for further evaluation of the lungs.
[**2167-4-21**] X-ray Knees - 1) No acute fracture is detected. Limited
views of the knees. 2) Probable small left knee joint effusion,
with prominence of the prepatellar soft tissues. The latter may
relate to a small subcutaneous hematoma versus prominent
prepatellar bursa.
[**2167-4-21**] Femur X-ray - 1) No acute fracture is detected. Limited
views of the knees. 2) Probable small left knee joint effusion,
with prominence of the prepatellar soft tissues. The latter may
relate to a small subcutaneous hematoma versus prominent
prepatellar bursa.
[**2167-4-21**] CT Torso -
1. Extensive perihepatic hematoma surrounding the liver.
Evaluation for parenchymal disruption is not possible due to
lack of IV contrast, and correlation to the prior outside CT
with contrast should be made to [**Month/Day/Year 11197**] the degree of parenchymal
disruption. Findings discussed with Dr. [**Last Name (STitle) 33863**] 3:00 pm [**2167-4-21**].
2. Small hemothorax. Ground glass opacity dependently consistent
with a combination of atelectasis and pulmonary
contusion/hemorrhage.
3. Multiple rib fractures and transverse processes fractures on
the right as described above.
4. Trace left apical pneumothorax, although better visualized on
the prior cervical spine CT than on this study.
[**2167-4-21**] ECHO - The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function appears to be at least moderately depressed; the
inferior and anterior walls, as well as apex, appear
hypokinetic. Right ventricular chamber size and free wall motion
are normal. The aortic root 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. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
[**2167-4-29**] ECHO - The left atrium is mildly dilated. Overall left
ventricular systolic function is mildly to moderately depressed
with inferior and infero-lateral akinesis including the
infero-apex. The remaining segments appear normal although the
anterior well is not completely visualized.. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. The tricuspid
regurgitation jet is eccentric and may be underestimated. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. Compared with the prior study (images
reviewed) of [**2167-4-21**], the findings are probably similar.
Brief Hospital Course:
The patient is a 59 yo man with hx of CAD s/p CABG in [**2161**], DM,
htn, CRI with baseline scr in the 2's who was taken to [**Hospital1 5979**] Hosp [**4-21**] after he was involved in a MVA. He was
transferred to [**Hospital1 18**] the same day. He sustained multiple
right sided rib fractures and fractures of his L1-3 transverse
processes. He also sustained liver laceration with associated
hematoma. He also had a small left apical pneumothorax. He was
originially seen by the trauma team but was followed by medicine
due to his multiple medical problems.
SOB: On [**4-24**] the pt became acutely SOB when returning from IR
suite where he had a HD catheter place. This was thought likely
[**1-1**] to volume overload as he had worsening renal failure. He had
also received 2 units of PRBCs prior to this incident. CXR
showed changes c/w failure (new from prior CXR). EKG at that
time demonstrated TWI/ST depressions in an anterolateral
distribution, but this was unchaged from his admit EKG. He
reported diaphoresis and right rib pain but denied any other sx.
His symptoms improved s/p HD and diuresis (received lasix 20 mg,
then 40 mg, in acute setting of SOB). Additionally he was on
torsemide as outpt, and this was being held. There was also the
possibility of ischemia at that time. His cardiac enzymes at
that time were negative and cardiology recommended optimizing
medical mgt with beta blockade, ASA, statin, plavix when hct
stable (ddx NSTEMI vs. cardiac contusion from trauma). His
respiratory function remained stable on the floor.
CRI: Pt has CRI likely [**1-1**] to HTN and diabetes. Patient's Cr
trended up to a peak of 5 during his admission, which is well
above his baseline. He had a trialysis catheter placed in R SC
on [**4-24**] and HD was initiated after that. Renal followed the
patient throughout his stay. He ended up needing 2 sessions of
dilaysis for fluid overload after which his creatinine trended
back to baseline. He will follow up with renal as an
outpatient.
CAD: s/p CABG in [**2161**]; His SOB was most likely [**1-1**] to volume
overload but could also have been [**1-1**] to CAD and ACS. Pt's cks
were elevated early on and troponin continued to trend up during
his stay with a peak of 1.28 on the day of discharge. His MB
index and MB fraction remained low. He had anterolateral ST
depressions/TWI on his EKG at admission and a ?new anterior
hypokinesis on echo. Cards was consulted and did not think he
was a good cath candidate. He was medically managed with ASA,
statin and a BB. The felt that the differential diagnosis
included NSTEMI vs. Cardiac contusion from trauma, but that if
it was an NSTEMI it was not acute. They recommended he follow
up with cardiology for an outpatient stress test.
DM: Pt has type one DM and was on insulin pump at home. He was
monitored closely on an insulin gtt in the MICU. He has an
insulin pump at home, but this was not working properly, so he
was given standing insulin and a humalog SS on the floor and
followed by [**Last Name (un) **]. His hgbA1c was noted to be 8.6. He was not
well regulated with lantus/humalog and he was switched to U500
standing dose with humalog and his sugars became better
controlled. His wife obtained a new insulin pump and he was
restarted on his home pump levels.
HTN: Contined BB and followed his pressures.
Hypercholesterolema: He was continued on a statin but his tricor
was held [**1-1**] renal failure. Cholesterol levels were checked and
his statin was increased to 40mg. 48 hours later his CK was
noted to have tripled and he developed a transaminitis. His
statin was decreased back to his home dose of 20mg.
Derm: He was noted to have blisters on the back of his neck.
Derm was consulted and thought it was likely [**1-1**] to volume
overload. They recommended bacitracin to open areas.
Liver laceration: The patient was admitted s/p MVA. He
developed a liver laceration during the accident. His hct was
followed and he require a transfusion of 2 units of PRBCs. He
was on the trauma surgery service initially, but no surgery was
done and he was transferred to the MICU after his SOB. His hct
remained stable after that.
MVA: The patient developed a liver laceration and rib fractures
after the MVA. HIs liver laceration was managed as above. His
pain was controlled with RTC tylenol and oxycodone. He will
follow up with trauma surgery as an outpatient.
Medications on Admission:
Meds at home:
Plavix 75
ASA 325
Insulin pump
Lipitor 20
Lopressor 25 mg [**Hospital1 **]
Atrovent
Torsemide 100
Tricor 145
Aricept 5
Prozac 20
Zetia 10
Allopurinol 300
.
Meds on transfer:
Calcium carbonate 1000 mg TID
Insulin gtt
nitro gtt
morphine PRN
Lopressor 25 mg [**Hospital1 **]
Protonix
Mupirocin cream
Discharge Medications:
1. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 bottle* Refills:*2*
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
5. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours) for 10
days.
Disp:*20 Tablet Sustained Release 12HR(s)* Refills:*0*
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain for 10 days.
Disp:*50 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Hibiclens 4 % Liquid Sig: One (1) Topical QD () for 10
days: apply to back of neck once a day.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Acute on Chronic Renal Failure
Diabetes Mellitus
Rib Fractures
Cardiac Contusion with troponin leak
Discharge Condition:
Stable. Hct stable. Tolerating PO intake and oral pain meds.
Discharge Instructions:
--We have increased your lopressor to 50mg three times a day.
You should continue to take liptor 20mg as you were prior to the
accident.
--You have now restarted your insulin pump and will need to see
your endocrinologist as soon as possible.
--You will also need to have a stress test to check you heart.
Please call the cardiology department to make an appointment.
Tell them you saw Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 34547**] in the hospital. The
number is:([**Telephone/Fax (1) 9490**].
Followup Instructions:
--Please call Dr. [**Last Name (STitle) 34548**] for a follow up appointment within
the next 1 week. You can ask Dr. [**Last Name (STitle) 34548**] to set up a stress
test for your heart.
--If the blisters on your neck worsen, you can call the
[**Hospital 2652**] Clinic for an appointment. The number is
[**Telephone/Fax (1) 1971**].
--Please make an appointment with your endocrinologist within
the next few days.
--If is very important for you to see a cardiologist and
schedule and outpatient stress test. Please call the cardiology
department to make an appointment. Tell them you saw Dr. [**Last Name (STitle) **]
and Dr. [**Last Name (STitle) 34547**] in the hospital. The number is:([**Telephone/Fax (1) 9490**].
-- You have an appointment with Dr. [**Last Name (STitle) **] (Trauma Surgery) on
Tuesday [**5-12**] at 10:30. Dr. [**Last Name (STitle) 34549**] office is located at [**Hospital Unit Name 34550**]. Please call [**Telephone/Fax (1) 6439**] if
you have questions or need to change the appointment. This is
an important appointment to check on your rib fractures and
liver.
--You also need to make an appointment with your nephrologist to
follow your kidney function.
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,800
| 132,255
|
42217
|
Discharge summary
|
report
|
Admission Date: [**2159-9-23**] Discharge Date: [**2159-10-1**]
Date of Birth: [**2076-1-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Cholangitis, Hypotension
Major Surgical or Invasive Procedure:
ERCP with stent placement
Laproscopic Cholecystectomy
History of Present Illness:
83yoF with hyperlipidemia, COPD, [**Hospital **] transferred from OSH with
concern for cholangitis and shock. Patient states earlier today
she had chills and abdominal pain, and at the urging of her
daughter, went to an OSH [**Name (NI) **]. She notes yesterday she had
nausea/vomiting and loose stools x 5 that were dark.
She went to OSH, where he SBP's were noted to be in the 60's.
Per report, she was started on dopamine peripherally and
received flagyl and cefoxitin. Unknown how much IVF she may have
received there. Per report, she was tachycardic, so a CTA was
done that showed ?PE.
Upon transfer to our ED inital vitals were, T 104 HR 100 BP
74/40 RR 16 Pox 98%. A right IJ was placed and she was started
on levophed. She received 5L IVF and had new oxygen requirement
of 4L NC subsequently. Labs were remarkable for lactate 2.8, WBC
20 with 7% bands, Hco3 18 with anion gap of 14, Na 131, Tbili
5.3, ALT 210, AST 201, AP 115. UA showed 22 WBC, few bacteria,
neg nitrites and leuk. Our radiologists were asked to read the
CTA from OSH and were not convinced of definitive PE;
recommended repeat CTA tomorrow. RUQ ultrasound showed: Dilated
intrahepatic bile ducts and CBD (to 1.3 cm). Moderately
distended GB with small neck stones. Pericholecystic fluid No
ductal stone detected, but limited evaluation of the distal
segment. Early cholecystitis and/or distal obstructive
choledocholithiasis cannot be excluded.
Surgery and ERCP were consulted. Surgery will follow along;
recommend ERCP, then will consider cholecystectomy. ERCP fellow
was contact[**Name (NI) **] by [**Name (NI) 153**] team and asked us to prepare for urgent
bedside ERCP, but had not yet staffed consult with attending.
Vitals on transfer BP 109/47 on levophed, RR 20-28, 100% on 4L
NC. CVP 14-16.
In the ICU, patient complains of SOB, stating it is difficult to
take in a breath. She also notes abdominal pain, and points
mostly to epigastric/RUQ area.
Past Medical History:
COPD
Osteoarthritis
Hypercholesterolemia
spinal tumor s/p radiation/chemo [**2141**]
L lung tumor s/p chemotherapy [**2142**]
Social History:
Has three daughters, son. [**Name (NI) **] is HCP.
- Tobacco: current smoker, 1ppd
- Alcohol: heavy in past, has now quit
- Illicits: Denies
Family History:
Non-contributory to septic shock from gallstones
Physical Exam:
Per admitting physician [**Name Initial (PRE) **]:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP to mid SCM in 45 degree angle, no LAD
Lungs: crackles R>L, decreased BS b/l
CV: Regular rate and rhythm, normal S1 + S2
Abdomen: Soft, +distension, tender at epigastrium and RUQ, no
rebound or guarding, normoactive bowel sounds
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Exam:
98.6 137/77 77 18 97%RA
Scant bibasilar rales
Abdomen protuberant but non-tender, surgical sites c/d/i
2+ LE edema
Pertinent Results:
admission labs:
[**2159-9-22**] WBC-20.4* RBC-4.24 HGB-11.7* HCT-35.2* MCV-83 MCH-27.5
MCHC-33.2 RDW-15.0
[**2159-9-22**] NEUTS-84* BANDS-7* LYMPHS-3* MONOS-3 EOS-0 BASOS-0
ATYPS-0 METAS-3* MYELOS-0
[**2159-9-22**] PT-16.2* PTT-37.0* INR(PT)-1.4*
[**2159-9-22**] GLUCOSE-85 UREA N-18 CREAT-1.1 SODIUM-131*
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-18* ANION GAP-17
[**2159-9-22**] ALT(SGPT)-210* AST(SGOT)-201* ALK PHOS-115* TOT
BILI-5.3*
[**2159-9-22**] LIPASE-15
[**2159-9-23**] LACTATE-2.1*
Micro:
blood cx: [**2159-9-22**]
[**1-3**] sets with:
GRAM NEGATIVE ROD(S)
|
CEFEPIME-------------- S
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- S
GENTAMICIN------------ S
TOBRAMYCIN------------ S
Imaging:
LENI: [**2159-9-24**]
No evidence of deep vein thrombosis
CTA: [**2159-9-23**]
IMPRESSION:
1. Technically limited study as discussed with [**First Name8 (NamePattern2) **] [**Doctor Last Name **] at
11:43 a.m. on
[**2159-9-23**] by [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 11623**] over the phone. This study may be
repeated if
clinical confirmation of PE is required.
2. Trace bilateral pleural effusions with associated
atelectasis.
CXR: [**2159-9-23**]
An ET tube is present, tip in satisfactory position
approximately 2 cm above the carina, though pointed towards the
right mainstem bronchus on this view. A right IJ central line
is present, tip over distal SVC.
Question background COPD. There is upper zone redistribution,
but no overt
CHF. There is minimal atelectasis at both lung bases. Slightly
more patchy
opacity at the left lung base is noted, but unchanged compared
with [**2159-9-22**] at 23:30 p.m. Otherwise, no focal opacity is
identified. No effusion
RUQ U/S: [**2159-9-22**]
Moderately distended gallbladder with multiple neck stones, CBD
and intrahepatic bile duct dilation, and focal gallbladder wall
edema.
Obstructive choledocholithasis is a strong consideration.
Cholecystitis is
also possible. Cholangitis cannot be diagnosed with this
technique
.
Discharge Labs:
[**2159-10-1**] 05:45AM BLOOD WBC-10.8 RBC-3.79* Hgb-10.4* Hct-31.9*
MCV-84 MCH-27.5 MCHC-32.8 RDW-16.5* Plt Ct-332
[**2159-9-29**] 06:10AM BLOOD PT-14.6* PTT-30.4 INR(PT)-1.3*
[**2159-10-1**] 05:45AM BLOOD Glucose-77 UreaN-2* Creat-0.5 Na-135
K-3.7 Cl-101 HCO3-27 AnGap-11
[**2159-9-29**] 06:10AM BLOOD ALT-28 AST-22 AlkPhos-98 TotBili-0.9
[**2159-9-29**] 06:10AM BLOOD Calcium-8.1* Phos-2.1* Mg-1.6
.
**FINAL REPORT [**2159-9-30**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2159-9-30**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
Operative Report:
PREOPERATIVE DIAGNOSES: Cholangitis, cholecystitis,
choledocholithiasis.
POSTOPERATIVE DIAGNOSES: Cholangitis, cholecystitis,
choledocholithiasis.
ASSISTANTS: [**Doctor Last Name **] [**Name Initial (MD) **] [**Name8 (MD) **], MD/[**Name6 (MD) 91517**] [**Name8 (MD) 69814**], MD
OPERATION PERFORMED: Laparoscopic cholecystectomy with
intraoperative cholangiogram.
FINDINGS: A large gallbladder with multiple gallstones,
moderate adhesions of the omentum to gallbladder, the cystic
ducts were enlarged and short. Intraoperative cholangiogram
showed no filling defects and no ductal injury.
INDICATION: The patient is an 83-year-old female who
presented on [**9-23**], with 2 days of epigastric abdominal
pain. The patient was seen at outside hospital and was found
to have ductal dilatation associated with cholelithiasis.
Her total bilirubin was 6.4 with elevated LFTs. The patient
was also hypertensive. Therefore, she was transferred to
[**Hospital1 18**] after getting cefoxitin and Flagyl. On her level, the
patient was on dopamine drip. Urgent ERCP was consulted and
the patient was admitted to the medical ICU for diagnosis of
cholangitis. The patient then underwent the ERCP on [**9-23**], which showed lots of mild pus to it at the sphincter of
Oddi. There was also a single periampullary diverticulum.
Due to cholangitic picture, stomach traction was not
performed and a stent were placed for drainage. The patient
recovered from her cholangitis and was transferred to the
floor. Her bilirubin continued to trend down and today
returned to [**Location 213**] limit of 1.3. Although the patient is a
high surgical risk due to her history of COPD and multiple
medical morbidity, including history of radiation to the
upper abdomen, we felt that she would benefit form interval
cholecystectomy to prevent future episode of cholangitis.
DESCRIPTION OF PROCEDURE: The patient was transferred from
[**Hospital Ward Name **] to wet campus preop area. Consent was verified
and the patient was brought to the operating room and placed
on the table in supine position. General anesthesia was
induced and the patient was intubated. The abdomen was
prepped and draped in normal surgical fashion. Preop
antibiotic cefazolin and Flagyl were given since the patient
had already received her usual dose of Cipro 500 more than 1
hour before the incision. Appropriate timeout was performed
to confirm the patient, the operation and location. Of note,
the patient's abdomen was noted to be distended and her
umbilicus was very close to the subxiphoid region. An
vertical incision was made 1 cm below the umbilicus. The
fascia was elevated and incised under direct visualization.
The entry into the abdomen was confirmed with the digit and 2
stay sutures were then placed. A 12-mm [**Last Name (un) 24631**] trocar was
then placed and secured. The abdomen was insufflated with
carbon dioxide to a pressure of 15 mmHg. The patient
tolerated the insufflation well. Laparoscope was inserted.
The abdomen was inspected. No injury from the initial trocar
placement was noted. The small bowel and colon were noted to
be dilated until there was no sign of ischemia. Additional
trocars were then placed in the following fashion: A 10-mm
trocar at the subxiphoid and two 5-mm trocar along the costal
margin. All the trocars were inserted under direct
visualization with the laparoscope. The table was then
placed in reverse Trendelenburg position with the right side
up.
The dome of the gallbladder was then grasped with atraumatic
grasper and passed through the lateral port and retracted
over the dome of the liver. The omentum was noted to be
adhesed to the gallbladder wall and was dissected away from
the gallbladder using both blunt and cautery. The
infundibulum was then grasped with atraumatic grasper through
the midclavicular port. This maneuver explored the
gallbladder infundibulum. The peritoneum overlying the
gallbladder infundibulum was then dissected with both blunt
and cautery. The cystic artery was identified and appeared
to be on the anterior area of the cystic duct. The
dissection was then carried out to isolate the cystic artery
and with visualization of the cystic duct. Due to the
abnormal anatomy and as the cystic artery was right on top of
the cystic duct, we proceeded to dissect the cystic artery
and doubly clamped and divided. The cystic artery was then
dissected away from the cystic duct. The dissection was
carried out to isolate the cystic duct which appeared to be
very dilated and short. Entry into the gallbladder was
individually made close to the proximal part of the cyst
duct. There was a moderate amount of small stones expressed
through the opening. As the cystic duct was dissected, we
saw that there were multiple gallstones inside the cystic
duct. Given her history of elevated BUN and alk phos still
elevated at 142, we decided to perform intraoperative
cholangiogram. Cholangiogram catheter was then passed
through the abdominal wall through an Angiocath into the
abdomen. The catheter tip was inserted through the opening
that was previously made on the gallbladder next to the
cystic duct. The Angiocath was passed through the common
bile ducts and we performed a sweep balloon extraction of the
stones and were able to extract a small amount of stones.
Cholangiogram was then performed. Results of cholangiogram
showed that the cystic duct, the common bile duct and the
hepatic duct were all dilated. There was no filling defects
and contrast was able to be visualized going to the duodenum.
The cholangiogram catheter was then withdrawn and the cystic
duct was then stable using Endo-[**Female First Name (un) 3224**] stapler.
The gallbladder was then dissected away from the liver bed.
Hemostasis was achieved using the cautery and 1 piece of
Surgicel.
The gallbladder was then removed using an endoscopic
retriever bag placed through the umbilical port. The
gallbladder was then passed off the table as specimen. The
gallbladder fossa was inspected and hemostasis was obtained.
Copious irrigation was performed with normal saline. There
was no evidence of bleeding of the gallbladder fossa or
cystic artery or leaking from the cystic duct stump.
The lap and the trocar were then withdrawn under direct
visualization of the laparoscope. The laparoscope was then
withdrawn and umbilical trocar was removed. The umbilical
trocar site was then closed with 0 Vicryl in 2 figure-of-
eight. The skin was closed in subcuticular fashion with 4-0
Monocryl and Steri-Strip was applied. Sterile dressing was
then placed.
The patient tolerated the procedures well and was taken to
the post anesthesia care unit in stable condition.
All sponge counts were correct at the end of operation.
The patient was extubated and transferred to the post
anesthesia care unit in stable condition.
Brief Hospital Course:
83F admitted to MICU with septic shock (on pressors) secondary
to E. Coli bacteremia from cholangitis secondary to a stone.
Hospitlization notable for ERCP with stent placement and
laproscopic CCY. Pt clinically improved on discharge.
ACTIVE ISSUES:
# Septic Shock: Initially presented with sepsis and hypotension
with elevated lactate signifying end organ hypoperfusion. She
received early goal directed therapy following MAP, CVP, and
SvO2 with hypotension refractory to IVF alone and requiring
pressors. Patient did require intubation during ERCP for airway
protection, but was able to be extubated following the procedure
with little difficulty. After treatment of underlying
cholangitis (see below) with ERCP and antibiotics, septic
physiology resolved.
# Cholangitis: As above, patient presented with septic shock
secondary to cholangitis with right upper quadrant ultrasound
showing CBD dilitation. She underwent emergent ERCP with
successful stent placement and drainage of pus. She was
initially placed on broad spectrum antibiotics with vancomycin/
cefepime/ flagyl which was narrowed to cipro/ flagyl based on
blood cx growing pansensitive Ecoli. Surveillance blood
cultures remained negative. Following ERCP, leukocytosis,
abdominal pain and LFTs all improved. She will require repeat
ERCP in [**3-7**] weeks for stent removal. On [**2159-9-26**] patient
underwent a laparascopic cholecystectomy. The patient had a mild
post-operative ileus that improved on [**9-28**] and the patient was
able to advance her diet. The patient will continue Cipro/Flayl
through [**2159-10-3**].
# Pulmonary Edema: Patient presented with new 4L NC oxygen
requirement and desaturation with exertion of unclear etiology.
Ddx included pulmonary edema [**1-3**] fluid resuscitation, underlying
COPD and possible PE given tachycardia. CTA x 2 (initially at
OSH, repeated on admission) were of poor quality/ nondiagnostic.
Patient was started empirically on heparin gtt pending further
diagnostic evaluation. Repeat CXR showed significant fluid
overload with bilateral pleural effusions. Respiratory symptoms
improved significantly with lasix for diuresis. After discussion
with chest radiology, V/Q scan was performed which was low
probability for PE and heparin gtt was stopped. The patient was
restarted on her home dose of spirinolactone.
# Oral Candidiasis: Pt initiated on nystatin for mouth pain once
found to have whitish plaques.
INACTIVE ISSUES:
# COPD: standing nebs, substitute advair for symbicort
# Hyperlipidemia: Restart statin on d/c.
.
TRANSITIONAL ISSUES:
- Direct signout provided to patients PCP who will be seeing her
on [**10-3**]. Antibiotics should be stopped at that appointment.
Patient still with significant LE edema. The inpatient team has
instructed the patient to restart her home spirinolactone 25mg.
This may need to be up-titrated over the next few days to weeks
until she is clinically euvolemic.
Medications on Admission:
simvastatin
Symbicort
Spiriva
Albuterol nebs
Azopt 1 % Eye Drops Ophthalmic
timolol drops
? antihypertensive
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Until [**10-3**].
Disp:*5 Tablet(s)* Refills:*0*
2. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
3. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*20 Capsule(s)* Refills:*0*
4. brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] ().
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*1 bottle* Refills:*0*
6. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
7. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
9. prednisolone acetate 1 % Drops, Suspension Sig: One (1)
Ophthalmic once a day.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnoses:
- E coli septicemia
- Cholangitis
- Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with low blood presure, due to a blood stream
infection that developed due to an obstruction of your
gallbladder system. You were treated with IV antibiotics and you
had an emergency procedure (ERCP) to relieve the gallbladder
obstruction. You later had your gallbladder removed by the
surgical team. You were started on antibiotics and restarted a
diuretic.
.
Please continue to take all of your medications please note the
following changes.
.
Please START taking:
1) Ciprofloxacin 500mg until [**10-3**]
2) Flagyl 500mg three times daily until [**10-3**]
.
Please continue taking spirinolactone 25mg daily
Followup Instructions:
PCP [**Name Initial (PRE) 648**]:
Wednesday, 1:30pm, [**10-3**]. [**Doctor Last Name **]-[**Last Name (LF) 91518**],[**First Name3 (LF) **]
[**Telephone/Fax (1) 91519**].
Dr.[**Name (NI) 21375**] office will call you to schedule a follow up ERCP
in [**3-7**] weeks.
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8,670
| 113,090
|
4486+55591
|
Discharge summary
|
report+addendum
|
Admission Date: [**2149-8-29**] Discharge Date: [**2149-9-9**]
Date of Birth: [**2079-1-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 70yo man with diabetes mellitus type 2, CAD,
140 pack year smoking history, who was transferred at the
request of his PCP from the [**Hospital6 33**] ICU to the
[**Hospital1 18**] MICU Friday [**2149-8-29**] for continued treatment of
respiratory distress requiring supplemental O2, labile blood
sugars, and a new lung mass found on CT. One week prior to
admission to [**Hospital3 **] he developped a non-productive cough,
fevers, and increased fatigue. He had a 10 pound unintentional
weight loss over the past 1-2 months. On Monday [**2149-8-25**] he was
found unresponsive at home with a FSBG of 21. He was working in
his yard when he felt dyspneic and fatigued and sat down. He
lost consciousness and awoke on the ground. He called a friend
and EMS arrived shortly.
.
In the [**Hospital6 33**] ED he received glucagon and his
glucose increased to 70. CXR revealed eosinophilic v. atypical
PNA v. inflammation from COPD exacerbation, so he was started on
Levaquin and Solumedrol and admitted. His BNP was elevated to
9248 and he was diuresed with Lasix 40 mg IV BID. On [**2149-8-27**] a
chest CT demonstrated a 4 cm spiculated mass in the LLL and
hilar and mediastinal lymphadenopathy. While on steroids, he
became hyperglycemic and he was transferred to the MICU for
insulin gtt. In the MICU he became hypoxic and was placed on a
NRB. CXR demonstrated bilateral airspace disease, pulmonary
edema, and possible atypical PNA. On transfer to the [**Hospital1 18**] MICU
on [**8-29**], his SOB was slightly improved, but he felt fatigued.
Past Medical History:
-CAD, s/p CABG in [**2131**], (LIMA to LAD, SVG to RCA, SVG to OM1,
SVG to
D1)
-PCI in [**2142**] with stenting of SVG to RCA and PDA
-Diabetes requiring insulin, complicated by peripheral
neuropathy, retinopathy
-Hypertension
-Hyperlipidemia
-Peripheral vascular disease
-Insomnia
-GI bleed secondary to peptic ulcer disease
-Chronic gastritis
-Depression
-Status post AAA repair in [**2131**]
-Status post aorto-popliteal bypass
Social History:
Married for 20 years. Worked as a machinist for [**Company 2318**], served in
the NAVY. Now retired. Reports exposure to asbestosis working
for [**Company 2318**] on a daily basis for 10 years. Never used mask or
ventilator. Tobacco: 140 pack year history, smoked 3.5 ppd, quit
14 years ago. History of alcohol abuse, sober for 37 years.
Family History:
Father died of asbestosis (worked in shipyards). Mother died of
COPD. CAD strong in family.
Physical Exam:
V/S: HR: BP: RR:18 02sat: 95% on 2 L/min)2
General: Awake and alert, lying in bed, pleasant, in no acute
distress
HEENT: Normocephalic and atraumtic, sclera anicteric, oral and
nasal mucosa pink and without exudates
Neck: full range of motion, no lymphadenopathy, no JVP seen with
head of bed elevated to 30 degrees, no thyromegaly or thyroid
nodules
Lungs: Diffuse rales bilaterally to halfway up lung fields, no
expiratory wheezes, no rhonchi, no friction rubs, no squeaks
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Midline scar, non-distended, normoactive bowel sounds,
soft, non-tender, no guarding, no organomegaly
GU: not examined
Ext: No edema, warm, well perfused, radial and dorsalis pedis
arteries have 2+ pulses bilaterally, + clubbing of fingernails,
no edema of lower extremities
Neuro: CN 2-12 intact, decreased sensation to light touch below
knees, ...
Pertinent Results:
[**2149-8-29**] 05:02PM BLOOD WBC-18.8*# RBC-3.66* Hgb-9.7* Hct-30.2*
MCV-83 MCH-26.5* MCHC-32.1 RDW-15.7* Plt Ct-390
[**2149-9-1**] 01:10PM BLOOD WBC-16.3* RBC-3.81* Hgb-10.3* Hct-32.2*
MCV-84 MCH-27.1 MCHC-32.1 RDW-14.7 Plt Ct-374
[**2149-9-5**] 02:44PM BLOOD WBC-20.6* RBC-3.79* Hgb-9.8* Hct-31.0*
MCV-82 MCH-25.9* MCHC-31.6 RDW-15.6* Plt Ct-530*
[**2149-9-7**] 07:20AM BLOOD WBC-27.5* RBC-3.38* Hgb-8.7* Hct-27.8*
MCV-82 MCH-25.7* MCHC-31.3 RDW-15.0 Plt Ct-550*
[**2149-9-8**] 03:41AM BLOOD WBC-23.7* RBC-3.23* Hgb-8.4* Hct-26.5*
MCV-82 MCH-26.2* MCHC-31.9 RDW-16.2* Plt Ct-492*
[**2149-9-9**] 06:40AM BLOOD WBC-30.6* RBC-2.97* Hgb-7.6* Hct-25.1*
MCV-85 MCH-25.6* MCHC-30.3* RDW-15.3 Plt Ct-429
[**2149-9-5**] 07:35AM BLOOD PT-12.1 PTT-31.2 INR(PT)-1.0
[**2149-9-5**] 02:44PM BLOOD PT-13.3 PTT-150* INR(PT)-1.1
[**2149-8-29**] 05:02PM BLOOD Glucose-172* UreaN-39* Creat-1.2 Na-138
K-3.8 Cl-104 HCO3-23 AnGap-15
[**2149-9-9**] 12:40PM BLOOD UreaN-57* Creat-1.5* K-5.2*
[**2149-9-5**] 02:44PM BLOOD CK(CPK)-397*
[**2149-9-9**] 06:40AM BLOOD CK(CPK)-4146*
[**2149-9-9**] 12:40PM BLOOD CK(CPK)-3956*
[**2149-9-9**] 06:40AM BLOOD Calcium-7.6* Phos-5.9*# Mg-2.1
[**2149-9-2**] 04:49PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2149-9-2**] 04:49PM BLOOD ANCA-NEGATIVE B
[**2149-9-5**] 03:21PM BLOOD Type-ART pO2-55* pCO2-40 pH-7.44
calTCO2-28 Base XS-2 Intubat-NOT INTUBA
[**2149-9-5**] 03:21PM BLOOD Glucose-159* Lactate-2.2* Na-133* K-4.1
Cl-96*
CT Chest [**2149-9-2**]:
IMPRESSION
Pulmonary fibrosis associated with emphysema.
Left lower lobe lung mass, malignant until proven otherwise.
Cytology Sputum (expectorated) [**2149-9-3**]:
POSITIVE, CONSISTENT WITH SQUAMOUS CELL CARCINOMA.
LENI [**2149-9-4**]:
CONCLUSION:
1. No ultrasound evidence of above-knee deep venous thrombosis
in relation to
either lower limb.
2. There is significant thrombus identified within the right
popliteal
artery, which is almost completely occluded. There is, however,
some
peripheral flow identified. The popliteal artery is
non-aneurysmal on the
right.
3. There is a small [**Hospital Ward Name 4675**] cyst seen on the right.
ART Ext [**2149-9-5**]:
IMPRESSION: Severe right lower extremity ischemia with absent
ankle signals
and flat PVRs. Mild/moderate left lower extremity occlusive
disease with
evidence of aortoiliac and tibial occlusive disease.
There is a significant deterioration on the right compared to
4/[**2149**].
CT Abd/Pelvis CT Angiogram [**2149-9-5**]:
IMPRESSION:
1. Aortobifemoral graft remains patent.
2. Occlusion of right fem-[**Doctor Last Name **] bypass close to its proximal
origin. No
previous imaging is available to determine the chronicity of
occlusion.
3. Patent bypass from the left common femoral artery to left
anterior tibial
artery.
4. Diffuse interstitial lung disease and left lower lobe mass as
identified
on prior CT.
5. Marked distention of the urinary bladder.
CT Head w/ & w/out contrast [**2149-9-5**]:
IMPRESSION:
Mild brain atrophy and old lacunar infarct in the right
thalamus, unchanged.
No contrast CT evidence of metastatic disease to the brain.
CXR [**2149-9-7**]:
FINDINGS: In comparison with the study of [**9-6**], there is little
overall
change. Again there are diffuse reticular markings more
prominent on the
right. Cardiac size remains within overall normal limits. The
radiographic
findings are again consistent with severe pulmonary fibrosis,
possibly
complicated by asymmetric pulmonary edema.
Brief Hospital Course:
70 yo M with h/o CAD s/p CABG, IDDM, and recently identified
emphysema, pulmonary fibrosis, & LLL lung mass, who presents
with respiratory distress and hypoglycemia.
.
#. Respiratory Distress: On admission, the patient was admitted
to the MICU where his presenting symptoms of dyspnea, cough, &
hypoxia (<90%) had improved with inhaled bronchodilators,
steroids, O2, and Levaquin. On [**8-31**], he was transferred to the
general medicine floor with a decrease in his supplemental O2
needs from 6L to 4L NC and a good response to IV Lasix. He
completed his course of Levaquin and an aggressive taper of
Prednisone while continuing to receive Lasix, Albuterol, and
Ipratroprium nebs. His O2 nasal cannula was weaned to 3L of O2
at ~92%. The pulmonary team was consulted and request a CT to
further evaluate his pulmonary disease. The CT demonstrated
paracentral and centrilobular emphysema in the upper lobes with
extensive ground glass opacities and peripheral interstitial
lung abnormalities in the right lung and the left lower lobe. It
also showed a 6mm anterior right upper paratracheal lymph node
and a 1.9 by 1.2mm right lower paraesophageal lymph node.
Finally, a 4cm mass was seen in the left lower lobe of the lung,
consistent with malignancy. The etiology of his interstitial
lung disease was unknown and he was scheduled to receive a
bronchoscopy for further evaluation, but this was cancelled
after the patient continued to trigger for hypoxic episodes with
O2 sats to the high 60's-low 70's on 3L's. These episodes of
hypoxia were complicated by poor surveillance due to PVD. As a
result of his hypoxia in conjunction with other medical concerns
(right popliteal thrombosis), his bronchoscopy was cancelled. He
continued to require 3L's of O2 and was discharged to home on 3L
of oxygen and inhaled bronchodilators.
.
# Right popliteal artery thrombosis: On [**9-4**], Mr. [**Known lastname 19122**] had an
episode of [**10-25**] sudden onset right calf pain following a
physical exam earlier in the day that was positive for dorsalis
pedis pulses bilaterally. At the time of pain onset, the
patient's right leg was cooler than the left with a thready
pulse. LENI's were obtained and he was found to have a nearly
occlusive right popliteal artery. He was started on a heparin
gtt and Vascular surgery was consulted. They were unable to
obtain dopplerable pulses in the right foot and despite the
heparin gtt the patient's foot worsened. Given his poor
pulmonary status and new diagnosis of malignancy, vascular
declined intervention. The patient additionally refused
amputation. As a result of the arterial thrombosis, his CK
levels became elevated (4000's) and his Cr began to rise. After
a discussion with the team about the progression of the disease,
the patient made himself DNR/DNI. After <24 hours in the MICU
for nursing needs, Palliative care was consulted and both the
patient and his wife requested that he be allowed to return home
on hospice. He was discharged to home on hospice with IVF's to
minimize the kidney damage caused by impending rhabdomyolosis,
SC Heparin 4 times daily to minimize the pain from his leg, and
pain medications.
.
# DM2: The patient has IDDM, for which he uses an insulin pump
at home. He has had frequent admissions to [**Hospital6 **]
over the past few months for hypoglycemia, and he was briefly in
the MICU at OSH for hyperglycemia [**2-17**] steroids. On admission to
the [**Hospital1 18**], he continued to have episodes of hypo and
hyperglycemia requiring an insulin gtt in the MICU. He improved
on this regimen and was transferred to the floor on his home NPH
38u [**Hospital1 **] and Humalog sliding scale. On [**8-31**] after transfer to the
floor, his FSG was 34 in the AM. [**Last Name (un) **] was consulted and
recommended changing his regimen to Lantus with a Humalog
sliding scale. This scale was refined in keeping with his
decreasing steroid regimen. As a result, his blood sugars ranged
from 150-300's, but he had no further episodes of hypoglycemia
or extreme hyperglycemia. Mr. [**Known lastname 19122**] was discharged on 18u of
Lantus qHS and a Humalog sliding scale.
.
# Pulmonary Nodule: The patient was found to have a 4 cm
pulmonary nodule in his LLL on CT at an OSH. This was concerning
for cancer, given his extensive smoking history, asbestos
exposure, and clinical history of weight loss and fatigue. A
repeat CT was performed at the [**Hospital1 18**] per Pulmonology work-up and
confirmed this 4 cm mass in the left lower lobe. An expectorated
sputum culture was also sent that was positive for squamous cell
carcinoma on [**9-4**]. The patient and his family was told of the
diagnosis on [**9-5**], but given his other medical concerns,
specifically his arterial thrombosis of the right leg, there was
no further work-up of the cancer as an inpatient. The patient
was discharged to home on hospice for his leg complications, so
outpatient oncology follow-up was not scheduled.
.
# CAD: The patient has a history of CAD, s/p CABG in [**2131**]. He is
currently followed by Dr. [**First Name (STitle) 437**] in cardiology. He denies chest
pain and had MI work up at OSH, and recent TTE showed EF 55%. As
an inpatient, his [**Last Name (LF) **], [**First Name3 (LF) **], and Carvedilol were continued
and he was discharged on these medications.
.
# Depression: The patient has a history of depression, for which
he takes Cymbalta and Sertraline at home. Cymbalta was recently
discontinued, as OSH was concerned for eosinophilic pneumonia,
but was restarted as an inpatient based on his clinical
presentation and progression. He was discharged to home on this
medication.
.
Mr. [**Known lastname 19122**] was admitted as FULL CODE, but became DNR/DNI during
this inpatient hospitalization and he was discharged to home
with hospice.
Medications on Admission:
Medications at home:
[**Known lastname **] 80 mg daily
Coreg 12.5 mg [**Hospital1 **]
Cymbalta 30 mg daily
Lisinopril 5 mg daily,
Neurontin 600 mg three times daily
Zoloft 75 mg daily
Aspirin 81 daily.
.
Medications on transfer from OSH:
Dextrose 50% 25 mL prn
Glucagon 1 mg prn
Zolpidem 5 mg qhs prn
Albuterol 2.5 mg nebulization q6h
Aspiring 81 mg daily
Atorvastatin 80 mg daily
Carvedilol 25 mg [**Hospital1 **]
Enoxaparin 40 mg daily (prophylactic dose)
Furosemide 40 mg IV BID
Gavapentin 600 mg TID
Lispro Insulin SS
Ipratropium nebulization q6h
Levofloxacin 500 mg IV daily
Methylprednisolone IV 60 mg q8h
Pantoprazole 40 mg daily
Sertraline 75 mg daily
Discharge Medications:
1. Home Oxygen
Continuous pulsed oxygen at 3 liters a minute
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) capsule Inhalation once a day.
Disp:*1 inhaler* Refills:*2*
11. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
disk Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Disp:*1 month supply* Refills:*2*
14. Humalog Pen 100 unit/mL Insulin Pen Sig: One (1) sliding
scale dose Subcutaneous qACHS: Please refer to your sliding
scale for dosing of insulin.
Disp:*1 month supply* Refills:*2*
15. Insulin Needles (Disposable) Needle Sig: One (1) needle
Miscellaneous qACHS.
Disp:*1 month supply* Refills:*2*
16. [**Hospital 485**] Hospital Bed
Dx: Respiratory Failure
17. Heparin (Porcine) 5,000 unit/mL Solution Sig: 3750 (3750)
units Injection every six (6) hours.
Disp:*2 week supply* Refills:*10*
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Hospital3 **]
Discharge Diagnosis:
Primary:
Chronic obstructive pulmonary disease,
Diabetes Mellitus Type II, Squamous cell carcinoma of the lung,
Right popliteal artery occlusion
Rhabdomyolysis
Coronary artery disease,
Dyslipidemia,
Depression,
Hypertension,
Peripheral vascular disease
Discharge Condition:
Improved. Oxygen saturation 95% on 3L. Right leg cool.
Discharge Instructions:
You were admitted to the hospital due to an episode of
respiratory distress and low blood sugars. While you were in the
hospital, you were placed on oxygen and several inhaled
medications to improve your breathing. You were also given a
short course of oral steroids to reduce the inflammation in your
lungs in order to ease your shortness of breath. Out of concern
for infection, you were placed on a regimen of antibiotics that
you completed in the hospital. Pulmonologists were consulted to
assess your respiratory distress and requested a CT scan of your
chest. It revealed evidence of emphysema as well as some
fibrosis of the lungs. They recommended that you be discharged
to home on oxygen and some inhaled medications to support your
breathing. The CT of the scan also revealed a mass in the left
lobe of the lung concerning for malignancy. A sputum culture
obtained during this admission, confirmed a diagnosis of
squamous cell cancer of the lung. There were no interventions
made on the cancer while you were here.
While you were in the hospital, your blood glucose levels
continued to fluctuate. The diabetes specialists from [**Last Name (un) **]
Diabetes Center evaluated you and recommended that you switch
your home NPH insulin to a once nightly dose of a different kind
of insulin called Lantus and that you replace your insulin pump
with individual injections of insulin before meals. You were
given teaching about how to use this insulin at home, so please
continue to follow this new insulin regimen. A home visiting
nurse will be able to monitor your blood glucose levels once you
were at home.
.
Also, while you were in the hospital, you had pain your right
leg that was determined to be a block in an artery in your leg.
You were put on a medication to thin the blood and help prevent
additional clots. Vascular surgery examined you and did not
believe that surgery would be able to restore the blood supply
to the lower leg. The physicians spoke with you and determined
that you were not interested in an amputation of the lower leg.
As a result, you were continued on blood thinners and
intravenous fluids to help flush enzymes from the damaged leg
out of your body so that they would minimize harm to your
kidneys. You are being sent home with a plan to continue to
receive fluids at home. At home, you will not be able to walk on
your leg, so you will have assistance at home to aid with moving
from place to place.
.
Medications:
The following changes were made to your medication regimen,
1. Oxygen: In the hospital, you were placed on oxygen to aid
your breathing and maintain an adequate oxygen level in your
blood. Please continue to use this oxygen at home when you are
active or if you feel short of breath.
2. Albuterol, 1-2 puffs every 4 hours as needed: This medication
is used to help with shortness of breath. If you have shortness
of breath, you should use this medication and can take it up to
every 4 hours as needed. If you are not short of breath, you do
not need to take this medication.
3. Advair 1 puff twice a day: This medication is also to help
with your breathing. Please take this twice a day as directed.
Please continue to take this medication each day even if you are
not feeling short of breath as its effect is long-term.
4. Spiriva 1 puff once a day: This medication was also
prescribed to help your shortness of breath. Please continue to
take this medication once a day even if you are not feeling
short of breath.
5. Lasix, 20mg twice daily: In the hospital, you were placed on
a medication called Lasix to help remove excess fluid from your
body. Please continue to take this medication as directed until
you follow-up with your primary care physician.
6. Lantus, 20 units each night: This medication is an insulin to
replace your previous dose of NPH. Please give yourself 20 units
of Lantus once a night.
.
If you have any new shortness of breath or difficulty breathing,
chest pain or pressure, lightheadedness, dizziness, or feelings
like you might lose consciousness, please call your hospice or
your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
Followup Instructions:
You may follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], on [**9-18**] at 11:40am, if needed.
Name: [**Known lastname 1395**],[**Known firstname **] [**Initial (NamePattern1) **] [**Known lastname 201**] Unit [**Name2 (NI) **]: [**Numeric Identifier 3159**]
Admission Date: [**2149-8-29**] Discharge Date: [**2149-9-9**]
Date of Birth: [**2079-1-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Addendum:
After further study, the cause of the patient's shortness of
breath on admission was determined to be due to lung cancer
causing interstitial lung disease and resultant hypoxia.
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Hospital3 413**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3224**] MD [**MD Number(1) 3225**]
Completed by:[**2149-10-7**]
|
[
"414.00",
"V66.7",
"V12.71",
"728.88",
"401.9",
"428.0",
"V45.82",
"428.31",
"515",
"V15.84",
"V15.82",
"486",
"V45.81",
"311",
"440.20",
"V58.67",
"440.4",
"491.21",
"V45.85",
"444.22",
"250.50",
"357.2",
"799.4",
"272.4",
"162.5",
"250.60",
"362.01",
"250.80"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
20988, 21210
|
7266, 13083
|
335, 341
|
15926, 15983
|
3785, 7243
|
20183, 20965
|
2752, 2845
|
13794, 15544
|
15650, 15905
|
13109, 13109
|
16007, 20160
|
13130, 13771
|
2860, 3766
|
275, 297
|
369, 1927
|
1949, 2381
|
2397, 2736
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,394
| 176,676
|
23527
|
Discharge summary
|
report
|
Admission Date: [**2196-10-4**] Discharge Date: [**2196-12-2**]
Date of Birth: [**2137-9-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9223**]
Chief Complaint:
59 y/o with hmorrage in the occipital [**Doctor Last Name 534**] of the left lateral
ventricle aassociated with focal edema and a sm3cm hematoma all
amount of IPH in the adjacent left post pareital and occipital
lobe. Associated obstructive hydrocephlus with dialtion of both
the lateral and third ventricle.
Major Surgical or Invasive Procedure:
Ventriculostomy Drain
Lumbar drain
VP Shunt
History of Present Illness:
59 y/o male with past medical history of CAD s/p CABG X4 in
[**2191**], DM, HTN, hyperlipidemia was in usual state of health until
[**2196-10-1**]. He went to [**Hospital3 4107**] compalining of bilateral
leg pain and headache. Associated with one episode of emesis.
He was diagnosed with UTI and admitted on [**2196-10-1**]. On [**2196-10-2**]
he noted to have headache associated with vomitting. On
[**2196-10-4**] he became comfused and agitated at CT scan at [**Hospital1 2519**] showed a 3cm edema and a small amount of IPH in the
adjacent left post pareital and hematoma in occipital [**Doctor Last Name 534**] of
the left lateral ventricle aassociated with focal occipital
lobe. Associated obstructive hydrocephlus with dialtion of both
the lateral and third ventricle.
Past Medical History:
CAD s/p CABG X4 in [**2191**], DM, HTN, hyperlipidemia, Peripheral
vascular disease, osteoarthritis and Gout
Social History:
Originally from [**Country 47535**], visiting US by way of [**Location (un) 14336**]. Had
been in Mass by way of [**Location (un) 14336**] for last week prior to admission.
His wife is in [**Country 47535**].
Smoker quit in [**2190**]
No alcohol or drug use
Family History:
Mother died of MI at age 61
Father alive age 84
Physical Exam:
GEN: In no acute distress orientated X1
Chest: Clear bilaterally
Cardiac: RRR S1/S2
ABD: Soft nontender
Ext: No edema
Neuro: Awake, alert, orientated X1, PERRLA-EOMI, no drift,
cranial nerves [**1-7**] incact, strength 5/5 in out all muscle
groups, reflexes 2+ throughout
Sensation intact
Pertinent Results:
[**2196-10-5**] 12:37AM BLOOD Plt Ct-248
[**2196-10-5**] 01:35AM BLOOD PT-13.6 PTT-23.9 INR(PT)-1.2
[**2196-10-5**] 12:37AM BLOOD CK(CPK)-71
[**2196-10-7**] 02:40PM BLOOD ALT-11 AST-11 AlkPhos-69 Amylase-62
TotBili-0.4
[**2196-10-5**] 12:37AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.7
[**2196-10-5**] 12:37AM BLOOD Phenyto-10.0
[**2196-10-5**] 06:11AM BLOOD Type-ART Temp-37.6 pO2-96 pCO2-34*
pH-7.49* calHCO3-27 Base XS-2
[**2196-10-5**] 06:11AM BLOOD freeCa-1.02*
[**2196-10-7**] 02:29PM BLOOD HEPARIN DEPENDENT ANTIBODIES-
Brief Hospital Course:
Mr [**Known lastname **] was admitted to the Neurosurgery Service, he had a
ventriculostomy drain placed at [**Hospital3 **]. He was
admitted to the ICU for close neurologic and vital sign
monitoring, his goal BP<140, He was ruled out for an MI. An MRI
was obtainted to rule out a AVM, metatsis or anuerysm. He MRI
work up was negative for all those possible diagnosis.
On his first hospital day he was found to have increased
solumlence, a GI consult was obtained for a upper GI bleed and
low HCT who recommended conservative management of PPI and
transfusion to follow up with endoscopy when discharged. A
repeat head CT on [**10-5**] showed a stable clot.
His second hospital Mr [**Known lastname **] remained solumlent, a stroke
neurology consult was obtainted to rule out stroke, they
recommened a toxic metabolic workup and transfusion as his hct
was again low to 24. Mr. [**Known lastname **] [**Last Name (Titles) **] also dropped to 58, his SQ
Heparin held due to the possibility of HIT. A Hem Consult was
also obtained. His ICP pressure remained in the 6-8 range. A
dobhoff tube was placed for nutrition.
On [**2203-10-9**] he became more wake alert and orientated X2
following commands. He also developed his first fever to 101.5.
He was transferred to the Neurostep down unit on [**10-9**],
tolerating soft foods.
On [**10-10**] an ID consult was obtained due to fever work up showed
[**12-1**] blood culutes was postive for GPC, he was started on 2 weeks
of Vancomycin. He continued to have numerous cultures and
X-Rays all were negative for a source of a fever. Mr [**Known lastname **] was
also on Dilantin and it was felt the fevers were related to
Dilatin. A CBC showed increased esophinicils, even more
suspicious for dilantin related to fever. His Dilantin was
D/C'd on [**10-25**] and he had no further fevers
Mr [**Known lastname **] had his ventriculostomy drain discontinued on [**10-13**],
on [**10-14**] a follow up LP was done which had a opening pressure of
26. He was followed serially with LPs on a daily basis which
showed consistently high opening pressures and occasional
improvement of mental status post LP. on [**10-19**] a Lumbar drain
was placed without complications. If Mr [**Name13 (STitle) 60241**] had remained
afebrile he would have had a VP shunt placed. However at the
time his source of his fever was unknown his surgery was
postponed until his ID issues were resolved.
On [**10-31**] he was brought to the OR and had a VP shunt placed and
his Lumbar drain was d/c'd. Postoperatively, he did well
however a follow-up CT showed nonoptimal positioning of his VP
shunt in the ventricle. He was brought back to the operating
room and a new VP shunt placed without complications on [**11-1**].
Follow up CT showed good placement, neurologically he was awake,
alert and orientated, walking without difficulty. He had a CSF
culture from [**11-2**] positive for staph coag neg, felt to be a
contaminent. He stayed on [**11-3**] to monitor his temperature and
CBC. On [**11-4**] the patient complained of severe abdominal pain
and a general surgery consult was obtained and the patient had a
KUB which showed free air under the diaphragm. the patient had
an ng tube placed. He was transfered to the ICU and intubated,
Patient had an abd Ct which showed a high grade bowel
obstruction. The patient was taken to the OR for exploratory
lap. He had his abd left with temporary closure. He was
monitored in the ICU and was taken back to the OR on [**11-9**] for
closure of his abd. He then developed elevated amylase and
lipase and was treated with bowel rest for pancreatitis. From
the neurosurgical standpoint, he was getting serial LP's and
eventually his opening pressures came back into the normal range
he no longer required LP's. His condition improved he was
extubated on [**11-11**]. patient continued to be followed by ID for
CSF infection and a positive intra-operative swab which was
positive for enterococcus. He was treated with two weeks of
Linezolid. Patient had speech and swallow eval which he passed.
His last LP was on [**11-14**] with an opening pressure of 14. The
patient was transfered to the floor on [**2196-11-16**]. he remained
neurologically stable with evaluation of his amylase and lipase
daily. They contined to decrease and he was discharged in stable
condition on [**2196-12-2**].
Discharge Disposition:
Home
Discharge Diagnosis:
L Occipital Parietal IPH, CAD s/p CABG X4 in [**2191**], DM, HTN,
hyperlipidemia, Peripheral vascular disease, osteoarthritis and
Gout
Discharge Condition:
Neurologically stable
Discharge Instructions:
followup with neurosurgeon in [**Country 6607**]
followup with PCP in [**Name9 (PRE) 6607**]
Followup Instructions:
see above
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 9225**]
Completed by:[**2196-12-2**]
|
[
"560.1",
"272.4",
"567.9",
"427.31",
"998.2",
"038.19",
"V45.81",
"401.9",
"274.9",
"443.9",
"584.9",
"431",
"790.4",
"995.92",
"276.5",
"715.90",
"996.62",
"250.00",
"E878.2",
"518.81",
"996.1",
"E870.0",
"331.4",
"568.0",
"998.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.42",
"38.93",
"54.59",
"88.72",
"54.63",
"38.91",
"96.6",
"46.73",
"96.04",
"03.31",
"02.34",
"96.72",
"00.14",
"99.04",
"54.11",
"03.79",
"54.12"
] |
icd9pcs
|
[
[
[]
]
] |
7225, 7231
|
2828, 7202
|
629, 674
|
7409, 7432
|
2286, 2805
|
7573, 7720
|
1910, 1959
|
7252, 7388
|
7456, 7550
|
1974, 2267
|
280, 591
|
702, 1485
|
1507, 1617
|
1633, 1894
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,076
| 131,618
|
18508
|
Discharge summary
|
report
|
Admission Date: [**2148-8-10**] Discharge Date: [**2148-8-26**]
Date of Birth: [**2080-5-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Heparin Agents
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2148-8-12**] - Cardiac Catheterization
[**2148-8-16**] - Coronary Artery Bypass Grafting to four vessels. (Left
internal mammary->Left anterior descending artery, Saphenous
vein graft(SVG)->Diagonal artery, SVG->Obtuse marginal artery,
SVG->Posterior descending artery).
History of Present Illness:
68 yo male with history of cardiac arrest in [**1-2**] s/p
resuscitation, cooling and cath showing 3-vessel disease but not
candidate for PCI/CABG now with an AICD brought in by ambulance
after sudden onset chest pain with shortness of breath. Mr.
[**Known lastname 31251**] had recently returned home from work, just eaten dinner,
and was with his family watching a movie when he suddenly felt a
sharp epigastric pain which he thought was indigestion. A cough
developed with no productive sputum. He tried some soda water
which typically helps him but the pain continued to progress.
The patient got more short of breath, diaphoretic, and became
nauseous and vomited once. He also became quite anxious. The
pain ranged from [**2-4**] to [**7-4**], getting progressively worse until
the ambulance arrived. The pain was midline, substernal and did
not radiate down either arm or into his neck or jaw, and it was
not focused on either side. He was given an aspirin,
nitroglycerin (4x SL), lasix 80mg IV, morphine 4mg IV prior to
arrival to the ED. Patient's pacemaker was recently
interrogated on Monday and settings were altered. The patient
notes that he has had two similar, but less severe, episodes of
pain over the last two months that he attributed to indigestion.
He also reports weight gain of [**11-8**] lbs over the last few
months, but states that he's been adhering to a good diet.
.
On arrival to the ED his vital signs were HR:60s BP:112/60
O(2)Sat:96 on NRB and his chest pain had completely resolved but
he was still reporting shortness of breath. EKG showed sinus
tachycardia with some PVCs. He was noted to have bibasilar
rales on exam. The patient was briefly started on BiPAP.
.
On arrival to the floor the patient was comfortable and in no
acute distress. He remained chest pain free and felt that his
shortness of breath was improving throughout the night. He
currently has no complaints and feels back to baseline. The
patient reports no orthopnea, PND, or recent leg swelling.
.
Past Medical History:
History of cardiac arrest s/p AICD
Coronary artery disease
Diabetes mellitus type 2
Hypertension
Cataracts
Social History:
Lives with his wife, four grown children all married three of
whom live in town. Worked as a small business owner (owned a gas
station). Does not currently smoke or drink, no illicit drug
use.
Family History:
Father had MI in 60s. + type 2 diabetes
Physical Exam:
On admission:
VS - Tm/Tc 97.2/97.2 BP 132/71 (120-132/48-71) P 80 (75-80) R 18
Sat 98%3L BG: 176
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 2 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g audible. No thrills, lifts. No S3 or
S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bilateral rales at
bases to [**1-28**] way up lung fields, no wheezes or rhonchi audible.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
On discharge:
Pertinent Results:
[**2148-8-10**] WBC-5.5 RBC-3.86* Hgb-12.0* Hct-35.3* RDW-14.6 Plt
Ct-158
[**2148-8-11**] Glucose-181* UreaN-23* Creat-1.0 Na-136 K-3.8 Cl-96
HCO3-31 A
[**2148-8-10**] cTropnT-0.02*
[**2148-8-10**] proBNP-434*
[**2148-8-11**] CK-MB-18* MB Indx-8.3 cTropnT-0.43*
[**2148-8-11**] CK-MB-21* cTropnT-0.46*
[**2148-8-11**] CK-MB-23* MB Indx-9.6* cTropnT-0.44*
[**2148-8-11**] CK(CPK)-218
[**2148-8-11**] CK(CPK)-239
[**2148-8-12**] %HbA1c-6.9* eAG-151*
ECG on admission: Sinus rhythm. Poor R wave progression.
Non-specific lateral ST-T wave changes. Compared to tracing #1
the rate is slower and there are now criteria for poor R wave
progression. Ventricular ectopy is not seen.
Preop Echocardiogram [**2148-8-13**]:
The left atrium is markedly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is normal (LVEF 65%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Pre-operative chest X-ray: Unchanged mild cardiomegaly.
Improvement of pulmonary vascularengorgement. No pleural
effusions. No focal parenchymal opacity suggesting pneumonia.
Unchanged course of the pacemaker leads.
Pre-operative carotid series:
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Impression: Right ICA stenosis <40%. Left ICA stenosis <40% .
[**2148-8-12**] Cardiac Catheterization
1. Selective coronary angiography limited to the left sided
circulation
in this left dominant coronary system revealed 2 vessel coronary
artery
disease. The LMCA had no angiographically apparant disease. The
LAD had
a 70% proximal stenosis and a diffuse 50% stenosis in the mid
vessel.
The mid and distal LAD were small in caliber. The Cx had a long
80%
proximal stenosis. A tiny OM1 was 99% occluded at its origin.
There was
a 60% stenosis at the bifurcation of the OM2. There was a 50%
stenosis
in the left PDA. The nondominant RCA is known to be small in
caliber and
non-dominant and was not evaluated during this left heart
catheterization.
2. Resting hemodynamics revealed normal central aortic
pressures. There
was elevation in the left sided filling pressure (LVEDP 32mmHg).
3. Left ventriculography revealed no valvular regurgitation. The
calculated EF was 52%. There was akinesis of the apex and
hypokinesis of th mid and distal inferior walls.
[**2148-8-26**] WBC-13.2* RBC-2.98* Hgb-9.1* Hct-27.0* RDW-17.0* Plt
Ct-261
[**2148-8-25**] WBC-10.6 RBC-2.97* Hgb-8.8* Hct-26.9* RDW-17.0* Plt
Ct-242
[**2148-8-24**] WBC-11.2* RBC-2.90* Hgb-8.9* Hct-26.2* RDW-16.6* Plt
Ct-246
[**2148-8-23**] WBC-11.8* RBC-2.88* Hgb-8.6* Hct-26.1* RDW-16.2* Plt
Ct-219
[**2148-8-22**] WBC-10.6 RBC-3.06* Hgb-9.2* Hct-27.3* RDW-16.1* Plt
Ct-203#
[**2148-8-21**] WBC-8.4 RBC-2.89* Hgb-8.9* Hct-26.1* RDW-15.7* Plt
Ct-124*
[**2148-8-20**] WBC-8.7 RBC-2.97* Hgb-9.0* Hct-27.1* RDW-15.5 Plt
Ct-125*#
[**2148-8-19**] WBC-10.7 RBC-2.94* Hgb-9.2* Hct-26.8* RDW-15.4 Plt
Ct-66*
[**2148-8-26**] UreaN-44* Creat-1.6* K-4.6
[**2148-8-25**] Glucose-150* UreaN-40* Creat-1.4* Na-132* K-4.0 Cl-94*
HCO3-27
[**2148-8-24**] Glucose-114* UreaN-43* Creat-1.2 Na-131* K-4.4 Cl-95*
HCO3-27
[**2148-8-23**] Glucose-154* UreaN-45* Creat-1.5* Na-131* K-4.7 Cl-96
HCO3-28
[**2148-8-22**] Glucose-262* UreaN-58* Creat-1.4* Na-134 K-4.6 Cl-100
HCO3-27
[**2148-8-21**] Glucose-126* UreaN-41* Creat-0.5 Na-132* K-4.5 Cl-98
HCO3-27
[**2148-8-20**] Glucose-205* UreaN-39* Creat-1.0 Na-134 K-5.0 Cl-101
HCO3-26
[**2148-8-26**] Mg-3.0*
[**2148-8-25**] Calcium-8.3* Phos-4.3 Mg-2.7*
Brief Hospital Course:
Mr. [**Known lastname 31251**] was admitted to the [**Hospital1 18**] on [**2148-8-10**] for further
management of his chest pain. He ruled in for a non-ST-Elevation
myocardial infarction and was started on plavix and heparin. He
underwent a cardiac catheterization which revealed severe 2
vessel disease. Please see cathterization report for details.
Given the severity fo his disease, the cardiac surgical service
was consulted and Mr. [**Known lastname 31251**] was worked-up in the usual
preoperative manner. A carotid duplex ultrasound revealed less
then a 40% bilateral internal carotid artery stenosis. aAn
isolated elevated amylase level was found twice during
admission. He complained of no abdominal pain, diarrhea,
constipation, or jaundice recently. He did, however, report
parotid gland manipulation many years ago. It was decided not to
work up this lab value with imaging due to this history. Plavix
was held and allowed to wash out prior to his surgery. He was
diuresed for volume overload. On [**2148-8-16**], Mr. [**Known lastname 31251**] was taken
to the operating room where he underwent coronary artery bypass
grafting to four vessels. Please see operative note for details.
Postopertaively he was taken to the cardiac surgical intensive
care uniit for monitoring. His AICD/Pacer was interrogated by
the electrophysiology service. He required vasopressors for
hypotension and was given methylene blue for cardio vasoplegic
syndrome intraop and postoperatively. He was transfused for
postoperative anemia. He later awoke neurologically intact and
was extubated. His pressors were slowly weaned off. Gentle
diuresis was initiated. On postoperative day three he was
transferred to the step down unit for further recovery. He had a
drop in platelets and HITT antibody sent was positive.
Hematology was consulted and it was recommended Coumadin and
Argatroban be started until Serotonin Release Assay result was
back. This result was negative on post operative day 7 and
argatroban and coumadin were stopped. He did devlop rapid
atrial flutter on post operative day 7 and converted to sinus
rhythm with amiodarone bolus and drip. He was being paced with
his internal pacer at this time and epicaridal wires were
discontinued without incidence once INR decreased and platelet
count had increased to >200. The physical therapy service was
consulted for assistance with his postoperative strength and
mobility. He remained fluid overloaded and continued to require
aggressive diuresis. Over several days, he continued to make
slow clinical improvements, and was eventually cleared for
discharge to home on postoperative day ten. Given fluid status
and LVEF 45%, he will continue to require diuresis at discharge.
At discharge, he will also be given a course of Keflex for
cellulitis of his left lower extremity. He will followup with
[**Wardname 5010**] in one week for wound check.
Medications on Admission:
lisinopril 5mg daily
aspirin 325mg daily
Lipitor 80mg daily
furosemide 20mg PO daily
glyburide 5mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
metoprolol Succinate 75 XL daily
pioglitazone 30mg daily
ranitidine 150mg daily
latanoprost 0.005% one gtt OS
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
Disp:*1 month supply* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: then drop to 1 tablet(200mg) daily.
Disp:*60 Tablet(s)* Refills:*1*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 14 days: then drop to 1 tablet(40mg) daily - continue
indefinitely.
Disp:*60 Tablet(s)* Refills:*1*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for
14 days: then drop to 1 tablet(20meq) daily - please take with
Furosemide.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*1*
13. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: Two (2)
puffs Inhalation twice a day.
Disp:*1 month supply* Refills:*0*
14. Cephalexin 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*21 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Weekly CBC, electrolytes, BUN/Cr - please fax results to cardiac
surgery office at [**Telephone/Fax (1) 5793**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
-Coronary artery disease, s/p CABG
-Diabetes Mellitus Type II
-Hypertension
-Chronic Diastolic Heart Failure, [**Hospital1 **]-ventricular diastolic
dysfunction
-Pulmonary hypertension
-H/o ventricular fibrillation Arrest now s/p ICD/PPM [**Company 1543**]
-Postop Thrombocytopenia(Possible Heparin Induced)
-Postop Atrial Fibrillation/Flutter(resolved)
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.
2+ Edema bilaterally
Discharge Instructions:
1) 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
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) No driving for approximately one month until follow up with
surgeon
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
You are scheduled for the following appointments:
- Surgeon: Dr. [**Last Name (STitle) **] [**9-18**], 1:00PM [**Telephone/Fax (1) 170**]
- Device Clinic [**2148-11-5**] 3:30 PM [**Telephone/Fax (1) 62**]
- EP, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**2148-11-5**] 4PM [**Telephone/Fax (1) 62**]
- [**Hospital Ward Name 121**] 6 in one week for wound check
Please call to schedule appointments with your:
Primary Care Dr. [**Last Name (STitle) **] in [**1-27**] weeks
Cardiologist Dr. [**Last Name (STitle) **] in [**1-27**] weeks
Completed by:[**2148-8-26**]
|
[
"427.31",
"428.0",
"511.9",
"458.29",
"285.9",
"289.84",
"V45.02",
"518.0",
"427.32",
"250.00",
"410.71",
"416.8",
"428.33",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.53",
"39.61",
"34.91",
"36.13",
"88.55",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
13173, 13222
|
7983, 10883
|
326, 602
|
13620, 13863
|
4005, 4459
|
14472, 15067
|
3002, 3043
|
11193, 13150
|
13243, 13599
|
10909, 11170
|
13887, 14449
|
3058, 3058
|
3986, 3986
|
276, 288
|
630, 2646
|
4473, 7960
|
2668, 2776
|
2792, 2986
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,595
| 135,280
|
7343
|
Discharge summary
|
report
|
Admission Date: [**2105-12-14**] Discharge Date: [**2106-2-12**]
Date of Birth: [**2034-7-2**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Orinal complaint - R eye vision loss
Major Surgical or Invasive Procedure:
[**2105-12-14**]
A diagnostic and therapeutic 23-gauge pars plana vitrectomy with
injection of vancomycin 2 mg ceftazidime 2 mg and amphotericin 5
mcg right eye.
[**2105-12-25**]
Incision and drainage of right groin abscess,
radical debridement of right groin and sartorius muscle flap
closure of groin wound.
[**2105-12-31**]
Successful PTCA and stenting of the proximal left circumflex
artery
with a Xience (3x18mm) drug eluting stent. Final angiography
demonstrated no angiographically apparent dissection, no
residual
stenosis and TIMI III flow throughout the vessel (See PTCA
comments).
[**2106-1-7**]
Debridement and drainage of groin; removal of distal end of
aortobifemoral graft and replacement with rifampin-soaked 8-mm
interposition Dacron graft segment; complete removal of
femoropopliteal graft; oversewing of popliteal artery.
[**2106-1-28**]
Percutaneous endoscopic gastrostomy.
History of Present Illness:
71yo man h/o MDS, CAD, PAD, and DM who presents with sudden
vision loss and eye pain. He was driving in [**State 108**] when he
noticed these symptoms 3 days prior to presentation. He was on a
trip visiting [**Location (un) 86**] and was feeling progressively worse with
associated fevers, chills, malaise, arthralgias, and myalgias
and decided to come to the ED for further evaluation.
.
In the ED, initial vs were: 96.4 66 102/59 18 96% RA. Patient
was given percocet 5/325 x 2. Last set of vitals were 70 118/62
16 95%RA. Opthalmology was consulted who recommended urgent
vitrectomy. Patient was sent to [**Hospital Ward Name 23**] OR where he underwent
diagnostic and therapeutic vitrectomy and [**Hospital Ward Name **] pus was
expressed from the vitreous fluid. They injected tetracaine
2gtt, intraocular vancomycin 0.1ml (1mg), ceftazidime 0.1ml
(2mg), amphotericine 0.1ml (5mcg), and amphotericin, and
recommended work up for systemic sources of infection. They also
gave 200cc of LR and patient was given remifentanil 50mcg IV
ONCE at 2245. Last set of vitals were 120/55 80 16 90%RA.
.
On the floor, the patient complains of right shoulder and right
sided chest pain. He describes it as sharp, radiating to the
back and down his right arm and right chest. He says he's never
had this pain before. He says the pain gets worse with movement
althouth he has not been moving much. His anginal equivalent is
dyspnea, and this is different that angina. He says he has no
history of arthritis in his shoulder, but was given cortisol
injections in his shoulder which did not help. Percocets in the
ED did help with the pain. He denies any associated SOB, nausea,
vomitting, diaphoresis, dizziness. There is no association with
coughing or taking deep breaths. He did go on a long car ride on
Sunday (12 hours), denies calf pain, swelling, cough,
hemoptysis. He denies abdominal pain, diarrhea, constipation. He
does report flu-like symptoms with rhinorrhea, fevers to 104,
chills, sore throat, arthralgias and myalgias. His arthralgias
and myalgias seem to persist into his current R shoulder, R
chest, and left arm pain.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest 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:
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
Asbestos exposure
Social History:
married, large family w/ many kids and grandkids.
Pt & wife spend most of the year living in [**State 108**].
-Occupation/Hobbies: pt is a retired pipe fitter & manager. He
enjoys hunting and has a new gun that he has been looking
forward
to using per his family
-Sources of Support: tight-knit family
-Religion/Spirituality: not explored
-Coping: family is struggling to cope w/ patient's decline
-Health-care [**Doctor Last Name 360**]/proxy: wife
Family History:
non contributory
Physical Exam:
Vitals: T: 98.1 BP: 133/87 P: 93 R: 24 SaO2: 97% 3L
General: Lethargic, but arousable to voice. Lying bed
uncomfortably
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MMM, no lesions
noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA in the anterior fields
Cardiac: RR, nl S1 S2, 2/6 SEM across the sternum, No rubs or
gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: Right groin dressing c/d/i VAC placed. Underneath
reveals a 5 x 5 cm wound with some granulation tissue, no [**Doctor Last Name **]
puss appreciated, The RLE is warm with faint distal pulses
Skin: no rashes or lesions noted. Toes are pink on the right.
Left leg is tender to touch, and is covered with linear
excorations which appear old
Neurologic: Patient unable to speak or follow simple commands.
Lack of attention noted. Withdraws all 4 extremities to pain.
Pertinent Results:
Admission Labs:
[**2105-12-14**] 07:20PM
LACTATE-1.7
[**2105-12-14**] 02:25PM
GLUCOSE-343* UREA N-15 CREAT-1.1 SODIUM-129* POTASSIUM-4.5
CHLORIDE-95* TOTAL CO2-25 ANION GAP-14
[**2105-12-14**] 02:25PM
CK(CPK)-45*
[**2105-12-14**] 02:25PM
CK-MB-2 cTropnT-<0.01
[**2105-12-14**] 02:25PM
WBC-5.3# RBC-3.90* HGB-12.0* HCT-36.3* MCV-93 MCH-30.7 MCHC-33.0
RDW-22.7*
NEUTS-58 BANDS-1 LYMPHS-25 MONOS-9 EOS-0 BASOS-0 ATYPS-1*
METAS-3* MYELOS-2* PROMYELO-1*
STOOL CONSISTENCY: LOOSE Source: Stool.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2106-2-6**]):
Feces negative for C.difficile toxin A & B by EIA.
[**2105-12-14**] 02:25PM
HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
[**2105-12-14**] 02:25PM
PLT COUNT-219#
[**2105-12-14**] 02:25PM PT-14.8* PTT-27.6 INR(PT)-1.3*
RECENT STUDIES:
[**2105-12-29**] ECHO:
The left atrium is mildly dilated. The left ventricular cavity
size is normal. There is moderate to severe regional left
ventricular systolic dysfunction with
inferior/inferolateral/septal hypokinesis with milder
hypokinesis elsewhere. Right ventricular chamber size is normal.
with probably mild global free wall hypokinesis. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is mild mitral valve prolapse. An
eccentric, posteriorly directed jet of mild to moderate ([**1-24**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is no pericardial effusion.
No vegetation seen (cannot definitively exclude).
Compared with the prior study (images reviewed) of [**2105-12-15**],
left ventricular systolic function is now much worse. Mitral
regurgitation appears similar.
.
CXRAY [**2105-12-28**]:
In comparison with the study of [**12-20**], there is continued
relatively low lung volumes. Enlargement of the cardiac
silhouette in a patient with intact midline sternal wires.
Continued diffuse prominence of interstitial markings that could
reflect chronic lung disease, elevated pulmonary venous
pressure, or both. Central catheter remains in place. There is
some haziness at the bases with blunting of the costophrenic
angle suggesting some pleural effusion.
.
CT OF HEAD W/ CONTRAST ON [**2105-12-28**]:
FINDINGS: There is a stable area of right occipital
encephalomalacia, with ex vacuo dilatation of the occipital [**Doctor Last Name 534**]
of the right lateral ventricle. There is no evidence, for an
acute major [**Doctor Last Name 1106**] territorial infarct or acute hemorrhage.
There is mild prominence of ventricles and sulci, as before.
There is mild mucosal thickening in the right sphenoid sinus
with a possible air-fluid level. The bones are unremarkable.
There is calcification of bilateral carotid siphons.
Apparent hyperdensity projecting over the posterior right globe
likely represents motion artifact.
IMPRESSION:
1. No evidence of acute intracranial abnormalities.
2. Stable right occipital encephalomalacia.
3. Apparent hyperdensity projecting over the posterior right
globe likely represents motion artifact. Please correlate with
eye exam.
[**2106-1-14**]
FINDINGS:
CHEST: An endotracheal tube terminates just beyond the thoracic
inlet, 8 cm above the carina. Retained mucus is noted in the
proximal trachea. There is no pneumothorax. Diffuse irregular
bronchial wall thickening may be consistent with small airways
disease, although the airways are patent to the segmental
levels.
There is severe, apical-predominant centriacinar and paraseptal
emphysema. Diffuse ground-glass opacities are present
throughout the lungs, consistent with combined pulmonary edema
and atelectasis, although superimposed infection cannot be
excluded. Moderate bilateral pleural effusions persist, with
adjacent compressive atelectasis.
A left internal jugular line again terminates in the distal left
brachiocephalic vein. Dense calcifications are noted in the
aortic root,
coronary arteries, and thoracic aorta. Within the limits of
contrast bolus
timing, there is no main or lobar pulmonary embolus, and no
evidence of acute aortic syndrome. The heart is normal in size,
without pericardial effusion.
Multiple prominent mediastinal and hilar lymph nodes are
present, likely
reactive, and measuring up to 10 mm in the right paratracheal
region.
ABDOMEN: Nasogastric tube terminates in the stomach. The small
bowel is
normal.
There is mild fatty infiltration of the liver. The gallbladder
is partially collapsed. The pancreas is slightly atrophic. The
spleen is normal.
The adrenals are normal. The kidneys are mildly atrophic, but
enhance and
excrete contrast promptly and symmetrically. Extensive
calcifications are
noted in the renal arteries.
Fat-containing umbilical and right parasagittal ventral hernias
are present.
PELVIS: The appendix is normal. Scattered descending colonic and
sigmoid
diverticula are present, without acute inflammation. Note is
made of a
patulous, fluid-filled rectum. A Foley catheter is present
within the
bladder.
An aortobifemoral graft is present, with contrast opacifying
both limbs.
Dense calcifications are noted in the abdominal aorta, iliac,
and femoral
arteries, with moderate stenosis of branch vessel origins. Soft
plaques are present along the posterior wall of the infrarenal
aorta, resulting in mild luminal stenosis. A rim-calcified,
nonenhancing 1.6 x 1.1 cm collection posterior to the proximal
left iliac artery likely represents a thrombosed pseudoaneurysm.
Within the abdomen, there is no evidence of contrast
extravasation, fat stranding, lymphadenopathy, or fluid
collections to suggest endoleak, infection, or other
complications.
Changes of debridement are again noted in the right thigh. There
are two
heteregeneously enhancing, lobulated soft tissue and fluid
collections
surrounding the proximal and distal ends of the right
femoropopliteal graft. These were incompletely imaged on the
most recent examination, but appear decreased in size from CT on
[**2106-1-10**]. The collection surrounding the proximal limb is
located in the right infrainguinal region (2:136) and
measures 6.1 x 2.8 cm, previously 6.1 x 3.7 cm. The collection
surrounding
the distal limb (2:146) is located in the medial proximal thigh
and measures 3 x 2.1 cm, previously 3.6 x 2.5 cm. Prominent
reactive inguinal lymph nodes are present, along with mild
subcuatenous edema and fascial thickening. There is no evidence
of intrapelvic extension.
No suspicious osseous lesions are identified. Moderate
degenerative changes are noted in the thoracolumbar spine.
IMPRESSION:
1. Decrease in fluid collections surrounding the ends of the
right
femoropopliteal graft. The appearance is nonspecific, but may
reflect
hematoma or phlegmon. No evidence of intra-abdominal extension;
if follow-up imaging is desired, please selectively image the
right thigh.
2. Patent aortobifemoral graft, without evidence of
complications.
3. Severe emphysema with diffuse pulmonary edema, effusions, and
atelectasis. Superimposed infection cannot be excluded.
4. ET tube just beyond thoracic inlet, please advance 3-5 cm.
The study and the report were reviewed by the staff radiologist
[**2106-2-1**]:
INDICATION: Status post PICC placement, assess position.
COMPARISON: Chest radiograph from [**2106-1-29**].
FINDINGS: The left PICC ends in the high SVC. The right lateral
lung is not included on this radiograph. There is unchanged mild
cardiomegaly. The
mediastinal contours are normal. There is no pneumothorax
identified. The
right mid-lower lung opacities are unchanged while the left
mid-lower lung
opacities have improved.
IMPRESSION:
1. Unchanged right mid-lower lung opacities and improved left
mid-lower lung opacities, may be secondary to pulmonary edema
and/or pneumonia. Recommend followup imaging to distinguish
between these entities.
2. Unchanged mild cardiomegaly.
3. Left PICC ending in high SVC.
ECHO:
[**2106-1-12**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %). 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) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is
borderline/mild posterior leaflet mitral valve prolapse. No
masses or vegetations are seen on the mitral valve, but cannot
be fully excluded due to suboptimal image quality. Mild (1+)
mitral regurgitation is seen. No masses or vegetations are seen
on the tricuspid valve, but cannot be fully excluded due to
suboptimal image quality. The pulmonary artery systolic pressure
could not be determined. No masses or vegetations are seen on
the pulmonic valve, but cannot be fully excluded due to
suboptimal image quality. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2105-12-29**], the findings are similar.
If clinically indicated, a transesophageal echocardiographic
examination is recommended.
IMPRESSION: no definite vegetations seen (suboptimal study)
[**2106-1-19**] 9:21 am PLEURAL FLUID
GRAM STAIN (Final [**2106-1-19**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2106-1-22**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2106-1-25**]): NO GROWTH.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2106-1-20**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
[**2-12**]:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
11.1* 3.21* 10.0* 30.6* 95 31.1 32.6 20.2* 130*
[**2-12**]:
Glucose UreaN Creat Na K Cl HCO3
194*1 22* 0.6 132* 3.7 99
Test Name Value Reference Range Units
[**2106-1-28**] 08:45
Report Comment:
Source: Catheter
GENERAL URINE INFORMATION
Urine Color Yellow
Urine Appearance Clear
Specific Gravity 1.016 1.001 - 1.035
DIPSTICK URINALYSIS
Blood SM
Nitrite NEG
Protein 25 mg/dL
Glucose NEG mg/dL
Ketone NEG mg/dL
Bilirubin NEG mg/dL
Urobilinogen NEG 0.2 - 1 mg/dL
pH 5.0 5 - 8 units
Leukocytes NEG
MICROSCOPIC URINE EXAMINATION
RBC 0-2 0 - 2 #/hpf
WBC 0-2 0 - 5 #/hpf
Bacteria NONE
Yeast NONE
Epithelial Cells 0-2 #/hpf
URINE CASTS
Hyaline Casts 0-2 0 - 0 #/lpf
OTHER URINE FINDINGS
Urine Mucous FEW
[**2106-1-31**] 4:09 am CATHETER TIP-IV Source: central line.
WOUND CULTURE (Final [**2106-2-2**]): No significant growth.
[**2106-1-15**] 9:12 am SWAB Source: Right Groin.
GRAM STAIN (Final [**2106-1-15**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2106-1-17**]): NO GROWTH.
[**2106-1-28**] 11:05 am BLOOD CULTURE
Blood Culture, Routine (Final [**2106-2-3**]): NO GROWTH.
Pertinent images:
#CXRAY [**2106-1-4**]:
In comparison with the study of [**1-1**], there is little overall
change. The Dobbhoff tube is uncoiled and in the upper stomach.
Bibasilar opacification with pleural calcification on the right
is essentially unchanged. Mild indistinctness of pulmonary
vessels could reflect some elevated pulmonary venous pressure.
.
#CT PELVIS ON [**2106-1-4**]:
in comparison to [**12-22**], fluid collections in the right groin
about the bypass grafts are slightly smaller in size -- a more
superior portion of the collection previously measured 2.5 x 3.2
cm is now 2.5 x 2.8 cm axially. a more inferior component
previously measured 2.3 x 4.1 cm is now 1.8 x 2.7 cm axially.
the craniocaudad extent is similar. while the collections about
the graft are smaller, the walls appear thicker and there is
increased overlying inflammatory change. this is deep to the
surgical staples, and may be post- operative, though clinical
correlation woudl be required to exclude infection. also noted
is a new superficial collection more laterally, not present on
prior study. this is of higher attenuation and may represent
evolving post-operative hematoma.
on the left, there is stranding consistent with recent
catheterization, but no large hematoma is identified.
the intrapelvic contents remain unremarkable. no deep fluid
collection or abscess is identified.
this study is not optimized for evaluation of the vessels,
however, no new vessel occlusion is identified. partial thrombus
of the right fem-[**Doctor Last Name **] graft is noted.
# US OF RIGHT FOOT ON [**2106-1-4**]:
Prelim report- no abscess or fluid collection. + subcutaneous
tissue edema
MRI: There has been little change compared to the [**2105-12-20**]
MRI. Again demonstrated is encephalomalacia in the right
parietal region and scattered FLAIR/T2 hyperintensities within
the cerebral white matter. There is no evidence of interval
hemorrhage, infarct, or mass. The post-gadolinium images are
unremarkable. Abnormal appearance to the right globe is similar
to prior with T2 hypointense material present within the
posterior globe. The major intracranial flow voids are
preserved. Ventricles, cisterns, and sulci are otherwise
significant for symmetric, age-related prominence.
Brief Hospital Course:
Mr. [**Known lastname 9250**] is a 71yo man with history of MDS on Dacogen (last
dose 5 weeks prior to admission), CAD, PAD, and DM who presented
with sudden vision loss and eye pain and was found to have
endocarditis with endophthalmitis.
# Endocarditis: His endophthalmitis was felt to be secondary to
endogenous source, and bacteremia was suspected. Patient
underwent TEE on [**12-16**] which showed a small vegetation on his
aortic valve consistent with endocarditis. His blood cultures
were persistently negative and either culture negative
endocarditis or fungal source was suspected. He was empirically
treated with vancomycin and ceftaz for bacterial coverage and
ambisome and doxycycline for fungal and atypical coverage.
Numerous serologies including mycoplasma, brucella, bartonella,
Q-fever and chlamydia were sent and which are negative to date.
Fungal workup included beta glucan and galactomannan serologies
and fungal cultures were are negative. Pt was on a variety IV
antibiotics per ID. See below brief hosptal course out line.
# ID: Mr. [**Known lastname 9250**] is a 71 year old man with a history of MDS,
[**Known lastname 1106**] disease who was admitted [**2105-12-14**] with 3-4 days of
vision loss in the right eye, which occurred acutely at his home
in [**State 108**]. A few weeks prior to this incident, he was treatedas
an outpatient with Levofloxacin for an "URI" during which he had
fevers to 103-104.
There has been no positive culture data during this
hospitalization, except for two universal PCR's done on [**12-14**]
vitreous fluid and [**12-25**] groin pus - Streptococcus agalactiae was
isolated both times.
He is currently on the floor and antibiotics were briefly
narrowed to Daptomycin only on [**2106-1-26**] (Vancomycin was changed to
Daptomycin over family's concern that Vancomycin may have been
contributing to drug fever). He continued to have fever to
101-102 on Daptomycin alone and upon the family's request on
[**2106-1-28**], a three drug regimen to cover other nocosomial organisms
(Aztreonam, Ciprofloxacin, and Metronidazole) was re-started.
Currently, the patient's last low grade fever was on [**2106-2-2**].
Even if he continues to have higher fevers on this regimen, the
antibiotic plan will be the same, unless there is new culture
data to change therapy.
On discharge pt is on Daptomycin IV untill [**2-18**], then keflex 500
[**Hospital1 **] for life, for supression therapy.
# Pururic skin lesions: Patient was noted to have a right medial
malleolar palpable purpuric skin lesion on admission. Over the
next couple days, he developed scattered discrete skin lesions
and one was biopsied by dermatology. The biopsy showed acute
necrotizing vasculitis and dermal abscess formation and noted
"Although an immune-mediated vasculitis may be present, the
dermal abscess formation is concerning for an infectious
process." He was evaluated for possible vasculitis by
rheumatology and serologies where negative. Rheumatology signed
off.
# Endophthalmitis: He was evaluated by ophthamology in the ER
and underwent urgent vitrectomy on [**12-14**] which produced pus.
This fluid was sent for gram stain which showed numerous polys
but no microorgansims. He received intraocular
Vanc/Ceftaz/Amphotericin. As mentioned above, this was felt to
be an endogenous infection. He was followed by ophthomology and
treated with numerous drops. Pt currently on drops as per med
list.
# Right shoulder pain: Patient complained of right shoulder pain
which he had for approximately a week prior to admission. MRI
of the shoulder was poor quality but found supraspinatous
rotator cuff tear. There was no evidence of infection. Rest
and anti-inflammatories were recommended by orthopedics with
agreement from rheumatology. His pain was treated with
oxycontin and oxycodone. This was DC'd when patient had
delerium. Once stable he should follow up with a orthopedist.
Other Info R shoulder pain: R shoulder pain and new left elbow
pain: MRI of R shoulder poor quality but no clear signs of
infection and rotator cuff tear. Films of R shoulder and L elbow
unremarkable. Ortho feels these pains are MSK related and
suggested rest with pain control/anti-inflammatories and
eventual PT. Rheum recommends consideration of AC joint tap to
rule out infection; ortho has deferred on this and does not feel
exam is c/w infxn. Overall symptoms are improving and feeling sl
better today with some improvement in ROM.
# MDS: He follows with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Location (un) 27087**] [**State 108**].
Patient s/p 5 cycles of Dacogen (started [**8-1**]) with last chemo
approximately 5 weeks prior to [**Hospital1 18**] admission. Patient usually
takes a week of Neupogen as needed for neutropenia after the 5
days of dacogen. Last BM bx in [**Month (only) 205**] showed some blast
proliferation concerning for MDS conversion to leukemia. A heme
Onc consult was obtained, for further management and
recommendations. Final Consult below.
Mr. [**Known lastname 9250**] has a history of MDS and was treated in [**10/2105**] with
decitabine. On presentation, he has anemia and thrombocytopenia
that are less severe than previous. Review of peripheral smear
showed modest dysplastic changes but not blasts
concerning for transformation to leukemia. MDS may results in
functional or absolute neutropenia and leukopenia that can
result in infection and thereby fevers. In the absense of this,
MDS itself should not be a cause of fever. We favor ongoing
infection or drug fever as the cause of Mr. [**Known lastname 27088**] fever.
With regard to his MDS, he should receive PRBC and platelet
transfusions as needed. No further therapy is available or
indicated for his myelodysplasia.
# CAD, Chest Pain: Patient does not take aspirin at home given
recent ASA induced gastritis but was started on this medication
when his plavix was held in the hospital per his cardiologist's
recommendation. Pt did have a NSTEMI. His was restarted on
plavix He was continued on vytorin, and metoprolol. He did have
a cardiac cath as outlined below.
Selective coronary angiography in this right dominant system
demonstrated native three vessel disease. The LMCA was patent.
The LAD was 100% occluded in the mid vessel. The LCx had a hazy
area of thrombosis/in-stent restenosis. The RCA was totally
occluded.
Arterial conduit angiography revealed the LIMA to LAD to be
widely patent. Venous conduit angiography revealed the SVG-RCA
and SVG-OM to be widely patent and without change.
Limited resting hemodynamics revealed normotension 118/56 mmHg.
Successful PTCA/stenting of proximal LCX with 3.0 X 15 mm VISION
BMS at 20 atms. Final angiogram showed 0% residual stenosis, no
dissection and normal flow in the distal vessel.
FINAL DIAGNOSIS:
1. Three vessel native coronary artery disease.
2. Patent LIMA to LAD.
3. Patent SVG to OM and SVG to RCA.
4. Successful placement of Vision bare metal stent in proximal
LCX.
Other Cardiac: Elevated Troponins/Cardiac ischemia: Pt has
significant hx of CAD with coronary angioplasty and stenting
[**2103**], CABG (LIMA to LAD, SVG to diagonal, SVG to OM, sequential.
Followed by Dr. [**Last Name (STitle) **]. On [**12-25**] in the setting of being hypotensive
in the PACU after his I&D, he had troponins checked which were
elevated. His troponins peaked at 0.88 on [**12-30**] and his CK/MB
peaked at 353/39 on [**12-26**]. EKG remains unchanged from prior. He
was tx as NSTEMI w/ hep gtt, ASA, Plavix. His repeat Echo on
[**12-29**] showed significant worsening LVF with EF decreasing from
50% to 30%. He went for cardiac cath on [**12-31**] which showed 100%
mid LAD occlusion, Lcx hazy thrombus in stent restenosis. He had
ballon angio and had BMS placed on PTCA, Plavix was changed from
Qday to 75mg [**Hospital1 **] x 1 week, then QD on ([**1-7**]), Cont ASA 325mg,
Cont simvastatin.
# DM: His blood sugars were initially elevated but improved with
sliding scale Humalog and evening Lantus. This was eventually
switched to SSI. Pt blood sugars stable on DC
# [**Month/Year (2) **] Brief: Incision and drainage of right groin abscess,
radical debridement of right groin and sartorius muscle flap
closure of groin wound [**12-25**] and Debridement and drainage of
groin; removal of distal end of aortobifemoral graft and
replacement with rifampin-soaked 8-mm interposition Dacron graft
segment, complete removal of femoropopliteal graft, and
oversewing of popliteal artery on [**1-7**]. Currenly patient has
minimal bllod flow to foot. [**Month (only) 116**] need future amp. Does have
collaterals. Pt did have ischemic leg. Was on IV heperin. This
was DC'd because of multiple GI blled. On Dc pt on asa, plavix.
We are now watching leg.
# Vision loss: Patient with most likely diagnosis of
endophthalmitis. Optho team concerned for endogenous source,
especially given his immunocompromised status. They recommend
vanc/ceftaz until cultures can confirm a pathogen. No pathogen
detected. On DC current eye drops per med list.
# Hypoxemia: Blood gas confirms hypoxemia. Concominant
respiratory alkalosis with hypocarbia points away from
narcotic-induced hypoventilation as etiology. Patient also with
interstitial changes c/w interstitial fibrosis versus emphysema.
Pt was intubated x 2. Weaned from ventalator. Each time
transfered to the VICU
.
# Hyponatremia: Most likely secondary to hypovolemia given
patient's history of very poor PO intake, dry MM, NS bolus 500cc
x 1, Maintanaince fluids, Urine lytes. On DC na is normalized.
# Elevated creatinine: Improving after IV fluids, back to
baseline. Could be related to ambisome or other medications.
Given IV fluids prior to IV contrast today
Continue to monitor lytes and creatine, thougt to be contrast
induced. Hydrated. On Dc creatinine is stable
# Pain management: Stopped all narcotics this AM given that pt
has AMS likely due to delusion- with hallucinations and
inattention which per family seems worse after receiving pain
meds, continue to close monitor MS and pain management, Cont on
tylenol PRN, Lidocaine patch
# Altered Mental Status: Pt alert and oriented x person. Having
hallucinations seen peopele in the room. He was previously
evaluated by neuro for AMS and was found to be due to metabolic
causes. He does not have a neuro defecit. He had head CT on
[**12-28**] and head MRI on [**12-30**] that showed no acute process or
changes when compared to prior MRI done on [**12-20**]. This was
likely due to combination of medications, poor sleep, pain. This
does not appear to be infectious since he has no other
menigitides symptoms. On DC mental staus has cleared, still
alittle confused at night. Neurology was consulted Neurolgoy
believes his change in MS is due to metabolic delerium. There is
also concern about septic emboli from ? endocarditis and
arterial graft infection, so ID recommended MRI of head for
evaluation of septic emboli.
MRI: There has been little change compared to the [**2105-12-20**]
MRI. Again demonstrated is encephalomalacia in the right
parietal region and scattered FLAIR/T2 hyperintensities within
the cerebral white matter. There is no evidence of interval
hemorrhage, infarct, or mass. The post-gadolinium images are
unremarkable. Abnormal appearance to the right globe is similar
to prior with T2 hypointense material present within the
posterior globe. The major intracranial flow voids are
preserved. Ventricles, cisterns, and sulci are otherwise
significant for symmetric, age-related prominence.
IMPRESSION:
1. No significant change compared to [**2105-12-20**].
2. Abnormal appearance of the right globe, compatible with the
patient's
known history of staphylococcal infection of his right globe.
#Thrombocytopenia/Coags: Pt was on hep drip which started on
[**12-25**] and had decrease in platelets which have trended down over
the last several days. This could be due to bone marrow
supression from the antibiotics, infection or MDS. His MDS
initial presentation was thromcytopenia and his last chemo dose
was 7 weeks ago, which he could be having bone marrow
transformation of abnormal cells. Doxi was stopped [**12-30**];
however he still on vancomycin. HIT was also in the
differential, but less likely given the rate of plalet decline.
His calculated pre-test prob for HIT is low-intermediate. So
anti-hep antibody was sent, this was negative.
# Anemia: pt has Hct trended down from low 30s->upper 20s, this
is stable. He has small hematoma at site of cath that is
unchanged, Pt transfused multiple times, Pt put on IV protonix.
Pt did have scope showed GI bleed. Gi was consulted, PPI
started, HCT followed. Did get a EGD [**1-14**].
Grade 3 esophagitis in the gastroesophageal junction In the
second part of the duodenum there was an adherent clot with
blood extruding under the clot. There was fresh blood in this
area. On injection of this area with 1/10,000 epi patient's
heart rate and BP increased. A clip was placed one cm. proximal
to the clot towards the stomach from this clot. This was to
allow an angiographer to know the location.
Otherwise normal EGD to third part of the duodenum.
Pt c/w drop in HCT. Transfused again. Another EGD was performed.
A single bleeding spot (? visible vessel) was noted in the
second part of the duodenum, at the same location as the
previously noted adherent clot, just distal to the bend where
the duodenal bulb meets the second part of the duodenum. The
area was washed and oozing was noted from the spot. One
endoclip was successfully applied for the purpose of hemostasis.
There was no further oozing from the spot. It was at a location
that was very difficult to identify and treat endoscopically.
Recommendations:
The findings account for the symptoms.
Continue IV PPI gtt, chanfged to IV BID.
Hold heparin gtt, this was done. pt on IV heperin for leg
ischemia. This was eventually DC'd.
# FEN: IVF, replete lytes prn. Pt was on tube feeds given poor
po intake. He pulled dobhoff tube off today while confused. Will
hold off in place tube back on since remains confused and was
difficult to place. It was eventually decided to place PEG. Pt
did have mutiple failed attempts at speech and swallow. On DC pt
getting TF's.
# Prophylaxis: hep SQ ppx, plavix, asa, IV protonix
Medications on Admission:
1) Glimipremide 2mg PO daily
2) Genuvia 100mg PO daily
3) Plavix 75mg PO Daily
4) nitro SL PRN chest pain
5) Lopressor 50mg PO daily
6) nortryptaline 25mg PO HS
7) Vytorin 10-40mg PO daily
Discharge Medications:
1. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic HS (at bedtime).
2. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever: prn for pain.
3. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezes.
11. Insulin
Sliding Scale
Insulin SC Sliding Scale
Q6H
Humalog
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-119 mg/dL 0 Units
120-159 mg/dL 2 Units
160-199 mg/dL 4 Units
200-239 mg/dL 6 Units
240-279 mg/dL 8 Units
280-319 mg/dL 10 Units
> 320 mg/dL Notify M.D.
12. PICC CARE
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.
13. daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours): DC ON [**2106-2-18**].
14. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day:
Please start on [**2-18**] after daptomycin is complete. life long AB.
15. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
16. haloperidol lactate 5 mg/mL Solution Sig: One (1) Injection
Q4H (every 4 hours) as needed for aggitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Infected R [**Doctor Last Name 27089**] PTFE graft (strep agalactiae)
c/b UGIB
persistent fevers
FTT - poor nutritional status
Delerium
endopthalmitis
Possible AV vegetation and peri-graft abscess
Melena, anemia - requuiring multiple blood transfusions
Active oozing at juncture of duodenal bulb and 2nd part of
duodenum
Hypotension / Hypoxia requiring intubation
DM
CAD
PAD
HTN
Septic emboli
NSTEMI
Hyponatremia
Complete R supraspinatus tear
ARF
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound, progress to ambulation
Discharge Instructions:
Please follow the course of antibiotics as scheduled for ID:
Daptomycin to continue until [**2106-2-18**]. After which the patient
will be placed on suppressive Keflex 500mg [**Hospital1 **]
PEG CARE
Foley to gravity, DC when ambulatory
Pt may need flex seal in future for loose stools
Vac to Right groin, change everry three days
Moniter RLE for signs of ischemia, Pt may need amputaton in
future
Moniter CK weekly while on Daptomycin. FAX: [**Telephone/Fax (1) 432**], ATTN:
OPAT
Moniter for fever and or chills, signs of septcemia,
neurological deficits, Loose stools / check for C - Diff
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2106-2-25**] 1:00
Provider: [**Name10 (NameIs) 2323**] [**Name11 (NameIs) 2324**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2106-3-26**] 11:30
Completed by:[**2106-2-12**]
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18,184
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2970
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Discharge summary
|
report
|
Admission Date: [**2142-6-27**] Discharge Date: [**2142-7-6**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
Hemodialysis.
History of Present Illness:
82 yo F with ESRD on HD, AF, CAD, DM, bilateral DVT, and
pancreatic mass concerning for cancer brought in from home with
weakness and lethargy.
.
Per pt's family: Pt was having oozing form PICC site, initially
blood then serosanguinous. distally some skin break down on the
right arm. Right leg wound appeared to be worse. No VNA came to
the home. Pt's daughter in law notes that pt's effort was poor
and she was lethargic. Family's concenr was for an infections.
.
Pt was recently admitted to [**Hospital1 18**] from [**6-13**] to [**2142-6-22**]. In
brief, pt was initially admitted to [**Hospital1 18**] for postiive bld
cultures. This admission was significant for discovery of
bilateral DVT's with couamdinizaiton, discovery of a pancraatic
mass, an echo which showed [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]; palliative care was
cosnulted. Pt was d/c home.
.
In the ED, 99.8, 114 [**Last Name (un) 3526**], 107/50, 16, 77% RA/100% NRB, GCS 13.
Given 20 IV diltizaem with good effect. Exam with [**Month (only) **] BS at
bases. Guiac + stool. Noted to be lethargic. Iniital coags were
elevated, repeat were more accurate.
.
On transfer, pt lying in bed. Pt is Farsi speaking and unable to
provide history. She does understand some English and follows
some commands.
.
Admitted to [**Hospital Unit Name 153**] for hypoxia.
Past Medical History:
1) HOCM: s/p PPM placement. No ablation done, as pt
asymptomatic. On carvedilol. LVOT gradient 50mmHg at rest,
120mmHg after PVC.
2) ESRD: Unclear etiology. Apparently had ARF from acyclovir
given for Shingles, along with possible contrast nephropathy.
Has been receiving HD in [**Hospital1 1559**] through Hickman catheter for
last six months. Anuric, has atrophic kidney. M/W/Fr
3) HTN
4) DMII (diet controlled)
5) AF: dx in [**5-8**], on coumadin, was going to get cardioverted
but echo shwoed thrombus
6) Pancreatic mass: seen on Us in [**6-7**], family wishes to not
proceed with workup, ? liver mets
7) DVT/Trousseau's syndrome: seen on Us in [**6-7**] admission
8) MRSA UTI found on last admission, being treated with 10 d
course of vanc by level
9) CAD: 90% ostial RCA blockage, and 50% OM2 blockage
on [**2136**] cath
Social History:
No h/o tobacco or EtOH. Lives with son and daughter-in-law.
[**Name (NI) 4906**] died last year. Recent discharge from a rehab facility
before admission (from prior admission to [**Hospital1 18**])
Family History:
NC
Physical Exam:
PE:
Temp 96.5
BP 114/61
Pulse 103, AF
Resp 24
O2 sat 100 % NRB
Gen - lyig in bed on NRB, breathign swallow breaths, eyes closed
but opens them to voice
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes dry
Neck - hard to assess, appears 7 cm
Chest - [**Month (only) **] BS at R and L bases, no wheeze, poor air mvmt from
base to half way up, no crackles
Chest wall- HD cath on left, no erythema, non tender
CV - IRRR, 2-3/6 SEM in aortic/LLSB; no heave or thrill
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds, ? subq LAD felt in RUQ/epigastrum
Back - No costovertebral angle tendernes
Extr - RUE with 2+ pitting edema of entire arm, LUE no edema;
bilateral LE edema [**1-5**]+ with bruises, 1+ DP pulses bilaterally,
faintly dopplerable, cool LEs
Neuro - mostly deferred [**1-4**] language barrier
Skin - mult ecchimosis
Pertinent Results:
Upon Admission:
[**2142-6-26**] 10:57PM LACTATE-3.6*
[**2142-6-26**] 11:00PM PLT COUNT-75*
[**2142-6-26**] 11:00PM NEUTS-77.0* LYMPHS-18.4 MONOS-3.5 EOS-0.4
BASOS-0.6
[**2142-6-26**] 11:00PM WBC-8.8 RBC-3.52* HGB-11.2* HCT-35.6*
MCV-101* MCH-31.9 MCHC-31.5 RDW-19.4*
[**2142-6-26**] 11:00PM CK-MB-NotDone cTropnT-0.13*
[**2142-6-26**] 11:00PM ALT(SGPT)-32 AST(SGOT)-28 CK(CPK)-58 ALK
PHOS-264* AMYLASE-13 TOT BILI-1.0
[**2142-6-26**] 11:00PM GLUCOSE-157* UREA N-33* CREAT-4.4* SODIUM-139
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-29 ANION GAP-12
[**2142-6-27**] 01:58PM TYPE-ART PO2-148* PCO2-36 PH-7.43 TOTAL
CO2-25 BASE XS-0
[**2142-6-27**] 02:18PM CK-MB-4 cTropnT-0.13*
[**2142-6-27**] 05:25PM CORTISOL-41.6*
[**2142-6-27**] 05:25PM CORTISOL-78.6*
[**2142-6-27**] 05:26PM URINE RBC-137* WBC-39* BACTERIA-MANY
YEAST-NONE EPI-0
[**2142-6-27**] 05:26PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
Brief Hospital Course:
Goals of Care: During this hospitalization there were extensive
conversations about goals of care. The patient, her family,
Palliative Care, the ICU and floor teams, her outpatient
doctors, Farsi interpreters and social work were involved to try
to clarify what was in her best interest. The overall result
was a decision to focus on care measures. Pt and her family are
interested in palliative/hospice care after leaving the
hospital. Pt written for comfort medications, including
morphine, hyoscyamine, tylenol, lopressor.
Hypoxia: DDx pulm edema [**1-4**] AF, PNA, PE, worsening pleural
effusion. Cardiogeneic pulm edema possible, altho small CAD hx.
Now stable on [**1-6**] L oxygen. PE most likely diagnosis given h/o
dvts and malignancy.
- did not tap pleural effusion as pt not in distress; likely
secondary to CHF, vol overload and possibly malignant
.
Hypotension: persisted throughout stay, started midodrine with
some benefit, still giving metoprolol despite bp in 80's for
tachycardia in 140s.
.
ESRD: Pt ultimately unable to tolerate HD because of
hypotension. Pt also desired stopping. Last HD was [**7-2**].
.
DM2: diet controlled at home, FS qid and ss insulin while in
ICU, FSs were discontinued on the floor per patient and family
request.
.
AF: While in the ICU pt was rate controlled on dilt. After
transfer to floor and stopping HD it was changed to lopressor
for rate control.
.
DVT/LE ulcers/thrombolphelitis/left atrial thrombus: cont
coumadin empirically at 0.5mg QHS (no blood work). situation
worse with chronic venous stasis and DVT, cont dressing changes.
.
Pancreatic cancer/mass; vague abd pain, treated pain with
morphine; family decided not to work up pancreatic cancer.
.
Guiac + stool: hct at pt's baseline, will monitor; likely no
major intervention given pts goals of care
.
UTI: Pt was treated with ceftriaxone for e.coli while on HD.
E.coli is not sensitive to any PO abx and pt is asymptomatic at
discharge.
.
FEN: diet as tolerated.
.
Comm: son, [**Name (NI) **], HCP; [**Telephone/Fax (1) 14208**]
.
Code: DNR/DNI/CMO/No vital signs/No blood draws/Tunneled
perminent catheter should not be accessed
Medications on Admission:
Meds:
warfarin 1 mg qd
levofloxacin 250 mg q48 (to end on [**6-29**])
tramadol 50 mg [**Hospital1 **]
famotidine 20 mg qd
oxycodone 5 mg q4
toprol 100 mg qd
diltiazem 240 mg SR qd
ASA
liptior 10 mg qd
Discharge Medications:
1. Midodrine 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day).
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q1-2H
() as needed.
5. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain, fever.
6. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: [**12-4**]
Tablet, Sublinguals Sublingual Q4H (every 4 hours) as needed for
secretions.
7. Warfarin 1 mg Tablet Sig: half Tablet PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Nursing Home - [**Location (un) 5503**]
Discharge Diagnosis:
Primary: Hypoxia, hypotension,
Secondary: end stage renal disease, atrial fibrilation, diabetes
mellitus, bilateral DVT, lower extremity ulcers, pancreatic mass
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed.
Followup Instructions:
Please follow up with the facility medical team. Your
outpatient doctors are [**Name5 (PTitle) **] available to you.
|
[
"157.8",
"197.7",
"425.1",
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"453.1",
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"403.91",
"415.19",
"V58.61",
"599.0",
"428.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7663, 7795
|
4609, 6762
|
225, 241
|
8001, 8011
|
3607, 3609
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7014, 7640
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6788, 6991
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8035, 8079
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2723, 3588
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178, 187
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269, 1619
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3623, 4586
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1641, 2471
|
2487, 2687
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,923
| 131,213
|
33223
|
Discharge summary
|
report
|
Admission Date: [**2154-10-31**] Discharge Date: [**2154-11-6**]
Date of Birth: [**2110-6-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
EP study and mapping
Unsuccessful atrial tachycardia ablation
History of Present Illness:
44 yo male with history of HTN presented to his PCP today
complaining of weakness, intermittent fatigue, and occassional
cough for one week. Over the past 2 days, he has had trouble
lying flat and has slept sitting in a chair. He reports
palpitations; feels like his heart is "beating like racehorse,"
but denies dizziness, or lightheadedness. Reports that
palpitations will last for few seconds and then self resolve.
He denies CP, but reports orthopnea. Also reports worsening
dyspnea on exertion. In the past was able to walk long distances
without any SOB, but in the last few days the patient reports
that he has not been able walk more than ten minutes for the
last two days without stopping [**1-23**] shortness of breath. The
patient denies ever having shortness of breath. Of note, the
patient also reports developing a dry cough, mostly during the
day. Started this past Wednesday. Denies any recent
fevers/chills, no sick contacts.
.
Of note, he has not been taking lisinopril and HCTZ for past 6
months, as he reports not knowing he needed to continue these.
He reports occaisional NSAID/ibuprofen use for headache. Reports
that [**Last Name (un) **] has been his "second home."
.
Patient was first noted to have hypertension in [**2150**], initially
started on HCTZ 25 mg daily, and then lisinopril 10 mg added on.
The patient has not been compliant with his medications; also
has had dietary indiscretions, even after being counseled about
the importance of low salt diet and exercise.
.
At [**Company 191**], he was found to have a HR in 150-160's with a narrow
complex SVT seen on EKG. Vagal maneuvers were attempted but
were unsuccessful. BP at the time was 150/100. He was sent to
the ED for further evaluation of his tachycardia.
.
Upon arrival to the ED, initial vitals were 98.0 120
170/160-200/130 18 100% on unclear amt of oxygen. Exam revealed
markedly elevated JVP, diffuse crackles, abdominal distension,
and [**12-23**]+ pitting edema. EKG revealed a narrow compelx
tachycardia. At 4pm, 12mg of adenosine was given through a
small right hand PIV, with conversion to sinus tachycardia at
140. IVF were started for tachycardia with total 1.5L given.
At 6pm, he was still tachy to the 180's with another dose of
adenosine 12mg given. He reverted to sinus brady at 50-60 for
10 seconds, then went back into sinus tachycardia. CXR was
obtained and revealed volume overload so IVF were stopped.
Bedside TTE revealed no effusion. EP was consulted and felt
this was likely acute heart failure [**1-23**] hypertension and SVT [**1-23**]
atrial stretch. They recommended lasix 20mg x2, nitro gtt, and
bipap for recruitment. RT started CPAP instead. Vitals prior
to transfer: 139 142/102, 20, 100% on CPAP.
.
On review of systems, denies any abdominal pain, n/v/d, changes
in BM, denies any urinary sx, no blood in stool.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY: none
Social History:
Denies tobacco, EtOH, illicits, not currently sexually active.
Family History:
DM, denies any cardiovascular disease, no h/o MIs.
Physical Exam:
Admission PE:
.
GENERAL: NAD. Oriented x3, tachypneic on NC, slightly flushed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to mid earlobe
CARDIAC: tachycardic, S1, S2, with S3, no murmurs appreciated
LUNGS: Poor air movement throughout, + wheezes throughout
ABDOMEN: Soft, slightly distended, +BS, no fluid wave
appreciated, non tender throughout
EXTREMITIES: warm well perfused, 2+ pitting edema b/l [**12-23**]
anterior shins
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Neuro: intact sensation/strength throughout, CN 2-12 grossly
intact
.
Discharge PE:
98.7 127/80 82 18 99 on RA
GENERAL: NAD. Oriented x3, tachypneic on NC, slightly flushed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP to mid earlobe
CARDIAC: tachycardic, S1, S2, with S3, no murmurs appreciated
LUNGS: Poor air movement throughout, + wheezes throughout
ABDOMEN: Soft, slightly distended, +BS, no fluid wave
appreciated, non tender throughout
EXTREMITIES: warm well perfused, 2+ pitting edema b/l [**12-23**]
anterior shins
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission Labs:
[**2154-10-31**] 03:50PM BLOOD WBC-9.7# RBC-4.56* Hgb-13.9* Hct-40.6
MCV-89 MCH-30.5 MCHC-34.2 RDW-12.6 Plt Ct-238
[**2154-10-31**] 03:50PM BLOOD Neuts-69.3 Lymphs-23.9 Monos-5.3 Eos-1.2
Baso-0.3
[**2154-10-31**] 03:50PM BLOOD Glucose-126* UreaN-20 Creat-1.3* Na-137
K-4.2 Cl-99 HCO3-26 AnGap-16
[**2154-10-31**] 03:50PM BLOOD ALT-228* AST-114* AlkPhos-86 TotBili-0.7
[**2154-10-31**] 03:50PM BLOOD D-Dimer-753*
[**2154-10-31**] 03:50PM BLOOD %HbA1c-5.8 eAG-120
[**2154-10-31**] 03:50PM BLOOD Triglyc-115 HDL-45 CHOL/HD-2.9 LDLcalc-63
LDLmeas-69
[**2154-10-31**] 03:50PM BLOOD TSH-2.1
.
Cardiac Enzymes:
[**2154-10-31**] 03:50PM BLOOD cTropnT-<0.01
[**2154-11-1**] 03:22AM BLOOD CK-MB-2 cTropnT-<0.01
[**2154-11-1**] 02:04PM BLOOD CK-MB-1 cTropnT-<0.01
.
Relevant EKGs:
1. [**2154-10-31**]: Supraventricular tachycardia at 163 beats per
minute with a short R-P interval configuration. Left ventricular
hypertrophy with T wave inversions in lead aVL and ST segment
sagging in leads I and V5-V6. Minimal J point elevation in the
inferior leads with inconsistent ST segment depression,
possibily artifactual in the inferior leads. ST segment
flattening in lead V4. No previous tracing available for
comparison.
2. [**2154-11-1**]: Sinus rhythm. Left ventricular hypertrophy. Left
atrial abnormality. Compared to the previous tracing of [**2154-10-31**]
sinus rhythm has replaced the supraventricular tachycardia. Left
ventricular hypertrophy is unchanged. T wave inversions in leads
I and aVL are improved. Non-specific ST segment flattening is
now prominent in the inferior leads and unchanged in the lateral
leads. QRS morphology in the precordial leads is again
different consistent with alteration in precordial electrode
placement.
3. [**2154-11-2**]: Sinus tachycardia versus atrial tachycardia. Left
ventricular hypertrophy with secondary repolarization
abnormalities.
.
TTE ([**2154-11-1**]):
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is moderately dilated.
There is moderate to severe global left ventricular hypokinesis
(LVEF = 30 %) with regional variation; the inferior free wall is
akinetic. The right ventricular free wall is hypertrophied. The
right ventricular cavity is dilated with depressed free wall
contractility. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. An eccentric,
posteriorly directed jet of moderate (2+) mitral regurgitation
is seen. Due to the eccentric nature of the regurgitant jet, its
severity may be significantly underestimated (Coanda effect).
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Renal Artery Ultrasound ([**2154-11-2**]):
1. Patent main renal arteries. While the study is limited as the
intraparenchymal renal arteries could not be adequately assessed
due to the patient's inability to breath hold, there is no
definite stenosis.
2. No hydronephrosis or renal stone.
3. 3.2 cm lower pole simple left renal cyst.
4. Echogenic liver, suggestive of hepatosteatosis.
5. Left pleural effusion.
.
Discharge Labs:
[**2154-11-6**] 07:15AM BLOOD WBC-9.5 RBC-4.56* Hgb-13.8* Hct-41.3
MCV-91 MCH-30.3 MCHC-33.5 RDW-12.8 Plt Ct-256
[**2154-11-6**] 07:15AM BLOOD Glucose-106* UreaN-21* Creat-1.2 Na-137
K-4.1 Cl-99 HCO3-32 AnGap-10
Brief Hospital Course:
Brief Hospital Course:
44 y/o male with hypertension and h/o of medication
non-compliance (according to the patient) who presented with
palpitations, fatigue, orthopnea, PND and occassional cough to
PCP office and found to have new systolic CHF, tachycardia and
aucte diney injury.
.
# Atrial Tachycardia: Initially thought related to hypertension
and CHF but did not resolve after diuresis and BP control. Pt is
asymptomatic with the episodes. Rates were 100-140's, increased
with activity. EP mapping and attempted ablation of AT was
unsuccessful so pt was started on amiodarone loading dose on day
of discharge with 300 mg [**Hospital1 **] for one month. He will f/u with EP
cardiology in 1 month at [**Hospital1 18**].
.
# Acute systolic heart failure: The patient initially presented
with signs and symptoms of heart failure, including severe
orthopnea, cardiac wheeze, 2+ peripheral edema and S3 on exam,
LVH on ECG and pulmonary edema on CXR. R/O'd by enzymes. His
blood pressure was controlled on nitroglycerin IV and furosemide
drip for diuresis. ECHO showed EF 30%, TR gradient of 39 and
global LV hypokinesis. Cardiac MR was done and results are
pending at the time of this summary. After a brisk diuresis, pt
was transitioned to carvedilol, torsemide and valsartan PO.
Weight at discharge was 180 pounds and all signs of CHF had
resolved. Teaching about medication complience, dietary Na
intake and daily weights was done but will need reinforcement.
.
# Hypertension: The patient was possibly having hypertensive
urgency with end organ ischemia evidenced by heart failure.
Blood pressure was controlled with vasartan (changed to
lisinopril after discharge because of insurance) and carvedilol.
Blood pressure should be followed as an outpatient for
medication adjustement.
.
# Acute Kidney Injury: Creat 1.3, baseline of 1.1 a year ago;
possibly end organ damage due to hypertension or decreased EF.
Creatinine had normalized to 1.2 at time
of discharge. Labs will be checked again as an outpatient.
.
Transitional Issues:
- Please follow up secondary hypertension work
up--metanephrines, aldosterone, and renin pending as of [**11-10**].
- Pt should be followed closely for complience to medicines as
this has been an issue in the past.
- Follow up cardiac MR results, pending as of [**11-10**].
Medications on Admission:
** Patient states that he had not been taking for at least 6
months prior to admission. **
1. Lisinopril 10 mg PO daily
2. Hydrochlorothiazide 25 mg PO daily
Discharge Medications:
1. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
2. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. amiodarone 200 mg Tablet Sig: 1.5 Tablets PO twice a day for
1 months.
Disp:*90 Tablet(s)* Refills:*1*
5. Outpatient Lab Work
Please check chem-7 on Friday [**2154-11-8**] and call results to Dr.
[**Last Name (STitle) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at Phone: [**Telephone/Fax (1) 250**]
Fax: [**Telephone/Fax (1) 3382**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Atrial tachycardia
Acute systolic congestive heart failure
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a fast heart rate that made your heart weak. We tried to
stun the part of the electrical system of the heart that was
causing the fast heart rate but were unable to do this. Instead,
we are starting you on a mew medicine to help to slow your heart
rate. You will need to take this medicine twice daily for one
month and will come back in one month to see Dr. [**Last Name (STitle) **]. It
is very important you take you medicine every day to help keep
your heart working well. Weigh yourself every morning, call Dr.
[**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds in
3 days. Also call Dr. [**Last Name (STitle) **] if you notice that you are having
trouble breathing or the swelling comes back. Please come to
[**Hospital Ward Name 23**] Clinical Center on Friday [**11-8**] to get your
blood checked, please bring the prescription with you.
.
We have started the following medicines:
1. START Carvedilol to lower your blood pressure and help your
heart pump better
2. START Valsartan to lower your blood pressure and help your
heart pump better
3. START Amiodarone to slow your heart rate. You will take this
dose for one month and will talk to Dr. [**Last Name (STitle) **] about changing
the dose after one month.
4. START Torsemide to get rid of extra fluid in your body.
Followup Instructions:
Test for consideration post-discharge: Aldosterone
.
Department: [**Hospital3 249**]
When: TUESDAY [**2154-11-12**] at 9:10 AM
With: DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]/[**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.**
.
Department: CARDIAC SERVICES
When: Friday [**12-13**] at 1:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"428.0",
"584.9",
"427.89",
"428.21",
"402.91",
"V15.81",
"425.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.26",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
11882, 11940
|
8699, 10692
|
317, 380
|
12056, 12056
|
5015, 5015
|
13548, 14508
|
3590, 3642
|
11197, 11859
|
11961, 12035
|
11014, 11174
|
12207, 13525
|
8440, 8653
|
3657, 4382
|
3377, 3456
|
10713, 10988
|
5635, 8424
|
4396, 4996
|
265, 279
|
408, 3269
|
5031, 5618
|
12071, 12183
|
3488, 3494
|
3291, 3357
|
3510, 3574
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,274
| 126,494
|
42973
|
Discharge summary
|
report
|
Admission Date: [**2130-7-30**] Discharge Date: [**2130-8-30**]
Date of Birth: [**2083-1-21**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 47 year old
female with type 1 diabetes status post kidney pancreas
transplant in [**2126**], status post cadaveric renal transplant on
[**2-23**] with Dr. [**Last Name (STitle) **] at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **], history of Clostridium difficile toxic megacolon,
status post subtotal colectomy [**10-27**], status post ileostomy
reversal [**12-27**], and status post ventral hernia and PD
catheter placed [**3-28**], most recently status post right IJ
PermCath line changed over wire on [**2130-7-12**], now with
diffuse crampy abdominal pain since yesterday, which is
[**2130-7-29**], similar to one prior small bowel obstruction
episode. No flatus nor bowel movement since yesterday. No
fevers, cough. No vomiting. Positive for nausea. Regular
bowel movements for 5 to 6 days.
PAST MEDICAL HISTORY: Type 1 diabetes, endstage renal
disease, coronary artery disease, legally blind, osteopenia,
history of Zoster, hypertension, depression, gastroparesis,
asthma, diarrhea, Clostridium difficile, ejection fraction of
40%, mitral regurgitation on [**6-26**].
PAST SURGICAL HISTORY: Coronary artery bypass graft status
post pancreas transplant in [**2126**], status post cadaveric renal
transplant kidney [**2127**], status post appendectomy, status post
subtotal colectomy, ileostomy take down on [**2128-12-23**],
bilateral cataract surgery, bilateral vitrectomy, status post
right open reduction internal fixation, status post ventral
hernia/PD catheter [**2130-3-24**].
ALLERGIES: Iodine.
MEDICATIONS:
1. Rapamune 4 mg once daily.
2. Prednisone 5 mg once daily.
3. Amiodarone 25 mg q od.
4. Aspirin 81 mg once daily.
5. Folate 1 mg once daily.
6. Bactrim Monday, Wednesday and Friday.
7. Desipramine 150 mg once daily.
8. Lopressor 100 mg b.i.d.
9. Lipitor 10 mg once daily.
10. Vasotec 15 b.i.d.
11. Protonix.
12. Multivitamins once daily.
13. Hydralazine 50 mg b.i.d.
14. Atrovent 2 puffs b.i.d.
15. Exelon 2 b.i.d.
16. Flovent 2 puffs b.i.d.
17. Ventolin, Predforte 1% one GT os q 3 days.
18. Acular 0.5% one drop o.s. q 3 days.
19. Zaditor ou p.r.n..
20. Alrex ou p.r.n..
21. Benadryl p.r.n..
22. Tylenol.
23. PhosLo 667 t.i.d./ a.c.
24. Norvasc 5 mg t.i.d.
25. Ambien 5 mg p.r.n.
26. Compazine p.r.n..
27. Claritin.
28. Lomotil 2 to 3 q6.
29. Colestid 2 b.i.d.
30. Estrace 0.01% once daily.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.8, heart
rate 81, blood pressure 113/82, respiratory rate 23, oxygen
saturations 100% on room air. GENERAL: The patient is tired
but awake. CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR SYSTEM: Regular rate and rhythm. ABDOMEN:
Bowel sounds present. Nondistended. Soft. Well healed
transplant scar. Tender to touch left lower quadrant.
RECTAL: Guaiac negative. No masses or stool. Normal rectal
examination.
LABORATORY DATA: White blood cell count 10.3, hematocrit
49.3, platelet count 199, neutrophils 67, lymphocytes 20,
monocytes 40, eosinophils 8, sodium 145.0, 94, 25. BUN and
creatinine of 47, 5.8 to 0 104. ALT 22, AST 55, alkaline
phosphatase 126, amylase 45, lipase 72.
The patient had a KUB on [**2130-7-30**], demonstrating
probable small bowel obstruction, possible ascites, prompted
to get a CT abdomen which demonstrated: 1) diffuse dilatation
of small bowel loops, most consistent in appearance with
ileus. Small bowel obstruction is less likely, 2) there was a
ventral hernia with small amount of fluid within the
subcutaneous tissues. No bowel loops were identified within
the hernia, 3) surgically absent colon, 4) transplanted
kidney in the right lower quadrant, transplanted pancreas not
well identified on this noncontrast examination. Later that
day CT abdomen with water soluble contrast enema was
performed demonstrating 1) a patent ileoanal anastomosis, 2)
obstructive narrowing located close to the ileoanal
anastomosis which was most likely caused by adhesions. The
patient for line access had a left subclavian line placement
and x-rays confirmed that there was no pneumothorax, and that
the catheter was in SVC.
On [**2130-8-1**], an abdominal x-ray was obtained to assess
any interval change in the partial small bowel obstruction
demonstrating that there was partial improvement of small
bowel obstruction. Because there was a partial small bowel
obstruction, NG tube was placed by radiology on [**2130-8-1**], demonstrating satisfactory NG tube placement. Also seen
was bibasilar atelectasis. No pneumothorax. The patient on
[**7-31**], was admitted to ICU because of hypotension and
responded well to boluses to maintain diastolics greater than
60, with more precautions to watch her overnight in the
emergency room. The patient did have early temperatures. The
patient was on levofloxacin and Flagyl prophylactically.
Blood culture and urine culture obtained demonstrating no
growth on [**2130-8-1**], CMV was obtained demonstrating CMV,
DNA not detected. Stool culture obtained which was
unremarkable.
While the patient was hospitalized the patient had dialysis 3
days a week. The patient received her first dialysis as an
inpatient on this admission on [**2130-8-1**]. GI was
consulted on [**2130-8-1**], to evaluate whether or not
endoscopic management of bowel obstruction secondary to
anastomotic structure could be performed. Nutrition was
consulted because of diarrhea and on their recommendations
the patient was continued wish NG tube.
Psychiatry saw her on [**2130-8-2**], because of being
overwhelmed by her diagnosis and "hysterical" and has a
history of depression. On [**2130-8-2**], the patient had a
sigmoidoscopy demonstrating an ileosigmoid pouch with
evidence of recent bleeding secondary to recent rigid scope.
There were no active sites of bleeding. Granulation tissue
seen at the presumed area of the anastomosis. No actual
opening was seen despite probing with biopsy forceps. The
entire pouch was normal otherwise.
The patient was transferred out of ICU to regular floor on
[**2130-8-3**], with stable blood pressure, vital signs were
stable. She was continued on levofloxacin and Flagyl. The
patient was continued on immunosuppressant medications which
include rapamycin, prednisone, Imuran and Bactrim. The
patient was potentially going to go to the OR on [**2130-8-3**], with a possible ileostomy versus anastomotic division.
Because the patient felt better, it was decided to hold off
on surgery. The patient continued to have dialysis. The
patient on [**2130-8-4**], complained of some nausea. She
was afebrile. Vital signs stable, blood pressure was stable.
The patient continued to be NPO, IV fluids continued with
good urine output.
On [**2130-8-6**], the patient was doing well clinically, so
NG tube was removed. She was tolerating clears. The patient's
diet was advanced. IV with Hep-Lock. Since NG was removed,
the patient still had nausea, vomiting, not tolerating PO
fluids; so the patient had a flexible sigmoidoscopy on [**2130-8-5**], to evaluate the distal ileal luminal narrowing and
flexible sigmoidoscopy with balloon dilatation. Findings - 1)
there was a high grade stricture noted at 20 cm from the
anus; the scope could not traverse the lesion, 2) unable to
pass a guidewire for balloon dilatation to the stricture due
to sharp angulation high grade narrowing, 3) the mucosa of
the colon up to 20 cm appeared normal.
On [**2130-8-10**], the patient went for a PICC line
placement and TPN was started to the left IJ, and central
line. On [**2130-8-10**], another view of abdomen obtained to
evaluate small bowel obstruction and findings demonstrated
that there was interval worsening of small bowel obstruction
since the prior examination. These findings were communicated
to the primary team at the time if interpretation. It was
decided that the patient probably would benefit from surgery.
On [**2130-8-10**], removal by right internal jugular
PermCath was performed and placing of left internal jugular
PermCath was performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Please see details
in the operative note. Then also on [**2130-8-12**], the
patient had exploratory laparotomy, lysis of adhesions,
resection of ileorectal anastomosis, and ileoproctostomy
because of ileorectal strictures performed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) 92758**] assisted. Please see details of the
operation and operative note.
Postoperatively the patient was using a PCA, NPO. NG placed.
The patient continued on rapamycin, prednisone and Imuran. On
[**2130-8-16**], the patient went back to the OR for
malfunctioning catheter with removal of tunnel dialysis
catheter, placement of Tesio tunnel dialysis catheter with
fluoroscopy performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Again please see
details of that operation in the operative note. Renal
continued to see the patient for her elevated creatinine.
Physical therapy and occupational therapy were consulted. The
patient continued to be NPO. The patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**]
drain placed. GI was consulted for ongoing very loose stools/
diarrhea and made recommendations. Dr. [**Last Name (STitle) 8494**] was following
the patient. The patient continued on TPN. His Flagyl was
discontinued on [**2130-8-19**]. He continued to be afebrile.
Vital signs stable. On [**2130-8-20**], the patient had
flatus, slight belching. The patient's diet was advanced
slowly. Because the patient had crampy abdominal pain on
[**2130-8-20**], abdominal x-ray was obtained demonstrating
no definite features of mechanical or small bowel
obstruction.
On [**2130-8-23**], CT of the abdomen was obtained because of
acute abdominal pain status post bowel obstruction
demonstrating, 1) persistent partial small bowel obstruction
with minimally dilated loops of small bowel and an air fluid
level. No focal transition point was identified. 2) There was
also a 6 x 4.2 right adnexal fluid collection with drain in
place within the fluid cavity, 3) subcutaneous fluid
collection along the patient's incision. A smaller fluid
collection at the level of the left upper lobe measuring 3.2
x 2.3 cm. A second fluid collection more inferiorly measures
5.7 x 2.5. This is smaller than on prior examination. Also
there was interval development of bilateral pleural
effusions, right greater than left and diffuse subcutaneous
edema. Also there was a stable interval appearance of right
pelvis renal transplant and pancreatic transplant within the
mid abdomen and severe atherosclerosis was seen too.
On [**2130-8-24**], the patient's PICC line was removed
because of fevers. The patient was placed on vancomycin when
fevers started prophylactically. Cultures were obtained.
Blood cultures were obtained on [**2130-8-23**],
demonstrating staph coag negative, with sensitivities. Also a
swab culture from the abdomen was obtained demonstrating
staph coag negative. PICC line tip that was removed
demonstrated that the organism was staph coag negative. Renal
was consulted because the peritoneal cavity catheter was
instilled to 250 cc of PD fluid and then it was flushed and
the fluid was sent off for culture because transplant team
was concerned about questionable abscess/ peritonitis.
Dialysis fluid from [**2130-8-25**], demonstrated gram
positive cocci and the actual species was Enterococcus
Faecium. The patient remained on vancomycin until
sensitivities were demonstrated. Linezolid was started on
[**2130-8-28**], since it was sensitive to the organism.
TPN was discontinued. The patient was encouraged to eat,
calorie counts were obtained. Dilaudid was changed from IV to
PO Dilaudid q3 to 4 hours p.r.n.. Physical therapy continued
to see the patient. The patient was having dressing changes
daily, afebrile, vital signs stable. On linezolid. Relatively
good PO intake with bathroom privileges. The patient does
well overnight. The patient will be able to be discharged to
home on [**2130-8-31**], on the following medications:
1. Hydralazine 50 mg b.i.d.
2. Dilaudid 1 to 2 PO q 3 to 4 hours p.r.n..
3. Tylenol 325 to 650 mg PO q4 to 6 hours p.r.n..
4. Albuterol neb.
5. Amlodipine 5 mg PO b.i.d.
6. Lipitor 10 mg once daily.
7. Azathioprine 25 mg PO q od.
8. Calcium acetate 667 mg PO t.i.d with meals.
9. Desipramine HCL 1 to 2 mg PO qhs.
10. Diphenoxylate-atropine 2 tabs PO b.i.d.
11. Enalapril maleate 15 mg PO b.i.d.
12. Insulin sliding scale.
13. Linezolid 600 mg q 12. The patient will need to take it
for total of 2 weeks. The patient should take medications
to [**2130-7-14**].
14. Also the patient will be taking Lopressor 100 mg b.i.d.
15. Protonix 40 mg q 24 hours.
16. The patient should take prednisone acetate 1%
ophthalmology suspension. Prednisone 5 mg q day.
Sirolimus 2 mg q day or it may change depending on the
Rapamune level on [**2130-9-1**].
17. Bactrim one tab every Monday, Wednesday and Friday.
18. Ursodiol 300 mg t.i.d.
19. Zolpidem tartrate 5 to 10 mg PO qhs.
The patient should follow up with transplant surgery at [**Telephone/Fax (1) 23572**]. The patient needs to call transplant surgery
immediately at [**Telephone/Fax (1) 23571**] for any fever, chills, nausea,
vomiting, abdominal pain, decreased energy, change in bowel
movement or urine output; and also if there any changes in
skin color, question about her medications. The patient may
or may not need labs every Monday and Thursday depending on
the transplant coordinator. If she does, she needs to have
them done every Monday and Thursday and have the results
faxed to [**Telephone/Fax (1) 32754**].
FINAL DIAGNOSES:
1. Abdominal pain secondary to small bowel obstruction.
2. Bacteremia.
3. Major surgical invasive procedures [**2130-8-10**],
removal of right IJ PermCath.
4. On [**8-12**], assessment with exploratory laparotomy with
some adhesions and resection of the ileorectal
anastomosis and ileo proctoscopy.
5. [**2130-8-16**] - status post removal of tunnel dialysis
catheter and placement of Tesio tunnel dialysis catheter.
6. Status post placement and removal of PICC line.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: The patient will need VNA services to
evaluate nutrition and just overall evaluation for home
services.
[**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2130-8-30**] 20:35:06
T: [**2130-8-31**] 01:54:03
Job#: [**Job Number 92759**]
|
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"557.1",
"997.4",
"996.62",
"250.61",
"536.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.97",
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"48.23",
"39.95",
"96.08",
"45.62",
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icd9pcs
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[
[
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14490, 14830
|
1380, 2610
|
13943, 14434
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2633, 13926
|
183, 1076
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1099, 1356
|
14459, 14466
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,274
| 114,948
|
21750+21751+21854
|
Discharge summary
|
report+report+report
|
Admission Date: Discharge Date:
Date of Birth: Sex: M
Service: ORTHO
DIAGNOSES:
1. Right scapular fracture.
2. Closed head injury.
3. Multiple lumbar fractures.
HOSPITAL COURSE: On the day of admission, Mr. [**Known lastname **] was
evaluated for his closed injury which was associated with
loss of consciousness. He was cleared for subarachnoid
hemorrhage by the Neurosurgery Service after a repeat scan
revealed no significant mass expansion. A head laceration
was repaired.
Orthopaedics evaluated him for a right shoulder injury -
which included a scapular fracture and possible rotator cuff
dysfunction. He will follow up with General Orthopaedics for
this.
Upon examination - and throughout his hospitalization - his
neurologic status in the upper and lower extremities remained
intact. His spinal injuries include compression fractures of
L1 and L2 and a compression fracture/stable burst fracture
pattern superior inner plate fracture of L5. He experienced
a moderate ileus which resolved with time and diet
restriction. He was fitted a thoracolumbosacral device and
mobilized to ambulatory status with assistance. A sling was
used for his right upper extremity.
He has resumed normal bowel and bladder function.
Plan for thoracolumbosacral wear is eight weeks full time and
one month of weaning. He will follow up in two weeks with
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 363**] for a radiograph of the spine - AP and
lateral of the lumbar spine - to assess the fracture
alignment and position. Then, 4-week intervals will be
established for further followup radiographically and
clinically.
He remains temporarily totally disabled from his work
activities for three months from his date of injury.
He and his wife have been counseled regarding the possible
long-term dysfunction related to his injuries - which include
disc disruption and back pain, axial, related to his injury,
but his fractures are in acceptable alignment and position
and he should not have significant risks for malunion and
pain related to that.
DISCHARGE DISPOSITION: He is discharged to acute
rehabilitation due to the need for upper extremity and
thoracolumbosacral orthosis bracing. He
requires assistance for transitions from bed to
walking and for activities of daily living.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**], [**MD Number(1) 3192**]
Dictated By:[**Last Name (NamePattern1) 3193**]
MEDQUIST36
D: [**2153-9-22**] 09:35:44
T: [**2153-9-22**] 09:59:22
Job#: [**Job Number 57156**]
cc:[**Name8 (MD) 57157**] Admission Date: [**2153-9-18**] Discharge Date: [**2153-9-26**]
Date of Birth: [**2107-5-25**] Sex: M
Service: ORTHO
ADDENDUM: Mr. [**Known lastname **] has slowly improved from the
previous dictation. He has now had a bowel movement and is
cleared for discharge from hospital setting care medically.
His injury list includes:
1. Closed head injury status post subarachnoid hemorrhage.
2. L1 and L2 fractures, compression.
3. L5 fracture, burst pattern.
4. Right scapular fracture
5. Pulmonary contusion and rib fracture.
Overall, Mr. [**Known lastname 57158**] progress has been slow and steady.
He is able to ambulate but has difficulties with transitions.
He is becoming independent in his activities of daily
living. He does not meet the criteria for acute
rehabilitative care. He may benefit from a skilled nursing
situation or home nursing assistance, mainly for activities
of daily living and/or therapeutic aids or devices in the
home.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**], [**MD Number(1) 3192**]
Dictated By:[**Last Name (NamePattern1) 3193**]
MEDQUIST36
D: [**2153-9-26**] 09:01:57
T: [**2153-9-26**] 09:17:45
Job#: [**Job Number 57159**]
Admission Date: [**2153-9-18**] Discharge Date: [**2153-9-28**]
Date of Birth: [**2107-5-25**] Sex: M
Service: ORT
HISTORY OF PRESENT ILLNESS: He is a 46-year-old gentleman
who fell 10 feet into an elevator shaft. He had a loss of
consciousness for approximately 1 hour. He had confirmed
injuries and fractures of L1 and L5, a right clavicle
fracture, and multiple rib fractures, a right maxillary sinus
fracture, and a subdural hematoma.
HISTORY OF PRESENT ILLNESS: Noncontributory.
ALLERGIES: No known drug allergies.
MEDICATIONS: None.
SOCIAL HISTORY: He works as a funeral director.
He had a left central sulcus with a small subdural hematoma.
There was no mass effect. Chest showed a right fifth rib
fracture. No pneumothorax.
PHYSICAL EXAMINATION AT TIME OF ADMISSION: He is awake and
alert. He is in a cervical spine collar. He has a clavicle
fractur which is mildly tenting the skin and is not an open
fracture. He has good strength throughout the upper extremities
and bilateral lower extremities.
His CT scan showed a C5 spinous process fracture. The L-
spine showed an L1 fracture and an L5 end plate fracture.
Again, he was kept on bed rest precautions initially.
Neurologically, he remained intact throughout both upper and
lower extremities. His sensation was intact throughout.
HOSPITAL COURSE: He was admitted initially to the Trauma
SICU and was followed carefully by the Neurosurgery staff for
2 days. He was then transferred to the floor. His lumbar
films appeared to be stable injuries, and he was fitted for a
TLSO brace. Because of the multiple injuries, he was slow in
terms of his transitioning from bed to chair. On [**2153-9-23**]
he was noted to have a small effusion on chest x-ray with no
infiltrate. He had minimal ileus with no nausea or vomiting.
There was no evidence of an acute pneumonic process. He was
begun on OxyContin for pain relief and Percocet q. 4h. He
was seen by Physical Therapy, and there was a question
whether he was stable enough to go home given his head injury
and his multiple extremity injuries. Then, after multiple
discussions with his wife and the Physical Therapy staff and
discharge team, he was felt to be stable to go home on
[**2153-9-28**] with visiting nurse follow-up.
DISCHARGE INSTRUCTIONS: He is to be followed up in Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] office for repeat x-ray evaluation of the lumbar
spine. He is to wear the TLSO brace when out of bed.
DISCHARGE CONDITION: Ambulating independently in the TLSO
brace.
DISCHARGE DIAGNOSES:
1. Small subdural hematoma
2. Multiple rib fractures
3. Clavicle fracture
4. Lumbar spine fracture
5. Cervical spine fracture
He is to follow up in 2 weeks' time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3191**], [**MD Number(1) 3192**]
Dictated By:[**Last Name (NamePattern4) 57338**]
MEDQUIST36
D: [**2153-10-16**] 11:01:29
T: [**2153-10-16**] 11:57:25
Job#: [**Job Number 57339**]
|
[
"E884.9",
"807.01",
"861.21",
"852.03",
"810.00",
"805.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2171, 4060
|
6459, 6504
|
6525, 6964
|
5277, 6211
|
6236, 6437
|
4417, 4494
|
4511, 5259
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,225
| 109,815
|
28299
|
Discharge summary
|
report
|
Admission Date: [**2149-5-30**] Discharge Date: [**2149-6-6**]
Date of Birth: [**2068-4-9**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an 81 yo gentleman with PMH significan for CHF, MI s/p
CABG and valve replacement who on Friday [**5-29**] was going to his
cardiologist's office by means of ambulance from a rehab
facility. On arrival the ambulance personel found him to be
hypotensive with SBP's in the 70s. He was taken to [**Hospital3 12748**] where he was give a 1L bolus of IVF and his SBP
pressures rose to the 90s. On admission his hematocrit was found
to be 28 and it was uncertain as to why at that time. He was
then transferred to [**Hospital1 18**] and admitted to the medical ICU. Mr.
[**Known lastname 68713**] does occasionally have bouts of hypotension as he describes
occuring about twice a week. They are associated with some light
headedness but denies chest pain, shortness of breath, arm/jaw
pain, changes in vision or increased perspirations with any of
these events. He did mention one prior episode of syncope
occuring 3-4 months prior assoicated with only light headedness
and no other symptoms. He woke up according to him seconds after
the event occurred. He also mentioned a decrease in his
nutritional intake for approximately two weeks since his last
admission to this hospital. He has not been eating or drinking
as much as he usually does. He denies missing doses of
antibiotics. He does endorse anorexia and poor PO intake but
says these have both been present for a while.
.
While in the medical ICU his initial SBP's were in the low 100s
and had a few bouts of light-headedness but unclear if these
were at the times of hypotension. Patient received volume
repletion of 3L in the ED, no additional volume in the MICU. His
ACEi, BB, Spironolactone and Torsemide were held. His pressures
increased somewhat overnight without further volume
adminisitration. His antibiotics were continued.
.
At the time of transfer he said he was feeling well back to his
normal baseline functioning. He did report a continuing cough
that began approximately 2 weeks ago and is productive of white
sputum. It has not been getting better or worse and denies any
recent history of a URI.
Past Medical History:
History of erosive gastritis
Diverticulosis/itis (13y ago)
Chronic Systolic Congestive Heart Failure (EF 15-20%)
Coronary Artery Disease
CABG complicated by Mitral Valve endocarditis(Eneterococcus)
Bioprosthetic MVR [**2148-2-7**]
Tricuspid annuloplasty
BiV pacemaker
Hypertension
Hyperlipidemia
Type II Diabetes Mellitus (diet-controlled)
Obstructive Sleep Apnea (patient denies having this dx)
Cataracts
Glaucoma bilaterally
Pulmonary nodule left lower lobe
Diverticulitis
Ventral hernia
Social History:
He lives with his wife and sister in law usually but has been in
rehab since his last discharge.
Occupation: retired electrical engineer; designed the radio
transmitter that was responsible for communication between the
NASA lunar module and orbiting capsule during the space race of
the [**2097**]
Tobacco: quit 25 years ago; 40-60 PYHx
ETOH: rare occ.
Recreational Drugs: denies use
Family History:
Son with MI requiring CABG at age 50. Brother had an MI at age
63. Mother died 65 believed to have lung dz otherwise
unspecified
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.3 HR 82 BP 92/51 (ranging high 80s to 110s) RR 16 94%
RA
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
no murmurs/gallops/rubs.
Pulm: rhonchorous breath sounds B/L, symm CW expansion, white
sputum observed after coughing
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: left melanocytic [**Last Name (un) **] on nipple
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT,
pain, temperature, vibration, proprioception. cerebellar fxn
intact (FTN, HTS). gait WNL.
Lymph:no cervical or inguinal lymphadenopathy present
DISCHARGE PHYSICAL EXAM:
Cards: RRR S1/2 no Murmurs, rubs, gallops
Pulm: CTABL, symm chest wall expansion,
Ext: LE 2+ pitting edema to mid calf, 2+ pedal pulses
Rest of exam unchanged from admission
Pertinent Results:
Admission Labs:
[**2149-5-30**] 08:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2149-5-30**] 08:20PM GLUCOSE-87 UREA N-29* CREAT-1.3* SODIUM-139
POTASSIUM-5.7* CHLORIDE-108 TOTAL CO2-22 ANION GAP-15
[**2149-5-30**] 07:55PM WBC-10.5 RBC-3.38* HGB-8.3* HCT-27.5* MCV-81*
MCH-24.4* MCHC-30.0* RDW-19.9*
[**2149-5-30**] 07:55PM NEUTS-82* BANDS-0 LYMPHS-9* MONOS-7 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2149-5-30**] 07:55PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
BURR-OCCASIONAL ACANTHOCY-OCCASIONAL
[**2149-5-30**] 07:55PM PT-13.3 PTT-22.1 INR(PT)-1.1
[**2149-6-1**] 07:40AM BLOOD WBC-9.1 RBC-3.39* Hgb-8.1* Hct-27.5*
MCV-81* MCH-23.9* MCHC-29.5* RDW-19.7* Plt Ct-371
[**2149-6-1**] 07:40AM BLOOD Glucose-102* UreaN-23* Creat-1.2 Na-141
K-3.7 Cl-105 HCO3-27 AnGap-13
Cardiac Enzymes
[**2149-5-30**] 08:20PM cTropnT-0.02*
[**2149-5-31**] 04:46AM BLOOD CK-MB-9 cTropnT-0.03*
[**2149-5-30**] 08:20PM BLOOD cTropnT-0.02*
[**2149-5-31**] 04:44PM BLOOD CK(CPK)-121
[**2149-5-31**] 04:46AM BLOOD CK(CPK)-115
[**2149-6-1**] 07:40AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.8
Discharge Labs:
[**2149-6-6**] 05:45AM BLOOD WBC-8.1 RBC-3.29* Hgb-8.5* Hct-27.0*
MCV-82 MCH-26.0* MCHC-31.6 RDW-19.2* Plt Ct-336
[**2149-6-6**] 05:45AM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-142
K-4.3 Cl-107 HCO3-28 AnGap-11
[**2149-6-6**] 05:45AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.0
URINE CULTURE (Final [**2149-5-31**]): NO GROWTH
Blood Cx no growth to date
CHEST XRAY [**2149-5-30**]:
1. Mild pulmonary edema.
2. Bilateral stable small-to-moderate pleural effusion.
3. Bibasilar opacities at the lung bases could be atelectasis,
cannot exclude superinfection in appropriate clinical setting.
Brief Hospital Course:
This is an 81 year old man with a past medical history of severe
CHF, CAD, and s/p MVR presenting after recent hospitalization
for GI bleed and endovascular infection with hypotension.
1) Hypotension: Differential is, of course, concerning including
sepsis vs cardiogenic shock. That being said pt had no fevers,
is on broad spectrum antibiotics, and does not suggest any signs
or have ECG suggestive of myocardial ischemia. He also was
minimally symptomatic and improved dramatically with fluid
boluses suggesting perhaps simply dehydration. His blood
pressures have remained mostly stable with systolic blood
pressures ranging between 90s-110s following the 1L NS given at
[**Hospital3 **] and another 3L NS given in ED at [**Hospital1 18**]. On the
hospital floor we have slowly started him back on his home
cardiac meds: metoprolol 12.5mg [**Hospital1 **] instead of 25mg [**Hospital1 **] which is
his home regimin and lisinopril 2.5mg QHS and his blood
pressures have remained stable. We have decided to stop
torsemide and spironolactone. During this admission. We tried to
begin torsemide during this admission but Mr. [**Known lastname 68713**] experienced
an episode of hypotension. We then reduced his home torsemide to
half what he was taking as an out patient and he had another
episode of hypotension. It seems as though Mr. [**Known lastname 68713**] might be
having difficulty keeping his daily oral intake up with his
current diuretic doses. He might need to have his cardiac
medication doses adjusted to this lower level of fluid intake.
We are holding his diuretics at the time of discharge and we
would like him to follow up with his cardiologist for further
changes to his cardiac meds.
2)Hx of GI Bleed/ UE DVT: Pt developed DVT in left arm around
his PICC line. We the pulled the PICC line and started him on a
Heparin Drip. Later on that evening he had a bloody bowel
movement and his hematocrit dropped to 23. We then transfused
two units of red blood cells and discontinued his heparin and
aspririn. His Hct has been stable since this episode and with ID
approval we switched him over to oral antibiotics for his
endocarditis. He currently does not have a PICC line in place
and was placed on Heparin 5000U SQ for prophylaxis. He also has
a questionable diagnosis of lymphoma that is being followed by
Heme/onc. Mr. [**Known lastname 68713**] at this time does not want to work up this
any further. We informed him that this may be the cause of his
hypercoagulable state but he is not willing at this time to
investigate this further.
3) Acute Kidney Injury on CKD: Likely due to dehydration from
poor PO, which is also contributing to hypotension. His Cr has
been trending down since admission after institution of fluid
boluses. His renal function has returned to his baseline.
4) CAD: No signs of acute ischemia at this time and low index of
suspicion for acute CV event causing shock. Troponins were 0.02,
0.03., 0.02 on this admission.
5)Cough: Persistent since last hospitalization without change.
Sounds like viral cough. Benzonatate was given for cough
suppression and his symptoms have improved since admission.
6)Anemia: Iron supplementation continued in the hospital. His
hemoglobin returned back to his baseline levels.
7)Left nipple Melanocytic nevi- This lesion was found on
admission physicial exam. We feel this finding warrants out
patient evaluation.
8)Transional: Has follow up appointments scheduled including
ultrasound of upper extremeties. He also has follow up apt with
his cardiology to discuss cardiac meds.
Would consider restarting Torsemide if pt gains three pounds.
He will also have weekly labs drawn at rehab to monitor for side
effects of linezolid. In addition they will be checking your
blood counts at rehab to make sure you are not continuing to
bleed.
Medications on Admission:
torsemide 10 mg PO once a day.
spironolactone 25 mg PO DAILY
metoprolol succinate 25 mg PO twice a day.
aspirin 81 mg PO once a day.
lisinopril 2.5 mg PO at bedtime.
simvastatin 40 mg PO DAILY
pantoprazole 40 mg PO once a day.
Metamucil Oral
ascorbic acid 250 mg PO twice a day.
ferrous gluconate 325 mg PO twice a day
Benzonatate 100 mg PO TID
docusate sodium 100 mg PO BID
ciprofloxacin 500 mg PO Q12H (intended through [**5-30**])
metronidazole 500 mg PO Q8H (intended through [**5-30**])
daptomycin 500 mg Q24H (intended through [**2149-6-23**])
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
5. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for until [**2149-6-23**] weeks.
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
11. ascorbic acid 500 mg Tablet Sig: 0.5 Tablet PO BID (2 times
a day).
12. linezolid 600 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**] - [**Location 9583**]
Discharge Diagnosis:
Primary Diagnosis- CHF
Secondary Diagnosis-
Endocarditis
Chronic cough
Anemia
CAD
Acute Kidney Injury
Left nipple melanocytic [**Last Name (un) **]
Primary Diagnosis-
CHF
DVT
Secondary Diagnosis-
Endocarditis
Chronic cough
Anemia
CAD
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 68713**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to the hospital because of a
bout of low blood pressure. Your blood pressure rose in response
to IV fluids suggesting that you were dehydrated on admission.
Please make sure to eat and drink regularly. Also please weigh
lbs. We have also changed your antibiotics to Linezolid and have
revomed you IV line. Also due to the recent blood clots found in
both of your arms we have placed you on Heparin injections twice
a day.
We would like you to follow up with your Cardiologist regarding
the current state of your heart failure and for any medication
modifications they would like to make to your current regimin.
Changes in Medications:
STOPPED Daptomycin, Torsemide, Aspirin, and spironolactone
STARTED Linezolid 600mg every 12hrs
CHANGED Metoprolol to 12.5mg twice a day
You will also have weekly labs drawn at rehab to monitor for
side effects of linezolid. In addition they will be checking
your blood counts at rehab to make sure you are not continuing
to bleed.
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2149-6-11**] at 1:45 PM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2149-6-18**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: SURGICAL SPECIALTIES
When: MONDAY [**2149-6-23**] at 9:45 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"518.89",
"E942.6",
"E878.1",
"327.23",
"421.0",
"E944.4",
"V42.2",
"412",
"280.9",
"250.00",
"786.2",
"999.31",
"366.8",
"216.5",
"428.22",
"458.9",
"428.0",
"584.9",
"276.51",
"578.9",
"365.9",
"V45.01",
"V49.86",
"202.80",
"453.71",
"V45.81",
"453.82",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11806, 11880
|
6341, 10170
|
314, 321
|
12180, 12180
|
4507, 4507
|
13469, 14434
|
3361, 3491
|
10771, 11783
|
11901, 12159
|
10196, 10748
|
12363, 13446
|
5730, 6318
|
3531, 4288
|
263, 276
|
349, 2427
|
4523, 5714
|
12195, 12339
|
2449, 2941
|
2957, 3345
|
4313, 4488
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,267
| 151,104
|
48382
|
Discharge summary
|
report
|
Admission Date: [**2193-2-13**] Discharge Date: [**2193-2-20**]
Date of Birth: [**2138-3-6**] Sex: F
Service: SURGERY
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
End Stage Renal disease, needs dialysis access
Major Surgical or Invasive Procedure:
[**2193-2-13**]: Placement of left upper extremity arteriovenous graft.
[**2193-2-13**]: Evacuation of left upper extremity hematoma, Control of
bleeding, Revision of AV graft.
History of Present Illness:
Ms. [**Known lastname 37559**] is a 55-year-old woman with end-stage renal disease
and multiple accesses on her left upper extremity. Her right
upper extremity was
deemed unusable and so we decided to try again on the left side.
Past Medical History:
- Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]
- Likely left AKA stump osteomyelitis requiring admission in
[**3-/2192**], on IV antibiotics, VAC dressing in place
- ESRD on HD. Last HD yesterday. Usually MWF schedule.
- HTN
- Diabetes Mellitus
- Renal Cell Carcinoma s/p right nephrectomy
- Obesity
- Depression
- s/p CCY
- Gastric Ulcer
- Obstructive Sleep Apnea. The patient reports that she used to
use a CPAP however her machine broke and she no longer uses it.
- Gastroparesis
- COPD on 3-4L NC baseline
- h/o ischemic colitis
- left adrenal adenoma
Social History:
Admitted from rehab. Has two sisters, one daughter. [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.
Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.
Physical Exam:
VS: 97.2, 115/56, 74, 18, 100%
Card: RRR, II/VI systolic ejection murmur
Lungs: Diminished bases
Abd: Soft, non-tender, +BS
Extr: [**Last Name (un) **] swollen and with faintly palpable graft pulse.
HD line in place Left Chest
Extrem warm
Pertinent Results:
At Admission: [**2193-2-13**]
WBC-6.6# RBC-3.48* Hgb-11.1*# Hct-35.0* MCV-101* MCH-32.0
MCHC-31.8 RDW-16.3* Plt Ct-116*
PT-16.4* PTT-41.0* INR(PT)-1.5*
Glucose-179* UreaN-32* Creat-4.7*# Na-141 K-3.9 Cl-110* HCO3-21*
AnGap-14
Calcium-7.9* Phos-6.2*# Mg-1.5*
NSTEMI:
[**2193-2-14**] 07:39AM CK(CPK)-57 CK-MB-NotDone cTropnT-0.20*
[**2193-2-14**] 06:02PM CK(CPK)-423* CK-MB-104* MB Indx-24.6*
cTropnT-1.44*
[**2193-2-14**] 10:04PM CK(CPK)-377* CK-MB-92* MB Indx-24.4*
cTropnT-1.51*
At Discharge [**2193-2-19**]
Glucose-102 UreaN-28* Creat-3.8*# Na-135 K-4.0 Cl-101 HCO3-21*
AnGap-17
Calcium-8.8 Phos-4.2 Mg-1.9
WBC-6.7 RBC-3.06* Hgb-9.6* Hct-29.3* MCV-96 MCH-31.5 MCHC-33.0
RDW-18.1* Plt Ct-109*
Brief Hospital Course:
On [**2193-2-13**] this 54 y/o female was admitted for placement of left
upper extremity arteriovenous graft. She is known to have have
multiple access issues/failures and an attempt was being made to
place an AVG in her left arm as the right arm has been deemed
unusable for dialysis access.
She was taken to the OR by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] who placed a left upper
arm graft initially without complication.
In the immediate post op period while in the PACU, the team was
called to assess the patients left arm due to swelling and
obvious discomfort. The arm was rigid and there was significant
oozing. Dr [**Last Name (STitle) 816**] took the patient back to the OR that evening for
evacuation of left upper extremity hematoma, control of
bleeding, and revision of the AV graft. The graft was able to be
salvaged, however the patient was kept intubated. The hematocrit
had an 8% drop. She received one unit of RBCs with good
response.
She remained in the PACU overnight and experienced hypotension
for which she was started on pressors. EKG and serial cardiac
enzymes were obtained. She was transferred to the ICU. She was
extubated but was still requiring some pressor support. She
complained of back pain, but never chest arm or jaw pain.
Serial CPK and troponins were followed which showed evidence of
MI. In addition, the EKG as interpreted by Cardiology showed an
NSTEMI. An echo was obtained showed hyperdynamic ventricles with
no specific wall motion abnormalities. In addition cardiology
did not feel a cardiac cath was indicated as she was a poor
candidate due to her co-morbidities. Medical management was
initiated and she was started on [**Last Name (STitle) **] and Plavix. In addition a
heparin drip was initiated x 48 hours.
Enzymes continued to be cycled which slowly trended back toward
normal.
The patient received CVVH while in the ICU and then was
transitioned back to intermittent hemodialysis once transferred
back to the surgical floor and more stable. She did continue to
have some degree of low BPs intermittently while in
hemodialysis. Last treatment [**2-19**] for which 3 liters was
ultrafiltrated via a subclavian tunnelled HD line. She also had
a R groin temporary dialysis catheter that was removed just
prior to discharge to the Nursing Home on [**2-20**].
The patient was seen by PT and recommended PT when back at her
home facility (St. Josephs in [**Location (un) 686**] ([**Telephone/Fax (1) **]).
Vascular was consulted for concern about right leg lower
extremity edema, compartment syndrome vs fluid overload. It was
deemed low suspicion for compartment syndrome as the calf was
soft and pulses dopplerable.Blood pressures returned to more
normal readings (SBP in 110s) Heparin drip d/c'd after 48 hours.
She will discharge back to St Josephs where she has been a
resident.
Outpatient follow-up with cardiology is arranged and is included
in the discharge paperwork.
Doxycycline 100mg PO BID and rifampin 300mg PO bid are to be
continued for chronic suppression of MRSA vertebral
osteomyelitis (hardware in place) for indefinite period of time.
She will need a follow up appointment with Spine Surgery.
Medications on Admission:
rifampin 300'', doxycycline 100'', metoprolol 12.5'',
simvastatin 10, nexium 20, reglan 5 qid, insulin lispro,
sevelamer 800''', lanthanum 500''', cinacalcet 60, nephrocaps,
fentanyl patch 12 mcg/hr q72hr, oxycodone prn, gabapentin 300
qHD, mirtazapine 15 qHS, tramadol 50'', [**Last Name (LF) 95641**], [**First Name3 (LF) **] 81, colace,
senna
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale
Subcutaneous ASDIR (AS DIRECTED).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
4. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): x
30 days then decrease to 81mg po qd.
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): for 9-12 months per Cardiology for NSTEMI.
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Sevelamer HCl 400 mg Tablet Sig: Six (6) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours): indefinate course per Spine surgery due to hardware.
13. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours): indefinate course per Spine surgery for
hardware.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection twice a day.
15. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
16. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name 1495**] Josephs
Discharge Diagnosis:
NSTEMI (perioperative) with diastolic heart failure
s/p placement of graft with arterial anastomosis rupture
Hematoma evacuation
Discharge Condition:
Stable/Fair
Discharge Instructions:
Please call the access clinic at [**Telephone/Fax (1) 673**] for bleeding, cold
fingers/hand, hand numbness, loss of pulse to left hand, loss of
bruit and thrill in left arm access or other concerning issues
with the left arm.
Monitor for bleeding or increased pain in the left arm
Dressing change daily to left arm, DSD
Continue hemodialysis per routine schedule. Last dialysis at
[**Hospital1 18**] was [**2-19**].
Continue home medications with:
FOLLOWING CARDIOLOGY RECOMENDATIONS:
**the addition of aspirin 325 mg x 30 days then 81 mg daily
**Continue Plavix 75 mg daily for 9 - 12 Months
**Simvastatin 80 mg daily
Continue patietns food, fluid restrictions per renal guidelines
If patient develops back, chest or jaw pain; transfer to ER for
evaluation
No shower or tub bath with dialysis catheter in place
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2193-2-25**] 9:00
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2193-3-11**]
3:00
APPT at [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**] [**Hospital1 18**], [**Location (un) **]; Cardiac
Services
Completed by:[**2193-2-20**]
|
[
"403.91",
"V49.76",
"585.6",
"250.00",
"428.30",
"410.71",
"496",
"998.12",
"V49.75",
"327.23",
"458.29",
"440.20",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.98",
"39.27",
"39.42",
"38.93",
"39.95",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
8348, 8410
|
2931, 6135
|
316, 495
|
8583, 8597
|
2210, 2908
|
9458, 9889
|
1769, 1936
|
6532, 8325
|
8431, 8562
|
6161, 6509
|
8621, 9435
|
1951, 2191
|
230, 278
|
523, 755
|
777, 1598
|
1614, 1753
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,482
| 144,200
|
53156
|
Discharge summary
|
report
|
Admission Date: [**2168-3-22**] Discharge Date: [**2168-3-25**]
Date of Birth: [**2106-7-14**] Sex: M
Service: NEUROLOGY
Allergies:
Latex / Oxycodone Hcl/Acetaminophen
Attending:[**First Name3 (LF) 5378**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
CC:[**CC Contact Info 109462**]
HPI: Mr [**Known lastname 11791**] is a 61 year old right handed man with a history
of
CAD, type 2 diabetes mellitus who was brought in by the EMS as a
code stroke. According to Mr [**Known lastname 11791**]' family, the patient was with
his wife in the kitchen when she was washing dishes at around 7
pm. He then started shaking his hands, and then he started
speaking gibberish to her. She stated that everything happened
very fast - his wife was [**Name (NI) 8003**] speaking only, and the
translation was carried out by his daughter [**Name (NI) **]
([**Telephone/Fax (1) 101581**]). His wife stated that he appeared to be losing
balance, and so she grabbed him, sat him down, [**Name (NI) 653**] the
EMS.
One of his daughter's who lives on the [**Location (un) 470**] came down, and
tried to take a blood glucose, but the glucometer was not
working. She said that he looked dazed. When the EMS arrived, he
was slumped to the left on a chair, and he was grabbing the
paramedics. The EMS then noted lip smacking, and they mentioned
that he had a generalized tonic clonic seizure in the ambulance,
and they gave him some ativan. He had no urinary incontinence or
tongue biting. He has never had a seizure before, and he has had
no recent fevers or chills, or falls or head trauma. His SBP
recorded by the paramedics was over 200 mmHg, and his blood
glucose was in the high 200s. According to his son, his BP at
his
cardiologist's office was 140/70.
ROS: unobtainable (according to his wife, he has been feeling
well)
Past Medical History:
Coronary Artery Disease
Hypertension
Type II Diabetes Mellitus
Dyslipidemia
Chronic Renal Insufficiency
Gastroesophogeal Reflux Disease
Left Shoulder Arthritis/Rotator Cuff Injury
History of Detached Retina
Social History:
Lives with wife. Several children, present at bedside. Smoked a
few cigs/day for 2-3 years, stopped in [**2117**]. Works at [**Hospital1 18**] in
environmental services. He only rarely drinks beer once in a
while for holidays. No recreational drugs.
Family History:
Parents with CAD in their 70s.
Physical Exam:
T-99.6 (rectal) BP-153/89 HR-88 intubated sats 100%
Gen: Lying in bed, the ER are in the process of intubating the
patient for airway protection (GCS 8)
HEENT: NC/AT, moist oral mucosa
Neck: no meningismus, no carotid or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: not rousable even with noxious stimulus
Cranial Nerves:
Pupils 3 to 2 mm bilaterally. Corneal reflexes are in tact.
Facial excursion looks symmetric. Dolls head reflex is normal.
Gag is difficult to assess, as the airway has just been
inserted.
Motor & sensory:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. He withdraws all 4 limbs equally away from noxious
stimuli.
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: Narrow based, steady.
Romberg: Negative
Pertinent Results:
Chem-7 hemolyzed
ALT: 23 AP: 114 Tbili: 0.4 Alb: 5.3
AST: 48 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 571 (repeat 44)
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
96
8.9 14.6 236
45.8
N:35.3 L:47.2 M:7.8 E:8.9 Bas:0.8
PT: 13.9 PTT: 24.1 INR: 1.2
U/A negative
Utox and serum tox is -ve
CT/CTA head [**3-22**]
IMPRESSION:
1. No acute intracranial pathology. No evidence of an acute
territorial
infarct. However, if not contraindicated, MRI is more sensitive.
2. Focal rounded contour abnormality of the anterior
communicating artery
likely represents a very small 1-2 mm aneurysm, related to
fenestration
(partial duplication) with insertion of one of the limbs at this
site.
Otherwise, unremarkable CTA of the head, without evidence of
hemodynamically
significant stenosis or dissection.
3. Intubated, with secretions in the nasal cavity, nasopharynx
and
oropharynx.
4. Marked periapical lucency surrounding the left maxillary
central incisor
([**Doctor First Name **] #9) with frank erosion of the anterior cortex, likely
related to
underlying periodontal disease; other similar, but less marked
lucent lesions
are seen elsewhere. Correlation with detailed dental examination
is
recommended.
Routine EEG [**3-23**];
IMPRESSION: This is an abnormal portable EEG due to slowing and
disorganization of the background rhythm suggestive of a
moderate
encephalopathy. Medications, toxic/metabolic disturbances and
infections are common causes. There were also bursts of frontal
intermittent rhythmic delta activity (FIRDA) which is a
nonspecific
finding that can be seen in the setting of a metabolic
disturbance or
associated with an underlying subcortical lesion, increased
intracranial
pressure or a deep midline lesion. No epileptiform discharges or
electrographic seizures were seen during this recording.
MRI +/- gad [**3-23**];
IMPRESSION:
1. No evidence of abnormal enhancement, mass lesion or evidence
of an
underlying epileptogenic substrate.
2. Mucosal sinus disease, with an air-fluid level in the right
maxillary
sinus, which may represent acute sinusitis.
Brief Hospital Course:
Mr [**Known lastname 11791**] is a 61 year old right handed man with a history of
CAD, type 2 diabetes mellitus who was brought in by the EMS as a
code stroke. Hospital course by problem;
Neurology; The patient was admitted and underwent lumbar
puncture to exclude an infectious etiology of his symptoms. CSF
was notable for 1 wbc, 22 rbc, and normal protein and glucose.
He received one dose of acyclovir and this was discontinued
after preliminary data was returned. HSV PCR is currently
pending. Urine and serum toxicology were negative and the
patient denied any recent alcohol use or recent illness or
exposures. The patient was started on keppra 1000 mg [**Hospital1 **]. The
following morning the patient had an MRI brain which showed no
structural cause for his seizure. A routine EEG showed slowing
and disorganization of the background rhythm suggestive of a
moderate encephalopathy. Medications, toxic/metabolic
disturbances and infections are common causes. There were also
bursts of frontal intermittent rhythmic delta activity (FIRDA),
which was a nonspecific finding. The following morning after
admission, the patient was extubated and had no focal deficits
on examination. On HD#2 he was transferred to the neurology
floor where he was monitored overnight. He was without
neurologic deficit on exam. He was discharged on keppra with
plans to be followed in neurology clinic. He was instructed not
to drive for at least 6 months due to his probable seizure and
in accordance with [**State 350**] law.
ID; The patient was afebrile with no leukocytosis. Lumbar
puncture as described above was not consistent with a CNS
infectious process.
Resp; The patient was extubated on HD#2 without difficulties and
is doing well on room air.
Abd/GI; On admission the patient was found to have an elevated
lipase which resolved on repeat testing. He was tolerating a
diet without any abdominal pain.
Renal; The patient has chronic renal insufficiency. He received
gentle hydration and renal function is at his baseline.
Endocrine; The patient was maintained on regular insulin sliding
scale for his diabetes. His home metformin was held.
Medications on Admission:
LISINOPRIL 2.5 mg Tablet Qday
METFORMIN 500 mg Tablet 1 Qday
METOPROLOL SUCCINATE 25 mg Tablet SR Qday
NABUMETONE 750 mg Tablet [**Hospital1 **]
NITROGLYCERIN 0.4 mg SL q5 min up to 3 doses as needed for
angina
PANTOPRAZOLE 40 mg
SIMVASTATIN - 40 mg Tablet Q day
TEMAZEPAM - 7.5 mg Capsule QHS QHS prn as required for insomnia
ASPIRIN 81 mg Tablet
Discharge Medications:
1. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Nabumetone 750 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Temazepam 7.5 mg Capsule Sig: One (1) Capsule PO at bedtime
as needed for insomnia.
9. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. NITROGLYCERIN 0.4 mg SL q5 min up to 3 doses as needed for
angina
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Diabetes type II
Coronary artery disease
Dyslipidemia
Chronic Renal Insufficiency
Gastroesophogeal Reflux Disease
Left Shoulder Arthritis/Rotator Cuff Injury
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You where admitted for evaluation following a seizure.
Unfortunately, we have not identified the cause of your seizure.
You are [**Doctor First Name **] discharged on a new medication (Keppra) to help
prevent further seizures. You will be seen in neurology clinic
in a few weeks to discuss this hospitalization and continuation
of this medication.
Because of your seizure, you should not drive for at least six
months from your last seizure. You should be careful to avoid
activities that would cause you harm if you where to have a
seizure.
Please follow up with your primary care doctor to discuss this
hosptialization.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 1792**]
NEUROLOGY:
Drs [**Last Name (STitle) **] and [**Name5 (PTitle) **]
([**Telephone/Fax (1) 5088**]
You will be [**Telephone/Fax (1) 653**] regarding the timing of this appointment.
If you do not hear from this office within 2 days, please call
to schedule follow up.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**]
Completed by:[**2168-3-25**]
|
[
"272.4",
"726.10",
"250.00",
"780.39",
"414.01",
"716.91",
"585.9",
"530.81"
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icd9cm
|
[
[
[]
]
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[
"03.31",
"96.04"
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icd9pcs
|
[
[
[]
]
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9047, 9053
|
5615, 7777
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305, 322
|
9263, 9263
|
3479, 5592
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10063, 10570
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2420, 2453
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8177, 9024
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9074, 9242
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7803, 8154
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9411, 10040
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2468, 2832
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258, 267
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350, 1905
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2928, 3460
|
9278, 9387
|
2856, 2856
|
1927, 2136
|
2152, 2404
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,575
| 111,158
|
39985
|
Discharge summary
|
report
|
Admission Date: [**2177-12-9**] Discharge Date: [**2177-12-30**]
Date of Birth: [**2121-12-28**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2177-12-9**] INCISION + DRAINAGE OF PERINEUM WITH EXTENSIVE SOFT
TISSUE DEBRIDEMENT [**Doctor Last Name **]
[**2177-12-10**] WASHOUT & DEBRIDEMENT PERINEUM [**Doctor Last Name **]
[**2177-12-11**] Incision, drainage and washout of infected rectum and
perineum, laparotomy with diverting sigmoid colostomy. [**Doctor Last Name **]
[**2177-12-12**] RESETTING OF TESTICLES & PLACEMENT OF WOUND VAC [**Doctor Last Name **]
[**2177-12-18**] percutaneous tracheostomy, flexible bronchoscopy,
debridement and washout of perineal / buttock wound [**Doctor Last Name **]
[**2177-12-19**] I&D PERINEUM, WOUND VAC DRESSING PLACEMENT
History of Present Illness:
55yM with h/o DM2 and gastroparesis, here with abdominal
pain. Pain is chronic and he was going to see a
Gastroenterologist this week. However, he developed more acute
LLQ pain and N/V this past few days. Also noted some right
buttock and scrotal pain. Was initially admitted to the medical
service
with surgical consultation for concern of perirectal infection
vs. Fourniers Gangrene. He had an unremarkable CT scan at
admission, but he was mildly septic with a HR in the 120s and BP
in the 90s which both responded to fluid challenge.
Past Medical History:
PMH: DM2, gastroparesis, MRSA infections, kidney stones, HTN,
Hyperchol.
.
PSH: left knee replacement
Family History:
Noncontributory
Physical Exam:
On presentation:
VS: T: 98.0 BP: 104/61 P: 96 R: 18 O2: 100% on 2L
PE:
Gen: mild distress, warm, AAOx3
HEENT: anicteric
CV: RRR
Pulm: CTA b/l
Abd: soft, LLQ mild TTP, no rebound or guarding, nondistended
Rectal: unable to perform rectal. Entire right buttock very
indurated with some spreading erythema. Posterior scrotum firm
as well and painful. No crepitus palpated. No spontaneous
drainage.
Pertinent Results:
IMAGING:
[**12-8**] CXR: No acute cardiopulmonary process. No evidence of free
air
beneath the diaphragms.
[**12-8**] KUB: pending
[**12-8**] CT ABD/PELVIS: 1. Bilateral small pleural effusions. 2. No
small-bowel obstruction. 3. Non-specific fat stranding about the
kidneys. Delayed contrast excretion. 4. Foley catheter and air
within the urinary bladder could be from placement of Foley;
correlate clinically. 5. Non obstructive 2mm stone at the lower
pole of left kidney.
[**12-9**] SCROTAL U/S: Extensive hyperechoic foci tracking to the
floor of the perineum concerning for gas w/in the scrotal cavity
and Fournier's. No fluid collection to suggest an abscess.
[**12-10**]: CXR:New right IJ catheter tip is in the upper-to-mid SVC
and there is no evidence of pneumothorax. ET tube tip is 6.6 cm
above the carina. NG tube tip is out of view below the
diaphragm, difficult to visualize. Cardiac silhouette is
unchanged. Mild pulmonary edema has worsened. Left lower lobe
retrocardiac opacity has worsened, consistent with worsening
atelectasis. Bilateral pleural effusions are small.
[**12-10**]:abd Xray:Motion artifact, unable to visualize nasogastric
tube. Recommend repeat imaging to further assess.
[**12-11**] ECHO:LA severely increased,RA is moderately dilated, mild
symm LVH with normal cavity size, moderate regional left
ventricular sys dysfunction with hypokinesis of the basal
anterior, anteroseptal and lateral walls and of the inferior
septum. increased left ventricular filling pressure
(PCWP>18mmHg). RV dilated.Aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mitral valve
leaflets are mildly thickened. Mild (1+) MR, moderate pulmonary
artery systolic hypertension, small to moderate sized
pericardial effusion
[**12-11**]: CXR: Persistent retrocardiac opacity, can't exclude
infectious process
[**12-11**]: ABD: G tube in gastric antrum
[**12-12**] CXR: Continued evidence of increased pulmonary venous
pressure with substantial enlargement of the cardiac silhouette.
There is continued opacification in the retrocardiac region
incompletely silhouetting the hemidiaphragm. Again this is
consistent with some combination of atelectasis, pneumonia, and
pleural effusion.
[**12-14**]: CXR: Mild pulmonary edema, most readily visible in the
right lung has improved. Moderate cardiomegaly and mediastinal
vascular engorgement have decreased slightly. Left lower lobe is
still collapsed.
[**12-15**]: CXR: cardiomegaly unchanged, diffuse b/l alveolar
opacities likely representing pulmonary edema worsening, LLL
atelectasis
[**12-15**]: KUB: tip of OGT in antrum of stomach
[**12-16**] CXR:e/o elevated pulmonary venous pressure. Extensive
opacification at the left base is consistent with volume loss in
the left lower lobe and pleural effusion
[**12-17**] CXR:enlarged cardiac shadow, decreased lung vol, LL
collapsed, minimal left pleural eff.
[**12-18**] CXR:enlarged cardiac shadow, decreased lung vol, LL
collapsed, minimal left pleural eff.
11/25CXR:As compared to the previous radiograph, the
endotracheal tube has been removed and replaced by a
tracheostomy tube. The tip of the tube is projecting 4.8 cm
above the carina. Unchanged course and position of the
nasogastric tube and of the right-sided central venous access
line. There is no evidence of complications, notably no
pneumothorax. Unchanged severe cardiomegaly with a small left
pleural effusion and left lower lobe atelectasis. No newly
appeared focal parenchymal opacities suggesting pneumonia.
[**12-20**]: CXR: No acute changes.
[**12-21**]: CXR: New large RLL consolidation consistent with
aspiration.
[**12-21**]: KUB: NG tube tip is in the proximal stomach
[**12-22**] CXR: Consolidation RML RLL, pulmonary edema periphery
right lung as well as the left has improved. Mod cardiomegaly
improved. Trach tube abuts right tracheal wall. RIJ line can be
traced junction of brachiocephalic veins. feeding tube w/ wire
stylet in place passes into stomach and out of view.
[**2177-12-29**] Chest
FINDINGS: In comparison with the study of [**12-23**], the monitoring
and support devices remain in place. There is continued
enlargement of the cardiac silhouette with elevation of
pulmonary venous pressure and bilateral pleural effusions more
prominent on the left. The more focal opacification in the right
mid zone is not appreciated at this time
[**2177-12-9**] 06:50PM GLUCOSE-154* UREA N-59* CREAT-2.9* SODIUM-133
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-23 ANION GAP-12
[**2177-12-9**] 06:50PM CALCIUM-7.9* PHOSPHATE-4.4 MAGNESIUM-1.7
[**2177-12-9**] 06:50PM WBC-18.9* RBC-2.77* HGB-8.4* HCT-25.0* MCV-90
MCH-30.2 MCHC-33.6 RDW-14.2
[**2177-12-9**] 06:50PM NEUTS-80* BANDS-11* LYMPHS-1* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
[**2177-12-9**] 06:50PM PLT SMR-NORMAL PLT COUNT-249
[**2177-12-9**] 06:50PM PT-13.1 PTT-22.5 INR(PT)-1.1
[**2177-12-9**] 04:55AM %HbA1c-8.1* eAG-186*
[**2177-12-8**] 09:30PM GLUCOSE-549* UREA N-57* CREAT-2.0*
SODIUM-131* POTASSIUM-4.4 CHLORIDE-94* TOTAL CO2-27 ANION GAP-14
[**2177-12-8**] 09:30PM ALT(SGPT)-13 AST(SGOT)-37 ALK PHOS-110 TOT
BILI-0.5
Brief Hospital Course:
Patient seen by acute care surgical team and was admitted for
ICU management and aggressive debridement.
ICU Course as follows per dictation of Dr. [**First Name8 (NamePattern2) 7656**] [**Name (STitle) **]:
[**12-9**]: admission to TSICU. R IJ CVL placed. Transfused 2U
overnight.
[**12-10**]: s/p further debridement in OR, upon transfer back to ICU
pt was hypotensive- received Calcium, neo, ephedrine by
anesthesia
[**12-11**]: Went to OR for debridement and colostomy. Plan to return
to the OR tomorrow. Tissue culture is growing coag negative
staph. Echo today showed EF of 35-40%. Post op he did well, but
Hct dropped to 25 from 30 and he was started back on Neo to
maintain MAPs>65. As a result, he received 1 unit PRBCs.
[**12-12**]: went to OR for further debridement. started TFs postop.
started NPH [**8-31**] in addition to insulin gtt.
[**12-13**]:[**Last Name (un) **] consulted,erythromycin started for high TF
residuals in pt with h/o gastroparesis
[**12-14**]: Started on statin and Lopressor, ASA increased to 325.
IVF and albumin were DC'd and he was started on Lasix 20 [**Hospital1 **].
required 2 additional doses of Lasix, but still did not diurese
well. He was down 1L as of midnight. He was somewhat
uncomfortable overnight but increasing the propofol/fentanyl
resulted in respiratory depression. As a result, he was put back
on a rate with improved ABG.
[**12-15**]: Lasix held. bedside VAC changed by ASC team. Aline
replaced.
[**12-16**]: CPAP, Started on Clonidine, ACS repaired vac leakage, TF
at goal
[**12-17**]: VAC taken down at bedside by ACS.
[**12-18**]: went to OR for repeat debridement, did not reapply VAC
given plans to return to OR again [**12-19**].
[**12-19**]: hct 20.5, transfused 2units, increased clonidine to
0.3TID, went to OR for debridement, all Abx dc'ed per ACS
[**12-20**]: 1U PRBC, did have periods of hypertension and tachycardia
at first thought to be related to pain. His fentanyl drip was
maximized, but he still was uncomfortable. Per discussion with
Dr. [**Last Name (STitle) 35981**], we decided to start on methadone, continued
clonidine, and due to some abdominal distention, started
relistor. He passed gas, but not much increase in stool via
ostomy. Was more calm after the methadone. Pulled out NGT
partially, it was replaced and CXR obtained
[**12-21**]: pt had several episodes of emesis with increased
abdominal distention and minimal ostomy output. TFs were held
and meds were switched to IV. pt continued to have projectile
vomiting despite NGT sumping well. Erythro changed to Reglan.
given another dose of methylnaltrexone in the evening.
[**12-22**]: Bedside VAC change. Methadone increased. D/c Dilaudid.
Diuresis.
[**12-23**]: NGT clamped for 4 hrs;XR KUB- unchanged position of NGT;
restarted TF.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
He was transferred to the regular nursing unit on [**2177-12-23**]:
His course as follows by systems per dictation by [**First Name8 (NamePattern2) 17148**] [**Last Name (NamePattern1) 2819**],
NP:
Neuro-he was noted to be delirious felt to be multifactorial.
His physical exam, meds and labs were reviewed carefully. The
decision was made to stop the methadone IV that was started
while in the ICU for control of his acute pain issues. He
actually had minimal pain issues once transferred to the floor
requiring only in rare occasion oral Dilaudid. He remains on a
Clonidine patch which was also started during his ICU stay for
helping to control agitation; this should be weaned once he is
at rehab. His mental status over the course of his stay on the
floor has improved significantly. He is very alert and oriented
x2-3 and cooperative with his care.
Cardiac-his blood pressure and heart rate have been relatively
stable with SBP 140's-150's, DBP 70's-80's, he continues on his
Norvasc and Lisinopril. There are currently no acute issues at
time of this dictation.
Respiratory-he continues with a trach and receives humidified
air, his saturations have been stable ranging 95-99%. he wears a
Passy-Muir valve for speaking. He should continue on his prn
nebulizer treatments.
Gastrointestinal-patient self removed his Dobbhoff. it was
decided that he be evaluated by Speech given that his mental
status improved. He was placed on a dysphagia diet of soft
solids with thin liquids. He has required 1:1 supervision for
meals. His colostomy care was followed closely by the Wound Care
Ostomy Nurse during his stay.
Genitourinary-he is currently being treated for a UTI with a
total of 5 days of oral Cipro. His Foley catheter was replaced
on [**12-29**] and is being recommended to remain in place because of
his extensive perineal wound.
Musculoskeletal-there are no active issues. He was evaluated and
seen regularly by Physical and Occupational therapy and is being
recommended for acute rehab.
Integumentary-he has an extensive wound that has required VAC
dressing since his surgery. For transfer to rehab he has a wet
to dry, but this should be changed back to the VAC @125 once at
rehab.
Endocrine-he intermittently had elevated blood sugars requiring
adjustment of his standing and insulin sliding scales.
Heme-his hematocrits have been low but stable with a recent Hct
of 25.4 on [**12-29**] which is up from 24.9 on [**12-28**]. He is not showing
any signs of active bleeding.
Prophylaxis-he is receiving Heparin for DVT prophylaxis.
Medications on Admission:
[**Last Name (un) 1724**]:Norvasc 10', Lasix 40', Neurontin 300'', Amaryl 4', Levsin
0.5''' prn, Lantus 38U'', Lisinopril 5', Reglan 10'''',
Lopressor
50'',Zocor 40'.
.
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
10. hyoscyamine sulfate 0.125 mg Tablet Sig: 2-3 Tablets PO TID
(3 times a day) as needed for GI spasm .
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
16. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
18. NPH Sig: Twelve (12) units Injection at breakfast.
19. NPH Sig: Sixteen (16) units Injection at supper.
20. Humalog 100 unit/mL Solution Sig: One (1) dose Subcutaneous
four times a day as needed for per sliding scale: see attached
sliding scale.
21. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**4-29**]
hours as needed for pain .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Fournier's gangrene
Respiratory failure
Urinary tract infection
Acute blood loss anemia
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:
You were hospitalized with a severe infection in your
scrotal/perineal region requiring an operation. As a result you
have an extensive wound that requires specialized dressing
changes and care.
It is important that you not sit for long periods of time
because of the location of your wounds.
Followup Instructions:
Follow up in [**Hospital 2536**] clinic in 2 weeks for evaluation of your wound;
call [**Telephone/Fax (1) 600**] for an appointment.
Completed by:[**2178-1-7**]
|
[
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"038.9",
"403.90",
"288.60",
"272.0",
"041.85",
"293.0",
"428.0",
"518.81",
"428.33",
"536.3",
"V12.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"61.3",
"46.11",
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"33.23",
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icd9pcs
|
[
[
[]
]
] |
14838, 14885
|
7262, 12703
|
320, 947
|
15016, 15016
|
2113, 7239
|
15511, 15674
|
1661, 1678
|
12923, 14815
|
14906, 14995
|
12729, 12900
|
15193, 15488
|
1693, 2094
|
266, 282
|
975, 1519
|
15031, 15169
|
1541, 1645
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,727
| 157,556
|
27141
|
Discharge summary
|
report
|
Admission Date: [**2129-5-16**] Discharge Date: [**2129-5-23**]
Date of Birth: [**2080-8-9**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache, Sleepiness, Gait changes, Weight loss
Major Surgical or Invasive Procedure:
Right frontotemporal craniotomy for R temporal and R frontal
mass resection
History of Present Illness:
48 M w/ schizophrenia who, in past few months has been much
less active, had no appetite, lost weight (30-40 pounds as per
family). Would usually garden, walk to stores daily; recently
stayed on couch all day. In past 2 weeks, he has been
complaining
of headaches, more important in the AM. Family took him to South
[**Hospital **] hospital today where a head CT revealed R temporal mass w/
significant mass effect and edema. He was transferred to [**Hospital1 18**]
ER
for further management.
Past Medical History:
Schizophrenia
Hepatitis C
Social History:
smokes 1 ppd
Family History:
Hepatitis C ([**4-25**] siblings), Diabetes mellitus, Colon CA c/o
father
who died of brain met.
Physical Exam:
VS T 98.2 HR 89 BP 120/70 rr 18 SpO2 99%
Gen: Somnolent but arousable for brief period of time; oriented
on
himself, only partially in time and space; mildly irritable;
follows command; no obvious speech impairment;
HEENT: Pupils isocore, isoreactive 3->2, symmetric; no apparent
EOM
deficit; VF cannot be tested appropriately; L facial assymetry
when smiles; otherwise no weakness; no sensory loss; tongue
midline, symetric; uvula midline;
Motor: no pronator drift, no objective weakness ([**5-20**]) in 4 limbs
but spontaneously moves less L side;
Sensory: no apparent sensory loss;
DTRs: [**Name2 (NI) **], tri, pron: 2, symetric; quad achill: 3, symetric;
Babinski
neg; no clonus;
Pertinent Results:
[**2129-5-16**] 10:15PM GLUCOSE-116* UREA N-11 CREAT-0.7 SODIUM-136
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-26 ANION GAP-17
[**2129-5-16**] 10:15PM WBC-14.0* RBC-4.94 HGB-15.2 HCT-43.8 MCV-89
MCH-30.7 MCHC-34.7 RDW-12.1
[**2129-5-16**] 10:15PM NEUTS-89.3* LYMPHS-8.2* MONOS-1.6* EOS-0.8
BASOS-0.2
[**2129-5-16**] 10:15PM PLT COUNT-239
[**2129-5-16**] 10:15PM PT-13.3* PTT-34.4 INR(PT)-1.2*
[**2129-5-16**] 10:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on the evening of [**2129-5-16**] with complaints
of change in activity, appetite, weight loss as described in
HPI. A CT at an outside hospital showed R temporal mass with
significant mass effect and edema. He was emergently intubated
for airway protection and started on Decadron, Mannitol, Lasix,
and hpyperventilation to PCO2 of 30.
[**5-17**] MRI w/ w/o contrast: Multiple enhancing masses, both solid
and rim shaped, which
appear more likely to be neoplastic, as opposed to infectious in
origin. There is extensive surrounding edema, right-sided
uncal-hippocampal, and right to left subfalcine herniation.
[**5-17**] CT Torso: Left lower lobe collapse without evidence for
obstructing mass
lesion. No definite evidence for metastatic disease in the
chest, abdomen, or
pelvis.
At this point the decision was made to bring Mr. [**Known lastname **] to the OR
for an emergent Right craniotomy for excision of temporal and
frontal masses. The surgery occurred with no complications and
multiple samples were sent to pathology. The EBL was 200cc.
He had an unremarkable perioperative course and was transferred
to the MICU and started on Dilantin, and continued on Decadron,
Mannitol and Ancef. Radiation Oncology was consulted.
[**5-18**] Post-op MRI- The two ring-enhancing lesions in the right
frontal lobe and anterior right temporal lobe are no longer
demonstrated. The two foci of contrast
enhancement in the lateral aspect of the thalamus on the right
side are still
seen. Adequate CSF space between the right cerebral peduncle and
the adjacent temporal lobe. The degree of displacement of
normally midline structures is similar to the previous
examination.
Mr [**Known lastname **] was extubated on [**5-18**]. On [**5-19**] physical exam was notable
for AOx3, full strength in all extremities, ad following
commands. His surgical dressing was removed and the incision was
noted to be C/D/I with mild swelling. Mr. [**Known lastname **] has a history of
schizophrenia and was noted to be agitated with descriptions of
hallucinations and inappropriate thoughts. A Psychiatric
consult was requested and patient was started on Haldol and
Lorazepam was D/C'd. Mr. [**Known lastname **] continued to progress and was
transferred from the SICU to the floor on telemetry on [**2129-5-20**].
His foley and A-line were removed.
He worked with physical therapy and occupational therapy, he was
walking independently, he his neurologically intact awake, alert
and orientated X3 no drift, with good motor strength. His
incision was clean and dry without redness. His Dilantin was
weaned and switched to Keppra in anticipation of chemotherapy.
He will be discharged to the care of his family.
Medications on Admission:
1 monhtly shot of Prolixin Decanoate?
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Take while on Decadron.
Disp:*60 Tablet(s)* Refills:*2*
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*2 inahler* Refills:*2*
5. Haloperidol 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. Dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours) for 7 days.
Disp:*35 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Use while taking Percocet.
Disp:*30 Capsule(s)* Refills:*1*
8. 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*
9. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Keppra 500 mg Tablet Sig: Three (3) Tablet PO twice a day:
start on [**5-28**].
Disp:*180 Tablet(s)* Refills:*2*
11. Decadron 4 mg Tablet Sig: One (1) Tablet PO at bedtime:
Start on [**5-30**] after (3mg tid dose completes) continue until
Brain tumor clinic follow up.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Brain Mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
Watch incision for redness, drainage, swelling, bleeding or if
you develop a fever greater than 101.5. Do not get wet until
stiches are out.
Avoid smoking
No driving while on medication
Follow up with your psychiatrist at [**Hospital3 **] Mental Health
ASAP
Followup Instructions:
Have suture removed This Friday [**2129-5-27**] at Dr[**Name (NI) 9034**]
office [**Last Name (NamePattern1) **] [**Hospital Unit Name 12193**] come between 0900-1200
Follow up in Brain tumor clinic on [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **]
[**2129-6-6**] at 10:30 am
Completed by:[**2129-5-23**]
|
[
"295.62",
"191.9",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"02.03"
] |
icd9pcs
|
[
[
[]
]
] |
6611, 6668
|
2405, 5141
|
366, 443
|
6723, 6747
|
1885, 2382
|
7054, 7392
|
1064, 1163
|
5229, 6588
|
6689, 6702
|
5167, 5206
|
6771, 7031
|
1178, 1866
|
279, 328
|
471, 969
|
991, 1018
|
1034, 1048
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
214
| 197,273
|
18475+18541+56957+56958
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2188-10-6**] Discharge Date: [**2188-10-21**]
Date of Birth: [**2125-4-29**] Sex: M
Service: [**Hospital1 **]
This report will cover the patient's stay through [**2188-10-20**].
HISTORY OF PRESENT ILLNESS: This is a 63 year old male with
a history of hypertension and colon cancer status post
hemicolectomy who is status post a nine foot fall from the
cab of his truck on [**2188-10-2**]. The patient was reportedly
down for about two hours before help arrived and has had
changes in mental status since his fall. He was originally
seen at the [**Hospital 1558**] Hospital where he was
admitted and found to have a left scalp abrasion that was
sutured, a left clavicle fracture, left rib fractures and a
head CT scan that did not show any evidence of intracranial
hemorrhage. His next CT scan was also negative for fracture.
The pain was controlled there with percocet and he was
cleared by Physical Therapy for discharge home with a
creatinine of 2.4 at discharge. At home, however, he was
unable to carry out his activities of daily living, became
short of breath and was brought to an outside hospital
Emergency Room where his CK was noted to be 2456 and he was
noted to have a troponin T of 2.4, creatinine of 3.5, and had
an O2 saturation of only 81% on five liters nasal cannula.
An echocardiogram was carried out which showed an ejection
fraction of 40 to 45% and an arterial blood gas at the
outside hospital showed a pH of 7.32, with pCO2 of 48 and a
pO2 of 50. A chest CT scan demonstrated right upper lobe and
right lower lobe consolidation consistent with
bronchopulmonary pneumonia thought to be secondary to
aspiration pneumonia. No pneumothorax was seen. Again, a
head CT scan was negative. Given the patient's white blood
cell count elevation, infiltrate and hypoxia, he was given
one gram of ceftriaxone, aspirin for positive cardiac enzymes
and morphine sulfate for pain and was transferred to [**Hospital1 1444**] for further care.
On admission to the [**Hospital1 69**], the
patient was alert and intermittently oriented. The patient
received in the Emergency Department aspirin, Flagyl and
further morphine sulfate for pain. The patient was noted to
have unequal blood pressures in his arms and a transthoracic
echocardiogram was carried out to rule out dissection.
The transthoracic echocardiogram demonstrated no evidence of
aortic or thoracic dissection and showed mile regional left
ventricular systolic dysfunction with posterior and apical
hypokinesis.
PAST MEDICAL HISTORY:
1. Hypertension times three years.
2. Colon cancer status post hemicolectomy in [**2175**].
3. Prostate cancer status post prostatectomy.
4. Remote history of Hepatitis B approximately 25 years ago.
MEDICATIONS ON ADMISSION:
1. Accupril 40 mg q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives alone; he is separated
from his wife. [**Name (NI) **] has two supportive daughters. [**Name (NI) **] has
smoked approximately two to three packs per day times 50
years. Has occasional ethanol. Denies any intravenous drug
use. He is a trucker and was independent before his fall.
PHYSICAL EXAMINATION: On admission, vital signs with
temperature of 98.0 F.; blood pressure 122/65; pulse 102;
respiratory rate 20; O2 saturation 84% on room air and
increased to 97 to 100% on a nonrebreather. In general, the
patient was found lying in bed guarding his left side in mild
distress. HEENT: Pupils equally round and reactive to
light. Extraocular muscles are intact. Oropharynx is clear.
The patient wears dentures. Neck with no lymphadenopathy.
Chest with diffuse rales and rhonchi on the right; clearer on
the left but dullness is present at the left base.
Ecchymoses are present over the left anterior chest wall and
he is tender to palpation on the left side of his chest.
Abdomen soft, nontender, slightly distended, positive bowel
sounds. Midline well healed scar. Extremities with no
edema, clubbing or cyanosis. Two plus dorsalis pedis and
radial pulses bilaterally. Neurological examination: The
patient is awake, oriented to person, occasionally to place,
occasionally to time. Cranial nerves II through XII are
intact. Strength is five plus in all regions.
LABORATORY: On admission, white blood cell count 22.1,
hematocrit 40.5, platelets 298. Sodium 138, potassium 5.2,
chloride 103, bicarbonate 24, BUN 41, creatinine 3.4 and
glucose is 117. CK is 2427, with an MB of 133 and a troponin
T of 3.41.
EKG demonstrates normal sinus rhythm with normal axis and
intervals and chamber size. There are no ST or T wave
changes.
Chest x-ray demonstrates minimally displaced rib fractures
within the fifth, sixth and seventh left ribs posteriorly as
well as a depressed fracture of the left clavicle which is
displaced inferiorly by the width of the bone. There is no
pneumothorax. Mild congestive heart failure is evidenced by
vascular engorgement. Lungs are otherwise clear.
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit. The patient was begun on
antibiotics for presumed aspiration pneumonia and was placed
on aspirin, beta blockers, given the elevated cardiac enzymes
on admission. The patient's O2 saturations initially
stabilized on therapy for presumed aspiration pneumonia and
the patient was transferred to the Floor.
However, on the day of transfer, the patient had a further
episode of hypoxia and hypotension with a drop in his
systolic blood pressure to the 80s. The patient was bolused
with a total of two liters of normal saline with improvement
of his systolic blood pressure to 100 to 105 and the patient
was transferred back to the Medical Intensive Care Unit for
further management.
On readmission to the Medical Intensive Care Unit, he had an
O2 saturation of 80% on six liters via nasal cannula. He was
transferred to a 50% face mask where his arterial blood gas
was found to be 7.34/44/55. The patient demonstrated
increasing agitation and required 50 mg of Haldol for
sedation.
HOSPITAL COURSE BY SYSTEMS:
1. PULMONARY: The patient's hypoxia was most likely
secondary to aspiration pneumonia as well as fluid overload.
He was diuresed with intravenous Lasix with improvement of
his respiration. He was continued on a 14 day course of
Levofloxacin and Flagyl for presumed aspiration pneumonia.
The patient's respirations further improved with chest PT and
he was transitioned back to nasal cannula and finally room
air. The patient was able to maintain adequate room air O2
saturations.
2. CARDIAC: The patient was noted to have nonspecific
inferior ST depressions with T wave inversions, that were 1
mm in V4 through V6 in the setting of sinus tachycardia. On
another occasion, the patient was noted to have T wave
inversions in III and AVF with 1/[**Street Address(2) 1766**] depressions in V4
and V5. On a further occasion, the patient was noted again
in the setting of sinus tachycardia to have [**Street Address(2) 1766**]
depressions in V4 through V6.
The patient was monitored on Telemetry and was noted to
undergo atrial fibrillation at a rate of 140 on the [**10-10**] with V4 through V6 ST depressions of 1 mm. Telemetry
demonstrated further intermittent episodes of atrial
fibrillation with rates up to 160 and a possible ten beat run
of Ventricular tachycardia. Transesophageal echocardiogram
demonstrated trace mitral regurgitation, trace tricuspid
regurgitation, mildly depressed ejection fraction with
posterior / apical hypokinesis and no evidence of dissection.
Furthermore, the transthoracic echocardiogram demonstrated
left ventricular hypertrophy with mild global hypokinesis.
The patient's CK was 2427 on admission and peaked at 2551 on
the [**10-8**], after which point it trended downward to
575 on the [**10-13**]. His CK MB was 133 on admission
and declined consistently throughout his hospitalization.
His CK MB was 5 on the [**10-13**].
His troponin T was 3.41 on admission and increased to a
maximum of 5.22 on the [**10-12**]. His elevated cardiac
enzymes were thought to be primarily due to renal failure in
the setting of rhabdomyolysis as well as demand ischemia in
the setting of tachycardia. The patient was begun on high
dose beta blocker for rate control of his atrial fibrillation
and nonsustained ventricular tachycardia. He was begun also
on aspirin. He was anti-coagulated with heparin for
prophylaxis of his atrial fibrillation.
Persantine MIBI was carried out on the [**10-15**] and
did not demonstrate any significant ischemic ST segment
changes. There was no evidence of fixed or perfusion defects
on nuclear study. Diffuse hypokinesis and depressed ejection
fraction of approximately 30% was noted. The patient was
initially taken to the cardiac catheterization laboratory on
the [**10-23**], but was unable to undergo the procedure
at that time secondary to mental status changes and the
cardiac catheterization was deferred to a later date.
The patient was noted to have intermittent episodes of
hypotension during subsequent hospitalization and his beta
blockers and ACE inhibitor doses were titrated.
3. RENAL: The patient was noted to have an elevated
creatinine of 3.4 on admission. It was difficult to
ascertain the patient's baseline creatinine level as he is
not per report had blood work done recently prior to this
admission; however, on admission to the [**Hospital 28978**] Hospital, shortly after his fall, he was noted
to have an elevated creatinine of 2.6. His creatinine
steadily declined during the course of his hospitalization
from the maximum of 3.4 on admission to a baseline of between
2.2 and 2.4. Renal ultrasound was carried out on the [**10-7**] and revealed diffusely increased echogenicity of the
renal parenchyma bilaterally consistent with chronic
parenchymal disease. The left kidney is atrophied. Overall,
the study was consistent with arterial vascular disease. No
hydronephrosis or proximal hydroureter was seen on the study.
4. PSYCHIATRIC: The patient was noted to have intermittent
episodes of delirium. A psychiatric consultation was
obtained. A neurological consultation was also obtained.
The patient's change in mental status were characterized by
confusion that appeared to have a temporal component to it,
with confusion occurring at its greatest at night time. At
times, the patient was noted to have paranoid delusions.
However, he never demonstrated any clear auditory or visual
hallucinations. He required intermittent Haldol for
sedation. An ammonia level was checked and was found to be
27. A CT scan of the head was obtained and did not
demonstrate any evidence of intracranial hemorrhage. The
patient's mental status was significant improved on the [**10-20**] and at the time of this dictation, the patient is
alert and oriented times three and had a normal mini-mental
status examination.
5. ENDOCRINE: The patient was found to be significantly
hypothyroid. He had a TSH of 38 on the [**10-10**].
Repeat TSH on the 19th revealed a level of 45. The patient
was begun on Levothyroxine at 12.5 micrograms per day. His
repeat TSH and thyroid studies will be carried out four weeks
after this was initiated.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 22711**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2188-10-20**] 17:12
T: [**2188-10-20**] 17:34
JOB#: [**Job Number 50812**]
Admission Date: [**2188-10-6**] Discharge Date: [**2188-10-21**]
Date of Birth: [**2125-4-29**] Sex: M
Service: [**Hospital1 **]
NOTE: This dictation covers the hospital course through
[**2188-10-20**].
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 50946**] is a 63 year old male
with a history of hypertension who is status post a nine foot
fall on his back on the [**12-2**] when he fell off the
cab of his truck. He was reportedly down for approximately
two hours before help arrived and has had changes in his
mental status since the fall. He was originally seen at
[**Hospital1 498**] where he was found to have a left scalp abrasion that
was sutured, left clavicle fracture, left rib fractures, and
a negative
DICTATION ENDS.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 22711**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2188-10-20**] 16:30
T: [**2188-10-20**] 16:35
JOB#: [**Job Number 50947**]
Name: [**Known lastname 9454**], [**Known firstname **] [**Last Name (NamePattern1) 5173**] Unit No: [**Numeric Identifier 9455**]
Admission Date: [**2188-10-6**] Discharge Date: [**2188-10-23**]
Date of Birth: [**2125-4-29**] Sex: M
Service:
ADDENDUM: This is an Addendum to the prior Discharge Summary
and will cover the [**Hospital 1325**] hospital course through [**10-23**] at which point the patient was transferred to Dr.[**Name (NI) 9456**] service for CABG..
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM
(CONTINUED):
1. CARDIOVASCULAR ISSUES: The patient underwent a cardiac
catheterization on [**10-21**]. The patient was found to have
3-vessel coronary artery disease as follows: His left main
coronary artery had a 40% distal stenosis. The left anterior
descending artery had diffuse disease with serial proximal
stenoses up to 70%. The mid portion had a 50% lesion with
moderate calcification. The circumflex had diffuse disease
proximally at gate origin to a moderate size. A single
obtuse marginal branch had 60% stenosis. The AV groove
circumflex was totally occluded after the first obtuse
marginal. The right coronary artery was totally occluded in
the proximal segment. There was significant left-to-right
collaterals. A left ventriculography was not performed due
to his renal insufficiency. He was noted to have moral right
and left filling pressures and no evidence of pulmonary
hypertension. His right internal iliac artery was totally
occluded. The left iliac system had moderate diffuse
disease. The left renal artery was single and a mid vessel
90% stenosis.
As part of his preoperative workup for a planned bypass
surgery, his echocardiogram on [**10-6**] was reviewed with
the cardiologist. He was noted to have an ejection fraction
of approximately 40% to 45% without any evidence of either
mitral valve or aortic valve disease; specifically, there was
no mitral regurgitation, no mitral stenosis, no aortic
stenosis, and no aortic regurgitation.
Given his diffuse disease and dynamic electrocardiogram
changes, treatment options were discussed at length with the
patient and with his family. The options of coronary artery
bypass graft versus multiple stent placements were discussed.
The decision was made by the patient and also by his family
to proceed with cardiac bypass which was planned for [**10-24**].
2. RENAL ISSUES: The patient's creatinine was 2.1 on
[**10-23**] and appeared to be stable. Level of 2.2 appeared
to be his approximate baseline. He was to follow up with Dr.
[**Last Name (STitle) 677**] for possible future intervention for his 90% renal
artery stenosis. Likewise, he was to follow up with Dr.
[**Last Name (STitle) 677**] for possible stenting of his lower extremity
occlusions.
3. PULMONARY ISSUES: The patient continued to have good
oxygen saturations on room air. A repeat chest film no
[**10-23**] demonstrated a small left pleural effusion and
resolution of his prior pneumonia.
His white blood cell count continued to decline and was 13.4
on [**10-23**] (which was down from a high of 22.1 on [**10-6**]). He has been off antibiotics for several days.
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 181**], M.D.
Dictated By:[**MD Number(1) 9457**]
MEDQUIST36
D: [**2188-10-23**] 17:30
T: [**2188-10-25**] 05:10
JOB#: [**Job Number 9458**]
Name: [**Known lastname 9454**], [**Known firstname **] [**Last Name (NamePattern1) 5173**] Unit No: [**Numeric Identifier 9455**]
Admission Date: [**2188-10-6**] Discharge Date: [**2188-11-4**]
Date of Birth: [**2125-4-29**] Sex: M
Service: Cardiothoracic Surgery
This is an addendum to the discharge summary that starts on
[**10-23**]. Discharge summary from [**Date range (1) 9459**] is already
in the patient's chart.
On [**10-23**], the patient was transferred to Dr.[**Name (NI) 9456**] service for coronary artery bypass grafting after
his care on the Medical service. His prior cardiac
catheterization on [**10-21**] showed severe three vessel
disease with a 40% left main distal stenosis, 70% LAD
stenosis, 60% OM stenosis with diffuse distal in his
circumflex and then total occlusion after the first OM and a
totally occluded right coronary artery. It was also noted at
that time that his right internal iliac artery is totally
occluded and the left iliac system had moderate diffuse
disease. The left renal artery was single and a mid vessel
90% stenosis was noted in the left renal artery.
His cardiac surgery was planned, and his preoperative
echocardiogram on [**10-6**] showed an ejection fraction of
approximately 40-45% without any valvular disease. Of note,
no left ventriculogram was shot also at cardiac
catheterization due to his renal insufficiency.
PAST MEDICAL HISTORY: As previously noted.
1. Hypertension.
2. Colon cancer status post hemicolectomy in [**2175**].
3. Prostate cancer status post prostatectomy.
4. Remote history of hepatitis B.
5. Severe three vessel coronary artery disease.
6. Occluded severe bilateral iliac disease.
7. Left renal artery stenosis.
Cardiac Surgery consult was done by Dr.[**Name (NI) 979**] team on
[**10-22**], who noted his fall from a ladder earlier in the
month with a fractured left clavicle and left rib fractures.
His recovery was complicated by rhabdomyolysis. At home, he
had desaturated, brought to an outside hospital Emergency
Room and he had acute shortness of breath. He came in with
pneumonia and a positive CPK. While in the hospital, the
patient had paroxysmal atrial fibrillation. His carotid
ultrasound also showed that his right internal carotid was
occluded with a 40-60% left internal carotid stenosis.
ALLERGIES: Patient had no drug allergies.
MEDICATIONS AT TIME OF CONSULT:
1. Thyroid medication 12.5 mcg p.o. q.d.
2. Atorvastatin 20 mg p.o. q.d.
3. Enteric coated aspirin 325 mg p.o. q.d.
4. Lisinopril 2.5 mg p.o. q.d.
5. Toprol XL 50 mg p.o. q.d.
PHYSICAL EXAMINATION: On exam, he was awake, alert, and
mentating well. His lungs were clear bilaterally. His heart
was regular rate and rhythm. His abdomen was benign. His
extremities were warm and well perfused.
He was referred to Dr. [**Last Name (STitle) 71**]. He was also seen with a
preoperative evaluation by Physical Therapy and continued to
be followed by Psychiatry for some confusion as noted in the
previous discharge summary. He continued to be followed also
by Neurology given his risk with severe bilateral carotid
disease.
Preoperative laboratory work as follows: On the 29th showed
a white count of 14.6, hematocrit 30.8. PT 13.4, PTT 31.9.
Platelet count 424,000. INR of 1.2. BUN 35, creatinine 2.2,
glucose 108, sodium 136, potassium 4.4, chloride 105, bicarb
26, anion gap of 9.0, calcium 8.6, phosphate 2.9, magnesium
1.4.
Preoperative EKG on the 23rd showed inferior T-wave changes
that were nonspecific. The patient was in sinus rhythm at
the time with a rate of 67.
On [**10-24**], he underwent coronary artery bypass grafting
x2 with LIMA to the LAD and a vein graft to the OM by Dr.
[**Last Name (STitle) 71**]. He was transferred to the Cardiothoracic ICU in
stable condition.
On postoperative day one, patient had no events overnight.
He was extubated and was satting 96% on 3 liters. He had a
cardiac index of 2.3. His white count rose to 30.7 with a
hematocrit of 31 postoperatively. His BUN was 20 and
creatinine was 1.8, which was down from his baseline of 2.6.
Neurologically, he was intact. He continued to start his
wean off oxygen. Chest tubes remained in. His Swan was
pulled to begin wean of his Neo-Synephrine, which he was at
at 0.1 mcg/kg/minute. He was also supported on an insulin
drip. He finished his perioperative Vancomycin and began
Lasix diuresis also.
On postoperative day two, again he had no events overnight.
He remained neurologically intact. His chest tubes were
pulled. His Lopressor was increased to 25 mg p.o. b.i.d.
Continued his Lasix, and cultures had been sent off. No
results at that time. His creatinine rose slightly to 20,
and his white count dropped from the 30s to 18.
On postoperative day three, he desatted very briefly to 88,
but then improved with increased oxygen therapy. He was at
89 in sinus rhythm with a blood pressure of 114/56, increased
his saturation to 98% on 2 liters nasal cannula. At the time
his cultures did not return any significant information. His
white count dropped to 14.5. His creatinine rose slightly to
2.2. He had decreased breath sounds at both bases, but
otherwise his examination was unremarkable. His Lopressor
was increased to 50 b.i.d. and he was off all drips at that
time.
He also was restarted on his levothyroxine and atorvastatin.
He was transferred from CSRU out to the floor on [**10-27**]
to begin his ambulation and physical therapy. He continued
to be followed by Case Management and Neurology. He had some
periods of confusion and agitation.
On postoperative day four, he had some bilateral rhonchi.
His sternum was stable. His incisions were clean, dry, and
intact. His white count remained stable at 13.6. His
creatinine also remained stable at 2.1 with a hematocrit of
29.6. Neurology recommended a head CT. Patient continued to
work with rehab, however, he did drop his blood pressure to
the 70s and 80s supine throughout the day on the 4th, and so
no ambulation was attempted at that time given the
instability of his blood pressure. He was slightly somnolent
when this happened on the 4th at 5:45 p.m., and this happened
after he came back from his CT scan. A blood gas was drawn
at that time. His blood pressure rose, but he was a little
bit somnolent. EEG was ordered for the morning. His
Lopressor was decreased pending his blood pressure changes.
Neurology examined him again and with recommendations for the
EEG, and the patient was transferred from [**Hospital Ward Name **] 2 back to CSRU
pending a full neurologic examination.
On the 5th, patient has EEG in the morning. White count
dropped to 10.7. He was in sinus rhythm in 80s with blood
pressure of 99/54 and a planned MRA in the afternoon.
Neurology examined him again and noted a homonomous inferior
quadrant autopsia on the left, but results were being
weighted both the EEG and the MRA.
Patient was back on Neo-Synephrine drip at 1.5 in the unit
for blood pressure support. He remained mildly confused on
the 6th. His examination was otherwise unremarkable. His
creatinine stabilized to 2.0, which is below his baseline.
On postoperative day seven, patient's Neo-Synephrine had been
weaned down to 0.25 mcg/kg/minute. With no final report from
his EEG, the decision made to hold on his MRI given that his
confusion cleared for assessment by the Neurology service.
Early in the morning on the 8th, he was alert and oriented,
very cooperative. He remained afebrile. His incisions were
clean, dry, and intact. He was satting 99% on room air,
using incentive spirometer and coughing and deep breathing.
He had no ectopy and his blood pressure was stable, and his
incisions were clean, dry, and intact, and he was transferred
back out to the floor on the 8th off all drips. His
examination continued to be unremarkable. He had no further
confusion.
On postoperative day nine, he continued to do his rehab. His
Foley was discontinued. He appeared to be neurologically
intact. His creatinine rose slightly to 2.9, which was above
his baseline.
On postoperative day 10, he had no events. Remained in sinus
rhythm with a blood pressure of 90/62 and a pulse of 85. He
was satting 99% on room air, again and appeared alert and
oriented. The patient was transferred back to [**Hospital Ward Name **] 2 on the
10th. He was pushing his own wheelchair and ambulating
independently. Incisions were clean, dry, and intact. He
was in sinus rhythm in the 90s. Patient had a chest x-ray,
results were not back at the time, and they were waiting for
the patient's daughter to arrive so they could speak to her.
They were not sure if the patient would qualify for rehab,
and the patient wanted to go home. These issues were worked
out with the case manager.
On postoperative day 11, the [**11-4**], the patient
was discharged to home in stable condition with a temperature
of 98.4, sinus rhythm at 88, blood pressure 144/77, satting
96% on room air. His heart was regular rate and rhythm. His
lungs were clear bilaterally. His incisions were clean, dry,
and intact. His abdominal exam was benign. He had no
complaints of pain and was oriented.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Aspirin 325 mg enteric coated p.o. q.d.
3. Levothyroxine 25 mcg p.o. q.d.
4. Atorvastatin 20 mg p.o. q.d.
5. Combivent 13-18 mcg aerosol 1-2 puffs inhalation q.6h.
prn.
6. Tylenol 650 mg p.o. prn q.4h.
7. Magnesium hydroxide 7.75% suspension 30 cc p.o. h.s. as
needed for constipation.
8. Bisacodyl 10 mg suppository rectally q.d. as needed for
constipation.
9. Protonix 40 in delayed release enteric coated p.o. q.24h.
Final results for the CT of the head that was performed on
[**10-28**] showed no intracranial pathology including no
signs of intracranial hemorrhage.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting x2.
2. Status post prostate cancer with prostatectomy.
3. Status post colon cancer with colectomy.
4. Remote hepatitis B.
5. Hypertension.
6. Hypothyroidism.
7. Status post fractured left clavicle and left rib
fractures.
8. Status post rhabdomyolysis from fracture injuries.
9. Bilateral severe carotid stenosis.
10. Left renal artery stenosis.
DISPOSITION: Again the patient was discharged to home on
[**2188-11-4**].
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 2728**]
Dictated By:[**Last Name (NamePattern1) 981**]
MEDQUIST36
D: [**2188-12-30**] 08:34
T: [**2188-12-30**] 09:06
JOB#: [**Job Number 9460**]
|
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icd9cm
|
[
[
[]
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icd9pcs
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25813, 26573
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25187, 25792
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2789, 2856
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5013, 6069
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6097, 11742
|
18589, 25164
|
11771, 17393
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17416, 18566
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2873, 3177
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,124
| 103,828
|
49718
|
Discharge summary
|
report
|
Admission Date: [**2189-5-20**] Discharge Date: [**2189-5-30**]
Date of Birth: [**2133-2-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4854**]
Chief Complaint:
fever, hypotension, afib with RVR
Major Surgical or Invasive Procedure:
redo LUE AV fistula & replacement R SCV tunneled HD
History of Present Illness:
56 yo male, h/o ESRD [**2-5**] anti-GBM disease, on HD, DM2, HTN, p/w
fevers s/p HD session. Pt was reportedly dialyzed today; HD was
almost completed but had to be stopped early secondary to
clotting in the fistula. Pt/wife stated that he had felt unwell
since dialysis session on Monday (2 days prior to admission).
At this time, he was having some bilateral shaking of his arms.
He also reports some pain in his right shoulder, above the site
of his HD catheter. He states that this was worse with
movement. He had 1 episode of loose stools 1 day PTA. He
denies any URI symptoms, no CP/SOB/abdominal pain. After HD
session on day of admission, he felt unwell/lethargic at home.
He had some more episodes of shaking/rigors. He took a nap, and
after awaking from this, had a fever to 104. At this time, his
wife brought him to the [**Name (NI) **].
.
On presentation to the ED, he was febrile to 103.9; HR was
initially in the 90s with SBP=130. He subsequently went into
afib with a ventricular response 150-170s, with SBPs as low as
40-50. In the ED, he received 3 L NS (CVP from [**9-18**]; max). He
was seen by renal who felt that this was likely septic shock,
recommended vanco/gent. Renal stated that HD catheter (right
SC) should be used for fluids/pressors/abx (pt has history of
difficult access, ?saving femoral sites for future HD
catheters). As his SBP did not significantly improve with IVF,
he was started on dopa gtt with some improvement in SBP but
?exacerbation of tachycardia. Bedside TTE showed no pericardial
effusion or signs of tamponade. He was reportedly mentating
well throughout ED course. Other ED events include treatment of
hyperkalemia (7.1 to 4.6) with bicarb, D50. On presentation to
the ICU, he remained hypotensive, in afib with RVR, was
mentating adequately. He had no specific complaints but did
state that he was having pain in right shoulder at site of HD
catheter.
Past Medical History:
1. ESRD: [**2-5**] anti-GBM disease, on HD since [**3-7**]
2. DM2: dx [**2177**]
3. HTN
4. Chronic low back pain [**2-5**] herniated discs
5. CHF
6. Peripheral neuropathy
7. Anemia
8. h/o nephrolithiasis
9. s/p cervical laminectomy; ?osteo in past
10. h/o depression
11. h/o MSSA bacteremia ([**3-9**]-infected HD catheter), E. coli
bacteremia
12. s/p L AV graft: [**7-7**]
13. h/o [**12-7**] of L4-5 diskitis, osteo, epidural abscess
Social History:
Lives w/ wife, son, daughter-in-law, and three grandchildren in
[**Name (NI) 86**] area, has been unemployed [**2-5**] disability, smokes tobacco
1 ppd x45 years, past alcohol, no recreational drug use.
Family History:
1. DM
2. Renal failure
Physical Exam:
Gen: pleasant male, sitting in bed, A&Ox3 ("[**Hospital3 **],"
"[**2189**]," "[**5-20**]," "[**Last Name (un) 2450**]")
HEENT: PERRL, OP clear
Lungs: CTA bilat, no w/r/r
CV: tachy s1/s2, no m/r/g appreciated
ABd: soft, nt/nd, nabs
Extr: no c/c/e, DP 1+ bilat
Skin: with right SC HD catheter; some tenderness superior to
this area, some firm areas around site
Pertinent Results:
[**2189-5-20**] 04:50PM BLOOD WBC-12.2*# RBC-3.86*# Hgb-11.5*#
Hct-35.9*# MCV-93 MCH-29.7 MCHC-31.9 RDW-18.4*
[**2189-5-22**] 04:08AM BLOOD WBC-7.9 RBC-2.98* Hgb-8.6* Hct-27.9*
MCV-94 MCH-28.8 MCHC-30.8* RDW-18.6* Plt Ct-275
[**2189-5-25**] 06:00AM BLOOD WBC-5.2 RBC-2.52* Hgb-7.3* Hct-23.6*
MCV-94 MCH-28.8 MCHC-30.8* RDW-18.9* Plt Ct-353
[**2189-5-29**] 04:55AM BLOOD WBC-7.1 RBC-3.13* Hgb-8.9* Hct-28.6*
MCV-92 MCH-28.4 MCHC-31.1 RDW-18.6* Plt Ct-550*
[**2189-5-20**] 04:50PM BLOOD Neuts-89* Bands-1 Lymphs-5* Monos-3 Eos-0
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2189-5-20**] 11:20PM BLOOD PT-16.6* PTT-33.4 INR(PT)-1.5*
[**2189-5-24**] 12:00AM BLOOD PT-19.3* PTT-42.1* INR(PT)-1.8*
[**2189-5-29**] 12:41PM BLOOD PT-14.2* PTT-48.9* INR(PT)-1.3*
[**2189-5-20**] 04:50PM BLOOD Glucose-109* UreaN-31* Creat-9.6* Na-131*
K-7.1* Cl-93* HCO3-21* AnGap-24*
[**2189-5-22**] 04:08AM BLOOD Glucose-74 UreaN-40* Creat-9.3* Na-138
K-4.6 Cl-101 HCO3-22 AnGap-20
[**2189-5-24**] 05:58PM BLOOD Glucose-113* UreaN-26* Creat-6.4*# Na-137
K-4.2 Cl-100 HCO3-23 AnGap-18
[**2189-5-28**] 06:05AM BLOOD Glucose-62* UreaN-8 Creat-4.7* Na-143
K-4.1 Cl-105 HCO3-28 AnGap-14
[**2189-5-29**] 12:41PM BLOOD Glucose-71 UreaN-12 Creat-6.6* Na-140
K-3.8 Cl-104 HCO3-28 AnGap-12
[**2189-5-21**] 03:34AM BLOOD ALT-4 AST-12 LD(LDH)-176 CK(CPK)-271*
AlkPhos-101 Amylase-25 TotBili-0.4
[**2189-5-20**] 04:50PM BLOOD CK-MB-2 cTropnT-0.39*
[**2189-5-20**] 11:20PM BLOOD CK-MB-3 cTropnT-0.37*
[**2189-5-21**] 03:34AM BLOOD CK-MB-2 cTropnT-0.34*
[**2189-5-20**] 11:20PM BLOOD Calcium-7.9* Phos-5.2* Mg-1.5*
[**2189-5-22**] 04:08AM BLOOD Calcium-7.9* Phos-5.4* Mg-2.3
[**2189-5-29**] 12:41PM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8
[**2189-5-28**] 06:05AM BLOOD TSH-5.9*
[**2189-5-28**] 06:05AM BLOOD Free T4-1.0
[**2189-5-21**] 03:34AM BLOOD Genta-1.5* Vanco-10.9*
[**2189-5-26**] 04:00AM BLOOD Vanco-19.9*
[**2189-5-29**] 03:45PM BLOOD Vanco-17.1*
Time Taken Not Noted Log-In Date/Time: [**2189-5-20**] 10:19 pm
BLOOD CULTURE
**FINAL REPORT [**2189-5-23**]**
AEROBIC BOTTLE (Final [**2189-5-23**]):
REPORTED BY PHONE TO [**Doctor Last Name **] [**Doctor Last Name **] AT 11:55AM ON [**2189-5-21**]
- CC6D.
STAPH AUREUS COAG +.
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.
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2189-5-23**]):
STAPH AUREUS COAG +.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
Time Taken Not Noted Log-In Date/Time: [**2189-5-20**] 10:20 pm
BLOOD CULTURE
**FINAL REPORT [**2189-5-23**]**
AEROBIC BOTTLE (Final [**2189-5-23**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 103963**] [**2189-5-20**].
ANAEROBIC BOTTLE (Final [**2189-5-23**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 103963**] [**2189-5-20**].
[**2189-5-22**] 1:00 pm CATHETER TIP-IV RIGHT TUNNELLED DIALYSIS.
**FINAL REPORT [**2189-5-25**]**
WOUND CULTURE (Final [**2189-5-25**]):
STAPH AUREUS COAG +. >15 colonies.
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
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
[**2189-5-23**] 5:33 pm BLOOD CULTURE
**FINAL REPORT [**2189-5-29**]**
AEROBIC BOTTLE (Final [**2189-5-29**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2189-5-29**]): NO GROWTH.
Cardiology Report ECG Study Date of [**2189-5-20**] 4:40:10 PM
Atrial fibrillation with rapid ventricular response
Ventricular premature complex
Indeterminate QRS axis
Late precordial QRS transition
Prominent/modestly peaked T waves - possible hyperkalemia
Consider also chronic pulmonary disease
Clinical correlation is suggested
Since previous tracing of [**2189-4-6**], findings as outlined now
present
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
147 0 80 258/342.57 0 90 10
[**First Name3 (LF) 706**] Final Report
US EXTREMITY NONVASCULAR LEFT [**2189-5-23**] 2:32 PM
US EXTREMITY NONVASCULAR LEFT
Reason: rule out fluid collection around LUE graft
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with tunneled HD catheter in R SC, ESRD, with L
AV graft
REASON FOR THIS EXAMINATION:
rule out fluid collection around LUE graft
INDICATION: 56-year-old man with tunneled hemodialysis catheter
in right subclavian vein, end-stage renal disease and left AV
graft. Evaluate for fluid collection surrounding the left upper
extremity graft.
LEFT UPPER EXTREMITY ULTRASOUND: The patient's left upper
extremity arteriovenous graft is again seen, without evidence of
intraluminal flow, and multiple internal echos suggesting
thrombosis. No fluid collections are seen surrounding the graft.
The fat, muscle, and fascial planes are preserved.
IMPRESSION:
1. No fluid collections surrounding the patient's left upper
extremity AV graft.
2. Graft thrombosis.
[**Hospital 706**] Final Report
MR L SPINE SCAN [**2189-5-23**] 8:02 AM
MR L SPINE SCAN; -52 REDUCED SERVICES
Reason: epidural abscess? discitis?
[**Hospital 93**] MEDICAL CONDITION:
56 year old man with h/o discitis and increasing pain
REASON FOR THIS EXAMINATION:
epidural abscess? discitis?
EXAM: MRI of the lumbar spine.
CLINICAL INFORMATION: Patient with history of discitis and
increasing pain. Rule out epidural abscess.
TECHNIQUE: T2 sagittal images were acquired. The examination is
limited as patient was unable to continue.
FINDINGS: Compared to the previous MRI of [**2188-1-24**], again noted
is endplate changes at L4-5 level with anterior displacement of
L4 over L5 secondary to spondylolisthesis. Since the previous
study, the high-grade narrowing of the spinal canal has resolved
which could be secondary to laminectomy at this level. No
evidence of spinal stenosis seen at other levels. Bilateral
severe narrowing of the neural foramina is noted. Disc bulging
is seen at L5-S1 level as before.
IMPRESSION: Limited study demonstrating chronic changes of
discitis and osteomyelitis at L4-5 level. For better assessment
a repeat study with gadolinium is recommended if clinically
indicated.
Conclusions:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Left
ventricular
systolic function is hyperdynamic (EF 70-80%). No masses or
thrombi are seen
in the left ventricle. There is no ventricular septal defect.
Right
ventricular chamber size and free wall motion are normal. The
aortic root is
moderately dilated. The number of aortic valve leaflets cannot
be determined.
The aortic valve leaflets are mildly thickened; there is focal
thickening of
the right cusp that could represent a vegetation. There is no
aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2187-11-19**], the aortic and tricuspid valve abnormalities are new, and
are highly
suggestive of endocarditis.
Cardiology Report ECG Study Date of [**2189-5-23**] 4:29:46 PM
Baseline artifact. Sinus rhythm. First degree A-V block.
Non-diagnostic poor
R wave progression. Compared to the previous tracing of [**2189-5-21**]
sinus rhythm
has replaced atrial fibrillation. Clinical correlation is
suggested.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 204 96 428/459.57 31 27 17
[**Last Name (NamePattern1) 706**] Final Report
CHEST (SINGLE VIEW) [**2189-5-29**] 12:50 PM
CHEST (SINGLE VIEW); CHEST FLUORO WITHOUT RADIOLOGI
Reason: H/O RENAL FIALURE, NOW INSERTIUON OF CATHETER FOR
DIALYSIS
CHEST 7:49 a.m. [**5-29**]:
HISTORY: Catheter insertion for dialysis.
IMPRESSION: A single frontal spot film of the chest centered
over the right lower lobe was provided for documentation of a
fluoroscopic guided procedure without a radiologist in
attendance. It shows a dual channel central venous line, tip
projecting over the right atrium.
Brief Hospital Course:
# MRSA Bacteremia and sepsis: Patient presented to the ED with
fevers/chills after partial HD session on [**5-20**] (stopped early
due to fistula clotting), he was admitted to the MICU in afib
with RVR and subsequent hypotension, found to have sepsis, MRSA
bacteremia. He responded to fluids and pressors, and vancomycin
and gentamicin. His subclavian line was changed over a wire and
the catheter tip also grew out MRSA. He was loaded on amio for
afib with good result (PR increased to 212 after amio started).
TTE showed no pericardial effusion or evidence of tamponade, but
was concerning for endocarditis given valve thickening. A TEE
was attempted but was unsuccessful due to inability to pass the
U/S scope. He was weaned from pressors on [**5-23**] but remained in
the MICU for until [**5-25**] for CVVH. He remained hemodynamically
stable, restarted hemodialysis without difficulty. All
surveillance blood cultures had no growth. For further ID work
up patient will need an outpatient MRI with gadolinium (to
further assess chronic changes of discitis and osteomyelitis at
L4-5) and TEE for more accurate assessment of endocarditis.
Patient will continue vancomycin for 6 weeks and will follow up
in the [**Hospital **] clinic on [**6-15**] at 2pm
.
# ESRD: Patient was continued on CVVH while in the MICU via a
new subclavian line changed over wire. He was transitioned back
to HD without difficulty once out of the MICU. ID recommended
removing the line altogether and resiting it to L subclavian.
However given L subclavian is a future site for dialysis access
via fistulas in his L arm. ON [**5-29**] LUE AV fistula was redone by
transplant surgery & replacement R SCV tunneled HD was placed.
.
# Afib with RVR: Patient was loaded on IV amiodarone while in
the MICU and then continued on PO amiodarone 400 po bid x 14
days. He will need oupatient follow up of his TFTs, LFTs, and
PFTs by his PCP. [**Name10 (NameIs) **] will need to restart anticoagulation once
cleared by surgery, that no further procedures are required.
.
# Chronic Pain: Patient was continued on methadone, oxycodone,
and neurontin per home regimen
.
# Anemia: Remained stable at baseline 26-30, attributed to ACD
and ESRD. Continued Epo and transfusions as needed with
dialysis.
.
# HTN: BP remained stable after MICU stay. Continued PO
amiodarone and BB. Consider restarting amlodipine and
lisinopril as BP allows as outpatient.
.
# CAD: Pt's elevated troponins attributed to end stage renal
disease. He was continued on BB and aspirin.
.
# Diabetes - Continued diabetic diet, SSI with FS QID.
.
# Depression - Continued paxil, remeron, and seroquel.
Medications on Admission:
Meds at home:
Oxycodone PRN
Colace
Amlodipine 10 mg
Paxil 20 mg
Protonix 40 mg
Seroquel 25 mg
Remeron 30 mg
Neurontin 200 mg QHD
Lisinopril 40 mg (recently held)
Methadone 10 mg q4h
Lopressor 100 mg TID, recently decreased to 50 mg TID
Coumadin 5 mg
Sevalemer 400 mg TID
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours).
6. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for back or surgical pain.
Disp:*30 Tablet(s)* Refills:*0*
16. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
DIALYSIS for 5 weeks: TO BE DOSED AND GIVEN AT DIALYSIS.
Disp:*0 0* Refills:*0*
17. Outpatient Lab Work
PATIENT NEEDS CBC DRAWN ONCE A WEEK
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
HD catheter sepsis
Discharge Condition:
good
Discharge Instructions:
please seek medical attention if you experience fevere > 101.5,
severe nausea, vomitting, pain
please take medications as instructed
no driving while taking narcotic pain meds
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2189-6-4**]
9:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. Date/Time:[**2189-6-12**] 11:30
INFECTIOUS DISEASE CLINIC [**6-15**] AT 2PM
[**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**] MD, [**MD Number(3) 4858**]
Completed by:[**2189-5-31**]
|
[
"458.9",
"995.92",
"427.31",
"250.60",
"585.6",
"357.2",
"428.0",
"403.91",
"311",
"785.52",
"V64.1",
"996.62",
"038.11",
"276.7",
"722.10",
"996.73",
"285.21",
"V13.01",
"V09.0",
"583.89",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"99.07",
"99.04",
"39.27",
"86.05",
"99.10",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17776, 17833
|
13249, 15900
|
348, 402
|
17896, 17903
|
3468, 9033
|
18129, 18608
|
3049, 3073
|
16221, 17753
|
10024, 10078
|
17854, 17875
|
15926, 16198
|
17927, 18106
|
3088, 3448
|
275, 310
|
10107, 13226
|
430, 2354
|
2376, 2813
|
2829, 3033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,790
| 145,471
|
43385
|
Discharge summary
|
report
|
Admission Date: [**2155-11-27**] Discharge Date: [**2155-12-4**]
Date of Birth: [**2078-7-12**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Ciprofloxacin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
CP s/p heart catherization
Major Surgical or Invasive Procedure:
PCI
History of Present Illness:
Pt is a 77 yo female with known CAD, HTn, high chol, DM2,
medically managed angina who was referred to [**Hospital1 18**] for elective
heart catherization after a outpateint ETT was significant for
reversible ischemia. Cath today revealed 3VD; LAD 80% diffuse,
RCA 95% long lesion, LCX subtotally occluded with dominant OM2.
Pt recieved [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] x 2 to RCA with PTCA to jailed RPLV. It
was complicated by bradycardia and hypotension requiring
atropine, dopamine and placement of a temporary pacing wire.
During which Pt developed global ST elevations with an acute
non-occlusive thrombosis to the RCA stent and probable jailing
of RCA brances secondary to stent placement. Pt recieved PTCA
and Heparin bolus, while Integrilin was stopped secondary to
groin hematoma. Intra-cath echo with preserved LVEF 60% but
general hypokinesis. Given hypotension and probable severe
global ischemia, decision made to place patient on Dopamine and
introduce an intra-aortic baloon pump. Pt transfered to CCU for
closer monitoring. Upon arrival to the CCU, Pt was HD stable
without pressors and requiring 2L NC, not complaining of chest
pain or shortness of breath.
Past Medical History:
CAD (no previous PTCA or CABG)
HTn
DM2
high cholesterol
hyperparathyroid
h/o PE ([**2120**])
neurogenic bladder
s/p back surgery (6/'[**55**])
Social History:
Lives with husband and daughter. [**Name (NI) **] [**Name2 (NI) **], EtOH, IVDU. Health
care proxy = sister [**Name (NI) 15359**].
Family History:
No CAD
Physical Exam:
VS: 96, 76 (70's), 92/52 (SBP 80-90's), 100% on 2LNC
PE
Lying supine, comfortable, NAD,
Anicteric, PERRL, OP wnl, dry MM
neck supple, JVP not appreciable
RRR, nl S1/S2, murmur secondary to IABP
anteriorly CTA bilat
groin sites intact with minimal ooze, left stable hematoma
ext without edema, DP 1+ bilat, warm and well-perfused
Alert and oriented, responds appropriately
Pertinent Results:
[**2155-11-2**]
AP PORTABLE UPRIGHT VIEW OF THE CHEST: There has been interval
removal of the ET tube and NG tube. There is left middle lung
zone discoid atelectasis. The cardiac contour is stable. There
is no focal infiltrate or effusion.
[**2155-11-27**] Catherization:
1. Coronary angiography of this right dominant circulation
revealed
3-vessel CAD. The LMCA had no flow-limiting lesions. The LAD had
a
tubular 80% stenosis of the mid vessel distal to a large D1
which was
mildly diseased. The LCX was subtotally occluded distally and
had a
total occlusion of OM2. The RCA had a tubular 95% lesion in the
mid
vessel.
2. Resting hemodynamics showed central aortic hypertension.
3. Successful PTCA and stenting of the RCA with a 3.0 mm and a
3.5 mm
Cypher drug-eluting stent. Final angiography showed no residual
stenosis, no dissection and normal flow (see PTCA comments).
4. Successful placement of a 40cc IABP for hypotension with
good
diastolic augmentation.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful stenting of the RCA.
[**2155-11-27**] Echo Conclusions:
Left ventricular wall thickness, cavity size, and systolic
function are
grossly normal (LVEF>55%). Due to suboptimal technical quality,
a focal wall
motion abnormality cannot be fully excluded. There is no
pericardial effusion.
[**2155-11-28**] Right Femoral U/S
FINDINGS: There is a large right groin hematoma measuring
14.4 x 8.2 x 9.6 cm. This is adjacent to the incisional site. In
this region, there is an actively bleeding pseudoaneurysm.
[**2155-11-28**] ECHO
Conclusions:
1. The left atrium is moderately dilated. The right atrium is
dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is difficult to assess but is probably normal
(LVEF>55%).
3. The right ventricular cavity is markedly dilated. There is
severe global
right ventricular free wall hypokinesis.
4. The aortic valve leaflets (3) are mildly thickened.
5. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
6. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension.
7. Compared with the findings of the prior report (tape
unavailable for
review) of [**2155-11-27**], there has been no significant change.
[**2155-11-27**] 11:47AM BLOOD WBC-13.2* RBC-3.51* Hgb-10.6* Hct-31.4*
MCV-90 MCH-30.2 MCHC-33.8 RDW-13.6 Plt Ct-207
[**2155-11-27**] 09:28PM BLOOD WBC-8.9 RBC-3.16* Hgb-9.6* Hct-27.6*
MCV-88 MCH-30.4 MCHC-34.8 RDW-13.8 Plt Ct-166
[**2155-11-28**] 09:22PM BLOOD WBC-11.8* RBC-3.59* Hgb-11.0* Hct-30.6*
MCV-85 MCH-30.6 MCHC-35.9* RDW-13.9 Plt Ct-113*
[**2155-11-29**] 03:53AM BLOOD WBC-9.8 RBC-3.44* Hgb-10.7* Hct-29.2*
MCV-85 MCH-31.1 MCHC-36.6* RDW-14.5 Plt Ct-111*
[**2155-11-29**] 01:01PM BLOOD Hct-31.2*
[**2155-11-30**] 03:00AM BLOOD WBC-11.5* RBC-3.35* Hgb-10.4* Hct-28.7*
MCV-86 MCH-31.0 MCHC-36.1* RDW-15.0 Plt Ct-105*
[**2155-12-2**] 06:55AM BLOOD WBC-11.1* RBC-3.51* Hgb-10.8* Hct-31.0*
MCV-88 MCH-30.8 MCHC-34.9 RDW-14.5 Plt Ct-123*
[**2155-12-3**] 06:55AM BLOOD WBC-9.3 RBC-3.30* Hgb-10.2* Hct-29.0*
MCV-88 MCH-31.0 MCHC-35.3* RDW-14.1 Plt Ct-143*
[**2155-12-4**] 08:50AM BLOOD WBC-11.8* RBC-3.68* Hgb-11.2* Hct-32.6*
MCV-89 MCH-30.5 MCHC-34.4 RDW-13.9 Plt Ct-178
[**2155-11-27**] 11:47AM BLOOD PT-13.9* PTT-71.5* INR(PT)-1.2
[**2155-11-27**] 09:28PM BLOOD PT-13.7* PTT-56.3* INR(PT)-1.2
[**2155-11-28**] 04:01AM BLOOD Plt Ct-145*
[**2155-11-28**] 03:37PM BLOOD Plt Ct-144*
[**2155-11-28**] 08:23PM BLOOD PT-14.2* PTT-33.4 INR(PT)-1.3
[**2155-11-28**] 09:22PM BLOOD PT-13.4 PTT-28.8 INR(PT)-1.1
[**2155-11-29**] 10:07AM BLOOD PT-13.6 PTT-27.6 INR(PT)-1.2
[**2155-11-30**] 03:00AM BLOOD PT-13.9* PTT-26.2 INR(PT)-1.2
[**2155-12-3**] 06:55AM BLOOD Plt Ct-143*
[**2155-12-4**] 08:50AM BLOOD Plt Ct-178
[**2155-11-27**] 11:47AM BLOOD Glucose-294* UreaN-23* Creat-1.1 Na-140
K-4.2 Cl-103 HCO3-24 AnGap-17
[**2155-11-27**] 08:01PM BLOOD K-3.7
[**2155-11-30**] 03:00AM BLOOD Glucose-113* UreaN-17 Creat-1.1 Na-146*
K-3.3 Cl-111* HCO3-28 AnGap-10
[**2155-12-2**] 06:55AM BLOOD Glucose-160* UreaN-24* Creat-0.8 Na-142
K-4.1 Cl-106 HCO3-28 AnGap-12
[**2155-12-3**] 06:55AM BLOOD Glucose-138* UreaN-21* Creat-0.9 Na-141
K-3.8 Cl-107 HCO3-27 AnGap-11
[**2155-11-27**] 11:47AM BLOOD CK(CPK)-55
[**2155-11-27**] 08:01PM BLOOD CK(CPK)-183*
[**2155-11-28**] 04:01AM BLOOD CK(CPK)-660*
[**2155-11-28**] 03:37PM BLOOD CK(CPK)-1027*
[**2155-11-28**] 09:22PM BLOOD ALT-19 AST-40 AlkPhos-51 Amylase-51
TotBili-0.8
[**2155-11-29**] 03:53AM BLOOD CK(CPK)-580*
[**2155-11-27**] 11:47AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2155-11-27**] 08:01PM BLOOD CK-MB-16* MB Indx-8.7*
[**2155-11-28**] 04:01AM BLOOD CK-MB-53* MB Indx-8.0* cTropnT-1.05*
[**2155-11-28**] 03:37PM BLOOD CK-MB-62* MB Indx-6.0 cTropnT-1.71*
[**2155-11-29**] 03:53AM BLOOD CK-MB-29* MB Indx-5.0 cTropnT-0.99*
[**2155-11-28**] 04:01AM BLOOD Calcium-7.3* Phos-2.8 Mg-1.4*
[**2155-11-28**] 03:37PM BLOOD Mg-2.6
[**2155-11-28**] 09:22PM BLOOD Calcium-9.3 Phos-3.8 Mg-1.9
[**2155-12-1**] 03:59AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.8
[**2155-11-29**] 06:13AM BLOOD freeCa-1.19
Hematology
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2155-12-3**] 01:01AM Yellow Clear 1.015
Source: Catheter
[**2155-12-2**] 11:57AM Straw Clear 1.018
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
[**2155-12-3**] 01:01AM LGE NEG 30 NEG NEG NEG NEG 5.0 SM
Source: Catheter
[**2155-12-2**] 11:57AM LG NEG TR 250 NEG NEG NEG 6.5 NEG
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2155-12-3**] 01:01AM 103* 9* FEW NONE <1
Source: Catheter
[**2155-12-2**] 11:57AM 21-50* [**3-28**] OCC NONE 0-2
OTHER URINE FINDINGS Mucous
[**2155-12-3**] 01:01AM FEW
Source: Catheter
Brief Hospital Course:
77 yo female with known 3VD previously managed medically, DM2,
HTn who was admitted to CCU following elective cardiac
catherization complicated by bradycardia and hypotension, ST
elevations requring pressors transiently as well as an IABP and
a temporary pacer wire.
1) CAD: Pt with known diffuse CAD evident in previous cardiac
cath (4/'[**55**]) who was brought for elective catherization after a
positive p-MIBI showing reversible inferior ischemia. As per
detailed report, catherization on admission significant for 80%
LAD, RCA 95%, LCx subtotally occluded. Intervention included
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] to RCA times 2 with subsequently jailing of RPLV with
ostial plaque shift rescued with angioplasty. Relook cath
showed patent RPLV/RCA but acute thrombosis treated with PTCA.
Catherization complicated by global ST elevations, bradycardia
requring atropine and hypotension requiring dopamine. Most
likely Pt suffered an acute RV infarction from occlusion of
marginal branches during catherization, confirmed by in cath
echo showing RV hypokinesis. Given clinical picture during
procedure, an IABP and temporary pacer wire was placed. Pt
transferred to the CCU HD stable not requiring pressors but
being paced. Pt continued on Hep gtt, ASA, statin, plavix with
Integrilin d/c secondary to groin hematoma. BB held given
bradycardia and all nitrates avoided. CK peaked during HD #1 at
1000. Pacer decreased showing underlying sinus bradycardia, and
weaned to off as NSR recovered in the first 24 hours. IABP also
removed during first 24 hours. However removal complicated by
right external iliac arterial bleed (see details below). For
the remaining hospital stay Pt medically managed with ASA.
lipitor 20 and plavix. BB continued to be held given RV infarct
and bradycardia. Lopressor added on after stabilization and was
tolerated well. To be discharged on lopressor 12.5 po BID and
titrated as tolerated as ouitpatient. Will stay on ASA, statin
and plavix for 300 days. Follow-up appointment in 2 weeks with
Dr [**Last Name (STitle) **].
2) Rhythm: Pt with bradycardia during catherization likely
secondary to RV infartcion. Pt requiring a temporary pacing for
the fist 24 hours until she recovered function and was
maintained in NSR after its removal.
3) Pump: Pt with hyperdynamic EF (60%)on echo during
catherization without previous history of CHF. Pt hypotensive
requiring dopamine for a brief while during cath. Upon transfer
to the floor, Pt was HD stable not requiring pressors. However
cath echo signicant for diffuse RV hypokinesis that gradually
improved over the following few days. D/C medical regimen to
include captopril 25 mg po tid to be changed to lisiniopril as
outpatient.
4) Vascular: Removal of IABP complicate by an iliac artery
rupture with subsequent retroperitoneal hemorrage. Pt required
resucitation with IVF and PRBC transfussion. The right iliac
artery was repaird surgically without complicated and Pt
transferred to CCU service intubated with JP drain in place.
After correction Pt with stable Hct's and no evidence of
continued bleed. Pt extubated without complication. Pt
followed closely by vascular surgery who on POD # 5 removed the
JP drain. Pt to follow up with Dr [**Last Name (STitle) **] in one week at
which point staples will be removed.
5) Mental Status: Pt confused and agitated overnight on
admission, requiring close supervision and haldol as precautions
for the stability of IABP and temproary wire. Pt much less
confused the following night and for the remaining of the
hospital stay was comfortable and at her baseline.
6) Fever: On night of expected discharge Pt developed a fever
to 101.1 without complaint. Pt with evidence of UTI by U/A,
given a dose of ceftriaxone and will be started on Cefpodoxime
PO times 7 days total.
**Pt discharged to [**Hospital3 **] for short-term stay with
followup appointments with Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) **] in the next
1-2 weeks.
Medications on Admission:
Imdur, lipitor, atenolol, lisinopril, ASA, Humalin 70/30,
prilosec, lasix, Bextra, nitrofuantoin, propxy, norvasc
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 9 months.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
12. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
twice a day for 6 days.
13. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
acute MI
iliac artery bleed
Discharge Condition:
good
Discharge Instructions:
please take all medications as prescribed.
please make sure to attend all follow up appointments, if you
are unable it is very important to reschedule as soon as
possible.
Please call PCP or return to ED if suffering from continued
fever greater than 101.4, chest pain, shortness of breath, acute
abdominal pain, persistent nausea and vomitting, inability to
tolerate food or liquid.
Followup Instructions:
please follow up with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 2394**]) on Wed [**12-14**] at 3:30 PM.
please follow up with vascular surgeon Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
([**Telephone/Fax (1) 3121**]) on Thursday [**12-11**] at 1:30 PM.
|
[
"401.9",
"998.2",
"E870.6",
"424.0",
"790.92",
"518.0",
"414.01",
"410.71",
"E879.0",
"458.29",
"250.00",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.31",
"37.61",
"37.22",
"97.44",
"36.01",
"96.04",
"99.20",
"37.78",
"36.07",
"88.56",
"54.19",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13582, 13652
|
8160, 11526
|
312, 317
|
13724, 13730
|
2307, 3283
|
14164, 14496
|
1890, 1898
|
12364, 13559
|
13673, 13703
|
12226, 12341
|
3300, 8137
|
13754, 14141
|
1913, 2288
|
246, 274
|
345, 1558
|
11541, 12200
|
1580, 1724
|
1740, 1874
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,177
| 179,856
|
30356
|
Discharge summary
|
report
|
Admission Date: [**2173-4-12**] Discharge Date: [**2173-4-15**]
Date of Birth: [**2095-4-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77 yo male with COPD, h/o CVA, dementia, PVD presents from
nursing home with acute onset of SOB with reported O2 sats 84 %
on 2 L NC. Given duonebs and increased O2 to 3 L NC and O2 sats
87%. Switched to NRB and O2 sats improved to 90-92% and he was
transferred to [**Hospital1 18**] ED.
.
In the ED, T 100.1, HR 137 BP 238/104 RR 45 o2 sats 93 % on 100%
NRB. He was given vancomycin 1g x1, ceftriaxone 1g IV x1,
combivent nebs, SL nitro x3, solumedrol 125 mg IV x1,
levofloxacin 250mg was started but devloped redness in hand so
stopped and given benadryl, pepcid.
.
On arrival to the ICU he was very SOB. Only able to speak 1 word
at a time therefore history is only obtained from records from
the nursing home. Patient does reports cough and SPB. Denies
CP.
Past Medical History:
-COPD s/p intubation in '[**62**], '[**71**], and '[**9-9**]
-PVD s/p R fem/profundus endarterectomy and fem/tib bypass '[**58**],
s/p L fem bypass '[**43**].
-L hip fracture in '[**65**] s/p ORIF
-DM
-h/o alcohol abuse - none since [**2-/2160**].
-CVA '[**55**] with R hemiparesis
-Depression
-Anemia - iron deficiency. Colonoscopy in [**3-8**] with benign
adenoma. EGD [**3-8**] with erosive esophagitis, no biopsies done. Pt
has chronic dysphagia but declines further workup.
-R inguinal hernia.
-prior CXR's show apical opacities c/w scarring - this is
chronic and has been stable on scans in [**2172**]. Pt has been
treated for positive PPD in the past.
Social History:
Patient lives at [**Hospital **] rehab. He is on hospice for end-stage
COPD. Patient reports he has a sister [**Name (NI) **] [**Name (NI) **] but he does not
know her number. Also reports that HCP [**Name (NI) **] [**Name (NI) **]. Cannot say
how he is related to him or where he know him from. Worked for
17 years in a paper factory. Has 2 sisters and one brother, all
living in [**Name (NI) 3914**]. He does not get along with brother. [**Name (NI) **] 5
children and does not know where they are. Ex wife lives
somewhere in [**Name (NI) 86**]. He does not keep in contact with his family
on a regular basis.
Family History:
noncontributory.
Physical Exam:
Vitals: T 99.3 (ax) BP 123/73 HR 128 O2 sats 98 % BiPap 5/5 40 %
FiO2
General: Elderly male breathing on BiPap, appearing
uncomfortable, using accerssory muscles to breath
HEENT: MMM, PERRL, EOMI
CV: RR, tachycardic, could not appreciate murmur
Lungs: bibasilar crackles, no wheezes
Abd: NABS, soft, NT/ND, well healed scar
Skin: no rashes
Neuro: oriented to person, hospital and year but occasionally
pulling at mask. could not assess CN as on BiPap mask, strength
in LE [**5-8**] and equal. RUE strength 5/5, LUE spastic [**2-5**] to old
CVA with handgrip in place
Ext: no edema
Pertinent Results:
CXR: bilateral infiltrates, right lung scarring and bullae
.
ECG: sinus tach, rate 135, no ST changes
.
LABS:
[**2173-4-15**] 03:34AM BLOOD WBC-22.9* RBC-4.12* Hgb-11.5* Hct-35.2*
MCV-86 MCH-28.0 MCHC-32.7 RDW-14.4 Plt Ct-286
[**2173-4-14**] 04:22AM BLOOD WBC-28.9* RBC-4.15* Hgb-11.5* Hct-35.3*
MCV-85 MCH-27.7 MCHC-32.6 RDW-14.4 Plt Ct-285
[**2173-4-13**] 04:10AM BLOOD WBC-33.4* RBC-4.12* Hgb-11.5* Hct-35.7*
MCV-87 MCH-27.9 MCHC-32.2 RDW-14.6 Plt Ct-276
[**2173-4-12**] 04:00AM BLOOD WBC-24.5* RBC-4.89 Hgb-13.9* Hct-42.7
MCV-87 MCH-28.5 MCHC-32.6 RDW-14.4 Plt Ct-371
[**2173-4-12**] 04:00AM BLOOD Neuts-88* Bands-1 Lymphs-6* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2173-4-15**] 03:34AM BLOOD Plt Ct-286
[**2173-4-12**] 04:00AM BLOOD Plt Ct-371
[**2173-4-12**] 04:00AM BLOOD PT-10.9 PTT-22.7 INR(PT)-0.9
[**2173-4-15**] 03:34AM BLOOD Glucose-100 UreaN-29* Creat-0.7 Na-135
K-4.1 Cl-97 HCO3-33* AnGap-9
[**2173-4-14**] 04:22AM BLOOD Glucose-163* UreaN-23* Creat-0.7 Na-137
K-4.1 Cl-99 HCO3-30 AnGap-12
[**2173-4-12**] 04:00AM BLOOD Glucose-97 UreaN-20 Creat-1.0 Na-137
K-4.7 Cl-96 HCO3-28 AnGap-18
[**2173-4-12**] 04:00AM BLOOD ALT-22 AST-30 LD(LDH)-318* CK(CPK)-73
AlkPhos-89 TotBili-0.2
[**2173-4-12**] 04:00AM BLOOD CK-MB-NotDone proBNP-278
[**2173-4-15**] 03:34AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.4
[**2173-4-12**] 04:00AM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.3 Mg-1.8
[**2173-4-12**] 06:54AM BLOOD Type-ART Rates-/28 Tidal V-491 PEEP-5
FiO2-40 pO2-159* pCO2-46* pH-7.43 calTCO2-32* Base XS-5
Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NIV
Brief Hospital Course:
77 yo male with h/o bad COPD, h/o CVA and PVD presenting with
respiratory failure likely secondary to PNA on already
compromised lungs
.
# Hypoxic respiratoy failure: Patient per records seems to have
bad COPD requiring steroids and standing nebs. Per outside
facility is on hospice for end-stage COPD. Presented with
elevated WBC, cough, infiltrates on CXR and elevated lactate.
Likely PNA superimposed on bad COPD. ABG 7.44/42/275 but this is
in the setting of breathing 40-50 times per minute. Patient
rapidly improved on steroids, antibiotics. Did not require
intubation but was treated with BiPAP briefly night of
admission. Transitioned to PO prednisone and PO antibiotics. He
needs to finish a taper of steroids as outlined and a course of
azithromycin/cefpodoxime as outlined. A discussion should be
pursued regarding patient's wishes re: hospice care.
.
# Fever and increased WBC: Likely [**2-5**] to PNA and possible
component of steroids. All culture data negative. Should have a
repeat WBC in a week to ensure count is decreasing.
.
# h/o CVA: Stable issue; continued soft diet.
.
# h/o dementia: Unclear baseline. Oriented to hospital, year and
person.
Medications on Admission:
Prednisone 20 mg PO QD
ASA 325 mg PO QD
MVI
Colace 100 mg PO BID
Omeprazole 20 mg PO QD
Advair 250/50 1 puff [**Hospital1 **]
Duonebs Q4H
Guiatuss cough syrup
Tylenol PRN
Dulcolax PRN
Discharge Medications:
1. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 2 days. Capsule(s)
2. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 4 days.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment
Inhalation Q4H (every 4 hours).
4. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) inhalation Inhalation once a day.
5. Prednisone
Prednisone 60 mg po qd [**4-16**]
Prednisone 40 mg po qd [**4-17**] - [**4-19**]
Prednisone 20 mg po qd [**4-20**] - [**4-22**]
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care Center
Discharge Diagnosis:
COPD flare
pneumonia
Discharge Condition:
stable
Discharge Instructions:
Please contact to doctor at your facility with any chest pain,
shortness of breath or other concerning symptoms. You should
finish your course of antibiotics and steroids.
Followup Instructions:
Please follow up with the doctor at your facility within the
next few days. Please continue the full course of antibiotics.
|
[
"486",
"294.8",
"428.31",
"491.21",
"428.0",
"518.81",
"443.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7013, 7074
|
4662, 5835
|
319, 326
|
7139, 7148
|
3082, 4639
|
7369, 7497
|
2447, 2465
|
6070, 6990
|
7095, 7118
|
5861, 6047
|
7172, 7346
|
2480, 3063
|
276, 281
|
354, 1118
|
1140, 1801
|
1817, 2431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,177
| 158,744
|
36099
|
Discharge summary
|
report
|
Admission Date: [**2132-11-11**] Discharge Date: [**2132-11-14**]
Date of Birth: [**2112-9-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
20 yo female with a history of narcotic abuse, was recently
diagnosed with NSAID gastritis following [**Hospital Unit Name 153**] admission for GI
bleed, presents with anemia. The patient was recently
discharged following brief ICU admission for upper GI bleed
([**Date range (1) 81889**]). EGD at that time showed likely NSAID gastritis.
The patient had reported significant NSAID use for chronic
migraines. Since that time, the patient had been unable to fill
her protonix prescription, but had been taking prilosec OTC.
She followed up in [**Company 191**], and was found to have a 10 point Hct
drop, (24). She reports intermittent dark stools since
discharge two weeks ago. She also reports intermittent nausea,
but denies vomiting. She was referred to the ED for further
workup.
In the ED her initial vital signs were T 97.4 HR 124 BP 131/80
RR 20 O2 100%. She was guaiac positive. A NG lavage was
performed with induced emesis which was grossly bloodly. She
cleared after 250ccs. She was tachycardic, but hemodynamically
stable. She received a total of 2 L of NS and 1 unit of PRBCs,
and was type and crossed. GI was consulted over the phone and
recommended MICU admission. Her labs were significant for a Hct
of 23.1, down from 24.9 earlier today, 34.5 on discharge on
[**2132-10-29**]. The patient was given 40mg pantoprazole. Her vital
signs on transfer were HR 119 BP 115/80 O2 100% on RA.
Review of systems is otherwise negative.
Past Medical History:
NSAID Gastritis
Social History:
Student at [**Last Name (un) **]. The patient has a history of using
marijunana and oxycontin recreationally, sober for 3 years.
Denies alcohol usage, quit smoking 4 months ago, prior to which
she smoked for 2 years.
Family History:
Mother and father are healthy. Grandmother has unknown liver
condition, no other GI conditions or cancers of GIT
Physical Exam:
VITALS: T 98.0 BP 121/75 HR 86 RR 17 O2Sat 100%RA
GENERAL: Pleasant, well appearing female in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MM dry. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Tachycardic, but regular. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP flat
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**11-30**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Studies:
.
[**2132-11-11**] EGD:
Esophagus: Normal esophagus.
Stomach:
Mucosa: Focal area of erythema and granular mucosa of about 4 cm
was noted in the fundus of the stomach consistent with
gastritis. But no active bleeding or signs of recent bleed was
noted.
Duodenum: Normal duodenum.
Impression: Abnormal mucosa in the stomach
Otherwise normal EGD to second part of the duodenum
.
[**2132-11-14**] CT ABD/PELVIS:
FINDINGS: The lung bases demonstrate no pleural effusions or
concerning
nodules or lesions. The visualized portions of the heart and
great vessels
are unremarkable.
.
The liver, spleen, bilateral kidneys, bilateral adrenal glands,
gallbladder, and pancreas are unremarkable. The small and large
bowel of normal size and caliber. The stomach appears normal. No
abdominal free air, free fluid, or lymphadenopathy is seen.
.
CT PELVIS WITH ORAL AND IV CONTRAST: The large bowel, rectum,
and bladder
appear normal. The uterus is normal in size and shape with
normal follicular activity for a patient of this age. No pelvic
free air, free fluid, or lymphadenopathy is seen.
.
BONE WINDOWS: The osseous structures are unremarkable.
.
IMPRESSION: Normal CT examination.
.
.
LABS:
[**2132-11-11**] 03:49PM BLOOD WBC-10.6 RBC-2.80*# Hgb-8.2*# Hct-24.3*#
MCV-87 MCH-29.2 MCHC-33.6 RDW-13.7 Plt Ct-272#
[**2132-11-11**] 09:55PM BLOOD WBC-9.3 RBC-2.74* Hgb-7.9* Hct-23.1*
MCV-84 MCH-28.8 MCHC-34.1 RDW-14.3 Plt Ct-295
[**2132-11-12**] 06:01AM BLOOD WBC-8.1 RBC-2.90* Hgb-8.6* Hct-24.0*
MCV-83 MCH-29.7 MCHC-35.8* RDW-14.7 Plt Ct-211
[**2132-11-13**] 02:34AM BLOOD WBC-8.1 RBC-3.21* Hgb-9.3* Hct-26.4*
MCV-82 MCH-29.1 MCHC-35.3* RDW-15.1 Plt Ct-212
[**2132-11-13**] 05:04PM BLOOD WBC-8.9 RBC-3.94* Hgb-11.8*# Hct-34.8*
MCV-88 MCH-30.0 MCHC-33.9 RDW-15.1 Plt Ct-218
[**2132-11-14**] 06:15AM BLOOD WBC-8.5 RBC-4.11* Hgb-12.0 Hct-35.0*
MCV-85 MCH-29.1 MCHC-34.2 RDW-14.8 Plt Ct-236
[**2132-11-11**] 03:49PM BLOOD Plt Ct-272#
[**2132-11-12**] 06:01AM BLOOD PT-12.3 PTT-23.3 INR(PT)-1.0
[**2132-11-13**] 02:34AM BLOOD Plt Ct-212
[**2132-11-14**] 06:15AM BLOOD Plt Ct-236
[**2132-11-11**] 09:55PM BLOOD Glucose-110* UreaN-14 Creat-0.7 Na-139
K-3.2* Cl-107 HCO3-24 AnGap-11
[**2132-11-13**] 02:34AM BLOOD Glucose-89 UreaN-19 Creat-0.6 Na-140
K-3.8 Cl-108 HCO3-23 AnGap-13
[**2132-11-14**] 06:15AM BLOOD Glucose-75 UreaN-15 Creat-0.8 Na-137
K-3.8 Cl-104 HCO3-22 AnGap-15
[**2132-11-11**] 09:55PM BLOOD ALT-27 AST-27 AlkPhos-87 TotBili-0.1
[**2132-11-11**] 09:55PM BLOOD Albumin-4.1 Calcium-8.7 Phos-2.7 Mg-1.9
[**2132-11-13**] 02:34AM BLOOD Calcium-8.1* Phos-3.8 Mg-2.1
[**2132-11-11**] 03:49PM BLOOD HDL-39 CHOL/HD-4.1
.
.
MICRO:
[**2132-11-12**] 6:01 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2132-11-14**]**
MRSA SCREEN (Final [**2132-11-14**]): No MRSA isolated.
.
.
Brief Hospital Course:
20F recently discharged after hemetemesis felt [**12-31**] NSAID induced
gastritis, returns with HCT drop.
#. acute blood loss anemia - pt noted to have decreased HCT upon
routine repeat labs with her PCP [**Last Name (NamePattern4) **] [**11-11**]. NG lavage in the ED
that precipitated hematemesis. She had EGD-proven NSAID
gastritis and may have been taking a reduced dose of Prilosec as
an outpatient (requires insurance prior authorization).
.
She denied any recent NSAID use. She was given a total of 4U of
PRBCs in the ICU. She underwent EGD the morning after admission
which showed multiple areas of erosions and gastritis in the
fundus but overall improved from previous EGD. She was changed
to PO PPI per GI, who felt that a small bowel pathology might
explain her anemia given some melena.
.
A CT ABDOMEN/PELVIS was obtained to evaluate for small bowel
pathology and was negative. Small bowel enteroscopy and
colonoscopy were offered non-emergently, and the patient and her
mother preferred to obtain these studies as an outpatient. Her
HCT remained stable. It was made clear to pt and family that
the source of her bleeding remained unknown.
.
At GI recommendations, she was instructed to closely follow-up
her HCT Q3D x 1 week after discharge. She was provided with the
phone and fax number of [**Company 191**] where results should be sent to f/u
these values. She was provided with copies of her EGDs, as her
mother asked if further GI workup could occur closer to home in
[**State 2748**]. She tolerated a regular diet without difficulty.
HCT at discharge was 35.
.
#. sinus achycardia - She was tachycardic on admission which was
most likely secondary to volume loss. She was given IV fluids
and her tachycardia improved, although she remained with HRs of
100 or so prior to arrival on the medical floor. upon
discharage, her heart rate was down to the 80s.
#. Insomnia: She was continued on home regimen of Seroquel.
#. History of Narcotic Abuse: At the patient's request, she was
not given narcotics while hospitalized.
#. Code Status: She was full code during this hospitalization.
#. Communication: Was with patient, mother and sister [**Name (NI) 81890**]
[**Telephone/Fax (1) 81891**].
.
# follow-up pt was instructed to follow-up with the [**Hospital **] clinic no
later than in [**12-7**] for repeat EGD and further small bowel
evaluation. an appointment already existed for repeat EGD, and
she was instructed to call to setup [**Hospital **] clinic follow-up. she
was also given the phone and fax of [**Company 191**], where she will have fax
her CBC results, to determine whether her HCT remains stable,
and if she needs additional transfusions.
Medications on Admission:
Seroquel PRN insomnia
Tylenol PRN for headache
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for prn insomnia.
3. Outpatient Lab Work
Please draw CBC 2-3 days after discharge (draw on [**2132-11-17**]), on
[**11-19**], on [**11-12**] and fax results to ATTN: Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 816**] (or her covering physician) at [**Telephone/Fax (1) **] (TEL),
[**Telephone/Fax (1) **] (FAX). After faxing, please call to confirm
reciept. This is to ensure that your blood count is stable.
Your HCT at the time of discharge is 35.
4. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea for
7 days.
Disp:*10 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-gastrointestinal bleed, unknown source
Discharge Condition:
stable, mental status OX3, ambulating normally
Discharge Instructions:
You were admitted to the hospital because of a drop in your red
blood cells. You received 4U of blood, your HCT at the time of
discharge was 35.
.
While you were here you had a endoscopy which showed
inflammation of your stomach and healing of the breakdown of
your stomach which had been seen last time. We are not exactly
sure what the bleeding this time was caused by, but are
concerned about a possible small bowel source. A CT was
obtained to examine this further, and you were offered a capsule
study and colonoscoy which you preferred to have done as an
outpatient, and will follow-up as below.
.
You were continued on your anti-acid pill (protonix or
omeprazole are both adequate). You should continue to take this
pill as prescribed.
You should avoid all NSAIDs (non-steroidal anti-inflammatory)
medications like Advil and Aleive. Instead, use Tylenol for
your headaches.
Be sure to have your labwork checked as described below.
Followup Instructions:
You will need to have your red blood cell level (hematocrit)
checked frequently as an outpatient. You can use the
prescription provided. You can either bring this to an urgent
care center or to a lab and ask them to call the results to your
primary care doctor (or the covering doctor) at [**Hospital **] at: [**Telephone/Fax (1) 1300**]. You should show them a copy of
this discharge paperwork and let them know that your Hematocrit
at discharge was: 35.0
This way they will be able to tell you if you need a blood
transfusion.
.
please have your CBC drawn on [**2132-11-17**]. Please have the results
faxed to your PCP (Dr. [**Last Name (STitle) 816**] at [**Telephone/Fax (1) **] (TEL), 617.667.
(FAX), please call after the results have been faxed to confirm
receipt, and determine whether any intervention needs to take
place.
.
Please schedule a follow-up appointment with the [**Hospital **] clinic.
Call [**Telephone/Fax (1) 81892**] to schedule this appointment. You can request
to be seen by Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] who saw you while you were
admitted. If you would like, you may follow-up with a local
gastroenterologist. You should be seen no later than the end of
[**Month (only) **], but ideally in early [**Month (only) **].
.
The following appointment is for the endoscopy previously
schedule only:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **],EAST PROCEDURES ENDOSCOPY SUITES
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2132-12-19**] 10:30
|
[
"535.40",
"578.0",
"346.90",
"V15.81",
"E935.9",
"305.93",
"285.1",
"427.89",
"780.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9605, 9611
|
5918, 8613
|
324, 352
|
9705, 9754
|
3074, 5895
|
10747, 12279
|
2127, 2241
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8710, 9582
|
9632, 9683
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8639, 8687
|
9778, 10724
|
2256, 3055
|
278, 286
|
380, 1838
|
1860, 1877
|
1893, 2111
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,248
| 132,919
|
3808
|
Discharge summary
|
report
|
Admission Date: [**2121-9-18**] Discharge Date: [**2121-10-2**]
Date of Birth: [**2068-2-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Toradol / Celebrex
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dizziness followed by ICD firing.
Major Surgical or Invasive Procedure:
[**2121-9-19**] cabg x3/ MV repair (LIMA to LAD, SVG to OM, SVG to
PDA, 30 mm [**Doctor Last Name **] Physio-Ring)
History of Present Illness:
53 yo male with several day history of intermittent angina
associated with diaphoresis. Had episode of dizziness on [**9-17**]
and AICD fired. Device interrogated and revealed a 13 sec period
of Torsades. He r/i for MI with CK peak 996 and troponin peak
19.2. Admitted at [**Hospital1 **] and cathed performed. Transferred
here for surgical evaluation after cath. Pt. has known ischemic
cardiomyopathy with left thoracotomy lead/generator change in
[**9-18**]. EF 35% most recently.
Past Medical History:
Ischemic Cardiomyopathy/Congestive Heart Failure w/ EF of 35%
Coronary Artery Disease s/p Myocardial Infarction [**2115**] s/p
thrombectomy and stent to OM1
Intraventricular Conduction Defects (IVCD) s/p Dual Chamber
pacer [**12-19**]
Hypertension
Hyperlipidemia
Cervical disc herniation s/p surgery x 2
s/p lumbar disc surgery x 2
s/p Cholecystectomy
s/p Left shoulder surgery
s/p Left total knee replacement
s/p pericarditis [**2115**]
Osteoarthritis
Social History:
Tobacco: 70pack/yr hx, one PPD currently
ETOH: denies
Family History:
Father w/ CABG at 57. Brother w/ Myocardial Infarction at 42.
Physical Exam:
98.0 HR 58 RR 18 98% RA sat
NAD
Alert and oriented X 3, MAE, nonfocal neuro exam
PERRL, EOMI, anicteric, poor dentition
neck supple, no LA/TM, no bruits
CTAB
RRR Sa S2 2/6 SEM
left ant. thoracotomy site well-healed
Pacer site left shoulder well-healed
soft, NT, ND, no HSM
extrems warm, no edema, no varicosities, left knee well-healed
2+ bil. carotids/radials/PT/DP/femorals
Pertinent Results:
[**2121-10-1**] 07:05AM BLOOD WBC-9.9 RBC-3.34* Hgb-10.2* Hct-32.2*
MCV-97 MCH-30.7 MCHC-31.8 RDW-16.6* Plt Ct-633*
[**2121-10-1**] 07:05AM BLOOD Plt Ct-633*
[**2121-10-1**] 07:05AM BLOOD Glucose-94 UreaN-21* Creat-1.0 Na-139
K-4.6 Cl-100 HCO3-31 AnGap-13
[**2121-9-30**] 07:30AM BLOOD ALT-78* AST-65* AlkPhos-165* TotBili-0.6
[**2121-9-29**] 08:20AM BLOOD Lipase-25
[**2121-9-18**] 09:10PM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE
Post Bypass
1. Patient is AV paced and receiving infusions of epinephrine,
phenylephrine and milrinone.
2. Biventricular systolic function is unchanged.
3. Annuloplasty ring seen in the mitral position. Appears well
seated. 1+ Mitral regurgitation present. Mean Gradient across
the mitral valve is 4 mm Hg.
4. Aorta intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician
Brief Hospital Course:
Admitted from [**Hospital1 **] on [**9-18**] and underwent IABP placement
that evening. Cath had revealed LM irregular plaques, LAD 90%,
CX 60%, RCA 80% EF less than 20%. Underwent cabg x 3 /MV repair
with Dr. [**Last Name (STitle) **] on [**9-19**]. Transferred to the CSRU in stable
condition on epinephrine, levophed and milrinone drips. Chest
tubes and pacing wires removed on POD #2, and epinephrine weaned
on POD #3. Extubated on POD #4. Milrinone weaned off on POD #5.
ACE started and titrated. Transferred to floor on POD #6 to
begin increasing his activity level. Beta blocker resumed and
titrated. Developed agitation and had a psych intervention when
he tried to leave on night of POD #7. Haldol and zyprexa
started. Levaquin also started for some sternal drainage. EP
also interrogated his pacer [**9-27**]. Pt. had some continuing
confusion and psych meds held per recommendations. Neuro consult
done on POD #10. CT of chest/head done (negative for bleed) and
he was pan-cultured for elevated WBC and delirium. Delirium
improved on antibiotics and Haldol. He was ready for discharge
on [**2121-10-2**].
Medications on Admission:
at home:
diovan 320 mg daily
coreg 25 mg daily
hydralazine 25 mg TID
clonidine 0.1 mg [**Hospital1 **]
lasix 40 mg [**Hospital1 **]
protonix 40 mg daily
prilosec 40 mg daily
lipitor 40 mg daily
digoxin 0.125 mg daily
norvasc 10 mg daily
ASA325 mg daily
on transfer:
integrilin drip
heparin drip
coreg 50 mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Transdermal
once a day.
Disp:*QS 1 month* Refills:*0*
8. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
coronary artery disease, mitral regurgitation,s/p MI [**2115**] with
stent Om1, s/p dual chamber pacer [**2119**], hypertension,
hyperlipidemia, s/p cervical disc herniation repair, s/p lumbar
disc repair, s/p L shoulder surgery, s/p L total knee
replacement, pericarditis [**2115**], gastric reflux, ischemic
cardiomyopathy
Discharge Condition:
good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 10 weeks.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Please see your primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17108**] in [**12-16**]
weeks ([**Telephone/Fax (1) 17110**].
Please see your cardiologist in [**12-16**] weeks.
Please see Dr. [**First Name (STitle) **] [**Name (STitle) **] in 1 month ([**Telephone/Fax (1) 11763**].
Please return for [**Hospital Ward Name 121**] 2 for a wound check as directed by the
nurse.
Completed by:[**2121-10-2**]
|
[
"V45.82",
"414.01",
"401.9",
"305.1",
"293.0",
"V43.65",
"424.0",
"410.91",
"998.59",
"428.0",
"412",
"V53.39",
"414.8",
"V17.3",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"39.61",
"35.12",
"99.20",
"37.61",
"36.15",
"99.04",
"36.12",
"88.72",
"97.44"
] |
icd9pcs
|
[
[
[]
]
] |
5600, 5649
|
2981, 4098
|
319, 438
|
6018, 6025
|
1994, 2958
|
6354, 6831
|
1515, 1578
|
4474, 5577
|
5670, 5997
|
4124, 4451
|
6049, 6331
|
1593, 1975
|
246, 281
|
466, 950
|
972, 1426
|
1442, 1499
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,841
| 106,951
|
53459
|
Discharge summary
|
report
|
Admission Date: [**2141-8-16**] Discharge Date: [**2141-8-19**]
Service: MEDICINE
Allergies:
Nsaids/Anti-Inflammatory Classifier
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
somnolence, dyspnea on exertion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 year old female with CAD, CHF, COPD, DMII, presented to PCP's
office yesterday complaining of increased daytime somnolence,
DOE in past couple of days (although son states a month). In
her PCP's office she was also noted to be feeling poorly with
dyspnea on exertion after walking several steps. Her son also
reported that she has been getting salt putting it on her food.
Her dose of lasix was increased from 40mg to 60mg and a Chem7
was done which showed an elevated bicarb. Her PCP referred her
to ED with concern for resp acidosis. Patient difficult to get
a history from given bipap, although she is also a poor
historian per the son. She denies chest pain, palpitations,
abdominal pain, fevers, chills, diarrhea. In her PCP's office
she noted increased PND, orthopnea but I was unable to elicit
this history. On previous admission in [**2136**], her pCO2 was noted
to be in the low 60's - unclear what baseline is, however, as
this was also an admission for COPD exacerbation.
.
ED: CXR without infiltrate or edema. ABG was 7.29/76/151 and
7.31/73/59. She was given a dose of steroids for concern of
COPD flare.
Allergy: NSAIDs - azotemia
Past Medical History:
PAST MEDICAL HISTORY:
1. Congestive heart failure in [**2124**]. Her ejection fraction
was found to be 40%.
2. Coronary artery disease.
3. History of an anterior-IMI in 9/[**2137**].
4. Diabetes type 2.
5. Congestive obstructive pulmonary disease.
6. Hypertension.
7. Obesity.
8. Degenerative joint disease.
9. Status post total abdominal hysterectomy.
10. Anemia, baseline hematocrit 31.
11. Chronic renal failure, baseline creatinine 1.1-1.5
12. History of being guaiac positive.
13. Meningioma.
.
MEDICATIONS ON ADMISSION:
ALBUTEROL SULFATE 90MCG--1-2 puffs QID prn
ASPIRIN E.C. 325 po qday
ATENOLOL 100MG po qday
ATROVENT 18MCG--2 puffs [**Hospital1 **]
COLCHICINE 600 MCG po qday
K-DUR 20MEQ po qday
LASIX TABLETS 40MG po qday
LISINOPRIL 40MG po qday
SERTRALINE HCL 50 MGpo qday
Social History:
She has VNA services. She has four sons and lives with one of
her sons. She is a widow and uses Life Line.
Family History:
Non-contributory
Physical Exam:
Vitals: Afebrile HR 47 BP 144/52 RR 17 100% bipap 40%
Gen: awake with bipap on, appears uncomfortable, but no acute
distress
HEENT: anicteric, unable to assess pupillary responses [**2-23**] mask,
OP clear, MMM
Neck: no JVD
CV: S1, S2, regular, bradycardic, no appreciable murmurs
Pulm: CTA-anteriorly
Abd: Normoactive bowel sounds, soft, ND/NT, no rebound or
uarding
Ext: baseline RLE >> LLE. warm with 1+ distal pulses
bilaterally.
Neuro: awake, but unable to provide history [**2-23**] bipap mask on.
Moving all extremities
Pertinent Results:
[**2141-8-16**] WBC-4.3 RBC-4.11* Hgb-12.3 Hct-35.9* MCV-87 MCH-30.0
MCHC-34.4 RDW-14.2 Plt Ct-157 Neuts-54.0 Lymphs-35.9 Monos-6.1
Eos-3.5 Baso-0.4
[**2141-8-16**] Glucose-175* UreaN-31* Creat-1.4* Na-143 K-4.4 Cl-102
HCO3-33* AnGap-12 Calcium-9.5 Phos-3.7 Mg-2.2
[**2141-8-15**] 01:00PM BLOOD ALT-20 AST-19 AlkPhos-85 TotBili-0.4
.
[**2141-8-16**] 08:14PM BLOOD proBNP-1344*
[**2141-8-16**] 08:14PM BLOOD CK(CPK)-53 CK-MB-NotDone cTropnT-<0.01
.
[**2141-8-15**] BLOOD Cholest-203* Triglyc-80 HDL-75 CHOL/HD-2.7
LDLcalc-112
[**2141-8-15**] 01:00PM BLOOD %HbA1c-7.4*
[**2141-8-15**] 01:00PM BLOOD TSH-0.71
.
[**2141-8-16**] 10:10PM BLOOD Type-ART FiO2-100 O2 Flow-2 pO2-151*
pCO2-76* pH-7.29* calTCO2-38* Base XS-7 AADO2-503 REQ O2-83 (On
40% bipap/5peep)
[**2141-8-16**] 11:45PM BLOOD Type-ART PEEP-5 FiO2-30 pO2-59* pCO2-73*
pH-7.31* calTCO2-39* Base XS-6 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2141-8-17**] 02:19AM BLOOD Type-ART pO2-120* pCO2-68* pH-7.29*
calTCO2-34* Base XS-3
.
[**2141-8-19**] 06:40AM BLOOD WBC-7.8 RBC-3.81* Hgb-11.5* Hct-34.5*
MCV-91 MCH-30.3 MCHC-33.4 RDW-14.3 Plt Ct-167
[**2141-8-19**] 06:40AM BLOOD Plt Ct-167
[**2141-8-19**] 06:40AM BLOOD Glucose-120* UreaN-37* Creat-1.2* Na-142
K-4.7 Cl-105 HCO3-32 AnGap-10
[**2141-8-19**] 06:40AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.4
[**2141-8-17**] 06:23AM BLOOD Type-ART Temp-35.6 Rates-/18 O2 Flow-2
pO2-62* pCO2-67* pH-7.33* calTCO2-37* Base XS-5
Intubat-INTUBATED
[**8-16**] CXR: no acute cardiopulm process
CHEST (PORTABLE AP) [**2141-8-16**] 11:10 PM
No evidence of CHF or pneumonia.
Brief Hospital Course:
Briefly, 84 year old female with CAD, CHF, COPD, DMII, presented
to PCP's office 2d ago complaining of increased daytime
somnolence, DOE in past couple of days, though family reports
symptoms have been more longstanding. Because of DOE with a few
steps in PCP office and Chem7 was done which showed an elevated
bicarb, she was sent ED with concern for resp acidosis. Pt. was
admitted to ICU for BIPAP after gas showing acidosis of
7.29/76/151 in ED. In a previous admission in [**2136**] had pCO2 of
65 in the setting of COPD exacerbation, and elevated bicarb. has
been longstanding per OMR. CXR was clear on admission.
.
Pt. initially given IV steroids/azithro for COPD exacerbation in
ICU, but withdrawn as resp. acidosis at baseline. Pt. stable in
ICU, hydrated for ARF, and transferred to floor on [**8-18**] with
baseline respiratory function and mental status. She continued
to be stable on the floor and was discahrged the next morning.
1. Resp Acidosis - appears to be chronic given pCO2 of approx
70, pH 7.31 and bicarb elevated at 33. Will check ABG after
trial of bipap. Could also consider whether patient may benefit
from bipap at night. Pt. to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **]
as outpt.
.
2. ?COPD flare - initially given solumedrol iv q8, standing and
prn Albuterol/Atrovent Nebs, Azithromycin and bipap. Patient
was not very wheezy on exam, and steroids/abx. were withdrawn
quickly as pt.'s respiratory status was determined to be
longstanding.
.
3. CHF - Patient has a history of CHF, but does not appear
clinically volume overloaded on exam. Suspect that increased
resp symptoms more likely COPD exacerbation. BNP checked and
elevated at 1300. Will resume increased lasix dose of 60mg po
qday as per PCP.
.
4. CV: continued beta-blocker, afterload reduction with ACEI,
and lasix at 60mg dose. cardiac enzymes were negative with no
EKG changes from prior. Continue ASA.
.
5. CRI - Creatinine 1.4 appears to be baseline. Avoid NSAIDs.
.
6. Depression - Continued sertraline.
.
7. Diabetes - Did not require insulin or oral hypoglycemics.
.
FULL CODE - per discussion with patient's son, [**Name (NI) **] [**Name (NI) **]
Medications on Admission:
ALBUTEROL SULFATE 90MCG--1-2 puffs QID prn
ASPIRIN E.C. 325 po qday
ATENOLOL 100MG po qday
ATROVENT 18MCG--2 puffs [**Hospital1 **]
COLCHICINE 600 MCG po qday
K-DUR 20MEQ po qday
LASIX TABLETS 40MG po qday
LISINOPRIL 40MG po qday
SERTRALINE HCL 50 MGpo qday
Discharge Medications:
1. oxygen Sig: One (1) liter Nasal continuous: to keep o2
saturations above 93%.
Disp:*4 qs* Refills:*5*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) qs
Injection ASDIR (AS DIRECTED).
6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
9. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*2 qs* Refills:*2*
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain, fever.
Disp:*30 Tablet(s)* Refills:*0*
12. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Chronic Obstructive Pulmonary Disease
Congestive Heart Failure
Diabetes Type II
Hypertension
_________________________________
Chronic Renal Failure
Discharge Condition:
good, ambulating with help, tolerating POs
Discharge Instructions:
Please seek medical attention if you develop worsening shortness
of breath, chest pain, lightheadedness or dizziness.
Please take all medications as prescribed. We have not changed
any of your medications other than adding home oxygen to your
regimen
Please follow up with Dr. [**Last Name (STitle) **] (through [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) at
your appt. next friday at 3:20. Please also call Dr. [**First Name (STitle) **]
[**Name (STitle) **], whose card you have, to follow up your pulmonary
function tests and lung function.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2141-8-25**] 3:40
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2141-9-14**] 2:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2141-12-12**] 11:10
Follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **], whose card you have
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"518.83",
"250.00",
"V58.67",
"585.9",
"584.9",
"496",
"401.9",
"428.0",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8257, 8343
|
4590, 6781
|
274, 281
|
8536, 8581
|
3004, 4567
|
9201, 9815
|
2419, 2437
|
7089, 8234
|
8364, 8515
|
6807, 7066
|
8605, 9178
|
2452, 2985
|
203, 236
|
309, 1468
|
1512, 1991
|
2293, 2403
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,231
| 157,669
|
37315
|
Discharge summary
|
report
|
Admission Date: [**2115-12-3**] Discharge Date: [**2115-12-11**]
Date of Birth: [**2048-12-17**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Neck pain.
Major Surgical or Invasive Procedure:
C1-T4 posterior instrumented spinal fusion
C4-6 laminectomy
History of Present Illness:
66 yo man who presented to [**Hospital 1474**] hospital with neck pain, had
CT showing C2 and C4 lesions, tx to [**Hospital1 18**]. He notes feeling like
his neck was stiff when he woke up 12/15. The pain was markedly
worse with any movment. He rated it [**10-29**] earlier today,
currently [**9-28**], at its best a [**7-29**] with pain meds, can only
describe it as excruciating in nature, and says it is located in
the midline back of his neck without radiation to head, arms or
down spine. He states he has had a stiff neck over the past
month and mentioned it to his oncologist but Dr. [**First Name (STitle) **] reportedly
did not think much of it. He denies any associated tingling,
numbness, weakness. He has no other complaints. Denies f/c, wt
change, night sweats, HA, visual change, sore throat, cough,
sob, cp, palps, abdominal pain, n/v, constipation, diarrhea,
melena, brbpr, dysuria, rash, other joint or muscle aches, other
back pain.
In the ED: VS: 98 92 afib 139/75 20 96 4L. He was given zofran
4mg iv and morphine 8mg iv. He was seen by spine who recommended
medicine admit for med onc c/s and rad onc c/s.
ROS: 10 point review of systems negative except as noted above.
Past Medical History:
Prostate CA: diagnosed 3 years ago and tx'd medically (has been
on ? lupron injections q3 months-next due [**2115-1-8**], and recently
started a new medication that he does not know the name of-5
months ago, last imaging 5 months ago, followed by Dr. [**First Name (STitle) **] at
[**Hospital 1474**] hospital, was on casodex in the past), known mets to
"many bones" at diagnosis
Hypertension
s/p appy
GERD
Social History:
Lives in [**Location 2498**]. Retired construction worker. He smoked 3 ppd
for 40 years ('off and on'), quit 6 years ago, drinks very rare
etoh, denies past/current illicit drug use. He lives alone.
Family History:
Mohter and sister with breast cancer.
Physical Exam:
VS: T 98.0 HR 72 BP 128/76 RR 20 Sat 99% 4L NC -> 92% on RA
Gen: Chronically ill appearing man in NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates
ENT: mucus membranes dry, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: irregularly irregular rhythm but normal rate,
normal s1, s2, no murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi, prolonged expiratory phase
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present
Extremities: No cyanosis, clubbing, edema, joint swelling
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, speech fluent; strenth [**4-23**] UE, LE
bilaterally, 2+ DTR's at biceps, bracioradialis, patellar,
sensation intact to light touch
Integument: Warm, moist, no rash or ulceration, multiple
scattered tattoos
Psychiatric: oddly indifferent to his medical problems, current
treatments or plan of care
Hematologic: no cervical or supraclavicular LAD
Pertinent Results:
Admit labs:
CBC: WBC-8.6 RBC-3.21* HGB-10.6* HCT-31.4* MCV-98 MCH-33.0*
MCHC-33.8 RDW-14.7 PLT COUNT-263; diff: NEUTS-83.7* LYMPHS-11.4*
MONOS-4.0 EOS-0.6 BASOS-0.3
Coags: PT-14.1* PTT-27.5 INR(PT)-1.2*
BMP: GLUCOSE-118* UREA N-22* CREAT-1.3* SODIUM-138 POTASSIUM-3.9
CHLORIDE-98 TOTAL CO2-28
CT Neck from [**Hospital1 1474**]: per ortho spine read: there are no acute
fractures or dislocations. There are multiple lytic lesions in
the body of C2, with intact cortex throughout. There is loss of
height and multiple lytic
lesions in the body of C4. There is no retropulsion or
radiographic
concern for cord compression.
ECG [**12-3**]: atrial fibrilation, 62, nl axis, nl qrs, qtc, no
acute st-t changes.
Brief Hospital Course:
66 yo man with metastatic prostate cancer who p/w lytic neck
lesions and neck pain.
1. Lytic cervical lesions: No apparent neurologic involvement.
Pain is the main issue and not clearly related these lesions
though could be explained by acute compression fracture at C4 if
this is acute.
- likely will need MRI, rad onc eval, biopsy
- obtain records from outside oncologist to know what imaging he
has had for metastatic w/u
- may need onc c/s
- pain control with iv morphine o/n, consider lidoderm patch,
unclear if would benefit from vertebroplasty (discuss with IR)
Seen by spine, recs as follows:
-lesions are probably related to metastatic prostate cancer
given his history, however, other primary tumors cannot be ruled
out
-patient should wear a c-collar for comfort: [**Location (un) **] J per spine
-Will need an MRI to assess soft tissue involement and stability
on an urgent, but not emergent basis
-Recommend pain control
2. New atrial fibrilation: asymptomatic. chads 2 score is 1
(htn), so aspirin vs. coumadin, will hold on either pending
further eval as above.
- may benefit from antihypertenisve that would also ensure rate
control, once home meds can be verified
- check tsh
3. Hypertension, benign: verify home meds in am and adjust if
needed for rate control as above.
4. Hypoxia: suspect has undiagnosed COPD given smoking history
and asymptomatic with sat of 92%, bicarb mildly elevated.
- obtain osh records for baseline sat
- consider cxr
5. CKD: stage [**Name (NI) 1105**], unclear duration, obtain records for baseline
crt, gentle ivf o/n given ct at [**Hospital1 1474**], unknown if got iv
contrast.
6. Anemia: normocytic, unknown baseline, send iron studies,
monitor, guaiac all stools.
7. GERD: cont. zantac.
Full code.
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Physical therapy was consulted for
mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet
Medications on Admission:
steroid injection (? lupron) q 3 months, next [**2115-1-8**]
antihypertensive (name unknown)
new medication for prostate ca (name unknown)
zantac 150mg daily
pharmacy is [**Company **] in [**Location (un) 5165**]: ([**Telephone/Fax (1) 83952**] - not open
overnight to verify meds.
Discharge Medications:
1. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: do not drink alcohol,
drive, or operate heavy machinery while taking this medication.
4. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
5. Famotidine 20 mg IV Q12H
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
7. Metoprolol Tartrate 5 mg IV Q4H:PRN hr > 100
hold for sbp < 100 or HR < 60
8. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q2H:PRN pain
Hold for RR<10 and/or sbp<100
9. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
metastatic lesions cervical-thoracic spine
Discharge Condition:
stable
Discharge Instructions:
You have undergone the following operation: Posterior Cervical
Decompression and Fusion
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit in a car
or chair for more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.
- Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks. You may remove the collar to take a shower. Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.
- Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. . Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
o We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Physical Therapy:
wbat, oob as able
Treatment Frequency:
keep wound clean and dry, may shower only, no tub bathing, no
soaking.
physical therapy daily, WBAT, OOB as able
Followup Instructions:
Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] in six weeks, please call office
to confirm/schedule appointment
Completed by:[**2115-12-11**]
|
[
"427.31",
"805.04",
"198.5",
"530.81",
"723.0",
"185",
"403.90",
"E928.8",
"285.9",
"584.9",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.79",
"81.63",
"96.71",
"81.03"
] |
icd9pcs
|
[
[
[]
]
] |
8085, 8182
|
4180, 6782
|
332, 393
|
8268, 8276
|
3448, 4157
|
11043, 11228
|
2279, 2318
|
7115, 8062
|
8203, 8247
|
6808, 7092
|
8300, 8389
|
2333, 3429
|
10867, 10885
|
10288, 10849
|
8422, 8645
|
282, 294
|
9216, 10276
|
421, 1615
|
10906, 11020
|
1637, 2046
|
2062, 2263
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,723
| 148,392
|
26518
|
Discharge summary
|
report
|
Admission Date: [**2196-2-11**] Discharge Date: [**2196-4-8**]
Date of Birth: [**2136-9-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatic mass, thrombosis of portal vein.
Major Surgical or Invasive Procedure:
Small bowel resection. Gastrostomy tube. Abdominal washout x4,
and eventual closure. Percutaneous tracheostomy.
History of Present Illness:
59M initially presented to PCP office with nausea, vomiting,
abdominal pain. CT demonstrated cystic mass at tail of
pancreas, and thrombosis of portal/SMV/splenic veins. He was
admitted for bowel rest, hydration and observation.
Past Medical History:
Rheumatoid arthritis
Social History:
20 pack year smoker, quit one month prior to admission.
Occasional EtOH. Retired, on disability.
Family History:
Father: DM, CAD, colon CA.
Mother: melanoma
Physical Exam:
No vital signs. No corneal or gag reflex. No breath or heart
sounds. No response to painful stimuli.
Brief Hospital Course:
Patient was initially admitted for observation, bowel rest and
hydration. He was anticoagulated and placed on parenteral
nutrition. A hypercoaguable workup and was unrevealing. His
clinical status deteriorated, and he was taken to the operating
room for emergent laparotomy -- for details see operative note.
His bowel was perforated, and the patient was resected and
left with an open abdomen. Over the subsequent weeks, he had
multiple returns to the operating room with washouts and
sequential closure. He developed sepsis, renal failure, ongoing
liver failure and had percutaneous trachesotomy performed.
Ultimately, his multi-organ system failure resulted in the need
for broad spectrum antibiotics, mechanical ventilation, TPN,
CVVH and vasopressors. After clinical decline, discussion was
carried out with the family and attendings and the decision to
withdraw care was made. He expired shortly thereafter.
Medications on Admission:
1. prednisone
2. Percocet
3. promethazine
4. methotrexate
Discharge Medications:
Expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Mesenteric ischemia. Portal venous thrombosis. Perforated
bowel. Sepsis. Renal failure. Enterocutaneous fistula.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
Completed by:[**0-0-0**]
|
[
"569.83",
"569.81",
"557.1",
"557.0",
"714.0",
"998.12",
"038.0",
"289.59",
"452",
"286.6",
"998.83",
"567.22",
"995.92",
"518.5",
"E934.2",
"584.5",
"444.89",
"577.9",
"593.81",
"567.21",
"287.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.95",
"54.25",
"00.14",
"54.72",
"99.15",
"45.62",
"54.12",
"45.91",
"54.61",
"54.4",
"39.95",
"31.1",
"54.3"
] |
icd9pcs
|
[
[
[]
]
] |
2160, 2169
|
1095, 2019
|
356, 472
|
2330, 2340
|
2397, 2432
|
907, 952
|
2127, 2137
|
2190, 2309
|
2045, 2104
|
2364, 2374
|
967, 1072
|
273, 318
|
500, 732
|
754, 776
|
792, 891
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,929
| 126,351
|
20872
|
Discharge summary
|
report
|
Admission Date: [**2167-3-12**] Discharge Date: [**2167-3-18**]
Date of Birth: [**2089-7-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Atorvastatin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
worsening DOE and fatigue without chest pain
Major Surgical or Invasive Procedure:
s/p CABGx2(LIMA-LAD, SVG-OM) [**3-13**]
History of Present Illness:
Mrs. [**Known lastname **] is a 77 yo patient with several month history of
worsening DOE and fatigue and recently had an abnormal ETT.
Cardiac catheterization showed left main, LAD and LCx coronary
disease. Prior echocardiogram had shown normal left ventricular
function. She was refered to Dr. [**Last Name (STitle) **] for operative
treatment.
Past Medical History:
Left ECA stenosis
hypercholesterolemia
arthritis
HTN
s/p DVTx2
GERD
anxiety
s/p colectomy for ulcerative colitis
nephrolitihiasis
Pertinent Results:
[**2167-3-18**] 06:35AM BLOOD WBC-6.6 RBC-3.73* Hgb-10.8* Hct-32.3*
MCV-87 MCH-28.9 MCHC-33.4 RDW-14.4 Plt Ct-295
[**2167-3-18**] 06:35AM BLOOD Plt Ct-295
[**2167-3-17**] 07:05AM BLOOD Glucose-106* UreaN-22* Creat-1.2* Na-140
K-4.4 Cl-105 HCO3-27 AnGap-12
Brief Hospital Course:
Mrs.[**Known lastname **] is a 77 yo who was admitted on [**3-11**] for cardiac
catheterization and was found to have coronary artery disease.
She was taken to the operating room with Dr. [**Last Name (STitle) **] on [**3-13**] for
CABG. She tolerated the procedure well and was transferred to
the ICU in stable condition. She was weaned and extubated from
mechanical ventilation without difficulty on POD#1. She
required neo synephrine to maintain adequate blood pressure and
it was weaned to off on POD#2. She developed atrial
fibrillation on POD#2 and was started on Lopressor and
amiodarone. She quickly converted to sinus rhythm and had no
further arrhythmias. She was transferred to the regular floor
on POD#3. She began ambulating with physical therapy and by
POD#5 she was able to climb a flight of stairs without
difficulty and was cleared for discharge to home.
Medications on Admission:
prilosec 20mg qd
paxil 20mg qd
aspirin 81mg qd
MVI
ativan 0.5mg prn
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5
days.
8. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD
s/p CABG
post operative atrial fibrillation
hypercholesteremia
anxiety
h/o DVT
s/p colectomy
Discharge Condition:
good
Discharge Instructions:
you may take a shower and wash your incisions with mild soap and
water
do not swim or take a bath for 1 month
do not drive for 1 month
do not apply lotions, creams, ointments or powders to your
incisions
do not lift anything heavier than 10 pounds for 1 month
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in [**1-18**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**1-18**] weeks
follow up with Dr. [**Last Name (STitle) 36737**] in [**3-20**] weeks
Completed by:[**2167-3-18**]
|
[
"401.9",
"272.0",
"411.1",
"429.9",
"530.81",
"716.90",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.56",
"36.11",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
3159, 3208
|
1195, 2075
|
323, 365
|
3349, 3355
|
915, 1172
|
3663, 3894
|
2193, 3136
|
3229, 3328
|
2101, 2170
|
3379, 3640
|
239, 285
|
393, 743
|
765, 896
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,090
| 182,065
|
3193
|
Discharge summary
|
report
|
Admission Date: [**2182-9-22**] Discharge Date: [**2182-10-6**]
Date of Birth: [**2104-4-20**] Sex: M
Service: MEDICINE
Allergies:
Doxycycline / Amoxicillin Sodium / Bactrim
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Bilateral foot pain/blue toes.
Major Surgical or Invasive Procedure:
Bilateral transmetarsal amputations.
Echocardiography.
Central line placement.
Hemodialysis.
History of Present Illness:
78M DM, ESRD, PVD. Pt admitted for dry gangrene on both feet
Past Medical History:
end-stage renal disease on hemodialysis
type II diabetes mellitus
atrial fibrillation
nephrolithiasis
grade 2 bladder transitional cell CA
depressoin
anemia
GI bleed
hypertension
Hyperlipidemia
gastric cancer s/p gastrectomy (Billroth 2)
B12 deficiency
Squamous cell cancer (face)
Social History:
married, lives with wife. [**Name (NI) **] additional family in [**Location (un) 86**] area,
including his son [**Name (NI) **] who is extrmely supportive. Originally
from [**Country 532**]. No recent EtOH use. No tobacco or IVDU
Family History:
NC
Physical Exam:
N/A pt decesed during this hopital stay
Pertinent Results:
pt deceased during this hopital stay. Pertinant studies / labs
on this admission.
Echo [**2182-10-3**]:
The left atrium is elongated. The right atrium is dilated. There
is severe regional left ventricular systolic dysfunction.
Overall left ventricular systolic function is severely
depressed. Resting regional wall motion abnormalities include
anteroseptal, anterior, and apical akinesis (the basal lateral
wall moves best). No apical thrombus seen (but cannot exclude).
Right ventricular chamber size is normal. There is focal
hypokinesis of the apical free wall of the right ventricle. The
ascending aorta is mildly dilated. The
aortic valve leaflets are moderately thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate to severe 3+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. EF of 25%
CT head [**10-3**]:
IMPRESSION:
1. No intra- or extra-axial hemorrhage, infarct, or mass effect.
2. Stable appearance of an ill-defined area of low attenuation
within the
right temporal lobe, corresponding to a cystic lesion with
surrounding edema seen on the previous MRI examinations.
Recommend follow up MRI with contrast to monitor lesion
size/characteristics.
3. Chronic microvascular infarction and lacunar infarction
[**2182-10-6**]
WBC-15.5* RBC-2.68* Hgb-8.7* Hct-28.3* MCV-105* MCH-32.3*
MCHC-30.7* RDW-17.8* Plt Ct-165
[**2182-10-6**]
PT-21.0* PTT-45.7* INR(PT)-3.1
[**2182-10-6**]
Glucose-10* UreaN-31* Creat-2.5* Na-142 K-5.3* Cl-101 HCO3-12*
AnGap-34*
[**2182-10-6**]
ALT-649* AST-1401* LD(LDH)-569* AlkPhos-141* TotBili-2.0*
[**2182-10-6**]
CK-MB-19* MB Indx-1.5 cTropnT-1.55*
[**2182-10-6**]
Albumin-2.3* Calcium-8.6 Phos-7.0* Mg-2.3
[**2182-10-4**]
Hapto-231*
[**2182-10-6**]
Type-ART pO2-170* pCO2-36 pH-7.16* calHCO3-14* Base XS--15
Brief Hospital Course:
Pt admitted on [**2182-9-22**] to [**Date Range 1106**] service for b/l lateral foot
pain / b/l gangrene of the feet.
[**2182-9-23**] - [**2182-9-24**]
Pt pre-op'd in the usual fashion / consented
Broad spectrum AB started.
Cx taken.
Pt set up for HD through nephrology for CRI.
[**2182-9-25**]
Pt undergoes a Bilateral transmetatarsal amputation, toes one
through five. Extubated in the OR. No complications noted.
Extubated in the OR. Transfered to the PACU in stable condition
Once recovered from aneshtesia. Pt transfered to the VICU in
stable condition.
[**2182-9-26**] - [**2182-9-29**]
Pt transfered to floor status / has increase temperatures. C/O
pain.
[**2182-9-29**] - [**2182-9-30**]
Pt difficult to arouse / somolent - CT head negative
Pt improves after narcotics stopped.
Pt with cardiac enzymes / EKG / CXR
CXR shows - pna - AB started
pos troponin ( could be secondary to CRI ), ckmb pos (
cardiology consulted ), pt transfered back to the VICU [**2182-10-1**]
[**2182-10-1**]
Becomes hypotensive with bradycardia / chest pain / repeat EKG
shows t wave inversions
SL nitro improves chest pressue
ASA given
Cardiology sees pt -
* Started on heprin drip
* Ischemia: Continue ASA, nitro gtt, heparin gtt, lipitor to 80.
Will consider addition of integrillin and plavix, however, if
remains stable will hold off. Will need to check with pharmacy
if there is a HD dosing of integrillin.
- Holding beta blocker given 1st degree AV delay and
bradycardia.
- EKG findings concerning for antero-septal-infero
ischemia/infarct ((?high LAD).
- NPO after midnight for possible cath in AM.
- Continue cycling enzymes -> if chest pain recurs and persists
or enzymes rise again will need to consider earlier cath.
* Pump: Last echo suggestive of diastolic dysfunction, though
this was prior to recent events. Will need to repeat echo or LVG
ASAP. At present does not appear volume overloaded and will not
need diuresis.
- Pending evaluation of EF, will likely need ACE. Consider
spironolactone if evidence of heart failure, but none at
present.
* Rhythm: First degree AV delay, sinus brady. No interventions
at present given asymptomatic. If becomes hemodynamically
unstable, will need to consider pacer wire vs.
pharmacotherapeutics (dopamine, isoproterenol etc.)
- Continue Amiodarone (presumably for afib)
* ESRD/HD: Will need dialysis in AM.
- Recheck lytes now given asterixis concerning for uremia.
[**2182-10-2**]
HD completed before cath
Chest pain improves on nitro / heparin drip
Pt transfered to MICU.
[**2182-10-3**]
ECHO reveal EF 20 percent
Pt c/o left hand pain
Pt BP increased / pressor initiated
[**2182-10-4**]
BP drops 80 / 90 SBP despite pressors
[**2182-10-5**]
Has increase in WBC
Unable to tolerate HD / a-line placed for monitering
[**2182-10-6**]
Pt coded for PEA
Pt deceased
Medications on Admission:
Amiodarone HCl .
Amlodipine .
Atorvastatin .
Docusate Sodium.
Protonix.
Discharge Medications:
N/A pt deceased during this hospital stay.
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A pt decesed during this hopital stay
Discharge Condition:
N/A pt decesed during this hopital stay
Discharge Instructions:
N/A pt decesed during this hopital stay
Followup Instructions:
N/A pt decesed during this hopital stay
Completed by:[**2182-11-18**]
|
[
"V10.04",
"410.71",
"427.31",
"287.4",
"496",
"250.00",
"585.6",
"403.91",
"440.24",
"997.1",
"V10.51",
"414.01",
"486",
"276.2",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.12",
"99.07",
"38.91",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6200, 6209
|
3163, 6011
|
335, 429
|
6292, 6333
|
1171, 3140
|
6421, 6492
|
1091, 1095
|
6133, 6177
|
6230, 6271
|
6037, 6110
|
6357, 6398
|
1110, 1152
|
264, 297
|
457, 519
|
541, 823
|
839, 1075
|
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