subject_id
int64 12
100k
| _id
int64 100k
200k
| note_id
stringlengths 1
41
| note_type
stringclasses 4
values | note_subtype
stringclasses 35
values | text
stringlengths 449
78.2k
| diagnosis_codes
listlengths 1
39
| diagnosis_code_type
stringclasses 1
value | diagnosis_code_spans
listlengths 1
21
| procedure_codes
listlengths 0
35
| procedure_code_type
stringclasses 1
value | procedure_code_spans
listlengths 1
5
| Discharge Disposition:
stringlengths 0
12
| Brief Hospital Course:
stringlengths 0
12
| Discharge Diagnosis:
stringclasses 1
value | Major Surgical or Invasive Procedure:
stringlengths 0
12
| Discharge Condition:
stringlengths 0
12
| Past Medical History:
stringclasses 1
value | History of Present Illness:
stringclasses 1
value | Social History:
stringclasses 1
value | Physical Exam:
stringclasses 1
value | Pertinent Results:
stringlengths 0
12
| Discharge Instructions:
stringclasses 1
value | Medications on Admission:
stringclasses 1
value | Followup Instructions:
stringlengths 0
12
| Family History:
stringlengths 0
12
| Discharge Medications:
stringclasses 1
value | DISCHARGE DIAGNOSES:
stringlengths 0
12
| PAST MEDICAL HISTORY:
stringclasses 1
value | DISCHARGE MEDICATIONS:
stringlengths 0
12
| [**Hospital 93**] MEDICAL CONDITION:
stringlengths 0
12
| DISCHARGE DIAGNOSIS:
stringlengths 0
12
| MEDICATIONS ON DISCHARGE:
stringclasses 983
values | MEDICATIONS ON ADMISSION:
stringlengths 0
12
| Cranial Nerves:
stringclasses 1
value | HOSPITAL COURSE:
stringlengths 0
12
| FINAL DIAGNOSIS:
stringclasses 974
values | CARE RECOMMENDATIONS:
stringclasses 32
values | DISCHARGE INSTRUCTIONS:
stringlengths 0
12
| PAST SURGICAL HISTORY:
stringclasses 1
value | DISCHARGE LABS:
stringclasses 1
value | Discharge Labs:
stringclasses 1
value | What to report to office:
stringclasses 286
values | Secondary Diagnosis:
stringclasses 1
value | ADMISSION MEDICATIONS:
stringclasses 204
values | DISCHARGE INSTRUCTIONS/FOLLOWUP:
stringclasses 212
values | Review of systems:
stringclasses 1
value | CARE AND RECOMMENDATIONS:
stringclasses 18
values | On Discharge:
stringclasses 1
value | Neurologic examination:
stringclasses 1
value | Discharge labs:
stringlengths 0
12
| Secondary Diagnoses:
stringclasses 1
value | On discharge:
stringclasses 1
value | [**Last Name (NamePattern4) 2138**]p Instructions:
stringclasses 138
values | HOSPITAL COURSE BY SYSTEM:
stringclasses 79
values | HOSPITAL COURSE BY SYSTEMS:
stringclasses 67
values | MEDICATIONS AT HOME:
stringclasses 429
values | MEDICATIONS ON TRANSFER:
stringclasses 1
value | Secondary diagnoses:
stringclasses 1
value | Secondary diagnosis:
stringclasses 1
value | TRANSITIONAL ISSUES:
stringclasses 1
value | PATIENT/TEST INFORMATION:
stringclasses 174
values | IMMUNIZATIONS RECOMMENDED:
stringclasses 1
value | -Cranial Nerves:
stringclasses 297
values | Transitional Issues:
stringclasses 1
value | Incision Care:
stringclasses 388
values | Past Surgical History:
stringlengths 0
12
| Discharge Exam:
stringclasses 1
value | DISCHARGE EXAM:
stringclasses 1
value | Labs on Discharge:
stringclasses 1
value | REGIONAL LEFT VENTRICULAR WALL MOTION:
stringclasses 171
values | PHYSICAL EXAM:
stringlengths 0
12
| Medication changes:
stringclasses 1
value | Physical Therapy:
stringclasses 313
values | Treatments Frequency:
stringclasses 226
values | SECONDARY DIAGNOSES:
stringlengths 0
12
| 2. CARDIAC HISTORY:
stringclasses 715
values | HOME MEDICATIONS:
stringclasses 441
values | Chief Complaint:
stringclasses 1
value | FINAL DIAGNOSES:
stringclasses 83
values | DISCHARGE PHYSICAL EXAM:
stringclasses 1
value | ACID FAST CULTURE (Preliminary):
stringclasses 214
values | Wound Care:
stringclasses 1
value | Blood Culture, Routine (Preliminary):
stringclasses 146
values | Discharge exam:
stringclasses 736
values | Neurologic Examination:
stringclasses 1
value | Discharge Physical Exam:
stringclasses 1
value | ACTIVE ISSUES:
stringclasses 1
value | CLINICAL IMPLICATIONS:
stringclasses 128
values | FUNGAL CULTURE (Preliminary):
stringclasses 365
values | FOLLOW UP:
stringclasses 645
values | PREOPERATIVE MEDICATIONS:
stringclasses 71
values | RESPIRATORY CULTURE (Preliminary):
stringclasses 133
values | SUMMARY OF HOSPITAL COURSE:
stringclasses 286
values | Labs on discharge:
stringclasses 1
value | MEDICATIONS PRIOR TO ADMISSION:
stringclasses 144
values | HOSPITAL COURSE BY ISSUE/SYSTEM:
stringclasses 131
values | SECONDARY DIAGNOSIS:
stringclasses 1
value | FOLLOW-UP APPOINTMENTS:
stringclasses 47
values | Cardiac Enzymes:
stringclasses 1
value | OUTPATIENT MEDICATIONS:
stringclasses 106
values | Review of Systems:
stringclasses 1
value | ADMISSION DIAGNOSES:
stringclasses 50
values | MEDICATION CHANGES:
stringclasses 1
value | Blood Culture, Routine (Pending):
stringclasses 88
values | TECHNICAL FACTORS:
stringclasses 60
values | PHYSICAL EXAMINATION:
stringlengths 0
12
| [**Last Name (NamePattern4) 4125**]ospital Course:
stringclasses 40
values | ADMISSION DIAGNOSIS:
stringclasses 115
values | Physical Exam on Discharge:
stringclasses 198
values | At discharge:
stringlengths 0
12
| RECOMMENDED IMMUNIZATIONS:
stringclasses 3
values | ON DISCHARGE:
stringlengths 0
12
| CHRONIC ISSUES:
stringclasses 1
value | Immediately after the operation:
stringclasses 71
values | Transitional issues:
stringclasses 965
values | FOLLOW-UP PLANS:
stringclasses 188
values | Changes to your medications:
stringclasses 809
values | Upon discharge:
stringclasses 1
value | REVIEW OF SYSTEMS:
stringlengths 0
12
| CARDIAC ENZYMES:
stringclasses 1
value | Cardiac enzymes:
stringclasses 361
values | Medication Changes:
stringclasses 665
values | [**Location (un) **] Diagnosis:
stringclasses 49
values | ACID FAST CULTURE (Pending):
stringclasses 59
values | Discharge PE:
stringclasses 99
values | General Discharge Instructions:
stringclasses 84
values | INDICATIONS FOR CATHETERIZATION:
stringclasses 54
values | WHEN TO CALL YOUR SURGEON:
stringclasses 31
values | Neurological Exam:
stringclasses 73
values | Exam on Discharge:
stringclasses 1
value | CHIEF COMPLAINT:
stringlengths 0
12
| REASON FOR THIS EXAMINATION:
stringlengths 0
12
| Relevant Imaging:
stringclasses 55
values | Active Issues:
stringclasses 353
values | [**Location (un) **] Condition:
stringclasses 42
values | RECOMMENDATIONS AFTER DISCHARGE:
stringclasses 2
values | [**Hospital1 **] Disposition:
stringclasses 38
values | TRANSITIONAL CARE ISSUES:
stringclasses 69
values | [**Hospital1 **] Medications:
stringclasses 41
values | [**Location (un) **] Instructions:
stringclasses 40
values | WOUND CULTURE (Preliminary):
stringclasses 63
values | DISCHARGE FOLLOWUP:
stringclasses 182
values | LABS ON DISCHARGE:
stringclasses 566
values | POST CPB:
stringclasses 1
value | URINE CULTURE (Preliminary):
stringclasses 70
values | Review of sytems:
stringclasses 249
values | Labs at discharge:
stringclasses 119
values | Immunizations recommended:
stringclasses 34
values | AEROBIC BOTTLE (Pending):
stringclasses 26
values | -Rehabilitation/ Physical Therapy:
stringclasses 39
values | FOLLOW UP APPOINTMENTS:
stringclasses 38
values | Mental Status:
stringclasses 1
value | Admission labs:
stringclasses 1
value | HOSPITAL COURSE BY PROBLEM:
stringclasses 131
values | [**Hospital 5**] MEDICAL CONDITION:
stringclasses 14
values | PHYSICAL EXAM UPON DISCHARGE:
stringclasses 47
values | WOUND CARE:
stringclasses 425
values | ANAEROBIC BOTTLE (Pending):
stringclasses 25
values | CURRENT MEDICATIONS:
stringclasses 82
values | FOLLOW-UP APPOINTMENT:
stringclasses 54
values | FINAL DISCHARGE DIAGNOSES:
stringclasses 23
values | TRANSFER MEDICATIONS:
stringclasses 76
values | Upon Discharge:
stringclasses 230
values | HISTORY OF PRESENT ILLNESS:
stringlengths 0
12
| CRANIAL NERVES:
stringlengths 0
12
| CT head:
stringclasses 1
value | Exam on discharge:
stringclasses 111
values | CT Head:
stringclasses 955
values | [**Location (un) **] PHYSICIAN:
stringclasses 130
values | Admission Labs:
stringclasses 1
value | secondary diagnosis:
stringlengths 0
12
| Head CT:
stringclasses 601
values | MRA OF THE HEAD:
stringclasses 48
values | INACTIVE ISSUES:
stringclasses 124
values | ADMISSION LABS:
stringlengths 0
12
| PROBLEM LIST:
stringclasses 49
values | PRIMARY DIAGNOSIS:
stringlengths 0
12
| OTHER PERTINENT LABS:
stringclasses 91
values | PROBLEMS DURING HOSPITAL STAY:
stringclasses 1
value | Medication Instructions:
stringclasses 48
values | IRON AND VITAMIN D SUPPLEMENTATION:
stringclasses 6
values | On admission:
stringlengths 0
12
| ANAEROBIC CULTURE (Preliminary):
stringclasses 227
values | MENTAL STATUS:
stringlengths 0
12
| ADMITTING DIAGNOSIS:
stringclasses 69
values | TRANSITIONS OF CARE:
stringclasses 92
values | Pertinent Labs:
stringclasses 205
values | 3. OTHER PAST MEDICAL HISTORY:
stringclasses 667
values | # Transitional issues:
stringclasses 71
values | [**Hospital1 **] Diagnosis:
stringclasses 24
values | Chronic Issues:
stringclasses 245
values | FOLLOW-UP INSTRUCTIONS:
stringclasses 101
values | CARE AND RECOMMENDATIONS AT DISCHARGE:
stringclasses 2
values | HOSPITAL COURSE: By systems:
stringclasses 1
value | NEUROLOGIC EXAMINATION:
stringclasses 339
values | Treatment Frequency:
stringclasses 26
values | Neurologic Exam:
stringclasses 63
values | DISCHARGE PLAN:
stringclasses 62
values | Active Diagnoses:
stringclasses 63
values | Medications on transfer:
stringclasses 568
values | Past medical history:
stringlengths 0
12
| SOCIAL HISTORY:
stringlengths 0
12
| CONDITION ON DISCHARGE:
stringlengths 0
12
| FLUID CULTURE (Preliminary):
stringclasses 112
values | Meds on transfer:
stringclasses 242
values | Exam upon discharge:
stringclasses 35
values | Other labs:
stringclasses 142
values | Discharge physical exam:
stringclasses 473
values | [**Hospital1 **] Instructions:
stringclasses 22
values | Imaging Studies:
stringclasses 111
values | Post CPB:
stringclasses 96
values |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
13,543
| 124,100
|
21176+57225
|
Discharge summary
|
report+addendum
|
Admission Date: [**2110-5-13**] Discharge Date: [**2110-6-13**]
Date of Birth: [**2047-5-23**] Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: This is a 62-year-old man with a
past medical history of hypertension, head and neck cancer in
[**2100**] status post resection, and recent pneumonia in [**1-12**],
who presented to an outside hospital on the morning of
admission after three days of progressive shortness of
breath.
Per the patient's wife, the patient has not been feeling well
for the last month, but has gotten significantly worse over
the last three days with fevers, chills, productive cough,
shortness of breath, weakness, and decreased appetite. Wife
reports that she has also been sick with a viral respiratory
illness for the last three weeks. Denies any recent travel.
Per the outside hospital ED records, the patient denied to
have pain.
Vital signs on presentation to the outside hospital were
temperature 98.9, blood pressure 133/67, heart rate 142,
respiratory 28, and saturating 66 percent on room air. He
was placed on nonrebreather, but there was no improvement in
his oxygen saturation with an ABG of 7.26/45/42. Therefore,
he was intubated for hypoxic respiratory failure, however,
his sats is not significantly improved and repeat ABG was
7.29/45/44. Oxygen saturation was 75 percent, that was on
assist control of 700/14, FiO2 of 1 and a PEEP of 10. Chest
x-ray showed a right lower lobe greater than left lower lobe
infiltrate. He was given IV levofloxacin and Zosyn.
[**Hospital 56130**] transferred to the outside hospital ICU and then was
transferred to [**Hospital1 18**] ICU by [**Location (un) **] for further management.
On arrival here, the patient was intubated with a temperature
of 101.8 rectally, blood pressure 182/71, heart rate of 138,
on assist control of 100/20, PEEP of 14, FiO2 of 1, oxygen
saturation in the 80s. He was paralyzed with vecuronium,
sedated with Versed, with some improvement in his oxygen
saturations. Urgent bronchoscopy was performed, which showed
the patent airways, but thick dark mucoid secretions in the
right lower and right middle lobes, which were aspirated and
sent for culture.
PAST MEDICAL HISTORY: Hypertension.
Head and neck cancer in [**2100**], status post right radical neck
dissection and XRT.
Hypercholesterolemia.
Headaches.
Pneumonia in [**1-12**].
ALLERGIES: No known drug allergies.
OUTPATIENT MEDICATIONS:
1. Atenolol 25 mg q.d.
2. Pravachol 20 mg q.d.
3. Tylenol No. 3 p.r.n.
SOCIAL HISTORY: He is married, lives with his wife. [**Name (NI) **] has
no pets. He quit tobacco in [**2100**], but his wife is a smoker.
He drinks approximately 5 beers per day.
FAMILY HISTORY: Positive for coronary artery disease.
PHYSICAL EXAMINATION: On admission to the ICU, temperature
101.8, blood pressure 98/45, heart rate 119, oxygen
saturation 88 percent on ventilator. General, the patient is
intubated, sedated, and paralyzed. Head and neck exam is
notable for dry mucous membranes and right neck with
postsurgical changes. Lungs with bilateral crackles, right
greater than left and bronchial breath sounds throughout.
Cardiovascular exam is notable for tachycardia. Abdominal
exam was soft. Extremities had no edema.
LABORATORY DATA: On admission, white count 1.2 with an ANC
of 990, hematocrit 35.1, and platelets 167. Chemistry,
sodium 140, potassium 4.5, chloride 105, bicarbonate 24, BUN
35, creatinine 1.2, and glucose 128. ABG 7.13/69/82 on
500/20 FiO2 of 1.0 and a PEEP of 14. Lactate was 3.5.
ASSESSMENT: This is a 62-year-old man admitted with hypoxic
respiratory failure and sepsis.
HOSPITAL COURSE: Sepsis. Etiology of the patient's sepsis
was most likely secondary to pneumococcal pneumonia and
bacteremia. Blood cultures drawn at the outside hospital
were [**4-13**] for streptococcal pneumonia that was penicillin
resistant. Cultures both blood and sputum obtained here at
[**Hospital3 **] remained negative for most of the [**Hospital 228**]
hospital course. He was initially started on broad spectrum
antibiotics including vancomycin and Zosyn as well as
azithromycin. He was not initially hypotensive, however,
cortisol stimulation tests reveals him to be a nonresponder,
therefore he got stress dose of hydrocortisone for several
days. Additionally he was given Zyvox for his sepsis. He
received a total of 14 days of antibiotics for his
pneumococcal pneumonia. As this initial sepsis resolved,
however, he appears later grew 1 out of 6 bottles positive
for [**Female First Name (un) 564**], the arterial line from which the blood culture
was positive was changed and he was given 10 days of
fluconazole as well as receiving an ophthalmology consult
that showed no end ophthalmitis. At times, during his
hospital course, mostly secondary to sedation, he briefly
required Levophed for blood pressure support. Additionally,
he continued to have low-grade fevers for most of his
hospital course. Cultures remained negative and LP was
performed and that was negative for meningitis. However, he
did develop pancreatitis as well as DVT in addition to his
ongoing ARDS, which may all contribute to his fever.
Then on [**6-6**], he spiked fevers to 102, developed increased
sputum production and grew MRSA from his sputum for which he
was started on vancomycin for this ventilator associated
pneumonia.
Respiratory failure. On presentation, the patient had both
hypoxic and hypercarbic respiratory failure secondary to his
pneumococcal pneumonia as well as to development of ARDS.
Initial CT showed near total collapse of his right lung with
minimal effusion and no PE. Additionally, there was some
left lower lobe consolidation and atelectasis. A repeat CT
seven to ten days later showed much improved with much
decreased consolidation, but now with a questionable new
cavitary lesion of the right lower lobe for which he will
need followup. Initially, when he came in, he had
significant amount of shunt. It was unclear if this was
entirely from his lung process or as far as his hypoxemia
could be possibly secondary to cardiac cause of shunt,
however, despite the echocardiogram showing mild global
hypokinesis consistent with returning from the sepsis, it did
not show evidence of any intracardiac shunt.
His respiratory failure was managed with ventilator using the
ARDSNet protocol of low tidal volumes and high rate. He
briefly required prone position and the first several days of
the hospitalization required paralytics. In addition to
heavy sedation in order to oxygenate him adequately. He also
underwent extensive diuresis after his initial few days in
the hospital as his initial sepsis required large volume
fluid resuscitation. He was successfully extubated on
[**2110-6-8**]. He is currently on a BiPAP and high flow oxygen
now.
Pneumothorax. The patient developed a spontaneous
pneumothorax on [**5-28**] likely secondary to blebs and his
underlying emphysema. Chest tube was placed urgently by CT
surgery. Initially, tube suction, but now no longer has an
air leak and is on water seal.
GI. The patient developed pancreatitis after his admission
and the enzymes have slowly improved. He initially was made
NPO and once the enzymes had improved, tube feeds were
restarted slowly. Enzymes are still elevated, but stable
since restarting his tube feeds. Additionally, on the [**5-28**],
he was noted to have newly elevated AST, ALT, alkaline
phosphatase, but normal bilirubin of unclear etiology. CT of
the abdomen and pelvis showed no evidence of pancreatic
abscess, no tumor, or fluid collection and a normal liver. A
right upper quadrant ultrasound several days later showed a
dilated gallbladder, but no evidence of cholecystitis and on
the [**5-30**], the patient had ultrasound guided aspiration of
gallbladder fluid with removal of 40 cc of bile. Cultures
were negative. This was undertaken secondary to consistent
pain and tenderness in the right upper quadrant on exam.
Renal function. The patient's baseline creatinine is
unknown, but it was elevated on admission likely a
combination of prerenal causes as well as possible ATN from
his sepsis. However, over the course of his admission, his
creatinine has been slowly improving.
Anemia. Workup for his anemia including hemolysis
laboratory, reticulocyte count, iron, B12, folate studies
were consistent with anemia of chronic disease versus bone
marrow suppression of his red cell line given that his
reticulocyte count was only 0.6 percent with a hematocrit of
at that time of approximately 25 percent. Anemia was
followed and treated supportively.
Hypernatremia. The patient developed hypernatremia during
this hospital course and therefore he was repleted with free
water.
DVT, when the patient continued to have low-grade fevers,
lower extremity Doppler ultrasounds were performed and showed
evidence of DVT in his left superficial femoral vein and
question of a partial thrombosis in his right superficial
femoral artery. He was therefore started on Lovenox for
treatment of his DVT.
Cardiovascularly, the patient has baseline hypertension.
Throughout his hospital course, he has generally been
normotensive to slightly hypertensive although he did have
several days where he required pressor support with Levophed,
but the patient thought he usually has been in better control
recently while undergoing a slow taper of his fentanyl and
Versed drips.
Oral HSV1. During his hospital course, the patient developed
perioral ulcers that were positive for HSV1. He was given 7
days of acyclovir.
Nutrition. The patient was initially fed through tube feeds,
but then with the development of his pancreatitis, he was
switched to parenteral nutrition. Once a postpyloric tube
was placed and his enzymes had come down, he was restarted on
his tube feeds.
The rest of the [**Hospital 228**] hospital course will be dictated by
the physician taking over this care.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4546**]
Dictated By:[**Last Name (NamePattern1) 49323**]
MEDQUIST36
D: [**2110-6-13**] 16:29:38
T: [**2110-6-15**] 01:53:55
Job#: [**Job Number 56131**]
Name: [**Known lastname 10526**], [**Known firstname **] Unit No: [**Numeric Identifier 10527**]
Admission Date: [**2110-5-13**] Discharge Date: [**2110-6-19**]
Date of Birth: [**2047-5-23**] Sex: M
Service: MED
During the remainder of the [**Hospital 1325**] hospital course, he
completed a 14 day course of vancomycin for his MRSA
pneumonia. His oxygenation continued to improve. He was
weaned off noninvasive positive pressure ventilation to
nonrebreather and then a face mask. On discharge, he is
requiring 3 liters by nasal cannula as well as a 40 percent
face mask tent to have oxygen saturations in the mid 90s.
The patient does not complain of any respiratory
difficulties.
The patient's pneumothorax resolved by chest x-ray and his
chest tube was discontinued by Thoracic Surgery service on
[**6-13**]. His liver function tests and pancreatic function
tests continue to improve. The patient remained
asymptomatic. Renal function improved to within normal
limits. His hypernatremia improved to the mid 140s. He
received D5 [**1-10**] normal saline as well as free water boluses
through his PEG tube.
For the patient's DVT, he was started on Lovenox on [**2110-6-2**]
and will complete a six month course of twice a day Lovenox
treatment dose.
For the patient's cardiovascular status, once he was off
noninvasive positive pressure ventilation, he was more
comfortable, less tachycardic, and hypertensive. He was
weaned off his Fentanyl and Versed drips without difficulty,
and his mental status cleared and improved. The patient
after extubation continued not to have a gag reflex. Speech
and swallow was consulted to evaluate his swallowing and the
patient did not pass a bedside swallow test. He did not take
anything by mouth and requested that PEG tube be placed for
nutrition.
On [**2110-6-18**], a PEG tube was placed by IR percutaneously
without complications. Peptinex tube feeds were initiated
and increased to his goal of 75 cc/hour continuously. He
received free water 200 cc q.6h. through his PEG.
During his hospitalization, the patient also had multiple
episodes of bradycardia with a junctional rhythm when the
patient removed his mask and desaturated or had mucus
plugging. These episodes were likely thought to be secondary
to transient hypoxia and resolved with increase in
saturations from replacing his mask or by deep suctioning for
mucus plugs. The patient remained hemodynamically stable
during these episodes.
For prophylaxis, he remained on Lovenox, a proton-pump
inhibitor, and a bowel regimen. The patient will be
discharged to a rehabilitation facility.
DISCHARGE STATUS: Good.
DISCHARGE MEDICATIONS:
1. Lovenox 70 mg subcutaneous b.i.d.
2. Colace 100 mg p.o. b.i.d.
3. Tylenol 650 mg p.o. q.4-6h. prn.
4. Protonix 40 mg p.o. q.d.
5. Albuterol and Atrovent MDIs prn.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], [**MD Number(1) 10528**]
Dictated By:[**Last Name (NamePattern1) 10529**]
MEDQUIST36
D: [**2110-6-19**] 13:32:27
T: [**2110-6-19**] 14:01:44
Job#: [**Job Number **]
|
[
"584.5",
"038.2",
"512.8",
"577.0",
"518.81",
"518.0",
"112.5",
"518.5",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"89.64",
"99.15",
"38.91",
"03.31",
"38.93",
"34.04",
"88.72",
"46.32",
"33.24",
"96.71",
"00.11",
"51.01"
] |
icd9pcs
|
[
[
[]
]
] |
2713, 2752
|
12945, 13404
|
3658, 12922
|
2439, 2512
|
2775, 3640
|
165, 2190
|
2213, 2415
|
2529, 2696
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,574
| 133,306
|
23714
|
Discharge summary
|
report
|
Admission Date: [**2182-2-26**] Discharge Date: [**2182-3-12**]
Date of Birth: [**2131-2-1**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11261**]
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
Left total hip arthroplasty with heterotopic bone excision
[**2182-2-26**]
History of Present Illness:
The patient is a 51 year old male who has severe heterotropic
ossification with essential fusion of the left hip. This has
caused him quite a great deal of discomfort. He presents for
definitive treatment.
Past Medical History:
EtOH abuse
Pancreatitis
MRSA bacteremia
MRSA pneumonia
Alcoholic hepatitis
C diff
ARF
DT
PSVT
Respiratory failure s/p trach and PEG
DMII
High triglyceridemia
Social History:
THe patient lives alone and has a chronic history of alcohol
abuse. He admits to 2 packs/day of smoking. He is cared for by
his brother.
Family History:
None
Physical Exam:
On discharge:
NAD
A+O
CTA b/l
RRR
Left hip incision: c/d/i, no erythema, no drainage
+[**Last Name (un) 938**]/FHL/AT/G/S
+SILT
+DP
Pertinent Results:
[**2182-2-26**] 08:22PM GLUCOSE-99 UREA N-7 CREAT-0.4* SODIUM-140
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-23 ANION GAP-10
[**2182-2-26**] 08:22PM CALCIUM-7.2* PHOSPHATE-4.1 MAGNESIUM-2.0
[**2182-2-26**] 08:22PM HCT-27.0*
[**2182-2-26**] 08:22PM PLT COUNT-120*
[**2182-2-26**] 08:22PM PT-12.4 PTT-28.0 INR(PT)-1.1
[**2182-2-26**] 02:28PM HCT-26.1*
[**2182-2-26**] 02:28PM PT-12.9 PTT-27.5 INR(PT)-1.1
[**2182-2-26**] 02:28PM FIBRINOGE-163#
[**2182-2-26**] 11:30AM GLUCOSE-126* UREA N-7 CREAT-0.4* SODIUM-142
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-24 ANION GAP-12
[**2182-2-26**] 11:30AM CALCIUM-7.3* PHOSPHATE-4.4 MAGNESIUM-1.2*
[**2182-2-26**] 11:30AM HCT-30.1*#
[**2182-2-26**] 11:30AM PT-12.6 INR(PT)-1.1
[**2182-2-26**] 10:14AM TYPE-ART TIDAL VOL-600 O2-50 PO2-123* PCO2-43
PH-7.37 TOTAL CO2-26 BASE XS-0 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2182-2-26**] 10:14AM GLUCOSE-93 LACTATE-0.9 NA+-139 K+-3.9 CL--108
[**2182-2-26**] 10:14AM HGB-10.5* calcHCT-32
[**2182-2-26**] 10:14AM freeCa-1.06*
[**2182-2-26**] 09:16AM TYPE-ART PO2-161* PCO2-40 PH-7.43 TOTAL
CO2-27 BASE XS-2 INTUBATED-INTUBATED
[**2182-2-26**] 09:16AM GLUCOSE-98 LACTATE-1.3 NA+-140 K+-3.9 CL--102
[**2182-2-26**] 09:16AM HGB-12.8* calcHCT-38 O2 SAT-95
[**2182-2-26**] 09:16AM freeCa-1.19
Brief Hospital Course:
The patient was brought to the operating room on [**2182-2-26**] for a
left total hip replacement with heterotopic bone excision. The
patient tolerated the procedure well. He was extubated and
brought to the recovery room in satisfactory condition. In the
PACU there was a lot of oozing from his incision which required
approximately [**3-1**] dressing changes per hour. This was expected
because of the amount of bone exposed in the procedure. He was
placed on serial hematocrits. His systolic blood pressure was
in the 80s and 90s and his heart rate was in the 100s-110s. The
patients urine output was in the low 20's. This was despite
approximately 5 units crystalloid. His hematocrit was 26 (It
had been 40 pre-op) and he was transfused one unit PRBC's. It
was decided that the patient should be admitted to the SICU for
closer monitoring and management. While in the SICU the patient
received 2 more units of PRBC's, bringing the Hct up to 27. The
oozing from the incision slowed down considerably, his urine
output stablized, and his vitals stabilized. The patient was
placed on a CIWA scale, thiamine, folic acid, because of his
history of alcohol abuse. On POD#1 was transferred to the
floor. He had some confusion requiring redirection from the
nursing staff. He started pulling at his IV lines, so a sitter
was placed in his room and he was placed in soft restraints. He
tolerated this fine. He was also seen by the addiction
specialist RN. It was recommended to give him Haldol PRN for
confusion and to continue with the CIWA scale. His Hct was 25.7
on [**2182-2-28**] and he was transfused one unit PRBC's without
incident. This brought his hematocrit up to 27.1. On [**2182-3-1**] he
underwent radiation to his left hip to prevent further HO. He
tolerated this well. His confusion lessened each day. He was
tapered off ativan and given valium as per Addiction services
recommendation. He no longer required a sitter on [**2182-3-6**]. The
valium was tappered as well. He remained in the hospital
because of rehab placement problems. His incision looked good.
His lab results and vital signs remained stable. He hospital
course was otherwise without incident. He is being transferred
today to rehab in stable condition.
Medications on Admission:
Denies
Discharge Medications:
1. Diazepam 2 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) for 1
days: please give [**2-10**].
2. Diazepam 2 mg Tablet Sig: 0.5 mg PO once a day for 1 days:
please give [**2-11**] .
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
15. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Left heterotropic bone with essential hip fusion
Discharge Condition:
Stable
Discharge Instructions:
Please keep your incision clean and dry. If you notice any
redness, swelling, discharge, pain, temperature >101.4, or
weight bearing of the left leg. Continue with physical therapy.
Take all medications as prescribed. You need to take aspirin
325 mg twice daily. Please follow up with Dr. [**Last Name (STitle) 7111**] as below.
Call with any questions.
Physical Therapy:
PWB LLE
Treatments Frequency:
Dry sterile dressing daily
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Date/Time:[**2182-3-29**] 12:15
Completed by:[**2182-3-12**]
|
[
"577.1",
"293.0",
"728.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.32",
"81.51",
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
6124, 6194
|
2490, 4754
|
333, 409
|
6287, 6296
|
1171, 2467
|
6778, 7002
|
998, 1004
|
4811, 6101
|
6215, 6266
|
4780, 4788
|
6320, 6679
|
1019, 1019
|
6697, 6705
|
6727, 6755
|
1033, 1152
|
280, 295
|
437, 646
|
668, 827
|
843, 982
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,528
| 162,135
|
28516
|
Discharge summary
|
report
|
Admission Date: [**2118-11-29**] Discharge Date: [**2118-11-30**]
Date of Birth: [**2053-7-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
COPD, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a long time smoker with advanced COPD, requiring
ventilatory support.
Past Medical History:
COPD, sleep apnea, CAD with MI (stents and pacemaker), Afib,
HTN, DM, diverticulitis.
Social History:
50+ pack years smoking history.
Pertinent Results:
[**2118-11-29**] 09:29PM BLOOD WBC-13.8* RBC-3.06* Hgb-9.1* Hct-27.7*
MCV-91 MCH-29.6 MCHC-32.8 RDW-19.4* Plt Ct-395
[**2118-11-29**] 09:29PM BLOOD Plt Ct-395
[**2118-11-29**] 09:29PM BLOOD PT-11.2 PTT-22.7 INR(PT)-0.9
[**2118-11-29**] 09:29PM BLOOD Glucose-249* UreaN-38* Creat-1.0 Na-142
K-4.7 Cl-97 HCO3-38* AnGap-12
[**2118-11-29**] 09:29P RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2118-11-29**] 9:43 PM
CHEST (PORTABLE AP)
Reason: pre-op
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman with h/o advanecd COPD here for trach
REASON FOR THIS EXAMINATION:
pre-op
INDICATION: Pre-operative chest for tracheostomy.
SINGLE-VIEW CHEST: This study is limited by rotation. No prior
for comparison. Cardiac shadow is enlarged. There is evidence of
emphysema. Dual-lead pacemaker is noted. There are increased
interstitial markings; however, no evidence of failure. No
definite pleural effusion on this single view. Degenerative
changes of both acromioclavicular joints. Round 5-mm opacity in
the medial right lung base represents either a granuloma or a
vessel en face. Repeat imaging with PA and lateral views
recommended for further evaluation.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name8 (NamePattern2) 4075**] [**Last Name (NamePattern1) 5999**]
M BLOOD Calcium-8.3* Phos-2.7 Mg-2.7*
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] for elective tracheostomy in
setting of her advanced COPD. As she was still on plavix and
aspirin, surgery was postponed. She is being discharged to
rehabilitiaton facility with instructions to not take aspirin or
plavix until after her surgery.
Discharge Medications:
Please resume taking all of your pre-admission medications
EXCEPT aspirin or Plavix.
1. Albuterol Sulfate 0.083 % Solution Sig: [**2-14**] Inhalation Q2H
(every 2 hours) as needed.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**2-14**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Theophylline 125 mg Capsule, Sust. Release 12HR Sig: Two (2)
Capsule, Sust. Release 12HR PO BID (2 times a day).
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
[**2-14**] Caps Inhalation DAILY (Daily).
13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for PAIN or FEVER.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for Constipation.
16. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for Upset Stomach.
17. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
18. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
19. Heparin Flush Midline (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
20. Methylprednisolone Sodium Succ 40 mg Recon Soln Sig: One (1)
Recon Soln Injection Q8H (every 8 hours).
21. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
22. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO Q sunday.
23. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
every twelve (12) hours: Please hold on night prior to surgery
and on morning of surgery.
24. Insulin
NPH Subcutaneously
20 units q am, 10 units q-pm
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
advanced COPD requiring ventilatory support
Discharge Condition:
Stable to rehab.
Discharge Instructions:
Please resume taking all previous medications EXCEPT aspirin or
Plavix.
Please do not eat or drink anything starting at midnight on the
day prior to surgery.
Please call to schedule appointment for elective surgery.
Followup Instructions:
Please call Dr. [**First Name (STitle) **] [**Name (STitle) **] to schedule surgery and follow-up.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2118-11-30**]
|
[
"427.31",
"518.83",
"V58.65",
"V64.1",
"496",
"401.9",
"V45.82",
"V45.01",
"V58.66",
"V58.61",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
4837, 4916
|
2093, 2388
|
329, 336
|
5004, 5023
|
623, 1078
|
5288, 5510
|
2411, 4814
|
1115, 1171
|
4937, 4983
|
5047, 5265
|
264, 291
|
1200, 2070
|
364, 446
|
468, 555
|
571, 604
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,961
| 159,902
|
8140
|
Discharge summary
|
report
|
Admission Date: [**2150-1-4**] Discharge Date: [**2150-1-8**]
Date of Birth: [**2078-8-31**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 71-year-old
woman who presents to an outside hospital status post a fall,
transferred for evaluation of a subdural hematoma.
PAST MEDICAL HISTORY: The patient has a past medical history
of breast cancer times 22 years with metastasis to the liver,
bone, and the GI system. She is status post a right
mastectomy.
REVIEW OF SYSTEMS: The patient reports feeling more tired
than usual a few days prior to the fall. She was at home in
bed and remembers getting up out of bed to the bathroom,
unsure if sitting on the bed or walking. No symptoms prior to
the fall. No dizziness. No headache, chest pain, or
shortness of breath. The next thing she remembers is that
she had fallen with loss of consciousness and found by her
husband. The patient noted some dizziness a few days prior
to a fall. She described the room spinning. Possibly she
had weakness in her legs.
STUDIES: A head CT showed bilateral acute subdural
hematomas, right greater than left and with a ribbon of
subarachnoid hemorrhage on the right side.
LABORATORY DATA FROM THE OUTSIDE HOSPITAL: INR 1.2.
Hematocrit 29.9, platelets 105,000. Sodium 127, K 4.2,
chloride 97, C02 21, BUN 29, creatinine 1.1. The patient was
admitted to the Neurosurgical Intensive Care Unit for close
monitoring. A Medicine consultation was obtained secondary
to a history of syncope. It was felt that it was most likely
related to dehydration and also a low sodium. The patient's
baseline sodium of 131-133. It was 127 on admission. The
medical recommendation was to keep the patient on telemetry
for 48 hours which was done. There were no episodes of any
cardiac events in that 48 hour period.
Therefore, telemetry was discontinued and the patient was
transferred to the floor. She was awake, alert, and oriented
times three, moving all extremities with good strength with
slight left-sided drift. The patient was monitored in the
Surgical Intensive Care Unit for 48 hours and then
transferred to the regular floor.
She was seen by Physical Therapy and Occupational Therapy and
found to require rehabilitation. Discussion with her primary
care physician recommended transfer to [**Hospital 25576**]
Rehabilitation where he could monitor her. A Cortisol level
was sent to check for addisonism as possible cause for
hyponatremia. The results are still pending. The hematocrit
on [**2150-1-8**] was 25.7. The patient was transfused with 1 unit
of packed cells. The vital signs otherwise have been stable.
The patient has been neurologically intact with a slight left
drift and ecchymosis of the left eye.
CONDITION AT THE TIME OF DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Calcium carbonate 1,000 mg p.o. q.i.d.
2. Lactulose 30 cc p.o. q. six hours p.r.n.
3. Percocet one to two tablets p.o. q. four hours p.r.n.
4. Spironolactone 25 mg p.o. q.d.
5. Colace 100 mg p.o. t.i.d.
6. Protonix 40 mg p.o. q. 24 hours.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2150-1-8**] 08:39
T: [**2150-1-8**] 07:32
JOB#: [**Job Number 28995**]
|
[
"287.5",
"197.5",
"198.5",
"197.7",
"276.5",
"E888.9",
"852.20",
"852.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2824, 3350
|
515, 2801
|
328, 495
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,202
| 146,126
|
34057
|
Discharge summary
|
report
|
Admission Date: [**2115-7-25**] Discharge Date: [**2115-8-11**]
Date of Birth: [**2051-4-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Worsening leukocytosis
Major Surgical or Invasive Procedure:
T12 bilateral laminectomy, medial facetectomy, foraminotomy.
Far lateral transpedicular decompression bilaterally at T12.
Biopsy of right-sided posterior elements and sent for pathology.
Exploration of fusion mass T10, T11, T12.
Removal of hardware at T12 with cutting of the rod and extension
of fusion distally.
Segmental instrumentation with application of dominoes and
extension of the rod with pedicle screw instrumentation, L1 and
L2.
Fusion arthrodesis T12-L1-L2.
Application of allograft.
Scar revision.
History of Present Illness:
64 yo M with h/o DM, asthma, bipolar disorder, hypothyroidism,
PCN allergy (s/p desensitization), with multiple admission for
treatment of recurrent bacteremia, T9-10 epidural abscess(MSSA),
and empyema requiring thoracic spine decompression and
decortication, found to have rise in WBC in [**Hospital **] clinic and sent
to ED for further evaluation.
.
Patient initally presented in [**2115-4-4**] with MSSA epidural
thoracic abscess with cord compression and empyema. He was also
noted to have C4-5 discitis and osteomyelitis. He also had
decortication of R lung for empyema. He was discharged on
[**2115-4-25**] on nafcillin.
.
The pt returned two weeks later with bilateral LE paralysis and
found to have recurrent thoracic epidural abscess requiring
emergent T8-11 laminectomy and debridement [**5-12**]. Blood cultures
from [**5-14**] revealed [**Female First Name (un) **] albicans and patient was started in
fluconazle. Pt returned to the OR for R thoracotomy, T9-T10
corpectomy w/ anterior thoracic fusion and posterior fusion. The
patient recured a chest tube [**1-5**] a PTX. The patient continued to
have low grade fevers and increased WBC. A BAL was performed
which showed serratia marcescens. The patient was treated for
VAP with 8 days of cipro. The patient had progression of CXR
innfiltrate, and was started on empiric vanco, zosyn,
fluconazole, which was narrowed to nafcillin, cipro, and
fluconazole with negative Bcx. A left thoracocentesis was
performed without growth on culture.
.
He was then readmitted on [**6-27**] with purulent drainage from
posterior midline incision. He went to OR for repeat I&D. Urine
cx, wound cx and 2 out of 4 bcx grew enterobacter cloacae
susceptible to meropenem, gentamicin and cefepime. He was sent
to rehab on IV cefipime and vancomycin, with a plan for for 8
weeks of vancomycin and at least 6 weeks of cefipime. While at
rehab course has been significant for increasing wbc. At d/c his
wbc was 11 and on [**7-24**], wbc was 17.6. He had been afebrile at
rehab, but had been noted to have loose stools. Work-up of
leukocytosis while at rehab included per verbal report a
negative CXR, negative u/a with neg LE and NT and pending U cx
and negative C diff.
.
At [**Hospital **] clinic today, pt noted to have dry mm and also with
purulent drainage from posterior incision site. His BP was 92/60
T 97.5. He was sent to ER for further evaluation of possible
recurrent wound infection.
.
In ER T 96.9, HR 58, 95/53 95% on RA. 95% on RA. He rec'd 2 L NS
woith inecrease of BP to 95/54, and was continued on prior abx
cefipime and flagyl. Pt was seen by ortho who would like c-spine
CT and are planning to take him to OR tomorrow.
Past Medical History:
Schizophrenia
Hypothyroidism
DMII, insulin dependent
Hyperlipidemia
Asthma
Depression
s/p epidural abscess(resistant acinetobactor) with multiple
drainage procedures and paraplegia
Enterobactor Bacteremia
Severe Malnutrition
Atrial Fibrillation
IVC filter
Social History:
Tob: Remote 30 pkyr hx; quit 20 yrs ago. No etoh. +Marijuana
use. No IVDU or other IV injection use. Retired; former
electrician. Lives with son, daughter-in-law and grandson. [**Name (NI) **]
been in and out of nursing facilities since [**2115-4-4**].
Family History:
Father DM2
Mother CAD
Physical Exam:
VS: T 97.4 BP 132/58 P 84 98 % RA
GEN: White male who appears states age, sleeping, falls asleep
during questioning, but answers appropriatly
HEENT: NCAT, PERRL, oropharynx clear and without erythema or
exudate
NECK: Supple, no LAD, no appreciable JVD
CV: RRR, normal S1S2, ? 1/6 SEM at USB, rubs or gallops
PULM: Barrel Chested, CTAB, no w/r/r, good air movement
bilaterally
ABD: Soft, NTND, normoactive bowel sounds, no organomegaly, no
abdominal bruit appreciated
EXT: Warm and well perfused, full and symmetric distal pulses,
no pedal edema. PICC in LUE c/d/i
NEURO: AAOx3, responds appropriately to questions, CN 2-12
grossly intact. Unable to move LE upon command and absense
sensation below hip. + perineal sensation. Up going babinski
b/l.
Pertinent Results:
Admission Labs:
[**2115-7-25**] WBC-15.8* RBC-3.49* Hgb-9.7* Hct-30.4* MCV-87 MCH-27.8
MCHC-32.0 RDW-14.6 Plt Ct-854* Neuts-72.4* Lymphs-19.1 Monos-4.3
Eos-3.8 Baso-0.5
PT-14.7* PTT-27.4 INR(PT)-1.3*
Glucose-72 UreaN-21* Creat-0.8 Na-136 K-4.9 Cl-98 HCO3-29
AnGap-14
ALT-9 AST-16 CK(CPK)-26* AlkPhos-147* TotBili-0.3
.
[**2115-7-25**] 02:45PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2115-7-25**] 09:35PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2115-7-26**] 02:46PM BLOOD CK-MB-NotDone cTropnT-0.03*
.
[**2115-7-28**] 07:22AM BLOOD Vanco-18.3
.
[**2115-8-1**] WBC-10.8 RBC-3.35* Hgb-9.6* Hct-29.6* MCV-88 MCH-28.7
MCHC-32.5 RDW-14.1 Plt Ct-586* Neuts-80.8* Lymphs-12.9*
Monos-4.1 Eos-1.9 Baso-0.3
Glucose-182* UreaN-12 Creat-0.7 Na-139 K-4.4 Cl-99 HCO3-31
AnGap-13
.
[**2115-7-31**] 05:35AM BLOOD ESR-125*
[**2115-7-25**] 09:35PM BLOOD ESR-150*
[**2115-7-25**] 02:45PM BLOOD ESR-130*
.
[**2115-7-31**] 05:35AM BLOOD VitB12-674
[**2115-7-31**] 05:35AM BLOOD TSH-5.5*
[**2115-7-31**] 05:35AM BLOOD T4-9.3
.
[**2115-7-31**] 05:35AM BLOOD CRP-92.0*
[**2115-7-25**] 09:35PM BLOOD CRP-100.8*
[**2115-7-25**] 02:45PM BLOOD CRP-118.8*
.
Microbiology:
[**2115-7-25**] Urine culture: Negative
[**2115-7-25**] Blood culture: Enterobacter cloacae sensitive to
cefepime, gentamicin, meropenem, tobramycin
[**2115-7-25**] Stool culture: Negative
.
All other blood cultures: negative
.
[**2115-7-26**] Wound culture: Acinetobacter sensitive to amikacin,
unasyn, tobramycin
.
[**2115-7-28**] C difficile toxin: Negative
[**2115-8-1**] C difficile toxin: Negative
[**2115-8-2**] C difficile toxin: Negative
.
[**2115-7-25**] CT T-spine: 1. Horizontal fracture of the superior
endplate of T12, with posterior translation of the fracture
fragment relative to the remainder of the vertebral body into
the central canal. Paired pedicle screws are located within this
displaced fracture fragment, and is displaced along with the
fragment into the central canal.
2. Soft tissue bulging at the site of this fracture, presumed to
represent a hematoma. However, superimposed infection cannot be
excluded.
3. Assessment for an abscess is limited without IV contrast.
.
[**2115-7-25**] CXR: 1. Posterior migration of the two distal set of
pedicle screws compared to CT chest of [**2115-6-6**], with acute
angulation and kyphosis of the thoracic spine at this level,
concerning for unstable hardware.
2. Moderate right pleural effusion with atelectasis.
.
[**2115-7-29**] ECHO: No endocarditis or abscess seen. Normal regional
and global biventricular systolic function. No pathologic
valvular abnormality seen.
.
[**2115-7-31**] EEG: This is an abnormal routine EEG due to the slow
background and bursts of generalized slowing. These
abnormalities suggest a mild to moderate encephalopathy.
Medications, metabolic disturbances and infection are among the
most common causes. No lateralized or epileptiform features were
noted.
Brief Hospital Course:
64 yo M with h/o DM, asthma, schizophrenia, hypothyroidism,
recurrent epidural abscess, T9/10 ostemyelitis and subsequent
spinal cord compression with paraplegia, and severe malnutrition
admitted with rising WBC count found to have enterobactor
septicemia and acinetobactor osteomyelitis of T9/10.
.
# Enterobactor Bacteremia/Sepsis: Enterobactor sensitive to
gentamicin, tobramycin, and meropenem. TTE showed no sign of
vegetation or abscess. Patient initially treated with IV
vancomycin and meropenem on admission while sensitivities were
pending. He was then transitioned to IV unasyn 3gm Q4H and
cefepime 1gm Q12 H on [**2115-7-29**]. Due to a concern for mental
status change in the setting of high dose unasyn, patient was
briefly transitioned to tobramycin over 4 days and continued on
cefepime. When his mental status returned to baseline, unasyn
was resumed and cefepime continued on [**2115-8-6**] at the
reommendation of the ID team. Patient was observed for 30 hours
on the high dose unasyn without evidence of worsening delirium
and discharged with plan to continue an 8 week course from
[**2115-7-29**]. Patient is to have weekly labs (CBC, Chem 7, CRP, ESR,
LFTs) faxed to the following ID team and follow up in their
clinic as scheduled. End date for antibiotics is approximately
[**9-23**], for patient to complete an 8-week course.
.
# Recurrent Epidural Abscess/Osteomyelitis at T9/10 and
paraplegia: Patient is s/p multiple procedures and debridements
with inability to move lower extremities and persistent urinary
retention. He has not regained any significant motor function in
the lower extremities. During this admission, he was taken back
to the OR for hardware removal and washout on [**7-26**]. Tissue
cultures obtained intra-op were positive for acinetobacter,
sensitive to unasyn and tobra. Spinal drains were discontinued
on HD#5. Wound care continued with daily dressing changes and
patient was encouraged to not lie directly on his wound to allow
for appropriate healing. Patient is allowed out of bed and to
participate in physical therapy with a TLSO brace in place.
Wound care is to continue as prescribed and patient has follow
up arranged with ortho spine team as scheduled.
.
# Delirium: Patient noted to have significant decline in mental
status with waxing and [**Doctor Last Name 688**] course complicated by visual
hallucinations on hospital day 4. Initial concern was for
worsening infection vs. metabolic abnormality vs. drug toxicity
vs. seizure. Patient was evaluated by the neurology team with an
EEG consistent with toxic/metabolic encephalopathy. Psychiatry
team consulted on the patient and recommended titrating his
anti-psychotics to off as they were prescribed at doses greater
than typically prescribed and to start haldol in there place.
Given that delirium started when high dose unasyn was started,
he was switched to tobramycin for concern of medication-induced
delirium. Patient's mental status improved over subsequent days
and was back to baseline by [**2115-8-5**] when mitt restraints were
discontinued. The patient did not develop any QTc prolongation
on haldol and demonstrated no signs of anti-psychotic
side-effects. Unasyn was resumed as above prior to discharge
without change in mental status. Patient is encouraged to
continue with haldol for treatment of his schizophrenia until
follow up can be arranged with his outpatient psychiatrist.
.
# Severe malnutrition: Nutirition was consulted during his stay
to evaluate for adequate caloric intake in the setting of poor
wound healing, recurrent infections, and severe malnutrition
with an albumin of 2.6. Supplementations were started TID and
patient was repeatedly encouraged to increase oral intake.
Psychiatry was consulted for concern of worsening depression
contributing to poor oral intake but on their exam did not feel
patient was depressed. Despite initial calorie counts at 50% of
goal, decision was made by the medical team to avoid TF or TPN
in this patient as he has a function gut and the ability to eat.
Please continue heart healthy diet with TID supplements for goal
calorie intake of 1800 kcal/day. Please assist patient with
meals to ensure adequate intake.
.
# Persistent Loose Stools: C. diff neg x3. Likely antibiotic
associated. Have been holding bowel regimen. Could consider
stsarting loperamide if symptoms persist and become troublesome.
Patient with fecal incontience at baseline.
.
# Atrial fibrillation: Recently diagnosed during last
hospitalization with one episode without hemodynamic
instability. Currently controlled on home regimen of digoxin,
metoprolol, and aspirin in sinus rhythm. Aspirin was originally
held on admission but resumed when spinal drains were removed as
per ortho spine recs.
.
# Diabetes Mellitus type II, complicated by hypoglycemia: Well
controlled, with last HgA1c of 5.0. During his stay, he
developed early am hypoglycemic episodes. These have been
avoided with initiation of [**Hospital1 **] glargine, 10 units QAM, 2 units
QPM. Patient has also been continued on QID insulin sliding
scale. He is likely to benefit from uptitration of glargine as
po intake is maintained.
.
# Hyperlipidemia: No issues. Continue home regimen of lipitor.
His fenofibrate was discontinued in the setting of persistent
looss stools.
.
# Asthma: No active issues. He has been continued on home
regimen of Fluticasone and Albuterol/atrovent inhalers.
.
# Hypothyroidism: No active issues. He has been continued on
levothyroxine. Last TSH 5.5 on admission. Should be rechecked
in 6 weeks.
.
# Schizophrenia: Hallucinations resolved, believed to be at
baseline now. Discontinued home regimen of Lexapro, Abilify in
setting of delirium. Psychiatry following as above. Continue
1mg [**Hospital1 **] haldol. No evidence of QTC prolongation during his stay.
Recommend outpatient psychiatry follow up.
.
# PPX: Patient with IVC filter ([**1-5**] spinal stabilization
surgery) during previous admission. Patient continued on heparin
SQ after spinal drains removed. He was provided with an Air bed
with daily monitoring for ulcers. His bowel regimen has been
held secondary to loose stools.
.
# ACCESS: PICC
.
# CODE: Full Code
.
# DISP: Patient discharged to rehab for continued care.
.
#Comm: with son: [**Name (NI) **] (for consents) [**2115**]
Medications on Admission:
1. Vancomycin 1000 mg IV Q 24H
2. CefePIME 2 g IV Q12H
3. Morphine Sulfate 2-4 mg IV Q4H:PRN breakthrough pain
4. Falgyl 500mg PO TID
5. Ondansetron 4 mg IV Q8H:PRN
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H as needed.
8. Docusate Sodium 100 mg Capsule PO BID
9. Senna 8.6 mg PO BID
10. Bisacodyl 5 mg PO DAILY as needed.
11. Zolpidem 5 mg PO HS
12. Fenofibrate Micronized 145 mg PO daily
13. Atorvastatin 40 mg PO DAILY
14. Escitalopram 30 mg PO DAILY
15. Aripiprazole 40 mg PO DAILY
16. Alprazolam 0.25 mg 1-2 Tablets PO BID as needed.
17. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H as needed.
18. Ipratropium Bromide 17 mcg/Actuation Two Puff Inhalation QID
19. Metoprolol Tartrate 25 mg PO BID
20. Levothyroxine 150 mcg PO DAILY
21. Ferrous Sulfate 325 mg (One Daily).
22. Aspirin 325 mg PO once a day.
23. Insulin Glargine 20 units Subcutaneous once a day.
24. Insulin Regular Human 300 unit/3 mL Insulin
25. Digoxin 200 mcg PO once a day.
26. Heparin (Porcine) 5,000 unit/mL TID
Discharge Medications:
1. Outpatient Lab Work
Please draw CBC, creatinine, BUN, AST, ALT, AP, T.bili, CRP, ESR
every week x 6 weeks.
Please fax results to [**Telephone/Fax (1) 432**] ATTN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
6. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
inhalation Inhalation every six (6) hours as needed.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
11. Lantus 100 unit/mL Cartridge Sig: 10 units qAM, 2 units qHS
units Subcutaneous twice a day: please administer 10units QAm
and 2 units QHS.
12. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
unit Injection four times a day: please administer regular
sliding scale QACHS as per attached sheet. unit
[**Unit Number **]. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 8 weeks: Day 1 = [**2115-7-29**].
14. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
17. Vitamin D 400 unit Tablet Sig: Four (4) Tablet PO once a
day.
18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
19. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
20. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day.
21. Unasyn 3 gram Recon Soln Sig: One (1) Intravenous every
four (4) hours for 8 weeks: DAY 1 = [**7-29**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary:
- Acinetobacter / Enterobacter wound infection
- Enterobacter bacteremia
- Pathologic burst fracture, T12, secondary to osteomyelitis
diskitis.
Failure of hardware s/p removal of hardware, segmental
instrumentation, fusion arthrodesis, scar revision.
- Toxic-metabolic encephalopathy / Delirium
- Anemia of chronic disease
- Malnutrition - severe
Secondary:
- Diabetes mellitus type II
- Hyperlipidemia
- Asthma
- Schizophrenia
- Hypothyroidism
- Paroxysmal atrial fibrillation
- IVC filter
- [**4-11**] MSSA epidural and thoracic abscesses, C4-5 discitis and
osteomyelitis, cord compression and empyema/hydropneumothrorax.
s/p resection of abscesses, laminectomy (T8-T12), VATS
decortication of right lung.
- [**5-12**] paraplegia secondary to recurrent abscess and cord
compression. S/p decompression of abscesses, T9-T10 vertebral
corpectomies and T8-T10 thoracic fusion with mesh cage and rod
placement was performed.
- [**6-27**] to [**7-10**] infection posterior incision c/b enterobacter
cloacae bacteremia and septicemia
Discharge Condition:
Hemodynamically Stable. Pain well-controlled on tylenol. Mental
status at baseline.
Discharge Instructions:
You have been admitted for an increased white blood cell count
discovered in the Infectious Disease clinic. Though you did not
have a fever, you were worked up for infection and found to have
bacteria in your blood. You were started on IV meropenem and
vancomycin. You were taken to the operating room for incision
and drainage with washout of your epidural abscess. The bacteria
in your blood was identified as enterobacter, while the bacteria
in your wound was identified as acinetobacter. You were started
on IV antibiotics to treat these infections. You are to continue
with IV cefepime and Unasyn to complete a 8-week course from
start date [**2115-7-29**]. You will have your blood counts monitored
weekly and faxed to the infectious disease doctors to closely
monitor your improvement and for any drug toxicities.
.
During your stay, you developed worsening confusion. No evidence
of worsening infection or seizure was found. You were evaluated
by psychiatry and they recommended decreasing your psychiatric
medications to off and starting haldol two times daily to treat
your confusion. Please follow up with Dr. [**Last Name (STitle) 78601**] to continue
titration of your medications by calling [**Telephone/Fax (1) 78602**].
.
During your stay, you were evaluated by the nutrition staff
because of your severe malnutrition. The initiated daily
supplementation with each meal and the intake of atleast 1800
kcals per day. To encourage you to intake sufficient calories,
you were assisted by an aid with each meal. If you continue to
be unable to appropriately consume enough calories, alternative
sources of nutrition will be considered.
.
Please continue daily dressing changes and wearing the TLSO
brace when you are out of bed. Please avoid direct lying on your
surgical incision to promote wound healing. You will have follow
up with Dr. [**Last Name (STitle) 1007**] as scheduled.
.
If you develop any fever, chest pain, shortness of breath,
numbness, tingling, weakness or any other general worsening of
condition, please call your PCP or come directly to the ED.
Followup Instructions:
You should see your Orthopaedic Surgeon Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] during
the first week in [**Month (only) 359**]. Please call [**Telephone/Fax (1) 3736**] to schedule
an appointment. You will have your wound examined and sutures
removed at this visit.
.
You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the
Division of Infectious Diseases on [**2115-9-5**] at 8:30 a.m.
Please call [**Telephone/Fax (1) 457**] if you need to reschedule.
.
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the Division
of Cardiology on [**2116-1-16**] at 10:40 AM. If you are unable to keep
your appointment, please call [**Telephone/Fax (1) 62**] to reschedule.
.
You should follow-up with your psychiatrist Dr. [**Last Name (STitle) 78601**] after you
are discharged from Rehab for ongoing management of your
psychiatric medications. Please call [**Telephone/Fax (1) 78602**] to schedule
an appointment.
.
Please follow-up with your Primary Care Physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 33575**]
after you are discharged from rehab.
|
[
"427.31",
"V58.67",
"996.49",
"493.20",
"998.59",
"296.50",
"E930.0",
"038.49",
"292.81",
"272.4",
"324.1",
"788.20",
"733.13",
"344.1",
"250.80",
"244.9",
"995.91",
"996.67",
"261",
"730.08",
"041.85",
"349.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"77.49",
"78.69",
"03.09",
"86.3",
"81.35",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
17633, 17713
|
7819, 14127
|
302, 817
|
18796, 18882
|
4902, 4902
|
21010, 22211
|
4094, 4118
|
15194, 17610
|
17734, 18775
|
14153, 15171
|
18906, 20987
|
4133, 4883
|
240, 264
|
845, 3527
|
4918, 7796
|
3549, 3807
|
3823, 4078
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,953
| 172,493
|
48221
|
Discharge summary
|
report
|
Admission Date: [**2141-10-27**] Discharge Date: [**2141-11-2**]
Date of Birth: [**2065-11-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2141-10-27**] - Mitral Valve Replacement (31mm [**Company 1543**] Mosaic
Porcine Valve)
History of Present Illness:
This 75-year-old patient with known mitral valve endocarditis in
the distant past in the year of [**2095**] presented at this time with
increasing shortness of
breath and was found to have severe mitral regurgitation with a
preserved left ventricular function. The coronary arteries were
normal on angiogram. He was electively admitted for mitral valve
replacement.
Past Medical History:
RHD/MR/CHF, Chronic AF, CRI(?), HTN, ?Parkinsons/tremor, AAA
(3.5 cm), Right iliac artery aneurysm (2.1)
Social History:
retired english professor
45 pack year history - quit [**2127**]
quit etoh [**2119**]
Family History:
father deceased from MI in [**2119**]
Physical Exam:
76 sr 110/60
GEN: Elderly appearing man in NAD. Poor hygiene (smelled of
urine/feces)
SKIN: Unremarkable
HEENT: Unremarkable, full dentures
NECK: Supple, FROM
LUNGS: CTA
HEART: Irregular with a HSM at the left lower sternal border
ABD: Soft, nontender, nondistended, normoactive bowel sounds.
EXT: Warm, well perfused, Trace LE edema. No varicosities.
Pulses 2+ throughout. No carotid bruits
NEURO: Alert, Slight shuffle to gait, poor balance, RUE tremor,
good strength, no focal deficits, CN II-XII grossly intact
Pertinent Results:
[**2141-10-27**] ECHO
PRE CPB The left atrium is markedly dilated. No thrombus is seen
in the left atrial appendage. No atrial septal defect is seen by
2D or color Doppler. Overall left ventricular systolic function
is low normal (LVEF 50-55%). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] Right ventricular systolic function is
normal. The ascending aorta is mildly dilated. There are simple
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is bileaflet prolapse
with a segment of posterior leaflet that appers flail. An
eccentric, posteriorly directed jet of Severe (4+) mitral
regurgitation is seen.
POST CPB Very limited echocardigraphic windows. Overall
biventricular systolic function appears unchanged from pre-CPB
though there may be some very mild inferior hypokinesis. Limited
windows prevent complete exclusion of other focal wall motion
abnormalities. There is a bioprosthesis located in the mitral
position. It is seen only in limited views. It appears well
seated and the leaflets appear to function normally. There is
trace valvular mitral regurgitation. A small perivalvular jet
can not be ruled out. The maximum measured gradient across the
mitral valve was 10 mm Hg with a mean of 5 mm Hg. Cardiac output
was 6.5 l/m.
[**2141-10-30**] CXR
In comparison with study of [**10-29**], there is relative elevation of
the right hemidiaphragmatic contour when compared to the left.
This probably represents a combination of a moderate right
pleural effusion with the eventration of the right hemidiaphragm
seen on the study of [**10-16**]. The endotracheal tube and
nasogastric tubes have been removed. The left chest tube
persists and there is no evidence of pneumothorax. The left base
is difficult to evaluate, though there is blunting of the
costophrenic angle consistent with some pleural fluid.
[**2141-11-2**] 07:00AM BLOOD WBC-5.3 RBC-2.83* Hgb-9.2* Hct-27.5*
MCV-97 MCH-32.7* MCHC-33.6 RDW-14.2 Plt Ct-176
[**2141-11-2**] 07:00AM BLOOD PT-17.9* PTT-26.3 INR(PT)-1.7*
[**2141-11-2**] 07:00AM BLOOD Plt Ct-176
[**2141-11-2**] 07:00AM BLOOD Glucose-107* UreaN-36* Creat-1.8* Na-145
K-4.0 Cl-110* HCO3-25 AnGap-14
[**2141-11-1**] 01:20PM BLOOD Glucose-154* UreaN-35* Creat-1.6* Na-145
K-4.4 Cl-111* HCO3-25 AnGap-13
[**2141-10-27**] 12:50PM BLOOD UreaN-39* Creat-2.1* Cl-116* HCO3-21*
Brief Hospital Course:
Mr. [**Known lastname 1007**] was admitted to the [**Hospital1 18**] on [**2141-10-27**] for surgical
management of his mitral valve disease. He was taken directly to
the operating room where he underwent a mitral valve replacement
using a 31mm [**Company **] mosaic porcine valve. Please see
operative note for details. Postoperatively he was taken to the
intensive care unit for monitoring. Later that day, Mr. [**Known lastname 1007**] [**Last Name (Titles) **]e and was extubated. Over thge next several hours, Mr. [**Known lastname 1007**]
became tachypneic and acidotic. He was subsequently reintubated.
He was noted to have an increasing left pneumothorax and a chest
tube was placed. On postoperative day one, Mr. [**Known lastname 1007**] was
transfused with packed red blood cells for postoperative anemia.
Beta blockade and aspirin were resumed. Coumadin was restarted
for his chronic atrial fibrillation. Digoxin was started for
rate control of his atrial fibrillation. On postoperative day
three, Mr. [**Known lastname 1007**] was successfully extubated. Free water boluses
were given for mild hypernatremia. His verapamil was titrated to
control his heart rate. Secondary to his elevated creatinine, a
digoxin level was taken on post-operative day 6 and found to be
1.0. By post-operative day six, Mr. [**Known lastname 1007**] was ready for
discharge to rehab.
Medications on Admission:
Coumadin
Toprol XL 25mg daily
Lisinopril dose unknown
Zyprexa 5mg daily
Temazepam 60mg daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. 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*
6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
titrate for a goal INR of [**1-27**].5 for atrial fibrillation.
Disp:*30 Tablet(s)* Refills:*0*
7. Verapamil 120 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
MR s/p MVR (31mm [**Company 1543**] Mosaic Porcine Valve)
Rheumatic heart disease
Pneumothorax with respiratory compromise requiring reintubation
AF
CRI
HTN
AAA
Right iliac artery aneurysm
?Parkinson's disease
Tremor
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wound for signs of infection. These include redness,
drainage or increased pain. Please contact your [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 4044**] with any wound issues.
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. Please weigh yourself daily.
4) No driving for 1 month.
5) No lifting greater then 10 pounds for 10 weeks.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**12-27**] weeks.
Follow-up with Dr. [**Last Name (STitle) 1057**] in [**1-28**] weeks.
Please call all providers for appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2141-11-2**]
|
[
"276.2",
"E878.1",
"512.1",
"585.9",
"427.31",
"403.90",
"332.0",
"394.1",
"398.91",
"285.9",
"V58.61",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"96.04",
"35.23",
"96.71",
"34.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6630, 6689
|
4211, 5589
|
312, 405
|
6950, 6957
|
1639, 4188
|
7416, 7829
|
1049, 1088
|
5733, 6607
|
6710, 6929
|
5615, 5710
|
6981, 7393
|
1103, 1620
|
253, 274
|
433, 801
|
823, 929
|
945, 1033
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,691
| 140,529
|
48123
|
Discharge summary
|
report
|
Admission Date: [**2151-5-8**] Discharge Date: [**2151-5-14**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest discomfort, s/p cath with 3VD and distal LMCA disease
Major Surgical or Invasive Procedure:
cardiac catheterization /IABP [**2151-5-10**]
CABG x3 [**2151-5-10**]
History of Present Illness:
The patient is an 86 year old female with a history of HTN who
presented at 5pm on [**5-7**] to BIDN with complaints of chest
discomfort. Describes that she noted a mild substernal chest
discomfort 2 evenings prior to presentation, but is not clear if
it woke her from sleep. It persisted throughout the night.
During the subsequent day, had persistent chest discomfort, that
she felt would worsen with activity. Describes as a mild
pressure, radiating to her back, without any associated
symptoms. On further questioning, reminded her of prior GERD
symptoms, so didn't think much of it. Also of note she had been
feeling increased fatigue over this time period. That evening,
she had persistent chest discomfort, but again, only mild in
nature. She doesn't feel that it ever resolved completly over
the 2 day time period. She called into her PCP, [**Name10 (NameIs) **] was reffered
to the BIDN ED.
.
On arrival to BIDN, patients intial viatls were HR 73, BP
155/60, 100% on RA. She was given SLNG x 3 with resolution of
pain. Chest discomfort returned during ED stay, and 2 additional
doses of SLNG were given to good effect. She was additionally
given 243mg of ASA, GI coctail, 1 inch of nitro [**Last Name (un) 18712**], and
started on a heparing gtt. EKG showed no ischmic changes.
Cardiac markers showed a normal CK at 113, an elevated MB at
9.5, and an elevated troponin at 0.07 in the setting of CKD (GFR
= 45.) The patient was transfered as a direct admit to the [**Hospital Unit Name 196**]
service.
.
While on the [**Hospital1 1516**] service the patient's cardiac enzymes peaked
at a CK of 233, MBI of 12.9, TnT of 0.53. She was noted to have
a small amount of BRBPR per patient, without a significant hct
drop, this was considered to be a minor bleed and the patient
was continued on a heparin gtt.
cardiac cath done [**5-10**], IABP placed and referred for CABG.
Past Medical History:
HTN
Social History:
A prior social smoker, but not currently. Drinks 1-2 drinks an
evening. No drug use. Spent most of adult life in NJ, but
recently moved to MA to be near her 2 daughters, and lives in a
retirement community.
Family History:
non contributory
Physical Exam:
VS - 97 129/54 76 96% on RA
Gen: Elderly female 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 6cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
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.
4'8" 98#
Pertinent Results:
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. A left-to-right shunt
across the interatrial septum is seen at rest. A small secundum
atrial septal defect is present. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. There are simple atheroma in the
ascending aorta. There are complex (>4mm) atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Mild to moderate ([**1-2**]+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is severe mitral annular
calcification. There is moderate thickening of the mitral valve
chordae. Moderate (2+) mitral regurgitation is seen. There is no
pericardial effusion. IABP in good position in the descending
aorta
POST CPB
1. Preserved [**Hospital1 **]-ventricular sustolci function with background
inotropic support (Epinephrine)
2. MR is mild now.
3. TR is mild now.
4. IABP in good position.
5. Intact aorta
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2151-5-10**] 14:44
[**2151-5-14**] 05:31AM BLOOD WBC-14.0* RBC-3.79* Hgb-11.2* Hct-32.9*
MCV-87 MCH-29.6 MCHC-34.0 RDW-15.3 Plt Ct-215#
[**2151-5-14**] 05:31AM BLOOD PT-10.2* PTT-25.0 INR(PT)-0.8*
[**2151-5-14**] 05:31AM BLOOD Glucose-103* UreaN-31* Creat-1.1 Na-131*
K-4.3 Cl-95* HCO3-28 AnGap-12
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2151-5-13**] 2:44 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 101468**]
Reason: eval for PTX
[**Hospital 93**] MEDICAL CONDITION:
86 year old woman s/p CT pull
REASON FOR THIS EXAMINATION:
eval for PTX
Final Report
INDICATION: Status post chest tube pull, please evaluate for
pneumothorax.
Comparison is made to the prior study of [**2151-5-12**].
Findings: The distal tip of right central line projects at the
expected
location of cavoatrial junction. Mildly enlarged heart size is
unchanged.
The aorta is tortuous. Small bilateral pleural effusions are
unchanged. No
pneumothorax is detected. Right chest tube has been removed.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2151-5-13**] 5:27 PM
Cardiac cath:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated two
vessel disease. The LMCA had a calcified distal 80% stenosis.
The LAD
had an 80% calcified mid stenosis. The Ramus intermedius had a
proximal
stenosis that extended from the left main stenosis. The LCx had
a 99%
proximal stenosis. The RCA had mild luminal irregularities.
2. Limited resting hemodynamics revealed elevated left-sided
filling
pressures with LVEDP 26mmHg. There was severe systemic arterial
hypertension with SBP 180mmHg and DBP 66mmHg.
3.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease and left main disease.
2. Normal ventricular function.
3. Refractory pain requiring IABP for hemodynamics support.
ATTENDING PHYSICIAN: [**Name10 (NameIs) 2052**],[**Name11 (NameIs) 2053**] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) 2052**],[**Name11 (NameIs) 2053**] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **]
[**Last Name (LF) 39562**],[**First Name3 (LF) **] G.
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Brief Hospital Course:
Patient is an 86 year old female with a history of hypertension
who presents with complaints of chest pain. While on the [**Hospital1 1516**]
service the patient's cardiac enzymes peaked at a CK of 233, MBI
of 12.9, TnT of 0.53. She was noted to have a small amount of
BRBPR per patient, without a significant hct drop, this was
considered to be a minor bleed and the patient was continued on
a heparin gtt.
Cath done [**5-10**] which revealed two vessel coronary artery disease
and left main stenosis and IABP was placed prior to undergoing
emergecy CABG x 3(LIMA->LAD, SVG->Ramus and LCX).
She tolerated the procedure well and was transferred to the
CVICU in stable condition on titrated phenylephrine and propofol
drips. She had her IABP dicaontinued immediately post op and was
extubated that night. She went into atrial fibrillation on POD
2 and was treated with amiodarone and converted to sinus rhythm.
She was transferred to the floor that evening and chest tubes
and pacing wires removed per protocol. She was gently diuresed
toward preop weight and worked with PT to help gain strength and
mobility. She went back into atrial fibrillation and was
started on Coumadin. She contiued to progress and was
discharged to rehab at Newbridge of [**Location (un) 1411**] on POD#4 in stable
condition. She will have her first INR drawn on [**5-15**] and has a
follow up appointment with Dr. [**Last Name (STitle) **] on [**6-16**] @ 1PM.
Medications on Admission:
Lisinopril believes 10mg, but not sure
Norvasc 5mg daily
HCTZ 25mg daily
Evista
Omeprazole 20mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days: Decrease dose to 200 mg PO daily after 7 days.
9. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
10. Lasix 20 mg Tablet Sig: Two (2) Tablet PO twice a day for 7
days.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7
days.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day for 2
doses: Titrate does for INR goal of [**2-2**].5. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
CAD s/p cabg x3
HTN
NSTEMI
postop A Fib
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with Ultram and Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] Wednesday [**6-16**] @ 1:00 pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments with your:
Primary Care Dr.[**First Name (STitle) 1726**] in [**1-2**] weeks [**Telephone/Fax (1) 62885**]
Cardiologist Dr. [**Last Name (STitle) **] in [**1-2**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication
Goal INR
First draw
Results to phone
fax
Completed by:[**2151-5-14**]
|
[
"403.90",
"414.01",
"414.2",
"427.31",
"585.9",
"578.1",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"37.22",
"88.53",
"88.56",
"37.61",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
10198, 10292
|
7303, 8748
|
327, 399
|
10376, 10610
|
3342, 5327
|
11452, 12173
|
2573, 2591
|
8901, 10175
|
5367, 5397
|
10313, 10355
|
8774, 8878
|
6722, 7280
|
10634, 11429
|
2606, 3323
|
228, 289
|
5429, 6705
|
427, 2306
|
2328, 2333
|
2349, 2557
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,328
| 160,572
|
50285
|
Discharge summary
|
report
|
Admission Date: [**2194-3-27**] Discharge Date: [**2194-4-8**]
Date of Birth: [**2137-8-27**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
polytrauma s/p MVC
Major Surgical or Invasive Procedure:
[**2194-4-7**]: Right VATS, tracheostomy, PEG
[**2194-4-8**]: Right thoracotomy
History of Present Illness:
57yo M with no PMHx presenting from scene post MVC, tractor
trailer vs tree.
In [**Name (NI) **], pt was found to be tachy with MAPs approx 60; Hct of 17;
pt received 2u PRBCs and crystalloid. Known injuries appreciated
in ED include parafalcine SDH and SAH, multiple R sided rib fx,
R thigh hematoma, facial laceration s/p repair.
Past Medical History:
PMH: denies
PSH: appendectomy
Social History:
He lives with his sister. [**Name (NI) **] works driving a tow truck. No
tobacoo use. Drinks 2 beers per day.
Family History:
non-con
Physical Exam:
Admission Physical
NAD, AOx3,
T 99.1 P 105 BP 94/62 RR 16 O2 93% 6L
HEENT: Extraocular muscles intact, Pupils equal, round and
reactive to light, multiple lacerations to face including a
chest scan avulsion flap to mid forehead and a small lack
adjacent to left eye. Trachea midline, Oropharynx within normal
limits
Chest: Equal breath sounds, Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing. Large approx 9cm hematoma over
R medial thigh
Thigh and leg compartments are soft
Skin: lacerations to left hand at left ring and middle finger,
abrasion to R flank, contusion to R bicep and marked swelling
and tenderness at the right
Pertinent Results:
CT Head [**2194-3-27**]: 1. Right anterior parafalcine subdural hematoma
and left parafalcine small subarachnoid hemorrhage with possible
second focus of hyperdensity overlying the inferior left frontal
lobe representing extra-axial hemorrhage versus contusion versus
artifact.
2. Subgaleal hematoma overlying the left aspect of the frontal
bone.
CT C-Spine [**2194-3-27**]: No fracture or dislocation.
CT Torso [**2194-3-27**]: 1. Right ribs 4 through 10 with comminuted
displaced fractures and associated right-sided pneumothorax
without evidence of tension.
2. Mild flattening of the L3 and L4 vetebral bodies of unclear
chronicity.
Brief Hospital Course:
Mr. [**Known lastname 931**] was evaluated in the ED as a trauma activation.
The following injuries were identified:
- Parafalcine SDH and SAH
- R ribs [**4-15**] comminuted displaced fractures with accompanying
hemothorax
- R thigh hematoma with no appreciated underlying fx
He was admitted to the TICU [**2194-3-27**] for further evaluation and
management. In brief, he was cared for in the ICU during his
entire stay with his primary issues being sepsis, emypema and
ultimately hemorrhagic shock leading to death. He was taken to
the OR [**4-7**] and [**4-8**] in an effort to control his thoracic bleed,
but he continued to decompensate. A family meeting was held [**4-8**]
and the group decision was made to make him comfort measures
only. He expired soon after in the early afternoon of [**2194-4-8**].
Neuro: Neurosurgery was consulted for his intra-cranial bleeds,
and he was started on dilantin for seizure prophylaxis. His
pain was monitored and managed appropriately. He admitted to a
significant alcohol history, including previous episodes of
withdrawal on HD 2. Shortly after, he became acutely agitated
and disoriented, and had to be intubated and sedated. He was
maintained on sedation and a CIWA protocol while withdrawing
from alcohol. Lactulose was started on [**2194-4-3**] out of concern
for hepatic encephalopathy.
CV: He was initially tachycardic, which improved with colloid
and crystalloid resuscitation. He had an EKG which did not
demonstrate evidence of ischemia. He became tachycardic and
hypertensive in conjunction with his withdrawal. This improved
with sedation and treatment of his withdrawal. He had an
episode of atrial fibrillation on [**3-31**], and was started on
amiodarone. He converted to normal sinus rhythm later that day,
and the amiodarone was stopped on [**4-1**]. He became hypotensive
with a pressor requirement at the same time, presumably due to
sepsis from a pneumonia. His pressor requirement continued and
increased following his interventions in the operating [****]
and [**4-8**]. By the morning of [**4-8**] he was on high dose of 3 pressors
(neo/levo/vaso).
Resp: He was given appropriate pain control for his right rib
fractures, and aggressive pulmonary toilet was encouraged. He
became septic while intubated, and imaging, bronchoscopic, and
laboratory results indicated a RLL pneumonia as the source.
Once treated, his respiratory status improved and his vent was
weaned. As his ventilator requirement decreased, he continued to
show evidence of retained hemothorax in his R chest. Chest tubes
were placed but were unable to drain the pleural collection so
he was taken to the OR [**2194-4-8**] for a VATS. See Dr[**Name (NI) 2347**]
Operative note for further details. The infected
hematoma/empyema was drained and three chest tubes were left in.
Over the next 12 hours he drained 1.8 liters of blood from those
chest tubes and had increased pressor requirements. He was taken
back to the OR [**4-8**] for thoracotomy. A portion of bleeding lung
parenchyma was identified and hemostasis was achieved.
GI: He was initially kept NPO with IVF. He was started on tube
feeds while intubated. These were held briefly while his sepsis
was treated, then restarted. His LFT's were elevated, which
prompted concern for possible occult liver injury, acalculous
cholecystitis, or underlying liver pathology. A CT of the
abdomen and RUQ ultrasound were normal. Hepatitis serologies
were sent, and were positive for hepatitis C infection. His
LFT's continued to rise, and hepatology was consulted who
recommended lactulose for presumed hepatic encephalopathy. A PEG
tube was placed [**4-7**]. The last three days of his stay he showed a
rising lactate, peaking at 12 and staying there for the last 24
hours. This was presumed to be due to under-resuscitation
leading to bowel ischemia, though we will await the medical
examiners evaluation to confirm this.
GU: He developed acute renal failure and nephrology was
consulted. CVVH was initiated and maintained for the remainder
of his stay.
Heme: His hematocrit was initially unstable, attributed to a
large right thigh hematoma. He was transfused appropriately,
and his hematocrit stabilized. He continued to slowly bleed into
his R chest. After his VATS, he had significant blood loss (1.8L
over 12 hours) and he was transfused 10u over the next 24 hours.
He was given platelets and FFP post-op for his coagulopathy.
ID: He became septic on [**4-1**]. He was started on a VAP protocol,
had all invasive lines changes, and was fully evaluated for
infection. His chest x-ray was concerning for RLL pneumonia,
and his sputum and blood eventually grew MSSA. When culture
data was available, his antibiotics were changed to Nafcillin.
He was briefly on Vanc/Zosyn for 24 hours prior to being made
CMO.
MSK: He was admitted with a large right thigh hematoma. This
was routinely monitored and stabilized early in his stay. The
skin was carefully cared for, and did not have any breakdown.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
polytrauma
Discharge Condition:
expired
Discharge Instructions:
-
Followup Instructions:
-
|
[
"427.1",
"E829.8",
"510.9",
"276.69",
"285.1",
"852.21",
"291.0",
"518.81",
"070.54",
"041.11",
"873.42",
"997.31",
"584.5",
"785.52",
"998.2",
"427.31",
"924.00",
"807.07",
"998.11",
"287.5",
"276.2",
"883.0",
"852.01",
"E878.8",
"V66.7",
"038.11",
"998.09",
"995.92",
"303.90",
"571.2",
"860.4",
"557.9",
"286.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"34.52",
"34.04",
"31.1",
"96.6",
"34.91",
"34.09",
"38.95",
"34.51",
"43.11",
"96.72",
"33.43",
"39.95",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7532, 7541
|
2433, 7448
|
321, 402
|
7595, 7604
|
1770, 2410
|
7654, 7658
|
960, 969
|
7503, 7509
|
7562, 7574
|
7474, 7480
|
7628, 7631
|
984, 1751
|
263, 283
|
430, 764
|
786, 817
|
833, 944
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,713
| 127,545
|
50310
|
Discharge summary
|
report
|
Admission Date: [**2147-12-18**] Discharge Date: [**2148-1-3**]
Date of Birth: [**2096-10-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
intubation, CVL
History of Present Illness:
51 yo F paraplegic with multiple prior admissions for PNA and
UTI complicated by sepsis presented to the ED with three days of
worsening lethargy and difficulty breathing. Her husband states
that the pt started noticing foul smelling urine and lethargy on
friday (3 days PTA). She called her PCP's Office and had a
UA/UCx done at an outside clinic--she did not start any Abx at
that time. She had no symptoms of UTI as she straight caths q4h
and has no sensation in the area at baseline. Lethargy and
productive cough worsened over the weekend until late last night
when the patient produced dark sputum and had O2 sat of 82% at
home.
.
Since her MVA in [**2143**], she has been hospitalized 15 times,
almost all of these admissions have been for UTI/PNA and many of
them have involved MICU stays. She was most recently discharged
from [**Hospital1 18**] in [**2147-10-3**]; she was admitted for PNA and UTI,
underwent a prolonged intubation & tracheostomy & had a PEA
arrest.
.
In the ED, initial VS: 98.1, HR=102, 84/49, 16, 80% room air.
She was placed on non-rebreather and given 2L NS with little
effect on her BP. RIJ CVL was placed in the ED and pt was
started on levophed. Pt was noted to be increasingly lethargic,
blood gas notable for hypercapnea & acidosis (7.14/84/151). She
was intubated in the ED. In total, she received, 7L normal
saline, levophed, nebs, zosyn, vanco, fentanyl/versed prior to
transfer to the MICU.
.
On arrival to the MICU, BP=150/90 on a-line with HR in 80s-90s.
Levophed was weaned quickly. Initial CVP was [**11-13**] & CXR was
notable for pulmonary vascular congestion with possible focal
areas of infiltrate in the LUL and RML.
.
Review of prior Micro data revealed that during her most recent
hospitalization in [**Month (only) **] [**Numeric Identifier 66979**], her sputum grew pan-sensitive
kleb and MRSA. In [**2147-6-2**], her urine had grown [**Year (4 digits) 40097**] Kleb. UA
and UCx were obtained from the outside clinic where she had sent
urine on friday, this showed Citrobacter freundii resistant to
cefazolin and flouroquinolones, and senitive to Imipenem but
with only MIC<=4.
.
ROS: Pt unable to answer, but per her husband, she had
experienced some shoulder and neck aching, no subjective fevers
at home, no focal weakness. Had not c/o photophobia. No recent
sick contacts---they screen visitors given pt's frail health,
but she had been out in public recently and had been to MD
office visits.
Past Medical History:
1. T1-T2 paraplegia following MVC [**1-5**]
2. Recurrent UTIs: [**Month/Year (2) 40097**] klebsiella
3. HCV, viral load suppressed
4. H/o recurrent PNAs: MRSA, pan-sensitive Kleb
5. Anxiety
6. DVT in [**2142**] -IVC filter placed in [**2142**]
7. Pulmonary nodules
8. Hypothyroidism
9. Chronic pain
10. Chronic gastritis
11. H/o obstructive lung disease
12. Anemia of chronic disease
13. S/p PEA arrest during last hospitalization in [**2147-10-3**]
Social History:
The patient currently lives at home wiht her husband and 2
children, ages 15 and 22. Former 35 packyear smoker. Denies
current tobacco or alcohol use.
Family History:
Non-contributory.
Physical Exam:
Vitals - afebrile, BP 95/60, HR 70s
GENERAL: Sitting up in bed in no apparent distress
CARDIAC: normal S1/S2, no murmurs appreciable
LUNG: clear bilaterally, no rales noted
ABDOMEN: soft and nontender
EXT: no lower extremity edema
NEURO: alert and oriented X3
Pertinent Results:
[**2147-12-18**] 11:05AM BLOOD WBC-6.2 RBC-3.96*# Hgb-11.0*# Hct-34.3*#
MCV-87 MCH-27.8 MCHC-32.1 RDW-15.8* Plt Ct-202
[**2147-12-18**] 11:05AM BLOOD Neuts-86* Bands-1 Lymphs-7* Monos-5 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2147-12-19**] 05:33AM BLOOD PT-18.1* PTT-35.5* INR(PT)-1.6*
[**2147-12-19**] 05:33AM BLOOD Fibrino-525*#
[**2147-12-18**] 11:05AM BLOOD Glucose-124* UreaN-10 Creat-0.5 Na-137
K-4.9 Cl-99 HCO3-32 AnGap-11
[**2147-12-18**] 03:08PM BLOOD Glucose-227* UreaN-7 Creat-0.3* Na-146*
K-3.5 Cl-114* HCO3-26 AnGap-10
[**2147-12-18**] 11:05AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8
[**2147-12-19**] 05:33AM BLOOD Hapto-208*
[**2147-12-18**] 12:19PM BLOOD Type-ART FiO2-100 pO2-151* pCO2-84*
pH-7.14* calTCO2-30 Base XS--2 AADO2-494 REQ O2-81 Intubat-NOT
INTUBA Comment-FM
[**2147-12-18**] 04:17PM BLOOD Type-ART pO2-112* pCO2-47* pH-7.25*
calTCO2-22 Base XS--6
[**2147-12-18**] 11:18AM BLOOD Glucose-125* Lactate-1.8 Na-139 K-4.5
Cl-92*
[**2147-12-18**] 04:17PM BLOOD Lactate-2.4*
[**2147-12-18**] 10:14PM BLOOD Lactate-1.5
.
Imaging:
Echo:
The left atrium is dilated. 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
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
.
MRI Head:
FINDINGS: There are bilateral confluent areas of
hyperintensities seen in the parietooccipital lobes and a small
focus of hyperintensity is seen in the left thalamus consistent
with posterior reversible encephalopathy. No evidence of
restricted diffusion seen in these regions. There is no midline
shift or hydrocephalus. Mild-to-moderate brain atrophy is seen.
Suprasellar and craniocervical regions are normal on the
sagittal images. The vascular flow voids are maintained. Small
amount of fluid is seen in the left mastoid air cells.
IMPRESSION: Bilateral parietooccipital white matter
hyperintensities also
involving [**Doctor Last Name 352**] matter consistent with posterior reversible
encephalopathy. No evidence of restricted diffusion seen.
Brief Hospital Course:
51 yo F paraplegic with a hx of recurrent UTIs, PNAs, sepsis,
presenting with 3 days of UTI (with + urine culture) and
worsening productive cough/hypoxia likely representing PNA, who
developed PRES in ICU setting.
.
# PNA: Patient presented in hypoxic & hypercapneic respiratory
failure, requiring intubation in ED. CXR was notable for
pulmonary vascular congestion with possible focal areas of
infiltrate in the LUL and RML. Patient received empiric
vanco/zosyn. She briefly required levophed, which was weaned at
arrival to the MICU. Given recent hospitalization in [**Month (only) **] and
MRSA in sputum, she was treated for healthcare associated PNA,
as well as for UTI, with vancomycin, meropenema and gentamycin.
She completed a 7 day course of vanco and gent, and 14 d of
meropenem.
On [**12-25**], she was extubated, but given her sedation and
incresed work of breathing, she was reintubated. The
possibility of a tracheostomy was raised but apparently the
patient refused.
The patient was educated about good airway clearance. She
received chest PT and was able to provide good coughing on her
own. 02 sat was 94-95% on room air at discharge.
.
#PRES: Patient became hypertensive to the 180s in the MICU
setting and was started on IV hydralazine. On [**12-29**], she
developed a severe headache with binocular blindness and
decreased facial sensation in the setting of high blood
pressures; CT and MRI were consistent with diagnosis of PRES
syndrome. Neurology was consulted who recommended a blood
pressure between 120 and 140. Chlorthalidone was started and BP
remained largely within goal range, with some blood pressure in
90-100s. Headache and vision greatly improved by discharge.
Neurology recommended follow-up MRI in 2 weeks and neuro clinic,
as well as [**Hospital 2081**] clinic appointments. The patient was instructed
to continue chlorthalidone and check BP at home twice daily. Dr.
[**Last Name (STitle) 665**] and neurology will determine need for continued
antihypertensives at home.
.
# UTI: Patient has h/o recurrent UTI [**3-6**] self-catheterization.
Urine culture Citrobacter Freundii, sensitive to Meropenem with
MIC < 4. ID recommended meropenem and gentamycin for synergy.
Completed 14 day course.
.
# ANEMIA: Stable. History of anemia of chronic disease. No
transfusions required.
.
# S/p traumatic spine injury/chronic pain: Initially held
methadone, oxycodone, oxybutynin, Klonapin. All meds restarted
prior to discharge.
.
# Hypothyroidism: continued home levothyroxine
.
# Hepatitis C: negative VL recently
Medications on Admission:
albuterol neb prn
baclofen 20mg qam, 10mg noon, 20mg qhs
citalopram 40mg daily
clonazepam 1mg qid prn, 2mg qhs
fluconazole 150mg qd prn yeast infxn
combivent 2 puffs tid
levothyroxine 75mcg qd
methadone 5mg tid
omeprazole 20mg [**Hospital1 **]
oxybutynin 10mg qam, 5mg noon, 10mg qhs
oxycodone 5mg q4-6h prn
lyrica 150mg tid
carafate 1g qid
trazodone 200mg qhs
calcium 500mg [**Hospital1 **]
cranberry extract 500mg [**Hospital1 **]
loratadine 10mg daily
Discharge Medications:
1. Baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a
day).
2. Citalopram 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
3. Levothyroxine 75 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Pregabalin 150 mg Capsule [**Hospital1 **]: One (1) Capsule PO three times
a day.
5. Sucralfate 1 gram Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times
a day).
6. Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
7. Polyethylene Glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1) PO
DAILY (Daily) as needed for constipation.
8. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
9. Chlorthalidone 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Trazodone 100 mg Tablet [**Hospital1 **]: 1-2 Tablets PO HS (at bedtime).
11. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID
(2 times a day).
13. Oxybutynin Chloride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO QPM
(once a day (in the evening)).
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as
needed for wheeze, sob.
15. Clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO four times a
day as needed for restlessness, agitation.
16. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation three times a day.
17. Methadone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day).
18. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
19. Calcium Carbonate 500 mg Capsule [**Hospital1 **]: One (1) Capsule PO
twice a day.
20. Cranberry Extract 500 mg Capsule [**Hospital1 **]: One (1) Capsule PO
twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
primary:
urosepsis
healthcare associated pneumonia
PRES (posterior reversible encephalopathy syndrome)
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:
It was a pleasure taking care of you. You were admitted for
urinary tract infection and pneumonia. You required intubation
for the pneumonia. You are at especially high risk for pneumonia
and should work on deep breathing and good coughing to clear
your lungs. You received antibiotics and improved.
You also had a syndrome called PRES, which caused vision loss
and headache. This occurred because your blood pressure
increased causing swelling in the back of your brain. This
syndrome gets better on its own and you will follow up with
neurology and opthalmology to make sure you completely recover.
You will need another MRI in 2 weeks. You will continue to take
chlorthalidone to control your blood pressure until you see Dr.
[**Last Name (STitle) 665**]. Please check your blood pressure twice a day and make a
record to show Dr. [**Last Name (STitle) 665**].
Followup Instructions:
Appointment #1
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: [**Hospital3 **] Post [**Hospital **] Clinic
Date/ Time: Monday, [**1-15**] at 1:50pm
Location: [**Hospital3 **], [**Hospital Ward Name 23**] Clinical Center, [**Apartment Address(1) **] Central, [**Location (un) 830**], [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 250**]
Special instructions for patient: This appointment is for follow
up to your hospitalization (Dr [**Last Name (STitle) 665**] not available that day
but will check his schedule and call you).
Appointment #2
MD:
Specialty: MRI
Date/ Time: Thursday, [**1-11**] at 3:55pm
Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **] radiology, [**Location (un) **], [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 327**]
Appointment #3
MD: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Neurology
Date/ Time: [**1-15**] at 4pm
Location: [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Location (un) 3387**], [**Location (un) 86**]
Phone number: [**Telephone/Fax (1) 44**]
You may call the [**Hospital 464**] clinic to make an appointment at
your convenience. [**Telephone/Fax (1) 253**]
|
[
"995.92",
"041.03",
"285.29",
"244.9",
"344.1",
"348.39",
"V12.51",
"300.4",
"428.0",
"V12.53",
"599.0",
"E929.0",
"338.29",
"V44.0",
"496",
"907.2",
"482.42",
"518.81",
"518.89",
"038.49",
"V45.89",
"535.10",
"425.4",
"996.64",
"E879.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.6",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
11347, 11353
|
6283, 8834
|
328, 345
|
11500, 11500
|
3801, 6260
|
12558, 13812
|
3486, 3505
|
9340, 11324
|
11374, 11479
|
8860, 9317
|
11670, 12535
|
3520, 3782
|
277, 290
|
373, 2827
|
11514, 11646
|
2849, 3301
|
3317, 3470
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,110
| 179,549
|
51615
|
Discharge summary
|
report
|
Admission Date: [**2109-3-28**] Discharge Date: [**2109-4-4**]
Date of Birth: [**2032-2-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
SOB with exertion
Major Surgical or Invasive Procedure:
CABG X 3 (LIMA > LAD, SVG>OM, SVG>PDA), AVR (tissue) on [**2109-3-28**]
History of Present Illness:
Ms. [**Known lastname **] is a 77 ywar old male who presented with DOE, he
underwent a stress test which was positive, he was then referred
for cardiac catheterization which showed severe thre vessel
disease and aortic stenosis.
Past Medical History:
Hypercholesterolemia
AS
Anemia
Bilateral knee arthritis
s/p TURP
s/p appy
Social History:
pipe smoker, no etoh.
Works as director of a research center
Family History:
Father deceased from MI at 72
Mother deceased from MI at 76
Physical Exam:
On admission:
NAD
HEENT unremarkable
Lungs CTAB
RRR with 3/6 systolic murmur
Abd benign
no edema
Neuro intact
Carotids with transmitted bruits
Pertinent Results:
[**2109-4-3**] 06:23AM BLOOD Hct-25.0*
[**2109-4-2**] 06:23AM BLOOD Hct-25.6*
[**2109-3-31**] 05:55AM BLOOD WBC-11.4* RBC-3.56* Hgb-10.1* Hct-29.1*
MCV-82 MCH-28.5 MCHC-34.9 RDW-18.2* Plt Ct-155
[**2109-4-4**] 06:32AM BLOOD PT-19.9* PTT-60.5* INR(PT)-1.9*
[**2109-4-3**] 06:23AM BLOOD UreaN-28* Creat-1.1 K-3.9
Brief Hospital Course:
Mr. [**Known lastname **] was admitted the morning of surgery, he was taken to
the operating room on [**2109-3-28**] where he underwent a CABG x 3
(LIMA->LAD, SVG->OM & PDA) and AVR with a 25 mm CE pericardial
valve. He wsa transferred to the intensive care unit in critical
but stable condition. Postoperatively he was noted to have a
right pneumothorax for which a chest tube was placed with near
total resolution of the pneumothorax. He ws extubated on POD 0,
His invasive lines and mediastinal drains were discontinued on
POD 1. He did have multiple episodes of atrial fibrillation for
which he ws treated with amiodarone and anticoagulated with
heparin and coumadin. His INR on [**4-4**] was 1.9 and he was ready
for discharge to home. Dr.[**Name (NI) 5765**] office was contact[**Name (NI) **] to follow
his INR after discharge.
Medications on Admission:
Lipitor
Toprol
ASA
FeSo4
Glucosamine
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. 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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: 400 mg(2 tablets) once daily for 1 week, then 200
mg(1 tablet) daily until d/c'd by Dr. [**Last Name (STitle) **].
Disp:*90 Tablet(s)* Refills:*0*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime:
Check INR [**4-5**] with results called to Dr. [**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
AS
hypercholesterolemia
arthritis
post-op AFib
Discharge Condition:
good
Discharge Instructions:
no lifting > 10# for 10 weeks
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**Last Name (STitle) **] in [**12-28**] weeks
with Dr. [**Last Name (STitle) **] in [**12-28**] weeks and for INR check and coumadin dosing
with Dr. [**Last Name (Prefixes) **] in 4 weeks
Completed by:[**2109-4-4**]
|
[
"512.1",
"E878.2",
"427.31",
"272.0",
"715.36",
"424.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"34.04",
"99.05",
"99.07",
"36.15",
"36.12",
"99.04",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
4021, 4079
|
1435, 2271
|
337, 411
|
4174, 4181
|
1100, 1412
|
861, 922
|
2358, 3998
|
4100, 4153
|
2297, 2335
|
4205, 4447
|
4498, 4726
|
937, 937
|
280, 299
|
439, 669
|
951, 1081
|
691, 766
|
782, 845
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,825
| 166,863
|
43259
|
Discharge summary
|
report
|
Admission Date: [**2133-2-25**] Discharge Date: [**2133-3-3**]
Date of Birth: [**2065-10-3**] Sex: M
Service: MEDICINE
Allergies:
Atenolol / MS Contin / morphine
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 13621**] is a 67-year-old male smoker with a history of severe
emphysematous COPD (not on home O2, current smoker), recent
DVT/PE ([**1-1**]) now off coumadin, AAA, HTN, and multiple
admissions for pneumonia who was discharged yesterday after an
admission for a COPD exacerbation and who called EMS this
morning with shortness of breath and cough.
EMS found him with pursed lip breathing and placed him on BiPap.
He was given albuterol nebs and 2g Mag. In the ED, he was
afebrile with RR 26 BP 133/81 HR 107, 100%biPap. VBG was
7.30/66/101/34. He was given 125mg IV solumedrol, azithromycin,
and aspirin. ECG was reportedly normal. CXR did not show
infiltrate. Has 2 PIV.
He has been hospitalized multiple times for COPD exacerbation
and pneumonia requiring ICU admission earlier this week
(discharged yesterday). On his last admission, he was initially
on BiPap and weaned quickly to nasal cannula with albuterol and
atrovent nebs and a prednisone taper. Hospice was considered but
not initiated as the patient was not fully understanding of the
extent of his illness. He also has a prior intubation on a
single occasion in [**2131-9-23**]. His baseline activity level is
limited as he become very short of breath upon ambulating
several steps on level surface.
On arrival to the [**Hospital Unit Name 153**], he continues to complain of shortness of
breath and cough. He states that he felt okay at the time of
discharge yesterday, but was awake all night coughing. His
breathing progressively worsened throughout the night and this
morning felt very short of breath so called EMS. He feels
slightly better while on BiPap. He does endorse mild dizziness
and mild confusion. He denies chest pain, does complain of right
sided back pain.
Review of Systems:
(+) Per HPI, also diarrhea about 1 week ago per last admission
note. Also with frequent urination overnight without dysuria.
(-) Denies fever, chills, headache, chest pain, palpitations,
nausea, vomiting, abdominal pain, dysuria, new numbness or
weakness, and rash.
Past Medical History:
-Right segmental PE and LLE DVT in [**12/2131**], off Coumadin
-Severe COPD, current smoker, not on home O2
-AAA
-HTN
-Hyperlipidemia
-Gout
-Osteoporosis, history of L1 burst fracture on chronic opioids
for pain relief, l3 compresion fracture
Social History:
Social History:
Home: Lives alone, son very involved, visits daily. EtOH: 4
beers per day, drank 2 last night. Drugs: Denies. Tobacco:
Currently smokes 1 pack every 3 days, trying to cut back and has
>80 PPY history. Hasn't smoked since discharge.
Family History:
No history of CAD. No history of clotting disorder
Physical Exam:
Admission Physical Exam:
VS: 96.8 102 114/72 28 98% on BiPap 12/5 FiO2 30% TV 600
Gen: Thin man, in mild-moderate respiratory distress, on BiPap
not speaking in full sentences
HEENT: MMM, no OP lesions obvious, JVP somewhat distended on
BiPap
CV: S1/S2, RRR, no murmurs appreciated
PULM: Substantially decreased BS throughout, scant expiratory
wheezes
ABD: BS+, soft, NTND, no masses or HSM
BACK: Some tenderness over lower right ribs
LIMBS: No LE edema, no calf asymmetry or tenderness, 2+
symmetric peripheral pulses
SKIN: No rashes or skin breakdown
NEURO: CNII-XII nonfocal, preserved U/LE strength b/l
Discharge Physical Exam
96.5 97 133/70 29 97%3L
Gen: Thin man, pursed lip breathing with prolonged expiration,
able to speak short sentences
HEENT: MMM, JVP non elevated
CV: S1/S2, RRR, no murmurs appreciated
PULM: poor air movement, prolonged expiratory phase, L>R sided
wheezes anteriorly
ABD: BS+, soft, NTND
LIMBS: No LE edema, no calf asymmetry or tenderness, 2+
symmetric peripheral pulses
SKIN: No rashes or skin breakdown
Pertinent Results:
Admission Labs
[**2133-2-24**] 04:07AM BLOOD WBC-11.7* RBC-4.38* Hgb-13.4* Hct-39.8*
MCV-91 MCH-30.6 MCHC-33.6 RDW-13.8 Plt Ct-184
[**2133-2-25**] 08:30AM BLOOD Neuts-83.2* Lymphs-8.2* Monos-7.7 Eos-0.3
Baso-0.7
[**2133-2-24**] 04:07AM BLOOD Glucose-184* UreaN-16 Creat-0.7 Na-137
K-4.0 Cl-104 HCO3-27 AnGap-10
[**2133-2-24**] 04:07AM BLOOD Calcium-8.3* Phos-1.3* Mg-2.0
Discharge labs:
[**2133-3-2**] 02:56AM BLOOD WBC-11.7*# RBC-4.89 Hgb-15.0 Hct-47.1
MCV-97 MCH-30.7 MCHC-31.8 RDW-14.0 Plt Ct-130*
[**2133-3-2**] 02:56AM BLOOD Glucose-110* UreaN-15 Creat-0.8 Na-143
K-4.6 Cl-99 HCO3-34* AnGap-15
[**2133-3-2**] 02:56AM BLOOD Calcium-9.3 Phos-3.7 Mg-1.9
Chest xray
FINDINGS: The mediastinal, hilar and cardiac silhouettes are
unremarkable. Stable bilateral hyperinflation with relative
lucencies of the upper lungs consistent with emphysematous
change. Stable biapical scarring. Minimal blunting of the right
costophrenic angle may be related to emphysematous change though
a small right pleural effusion cannot be excluded. No
pneumothorax. Vascular calcifications noted in the left neck
possibly within the left common carotid artery. Stable spinal
fusion hardware with fibular graft.
IMPRESSION: No acute process
Brief Hospital Course:
67-year-old M smoker with a history of severe COPD, prior PE/DVT
now off coumadin, AAA, and multiple admissions for pneumonia who
presents again with dyspnea, cough and is transferred to the
[**Hospital Unit Name 153**] for management of COPD exacerbation requiring BiPAP. Given
severity of his disease, goals were changed to symptom
management and he was discharged to hospice/comfort care.
#. COPD exacerbation: Presentation on admission with change in
sputum production and worsening dyspnea, in the setting of an
extensive smoking history. No leukocytosis or focal
consolidation on CXR. He was initially treated with non-invasive
ventilation (BiPap) for hypercarbic respiratory failure. He was
treated with a prednisone taper and standing nebulizer
treatments. He had not previously been on advair and was started
on advair discus. He completed a 5 day course of azithromycin.
He was weaned to nasal canula however his hospital course was
complicated by frequent episodes of respiratory distress and
hypoxia. After goals of care discussion with patient and family,
he was confirmed DNR/DNI and made it clear that he would not
want additional non-invasive ventilation in the future. He was
treated with morphine (changed to dilaudid for pruritis) to
relieve respiratory distress. His goals of care were changed to
focus on symptoms and he was discharged for comfort care.
#. Delirium: Patient became intermittantly agitated, pulling at
lines, climbing out of bed always in the setting of worsening
hypoxia and moderate respiratory distress. He was treated with
narcotics and non-rebreather in these episodes and gradually
improved. Patient received trazodone (one of his home meds) for
insomnia and became agitated and confused and this medication
was not resumed. Delirium resolved by the time of discharge.
INACTIVE ISSUES
===============
#. Hx of DVT/PEs: Diagnosed with right segmental PE and LLE DVT
in [**12/2131**], coumadin stopped in [**2132-5-22**] in setting of concerns
related to medication adherence. Found to have non-occlusive
thrombus in left superficial femoral vein, anticoagulation not
restarted.
#. Osteoporosis: history of L1 and L3 compression fractures on
chronic opioids for pain relief, l3 compresion fracture. On
admission, patient reported intermittent right back pain pain
was controled with home dose of oxycodone/acetaminophen.
#. Steroid DM: Patient had elevated serum glucose in the setting
of steroid use. Has had elevated FSBG levels in the past while
on steroids.
#. Gout: Continue outpatient allopurinol
#. HLD: Held Lipitor during admission due to concurrent
macrolide.
#. Current tobacco use: Provided smoking cessation counseling
and gave a nicotine patch during this admission.
#. Emergency Contact: [**Name (NI) **] [**Name2 (NI) **] [**0-0-**]
#. Code Status: DNR/DNI no BiPap
Medications on Admission:
Azithromycin 250mg po daily on day 4
Prednisone 40mg po daily, plan for 4 more days
Percocet 5-325mg 1-2 tabs po q4-6h prn pain
Albuterol 0.63 mg/3 ml inh q4-6h prn SOB/wheeze
Albuterol inhaler 90mcg inh QID prn SOB/wheeze
Alendronate 70 mg po qweek
Allopurinol 150mg po daily
Atorvastatin 10mg po daily
Bupropion HCl 150mg po bid
Fluticasone-salmeterol 250-50 mcg/dose 1 puff inh [**Hospital1 **]
Ranitidine HCl 150mg po bid
Tiotropium bromide 18 mcg po daily
Trazodone 25mg po qhs
Docusate sodium 200mg po daily
Ergocalciferol (vitamin D2) 800 unit po daily
Ferrous sulfate 325 mg po daily
Nicotine 21 mg/24 hr Patch TD daily
Senna 8.6 mg po qhs prn constipation
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
4. allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough: please hold for RR<14 or
sedation .
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q4H (every 4 hours).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation Q2H (every 2 hours) as
needed for dyspnea, wheezing.
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation four times a day as needed for dyspnea.
13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) cap Inhalation once a day.
14. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day.
15. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
16. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
17. HYDROmorphone (Dilaudid) 0.25 mg IV Q3H:PRN air hunger
hold for signs of oversedation or RR<12
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
-Acute exacerbation of end stage chronic obstructive pulmonary
disease
Secondary:
-Tobacco use
-History of right segmental PE and LLE DVT in [**12/2131**], off
Coumadin
-Abdominal aortic aneurysm
-Hypertension
-Hyperlipidemia
-Gout
-Osteoporosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Only can ambulate a few steps before significant
dyspnea.
Discharge Instructions:
Mr [**Known lastname 13621**],
As you know, you were admitted to the hospital for an acute
worsening of your emphysema/COPD. We treated you with nebulizer
treatments and steroids. Unfortunately, your disease is very
advanced. After discussion with you and your family, we agreed
to focus on symptoms control. You are being transferred to
hospice care where doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**] [**Name5 (PTitle) **] continue to manage
your symptoms and focus on quality of life.
MEDICATION CHANGES
STOP Trazodone
STOP Prednisone
STOP Azithromycin
Followup Instructions:
You may follow up with whomever you wish.
The following appointments were scheduled for you. Please
contact the appropriate people if they are not needed:
Department: [**Hospital3 249**]
When: TUESDAY [**2133-3-31**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2133-4-28**] at 9:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name 1570**]
When: TUESDAY [**2133-4-28**] at 10:00 AM
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"274.9",
"287.5",
"441.4",
"491.21",
"272.4",
"V49.86",
"E932.0",
"780.09",
"272.0",
"401.9",
"733.00",
"518.81",
"733.13",
"305.1",
"249.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10654, 10753
|
5304, 8140
|
299, 306
|
11053, 11053
|
4059, 4431
|
11899, 12841
|
2933, 2986
|
8856, 10631
|
10774, 11032
|
8166, 8833
|
11298, 11876
|
4447, 5281
|
3026, 4040
|
2117, 2384
|
252, 261
|
334, 2098
|
11068, 11274
|
2406, 2651
|
2683, 2917
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,023
| 175,634
|
9671
|
Discharge summary
|
report
|
Admission Date: [**2194-3-24**] Discharge Date: [**2194-4-5**]
Date of Birth: [**2121-9-24**] Sex: F
Service: CARDIAC SURGERY
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 72 year old female who
is status post mitral valve replacement in [**2190-10-8**],
with a #31 millimeter Carbomedics mechanical valve with a
complaint of one month history of shortness of breath with
exertion. The patient also is status post several severe
bouts of pneumonia, after which the patient was found to have
lymphoma, for which she underwent right lung resection in
[**2193-1-6**]. The patient reports being in her usual state
of health from a cardiac standpoint since her heart surgery
in the [**2190**], until one month ago when she began experiencing
shortness of breath on exertion and a feeling of chest pain
only when she was under stressful situation. The patient saw
her cardiologist who sent her for a transesophageal
echocardiogram which revealed a perivalvular leak. The
patient now presents for cardiac catheterization, which
showed normal coronaries and moderate mitral regurgitation,
ejection fraction of 55%. The patient is to be evaluated for
redo mitral valve repair by Dr. [**Last Name (Prefixes) **].
PAST MEDICAL HISTORY:
1. Mitral regurgitation, status post mitral valve
replacement in [**2190-10-8**].
2. Atrial fibrillation.
3. Congestive heart failure.
4. Hepatitis, question possibly due to transfusion during
hysterectomy.
5. Hypertension.
6. Status post hysterectomy.
7. Status post cholecystectomy.
8. Status post right lung resection for lymphoma in [**2193-1-6**].
9. Irritable bowel syndrome.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Digoxin 0.125 mg p.o. once daily.
2. Toprol XL 25 mg p.o. once daily.
3. [**Doctor First Name **] 60 mg p.o. twice a day.
4. Coumadin 2.5 mg p.o. once daily.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives with husband in [**Name (NI) 5110**],
[**State 350**]. The patient is not employed, housewife, and
grandmother. The patient stopped smoking approximately
twenty-six years ago and smoked one pack per week for
twenty-six years. She drinks approximately three to four
glasses per week.
PHYSICAL EXAMINATION: Blood pressure was 120/50, heart rate
67, and in atrial fibrillation. Generally, the patient is in
no acute distress. The pupils are equal, round, and reactive
to light and accommodation. Extraocular movements are
intact. Normal buccal mucosa. No dentures. Normal
dentition. Neck is supple with no jugular venous distention,
no thyromegaly. No carotid bruits. Lungs are clear to
auscultation bilaterally. No wheezing or rhonchi. Sternum
is stable. Cardiovascular - irregularly irregular rate with
S1 and S2 and II to III/VI murmur left sternal border fourth
intercostal space. Positive mechanical valve click. The
abdomen is soft, nontender, nondistended, no guarding, no
rebound, no rigidity. Extremities are warm with no edema, no
cyanosis or clubbing, positive varicosities. Pulse are 2+
posterior tibial and dorsalis pedis bilaterally. Neurologic
examination is grossly intact. No motor or sensory defects.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Surgery service. The patient was put on Heparin and stopped
her Coumadin. The patient's INR was 1.0. Partial
thromboplastin time was 30.0 on hospital day number two and
was increased to be therapeutic partial thromboplastin time
on hospital day number three. The patient was on Heparin
drip at 700, remained afebrile and still in atrial
fibrillation. Normal white blood cell count of 5.9,
hematocrit 35.7, creatinine 0.5. The patient was preopped
for the surgery.
On hospital day number three, the patient underwent mitral
redo sternotomy perivalvular leak repair for mitral
perivalvular leak, status post mitral valve replacement. The
patient had a mean arterial pressure of 88, central venous
pressure was 7, PAD was 11, [**Doctor First Name 1052**] was 16, and atrial
fibrillation rate of 98 and was on Epinephrine 0.03
mcg/kg/minute and Nitroglycerin 1.4 mg/kg/minute and Propofol
titrated when she was transferred to the CSRU.
On postoperative day number one, the patient was extubated.
The patient received a bolus of lactated ringer's for low
urine output. The patient had Nitroglycerin drip of 0.6,
remained afebrile and continued to be in atrial fibrillation.
The patient was net positive five liters, white blood cell
count 12.9, hematocrit 27.3, creatinine 0.5. The patient was
started on Lopressor 25 mg twice a day and Lasix 20 mg twice
a day and chest tubes were removed and the patient was
transferred to the floor.
On postoperative day number two, the patient remained
afebrile, pulse 105, atrial fibrillation, and blood pressure
150s over 60s. She was taking good p.o. and making good
urine. White blood cell count was 12.9. The patient was
started on Heparin and started on Coumadin at 2 mg and
Lopressor was increased to 50 mg twice a day.
On postoperative day number three, the patient continued on
the Heparin drip and was afebrile, continued to be in atrial
fibrillation, was taking good p.o. and making good urine.
White blood cell count was 13.8, creatinine 0.6.
On postoperative day number four, the patient continued to be
on Heparin drip, had low grade temperature of 100.4, still in
atrial fibrillation, making good urine. The patient's INR
was 1.2.
On postoperative day number five, the patient continued on
Heparin drip, was in atrial fibrillation, up to 120s to 140s,
however, blood pressure was 122/80, making good urine, taking
good p.o., and INR was 1.2. The patient was on 3 mg of
Coumadin.
On postoperative day number six, the patient was continued on
Heparin drip, remained afebrile, atrial fibrillation, taking
good p.o. and making good urine. The patient's INR was
continued to be 1.2 and Heparin was titrated to partial
thromboplastin time between 62 and 80. The patient remained
afebrile with stable vital signs. The patient was making
good urine and taking good p.o. INR was 1.7.
On postoperative day number eight, the patient remained
afebrile, in atrial fibrillation, taking good p.o. and making
good urine and INR was 2.4.
On postoperative day number nine, the patient's INR was 2.5
and the patient was discharged home to be followed being in
therapeutic range.
FINAL DIAGNOSES:
1. History of mitral regurgitation, status post mitral valve
replacement in [**2190-10-8**].
2. Atrial fibrillation.
3. Congestive heart failure.
4. Hepatitis.
5. Hypertension.
6. Status post hysterectomy.
7. Status post cholecystectomy.
8. Status post right lung resection for lymphoma.
9. Irritable bowel syndrome.
10. Perivalvular leak, status post mitral valve repair.
MEDICATIONS ON DISCHARGE:
1. Percocet 5 one to two tablets q4hours p.r.n. pain.
2. Aspirin 325 mg p.o. once daily.
3. Colace 100 mg p.o. twice a day.
4. Metoprolol 50 mg p.o. twice a day.
5. Coumadin 2.5 mg p.o. q.h.s. for tonight and tomorrow.
Please have INR checked on Monday morning and adjust the
Coumadin dose based on the result.
6. Fexofenadine 60 mg p.o. twice a day.
7. Digoxin 0.125 mg p.o. once daily.
8. Lasix 20 mg p.o. twice a day for seven days.
9. Potassium Chloride 20 mEq p.o. twice a day for seven
days.
FO[**Last Name (STitle) **]P: Please follow-up with Dr. [**Last Name (Prefixes) **] in four
weeks. Please call for follow-up appointment. Please
follow-up with Dr. [**Last Name (STitle) **] in one to two weeks and please
have INR checked on Monday, to have Coumadin dose adjusted by
Dr. [**Last Name (STitle) **] on Monday.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Home with VNA services.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3118**]
MEDQUIST36
D: [**2194-4-5**] 13:25
T: [**2194-4-5**] 13:46
JOB#: [**Job Number 32706**]
|
[
"401.9",
"573.3",
"996.02",
"427.31",
"V58.61",
"202.80",
"E878.1",
"564.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.39",
"89.68",
"88.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
1907, 1925
|
6819, 7655
|
1724, 1890
|
3218, 6393
|
6410, 6793
|
2270, 3200
|
1268, 1698
|
1942, 2247
|
7680, 7993
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,918
| 162,382
|
31061
|
Discharge summary
|
report
|
Admission Date: [**2101-7-12**] Discharge Date: [**2101-7-19**]
Date of Birth: [**2056-10-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
44 yo male with pmhx significant for aggressive GIST s/p partial
resection ([**4-/2101**]), imatinib treatment, and currently being
treated with Sutent that finished 14 [**Known lastname **] ago. Pt initially
presented to [**Hospital1 18**] ED earlier today complaining of worsening SOB
for the past few [**Known lastname **]. In the ED he underwent a CTA to r/o PE,
and a CXR was done which showed increase in left lung base
opacity. While in the ED, the patient had coffee- ground emesis.
Per patient and family, this has been occurring up to three
times per [**Known lastname **] for the past week, although the amount in the ED
was greater than usual. The patient refused an NG tube
placement. He was given 3 liters IVF and admitted to OMED.
.
While on the floor, the pt was noted to be febrile, tachycardic
and pale, BP in low 100's systolic. The patient was typed and
cross with plan to transfuse 2 units PRBCs. Surgery and GI were
both consulted, and a transfer to ICU was requested given
hemodynamic instability. IV PPI was started, and the patient was
ordered for a dose of Cefepime and Flagyl.
.
Currently the patient denies abdominal pain, does note
persistent nausea. Denies feeling lightheaded or dizzy. Denies
recent melena or BRBPR, denies hematemesis. Notes worsening SOB
over the past few [**Known lastname **], mild cough of whitish sputum, no
hemoptysis. All other ROS negative.
Past Medical History:
Past Medical History;
GIST since [**4-25**]
.
Past Surgical History:
[**4-25**] Partial resection of GIST, takedown of splenic flexure and
omental flap
'[**93**] Bilateral inguinal hernia repair
'[**72**] Appendectomy
s/p repair of cleft lip/palate
.
Oncologic history: Developed abdominal pain, back pain, and
anorexia in [**2101-4-19**], and noted to have a large abdominal tumor
on CT scan; he went to the OR for operative management, and the
tumor was discovered to be hemorrhagic with wide involvement of
several organs. He underwent partial resection on [**2101-4-26**]. On
follow up 5/29, he was noted to have extensive recurrence with
compression of various organs; on [**2101-5-18**] he was started on
imatinib, after which he had worsening back pain, nausea, and
anorexia. Imatinib dose was increased until PET scan performed
approximately two weeks later showed no significant change in
FDG uptake in the tumor, at which time he was started on Sutent
(started [**2101-6-1**]; 4 week on, 2 week off).
Social History:
The patient is single, and lives alone. He works as an
accountant. He denies use of tobacco. He has [**1-22**] alcoholic
beverages a week. He denies use of illicit drugs. Sister lives
close by, involved with care.
Family History:
Father: CAD, died from complications of CHF
Mother: [**Name (NI) **] cancer, alive at age 85
Physical Exam:
vitals: temp 100.6/ bp 107/65/ hr 131/ rr 14/ 99% on 2L NC
GEN: awake, alert, pale, lying flat in bed, NAD
HEENT: atraumatic, anicteric sclera, PERRLA, EOMI, dry mucosa
NECK: no JVD, no LAD
CV: tachy, nml s1/s2, no murmurs
LUNGS: decreased BS at bases, no conversational dyspnea, no
accessory muscle use
ABD: tight, distended, hypoactive BS, + diffuse tenderness,
guarding mainly in upper quadrants, questionable rebound
EXT: [**12-21**]+ pretibial pitting edema B/L, symmetric. DP pulses full
B/L
SKIN: pale, faint maculopapular rash on upper extremities, also
noted on chest and back
NEURO: A/OX 3, follows all commands, moves all extremities
spontaneously, no focal deficits
Pertinent Results:
[**2101-7-12**] 11:00AM
- 2.2\8.0 /220 [**Age over 90 **]|106|25 /137
/24.5\ 4.1|24 |0.4\ Lactate 2.4
66.2N 27.7L 4.7M
- Ca 7.5 Phosphate 3.2 Mg 2.0 Alb 1.9
- LFTs: ALT - 168 AST - 181 AP - 229 Tbili - 0.6
Amylase - 49 Lipase - 44
.
[**2101-7-12**] 04:50PM
- Hct - 21.1
- UA negative except speicfic gravity 1.037, urobilinogen-12
.
[**2101-7-12**] 07:57PM
PT-14.8 PTT-29.6 INR-1.3
Hct-27.1
TSH-3.2
ALT-187 AST-228 AP-228 LDH-734 CK-37 Tbili-0.5 Amylase-41
Lipase-31
.
Hct trend: [**7-13**] 0451 - 26.0 | [**7-13**] 1343 - 26.6 | [**7-13**] [**2015**] -
26.1
[**7-14**] 0317 - 25.3 | [**7-14**] 1727 - 26.7
.
[**7-13**] [**Numeric Identifier 73347**]
Lactate-2.1
.
[**7-13**] 0451
FDP 10-40
Fibrinogen 338
Retic count 2.3%
.
Imaging:
CXR: 1. Low lung volumes.
2. Mild interval increase in the left lung base opacity likely
represents moderate pleural effusion and atelectasis. Cannot
rule out consolidation.
3. Unchanged left PICC.
.
CTA: Suboptimal study. No central or lobar PE. Interval increase
pleural effusions. Air fluid level within the abdominal mass,
worse since prior exam.
.
Abdominal radiograph:A non-obstructive bowel gas pattern with
air noted distally within the [**Month/Year (2) 499**] and excreted contrast like
layering within the urinary bladder. There is no evidence of
pneumatosis or pneumoperitoneum. A large density is noted
projecting over the mid portion of the abdomen consistent with
known recurrent GI stromal tumor. A few small air-fluid levels
are noted within the left upper quadrant as noted on the CT,
probably within the GIST and stomach. Multiple radiopaque
appearing small coils are noted to project over the pelvis.
.
.
Micro: Blood cultures x 4 - Negative to date
Urine culture - no growth
Abdominal wound GS & culture: GRAM STAIN (Final
[**2101-7-12**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2101-7-14**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
PROBABLE ENTEROCOCCUS. MODERATE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). MODERATE
GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
A&P 44 yo M with GIST on Sutent, presenting with dyspnea and 1
week history of coffee ground emesis including 1 episode in ED
today.
.
# Hematemesis: Source is most likely his GIST tumor as noted to
be hemorrhagic on op note from partial resection. A KUB was
obtained, but not suggestive of perforation. An NG tube was
placed which put out low volumes of thick cofee-ground emesis.
The patient was started on IV PPI [**Hospital1 **]. Given a Hct drop to 21.1,
he was transfused with 2u PRBCs with HCT increase to 26.7. He
was typed and crossed fo further units if necessary. HCTs were
then trended and stable over 48hours. Surgery evaluated and
recommended against any surgical options at thsi time. GI
decided against EGD given stable Hcts. The NG-tube was d/c'ed
on the 25th becasuse of low output. The patient remained
predominantly NPO with intermittent liquid intake and nutrition
was supplemented with TPN. On [**7-17**] received another blood
transfusion for low HCT, which responded well. HCT remained
stable until discharge.
.
# Fevers of Unknown Origin. In the setting of initial
neutropenia, many possible etiologies of potential infection.
These included the abdominal wound where drain had been placed
and the left lower lobe consolidation/ pleural effusion on CXR.
The patient was therefore placed on broad spectrum antibiotics
(vanc/cefepime/flagyl). Cultures showed multi-bacterial
colonization of abdominal wound site, while blood and urine
cultures were negative. Pt was afebrile on the [**Known lastname **] of
discharge.
.
# Anemia: Baseline pancytopenia likely sceondary to
chemotherapy. Further anemia due to acute GI bleed as above.
Treated with blood transfusions, as noted.
.
# Dyspnea: Progressive dyspnea over the past few [**Known lastname **]. Possibly
related to worsening pleural effusions (hypoalbuminemia vs.
impairment of lymphatic drainage secondary to metastases).
Thought unlikely to be cardiac-related given normal echo in
[**Month (only) **]. CTA was negative for PE. Breathing appeared to improve
somewhat on O2 by nasal canula and with Ativan.
.
# GIST: Aggressive GIST, currently being treated with Sutent
since [**6-1**], last dose 14 [**Known lastname **] ago. Onc wished to evaluate
treatment with abdominal CT and/or PET scan. Pt's family
declined CT because unsure of utility at this time. Surgical
team has been clear in their opinion that no operation woudl be
useful at this time. The patient and his family have been in
touch with palliative care in the [**Hospital Unit Name 153**], and appear to be
considering end-of-life issues and on [**7-19**] decided that he would
be most comfortable going home with hospice care.
#FEN: Restarted TPN, allowed liquids as tolerated. Bolused PRN
for tachycardia/ hypotension.
Medications on Admission:
Sutent 50 mg PO daily
ASA
Protonix
Lopressor
Discharge Medications:
1. Line care per NEHT protocol
2. Yankauer suction as needed
3. oxygen
Home oxygen titrated to comfort
Dx:Gastrointerstinal stromal tumor
Room air sat: 92%
4. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
Disp:*60 Tablet(s)* Refills:*2*
5. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4H (every 4 hours) as needed.
Disp:*30 Suppository(s)* Refills:*0*
6. Morphine 10 mg/5 mL Solution Sig: [**12-21**] mL PO every 4-6 hours
as needed.
Disp:*500 mL* Refills:*0*
7. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch
Transdermal every 3 [**Known lastname **] as needed for secretions.
Disp:*10 patches* Refills:*2*
8. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed.
Disp:*90 Tablet(s)* Refills:*0*
9. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0*
10. Compazine 25 mg Suppository Sig: One (1) suppository Rectal
every 6-8 hours as needed for nausea.
Disp:*60 suppositories* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Greater [**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
1.) Gastointestinal bleed
2.) Gastointestinal stromal tumor
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital because of a GI bleed, and
treated with blood transfusions, antibiotics and received IV
nutrition.
.
If you develop chest pain, difficulty breathing, fever, or
chills, contact your hospice provider.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in [**12-21**] weeks after discharge, the
office will contact you with the date and
time.Phone:[**Telephone/Fax (1) 22**]
.
Please arrange medical care as recommended by your hospice
provider.
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
|
[
"578.9",
"724.5",
"197.7",
"V17.3",
"780.6",
"V16.0",
"E933.1",
"288.03",
"197.8",
"511.9",
"285.1",
"263.9",
"151.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
10541, 10651
|
6562, 9342
|
335, 342
|
10755, 10762
|
3860, 6478
|
11043, 11410
|
3052, 3146
|
9438, 10518
|
10672, 10734
|
9368, 9415
|
10786, 11020
|
1861, 2804
|
3161, 3841
|
276, 297
|
370, 1770
|
6514, 6539
|
1792, 1838
|
2820, 3036
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,269
| 110,753
|
30288
|
Discharge summary
|
report
|
Admission Date: [**2182-12-4**] Discharge Date: [**2182-12-10**]
Date of Birth: [**2151-12-6**] Sex: F
Service: MEDICINE
Allergies:
Lamictal
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Pericardial Effusion
Major Surgical or Invasive Procedure:
Pericardial Window
Right Heart Catheterization and attempted Pericardiocentesis
History of Present Illness:
This is a 30 y/o F with h/o Depression, PTSD, bipolar disorder
who is admitted after Echo showed early sings of tamponade.
.
Patient was seen on [**2182-11-29**] at [**Hospital 191**] clinic with multiple
complains, including disphagia, dysuria and abdominal pain. A Ct
scan was done on [**2182-12-2**] that did not reveal any intraabdominal
pathologies, but it showed a large pericardial effusion. She had
an Echocardiogram on [**2181-12-4**] that showed + RA collapse, pulses
in clinic 15-20. BP 100/60, HR 100 so she was refered for
pericardiocentesis.
.
She reports that over last 6 weeks, she had join aches, fatigue,
sore thorat, + dry ocugh and low grade fevers. Over last 2
weeks, she had worsening shortness of breath on exertion,
feeling more fatigue while walking or going up stairs. Also
reports, increase orthopnea going from 2 to 5 pillows. She also
had ongoing episodic abdominal pain over last month. Diffusse,
not nausea of vomit. Intermittent loose stools.
.
In the cath lab, multiple attempts to acces fluid by subxiphoid
approach failed. Pressures RA 7, RV 18/1/6, PA 14/7/10, PCW 3.
Echo post procedure showed a moderate to large sized pericardial
effusion with brief right atrial diastolic collapse. There was
also intermittent, localized (inferior RV free wall) RV
compression suggestive of elevated intrapericardial pressure
and/or early, focal tamponade.
.
Patient was transfer to CCU for monitoring.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery. No urinary symptoms.
.
*** Cardiac review of systems is notable for + chest thitgness,
dyspnea on exertion, orthopnea. No ankle edema.
Past Medical History:
Depression
Post traumatic disorder
Border line personality disorder
Dissociative identity disorder
Sexual aversion disorder
Conversion disorder
Anorexia
h/o self harm and suicidal ideation
GERD
Premature ovarian failure
Migraines
Chornic fatigue syndrome
CKD likely secondary to lithium
Inflammatory arthorpathy - likely psoriatic arthritis
Fibromyalgia
Osteopenia
Mitral valve prolapse
Pituitary adenoma
.
Cardiac Risk Factors: Diabetes (-), Dyslipidemia (-),
Hypertension (-
Social History:
Lives in a group home. Cambrige.
works partime as pharmacy technician. NO smoking, alcohol or
illicit drug use.
Family History:
Mother, grand mother, and grand grand mother with breast cancer.
Physical Exam:
VS: T 97.3, BP 118/75 , HR 68 , RR17 , O2 %100 2L
Pulses: 4mmHg
Gen: non apparent distress, pale
HEENT: Sclera anicteric. Pale conjuctiva. dry oral mucose.
Neck: JVP flat.
CV: RRR, s1-s2 normal,no murmurs, rubs or gallops appreciated.
Chest: Clear to auscultation anteriorly
Abd: soft, mild diffuse tenderness, no rebound
Ext: No edema. distal pulses preserved.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: strong distally
Skin: no hematoma on groin site. subxiphoid incision clean.
Pertinent Results:
EKG: NSR, her 83, normal axis, normal intervals, no t wave or st
changes
[**2182-12-4**] 12:45PM WBC-5.1 RBC-3.68* HGB-12.1 HCT-34.2* MCV-93
MCH-32.8* MCHC-35.4* RDW-12.6
[**2182-12-4**] 12:45PM PLT COUNT-178
[**2182-12-4**] 12:45PM GLUCOSE-115* UREA N-22* CREAT-1.6* SODIUM-142
POTASSIUM-4.8 CHLORIDE-108 TOTAL CO2-24 ANION GAP-15
[**2182-12-4**] 05:52PM WBC-4.6 RBC-3.73* HGB-11.7* HCT-35.3* MCV-95
MCH-31.2 MCHC-33.0 RDW-12.6
[**2182-12-4**] 05:52PM NEUTS-81.2* LYMPHS-14.4* MONOS-3.2 EOS-0.9
BASOS-0.3
[**2182-12-4**] 05:52PM TSH-1.3
[**2182-12-4**] 05:52PM GLUCOSE-151* UREA N-20 CREAT-1.5* SODIUM-142
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-25 ANION GAP-12
[**2182-12-4**] 05:52PM CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-2.3
[**2182-12-7**] 09:22AM BLOOD WBC-2.5* RBC-3.39* Hgb-10.8* Hct-32.3*
MCV-95 MCH-31.9 MCHC-33.5 RDW-12.4 Plt Ct-137*
[**2182-12-10**] 06:10AM BLOOD WBC-4.3 RBC-3.68* Hgb-11.8* Hct-35.7*
MCV-97 MCH-32.2* MCHC-33.2 RDW-13.0 Plt Ct-220
[**2182-12-10**] 06:10AM BLOOD Glucose-98 UreaN-17 Creat-1.5* Na-142
K-3.8 Cl-111* HCO3-24 AnGap-11
[**2182-12-7**] 09:22AM BLOOD TotProt-4.9* Calcium-8.5 Phos-2.9 Mg-1.8
[**2182-12-7**] 09:22AM BLOOD LD(LDH)-124
[**2182-12-6**] 06:59AM BLOOD Cryoglb-NO CRYOGLO
[**2182-12-4**] 05:52PM BLOOD TSH-1.3
[**2182-12-6**] 06:59AM BLOOD ANCA-NEGATIVE B
[**2182-12-6**] 06:59AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2182-12-6**] 06:59AM BLOOD RheuFac-6 CRP-1.0
[**2182-12-6**] 06:59AM BLOOD C3-88* C4-27
[**2182-12-9**] 04:40AM BLOOD HIV Ab-NEGATIVE
[**2182-12-9**] 03:55AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG & IGM)-PND
[**2182-12-7**] 01:21PM BLOOD DNA AUTOANTIBODIES, SS-Test
[**2182-12-7**] 01:21PM BLOOD SM ANTIBODY-Test
[**2182-12-7**] 01:21PM BLOOD RO & [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]
[**2182-12-7**] 01:21PM BLOOD RNP ANTIBODY-Test
[**2182-12-7**] 01:21PM BLOOD ANTI-HISTONE ANTIBODY-Test
[**2182-12-6**] 06:59AM BLOOD SCLERODERMA ANTIBODY-Test
[**2182-12-6**] 06:59AM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG-Test
[**12-7**] Pericardial Fluid:
[**2182-12-7**] 12:02 pm FLUID,OTHER
GRAM STAIN (Final [**2182-12-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2182-12-10**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2182-12-9**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
[**2182-12-7**] 12:02PM
Report Comment:
PERICARDIAL FLUID
ANALYSIS
WBC, Other Fluid 130* #/uL 0 - 0
RBC, Other Fluid 7760* #/uL 0 - 0
Polys 0 % 0 - 0
Lymphocytes 58* % 0 - 0
Monos 7* % 0 - 0
Macrophage 33* % 0 - 0
Other Cell 2* % 0 - 0
Pericardial Fluid Adenosine Deaminase - negative
[**2182-12-9**] TTE: Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2182-12-6**], the
pericardial effusion has resolved.
.
[**2182-12-6**] TTE: There is a moderate to large sized pericardial
effusion. The effusion appears circumferential. There is
sustained right atrial collapse, consistent with low filling
pressures or early tamponade. There is mild right ventricular
diastolic collapse, consistent with impaired fillling/tamponade
physiology.
Compared with the findings of the prior study (images reviewed)
of [**2181-12-4**], the pericardial effusion is similar in size;
however, left atrial chamber invagination is now present. In
addition, the right ventricvle appears somewhat more compressed
.
[**2182-12-4**] Cath: . Pericadial effusion without clinical signs of
tamponade
and with normal RA pressure.
2. Unsuccesful pericardiocentesis. Multiple attempts to access
the
pericardial space using a subxiphoid approach were unsuccesful.
TTE
obtained during the procedure showed anterior collection but not
at apex
and beneath liver edge. Despite echo guidance, the operator was
still
unable to enter the pericardial space. The patient developed
left
shoulder pain during the procedure attempts that resolved with
removal
of the needle.
FINAL DIAGNOSIS:
1. No clinical signs of tamponade, normal RA pressure.
2. Unsuccesful pericardiocentesis
Brief Hospital Course:
# Pericardial effusion: On admission the patient was taken to
cath lab for pericardiocentesis. During the procedure
pericardial fluid was failed to be obtained. Hemodynamics
inconsistent with tamponade physiology. The patient was admitted
to the CCU for continued monitoring. Repeat TTE [**12-7**] demonstrated
new LA and RV invagination. CT surgery was consulted and the
patient was taken for pericardial window. She tolerated the
procedure well with no complications. Drain and chest tube
placed during procedure. Removed on [**12-10**] after repeat TTE on [**12-10**]
demonstrated a normal left ventricular wall thickness, cavity
size, and normal systolic function and a resolution of
pericardial fluid. Her pericardial fluid was of unclear
etiology. Rheumatology was consulted and her sulfasalazine was
discontinued for concern of drug induced lupus given effusion
and decreasing WBC. WBC did stabalize after stopping medication.
Also concern for collagen vascular disease. Panel of autoimmune
antibodies pending at time of discharge. Cytology and
pericardial biopsy also pending at time of discharge. [**Doctor First Name **] to
evaluate for TB as cause pending. The patient did report recent
URI symptoms, can consider pericarditis as cause of effusion.
EBV, CMV pending. HIV negative. She also reports a family
history of breast CA - recent mamogram WNL. The patient was
discharged home in good condition to follow up with her PCP and
rheumatology for further management.
.
# Hypotension - Pt BP range 80s-110 systolic. The patient does
have low BP at baseline. Reported recent poor po intake and
history of eating disorder. She received intermittent fluid
bolus, likely due to increased insensible losses. She also has a
history of increased urine output with lithium induced CRI.
.
# Psych: continued on home medications Abilify, Quetiapine
.
# Question of Psoriatic arthiritis: continued prednisone per
Rheumatology recommendation. Sulfasalazine DC'd due to concern
for drug induced lupus
.
# Vaginal Bleeding - During her hospitalization the patient
reported scant vaginal bleeding. She has been post-menopausal
for many years. She was advised to undergo further workup for
this bleeding as outpatient. Given her past history of sexual
abuse she has reported refusing previous pelvic examination.
.
# Fibromyalgia: continued tizanidine and Ultram
# CKD: creatinine at baseline.
.
The patient is scheduled to follow up with Cardiology, CT
surgery, Rheumatology and her PCP for further management. Also
to follow up on outstanding pericardial fluid cytology and
biopsy, as well as pending Autoimmune workup.
Medications on Admission:
Ativan 1 mg [**Hospital1 **]
Ativan 2 mg qhs
Colace
Correctol 2 tab once a day (not taken over last 3 days
Cymbalta 120 qhs
Desmopresin 0,3mg qhs
fioricet 100-650 PRH
MVI
Naproxen 250 q4h prn
Prednisone 10 mg/daily
Proair HFA 2 puffs inh 4-6h
seroquel 400 TID and 800 qhs
Sulfasalazine 1500 [**Hospital1 **]
Synthroid 50 mcg/daily
Topamax 75 [**Hospital1 **] 100 mg qhs
Ultram EF 300/daily
Vistaril 50mg QID PRN
Zanaflex 4mg qhs
Prilosec 40 [**Hospital1 **]
Ranitidine 150 qhs
Abilify 30 mg/qhs
Hydroxizine
prazosin
Discharge Medications:
1. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Four (4)
Capsule, Delayed Release(E.C.) PO HS (at bedtime).
4. Desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-4**]
Tablets PO DAILY (Daily) as needed.
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Quetiapine 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
9. Quetiapine 200 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Topiramate 25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
12. Topiramate 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day) as needed.
14. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Prazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
18. Aripiprazole 10 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
20. Ultram ER 300 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
21. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every 4-6 hours as needed.
22. Correctol 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Pericardial Effusion
2. Pericarditis - Post Viral
Secondary:
1. Chronic Renal Insufficiency
2. Inflammatory Arthropathy
Discharge Condition:
Good, Clinically Improved
Discharge Instructions:
You were admitted with a fluid collection around your heart
called a pericardial effusion. You underwent a catheterizaton to
attempt drainage of this effusion however no fluid could be
obtained. You then underwent a pericardial window by
cardiothoracic surgery to open your pericardial space to drain
the fluid.
.
Your workup from your pericardial effusion has been negative to
date. The cytology and biopsy from your procedure are still
pending as well as viral studies. You will follow up with
Cardiology and Rheumatology for further workup.
.
Your medication Sulfasalazine has been discontinued. You should
continue to take your medication Prednisone 10mg daily until
follow up with Dr. [**Last Name (STitle) **] in Rheumatology.
.
You continue to have a high urine output related to your kidney
disease. Please continue to drink plenty of caffeine free fluids
at home. If you develop lightheadedness please return or call
your primary care physician.
.
You have complained of occassional vaginal spotting during your
hospital stay. You should follow up with your primary care
physician for further workup.
.
If any chest pain, shortness of breath, fevers or any other
sympotms that may concern you, plaease call your PCP or come to
the emergency department
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] regarding your pericardial
effusion, in the cardiology clinic. An appointment has been made
for you on [**2183-1-1**] @ 10AM, in the [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **]. Please call [**Telephone/Fax (1) **] if you have any questions or
concerns about this appointment.
.
Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 5808**] Date/Time:[**2182-12-26**] 10:20
.
Please follow-up with your Rheumatologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2182-12-19**] 8:30
.
Please follow up with Cardiothoracic Surgery with Dr. [**Last Name (STitle) 72103**]
[**Name (STitle) 914**] in the [**Hospital Unit Name **], [**Location (un) **] CARDIAC SURGERY LMOB 2A
Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2182-12-25**] 2:00
|
[
"309.81",
"E939.8",
"424.0",
"301.83",
"V58.65",
"585.9",
"423.3",
"733.90",
"696.0",
"296.50",
"420.91",
"729.1",
"300.14"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.21",
"88.55",
"37.12"
] |
icd9pcs
|
[
[
[]
]
] |
12702, 12708
|
7730, 10350
|
291, 373
|
12884, 12912
|
3361, 5638
|
14221, 15282
|
2755, 2823
|
10916, 12679
|
12729, 12863
|
10376, 10893
|
7616, 7707
|
12936, 14198
|
2838, 3342
|
5721, 5837
|
5866, 7599
|
231, 253
|
401, 2110
|
5674, 5688
|
2132, 2610
|
2626, 2739
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,131
| 163,978
|
3624+3625
|
Discharge summary
|
report+report
|
Admission Date: [**2107-6-27**] Discharge Date: [**2107-7-5**]
Date of Birth: [**2041-8-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2356**]
Chief Complaint:
pericarditis
Major Surgical or Invasive Procedure:
Throacentesis
History of Present Illness:
65 year old female no previous cardiac history developed
substernal chest pain radiated to neck over the weekend. She
came to the OSH ED this am EKG with diffused ST elevations and
PR depressions in V2,3,4,5,I,II, and III. She was given ASA 81
mg x 4 tabs, Plavix 600mg at 1300, started on heparin @ 700
units per hr. She was pain free and was initially being
transferred for cardiac cath. However, the cath was cancelled
after not making any cardiac enzymes. She was admitted for
evaluation and treatment of pericarditis with possible small
pericardial effusion on ECHO (done at OSH, no report in chart).
Gallbladder U/S for elevated liver enzymes per OSH.
.
At OSH, vital sign range (BP/ O2 sat / HR / Tele): -98.7,
HR-106 ST, B/P 141/84, RR-18, Sat 98% RA now 100% 2 L. Labs:
<B>WBC 17.3 </B>, HCT 40, PLT 169; diff (<B>N 88.5</B>, L 4.9, M
5.6, Eso 0, Bas 1.1), INR 1.0, PTT 29.8; CHEM7: Na 133, <B> K
2.7 </B>, CL 97, <B>HCO 33.8</B>, Bun 12, Cr 0.8, glu 104; LFT
(TP 6.8, <B> TB 1.96, Alk Phos 245, ALT 216, AST 186 </B>, Ca
[**07**], Alb 3.4), Trop <0.01, CK-MB 35.
.
On floor, she is in mild distress with a pulsus of 6. Still has
pain in her neck and shortness of breath
.
On review of systems, she reported positive for joint swelling
in her knee and shoulder, no muscle pain or rashes. She denies
any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. He
denies recent fevers, or rigors. He denies exertional buttock or
calf pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Cardiac Risk Factors: - Diabetes, - Dyslipidemia, + Hypertension
.
Cardiac History: no CABG/PCI/ICD/Pacer.
.
Other Past History:
HTN
anxiety
hyperparathyroidism
hypothyroid
osteoporosis
Prior fractures:ankle at 21 falling on stairs
C section
Social History:
Housewife, Exercise hx: [**3-24**] miles walking daily, Tobacco use:no,
Alcohol use:rare, Steroid use:no, Heparin use:no
Family History:
Father died of MI age 59. Mother had PCI/CABG passed away from
lung ca. Father side (all uncles and aunts died of MI). Brother
had an MI at 61. + for osteoporosis in mother, but no hip fx no
FH of hypercalcemia
Physical Exam:
VS - 98.6 107/66 98 29 100 RA
Gen: Thin female in mild distress. 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 8 cm.
CV: Tachycardic, RR, normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4.
Chest: pectus excavatum. Resp were mildly labored, no accessory
muscle use. CTAB, positive crackles on left, no wheezes or
rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2107-6-27**] 06:55PM BLOOD WBC-21.1* RBC-4.25 Hgb-12.1 Hct-36.7
MCV-86 MCH-28.4 MCHC-32.9 RDW-13.7 Plt Ct-190
[**2107-6-27**] 06:55PM BLOOD Neuts-94.7* Lymphs-3.0* Monos-1.8*
Eos-0.3 Baso-0.1
[**2107-6-27**] 06:55PM BLOOD PT-12.3 PTT-24.1 INR(PT)-1.0
[**2107-6-30**] 04:44AM BLOOD ESR-88*
[**2107-6-28**] 06:45AM BLOOD Parst S-NEGATIVE THIN AND THICK SMEAR
REVIEWED
[**2107-6-27**] 06:55PM BLOOD Glucose-149* UreaN-11 Creat-0.6 Na-138
K-3.7 Cl-99 HCO3-29 AnGap-14
[**2107-6-27**] 06:55PM BLOOD ALT-166* AST-140* LD(LDH)-172
AlkPhos-201* TotBili-3.4* DirBili-2.7* IndBili-0.7
[**2107-6-29**] 06:41AM BLOOD TotProt-5.4* Albumin-3.0* Globuln-2.4
Calcium-8.6 Phos-1.8* Mg-2.1
[**2107-6-27**] 06:55PM BLOOD TSH-1.2
[**2107-6-27**] 06:55PM BLOOD T4-2.7*
[**2107-6-28**] 06:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2107-6-27**] 07:51PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2107-6-27**] 06:55PM BLOOD RheuFac-26*
[**2107-6-27**] 06:58PM BLOOD HIV Ab-NEGATIVE
[**2107-6-28**] 06:45AM BLOOD HCV Ab-NEGATIVE
[**2107-6-27**] 09:21PM URINE Hours-RANDOM UreaN-747 Creat-143 Na-10
K-82 Cl-12
[**2107-6-29**] 12:49PM PLEURAL WBC-950* RBC-3075* Polys-50* Lymphs-6*
Monos-19* Meso-13* Macro-12*
[**2107-6-29**] 12:49PM PLEURAL TotProt-2.7 Glucose-111 LD(LDH)-115
Albumin-1.6 Misc-PND
2D-ECHOCARDIOGRAM performed on [**2107-6-27**] demonstrated: The left
atrium is normal in size. The estimated right atrial pressure is
0-10mmHg. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is a
moderate sized pericardial effusion.
[**2107-6-29**] Cardiology ECHO
Overall left ventricular systolic function is normal (LVEF>55%).
with borderline normal free wall function. There is a small to
moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2107-6-28**], the
pericardial effusion appears slightly smaller.
[**2107-6-29**] Cytology PLEURAL FLUID
NEGATIVE FOR MALIGNANT CELLS.
[**2107-6-28**] Radiology CTA CHEST W&W/O C&RECON
IMPRESSION:
1. No acute pulmonary embolism is detected. Small recanalized
chronic
thrombus, lateral basal segment, right lower lobe.
2. Moderate partially hemorrhagic or exudative pericardial
effusion. No
evidence of tamponade.
3. Moderate, layering pleural effusions, likely inflammatory,
responsible for
substantial bibasilar atelectasis.
4. Air trapping, less likely mild pulmonary edema.
5. No acute thoracic aortic pathology.
Brief Hospital Course:
65 year old female no previous cardiac history developed
substernal chest pain radiated to neck over the weekend, found
at OSH to have pericarditis.
Mrs [**Known lastname 16479**] arrived to [**Hospital1 18**] with pericarditis. She was plavix
loaded, heparinized, and given aspirin at OSH for questionable
ST-elevation MI. However, it was later determined that she had
pericarditis given negative CE and classical EKG changes. She
recieved Echo and RUQ US at outside hospital. ECHO showed
pericardial effusion (pulsus of [**6-28**]) on admission. RUQ US was
within normal limits. She was given Ibuprofen and cochicine,
with x1 prednisone. Dispite the intervention, she had increase
oxygen requirement over the course of her hospitalization. She
went into AVNRT to the rate of 140's on the second day. She was
converted with adenosine and controlled with metoprolol (pulsus
was 8 during this event). Given her increased oxygen
requirement with pericardial effusion and tachycardia, she was
transferred to CCU for futher managment.
In the CCU we monitored her pulsus which remained < 8. She had
no hypotension. She did go into atrial fibrillation with RVR
that we felt was secondary to her pericarditis with HRs in the
140s-160s; she was also hypoxic around this time which we felt
was secondary to her bilateral pleural effusions and her atrial
fibrillation. She required O2 at 4 L. We attempted rate
control of her atrial fibrillation with lopressor and diltiazem
with some improved to the 100s; however she remained in atrial
fibrillation with recurrent RVR. We attempted cardioversion
with ibutilide however this was not immediately successful. She
spontaneously converted back to sinus rhythm. Pulmonary was
consulted for her bilateral pleural effusions. Her pleural
effusions were tapped; pleural fluid was transudative. Her
hypoxia improved significantly following drainage; 600 ccs was
removed from right pleura and 800 ccs from left. She was
started on antibiotics for community acquired pneumonia with
last day of azithromycin on [**7-4**] and last day of ceftriaxone on
[**7-6**]. Her pericarditis was felt secondary to likely viral
syndrome given concomittant transaminase elevations,
leukocytosis. Rheumatological process was considered given
history of joint pain, effusions, and erythema; RF was
borderline positive, CCP was pending. Rheumatology consulted;
they did not feel the pericarditis was secondary to a
rheumatological process but likely secondary to viral syndrome.
Several serologies were ordered however for Sjogren's and lupus
and are currently pending. She was initiated on NSAIDs and
colchicine which she should continue for several months. She
was transferred to the floor once her hypoxia stabilized; she
was 96% on 2 L in sinus rhythm at time of transfer.
.
On the floor, she developed diarrhea that was c. diff related.
She was placed on flagyl and improved on this treatment. Her
shortness of breath improved and was able to tolerate PO prior
to discharge. She was discharged in stable condition with
colchicine and indomethacine (she will readdress the need of
this medication with her cardiologist at the visit).
Medications on Admission:
ESCITALOPRAM [LEXAPRO] 2.5 mg by mouth daily
HYDROCHLOROTHIAZIDE 12.5 mg by mouth daily (recorded)
LEVOTHYROXINE [LEVOXYL] 88 mcg by mouth qday
ZOLPIDEM [AMBIEN] - 5 mg Tablet mouth HS
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] PO daily
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: 0.25 Tablet PO QHS (once a day
(at bedtime)).
2. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
7. Diltiazem HCl 240 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO Q4H:PRN as needed
for anxiety: This medication is sedating. Please do not drive
while taking this medication.
Disp:*30 Tablet(s)* Refills:*0*
10. Indomethacine 25mg Tablet Sig: One (1) Tablet PO Three times
a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Pericarditis
c. diff colitis
transaminitis
HTN
anxiety
hyperparathyroidism
hypothyroid
osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with chest pain and we found that you
had a pericarditis. You had a short stay in the cardiac
critical care unit and we determined that your pericarditis was
due to a viral infection. You had fluids surrounding your lungs
and we drained the fluid to help you breath. We were also
diuresising you to get rid off the fluid. You also had very
high heart rate during your stay with us, which we controlled
with medication. You were discharged in stable condition.
Please follow up with your physicians.
Please note we made the following changes to your medications.
1. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 2 weeks.
3. Diltiazem HCl 240 mg Tablet Sustained Release 24 hr Sig:
One (1) Tablet Sustained Release 24 hr PO once a day.
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
5. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO Q4H:PRN as
needed for anxiety: This medication is sedating. Please do not
drive while taking this medication.
6. Indomethacine 25mg Tablet Sig: One (1) Tablet PO Three times
a day.
It was a pleasure taking care of you. We wish you a speedy
recovery.
Followup Instructions:
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2108-6-21**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10545**], M.D. Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2108-6-21**] 11:30
PCP [**Name Initial (PRE) 648**]: Wednesday, [**7-13**] @11:30am
Name: [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **],MD
Location: CARDIOLOGY ASSOCIATES OF GREATER [**Location (un) **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**0-0-**]
Pulmonary Appointment:
The department will call you at home at this #[**Telephone/Fax (1) 16480**] to
schedule a follow up appointment. If you have not heard from
them by Monday-[**7-11**] or the above number I have for you is wrong,
please call for a new patient appointment at this number
[**Telephone/Fax (1) 612**].
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]
Admission Date: [**2107-7-8**] Discharge Date: [**2107-7-15**]
Date of Birth: [**2041-8-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2356**]
Chief Complaint:
Dyspnea on exertion, pericardial/pleural effusions, CDiff
Major Surgical or Invasive Procedure:
Thoracentesis X2
History of Present Illness:
Mrs. [**Known firstname 4134**] [**Known lastname 16479**] is a 65 year old female with a history of
HTN, hyperparathyroidism, and hypothyroidism who was recently
discharged from the [**Hospital1 18**] Cardiology Medicine service where she
had been treated for pericarditis, presumed viral etiology. Her
hospital course was complicated by frequent episodes of AVnRT
(started on diltiazem), community acquired pneumonia (completed
course of azithromycin and ceftriaxone), and C. difficile
colitis (started on metronidazole). Her bilateral pleural
effusions were also tapped during that admission.
.
The patient was transferred from [**Hospital1 18**]-[**Location (un) 620**] for worsening
shortness of breath, bilateral shoulder and neck pain X2 days.
The patient had been sent there by her cardiologist, who saw her
in clinic and found her to be tachycardic. On ultrasound in
clinic, she had a small pericardial effusion but generally poor
"squeeze" concerning for congestive heart failure.
.
In the ED, initial vital signs were pain T 97.7, HR 114, BP
114/77, RR 17, O2 sat 97%. Exam was negative for friction rub,
jugular venous distension, distant heart sounds. Pulsus
paradoxus has remained stable at 6-7. She received morphine (1mg
IV), zofran (4mg IV), intravenous fluids and was started on
Vancomycin/Cefepime with improvement. Was also started on PO
Vancomycin and switched to IV Flagyl.
.
Upon arrival to the floor, the patient was resting more
comfortably in bed with no complaints.
.
On review of systems, she denies any prior history of
stroke/TIA, deep venous thrombosis, pulmonary embolism,
myalgias, cough, hemoptysis, fevers/chills. All of the other
review of systems were negative.
*** Cardiac review of systems is notable for absence of chest
pain, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Cardiac Risk Factors: - Diabetes, - Dyslipidemia, + Hypertension
.
Cardiac History: No CABG/PCI/ICD/Pacer.
History of pericarditis
.
Other Past History:
Hypertension
Anxiety
Hyperparathyroidism
Hypothyroid
Osteoporosis
Prior fractures to ankle at 21yo s/p falling on stairs
C section
Social History:
Housewife who previously walked [**3-24**] miles daily. Denies tobacco,
steroid of illicit drug use. Rare alcohol use.
Family History:
Father died of MI at age 59. Mother had PCI/CABG and passed away
from lung cancer. All paternal uncles/aunts died of MIs. Brother
had an MI at 61. + for osteoporosis in mother, but no hip
fractures or family history of hypercalcemia.
Physical Exam:
Discharge Physical Exam:
VS: T95.8, BP 131/68, HR 92, RR20, 94% RA
Gen: Well-developed, cachectic woman in NAD. Alert and oriented
X3. Mood and affect appropriate - slightly anxious.
HEENT: NCAT. Sclera anicteric. EOMI. Dry mucus membranes, normal
oro/nasopharynx.
Neck: Soft, supple without JVD
CV: PMI located in 5th intercostal space, midclavicular line.
Tachycardia, regular, normal S1/S2. No murmurs/gallops. No
friction rub.
Chest: Anterior chest wall deformity. Respirations unlabored, no
accessory muscle use but slightly uneven. CTAB. No
wheezing/rhonchi/rales but mild left basilar crackles.
Abd: Soft, non-tender, non-distended. +bowel sounds. No HSM or
tenderness.
Ext: No cyanosis, edema. Scattered ecchymosis of bilateral upper
extremities.
Skin: No stasis dermatitis, ulcers, or xanthomas.
Pulses: Right: DP 2+ PT 2+ ; Left: DP 2+ PT 2+
Pertinent Results:
ECG: Sinus tachycardia, low voltage, no electrical alternans.
.
CXR (my read): Significant left costophrenic angle blunting
suggestive of effusion vs. consolidation - more likely the
former given meniscus. ?wedge on lateral view suggestive of
lobar pneumonia.
.
[**2107-7-8**] TTE (prelim): The left atrium is normal in size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The number of
aortic valve leaflets cannot be determined. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. Stranding
is visualized within the pericardial space c/w organization.
[**2107-6-29**] TTE: Overall left ventricular systolic function is normal
(LVEF>55%). with borderline normal free wall function. There is
a small to moderate sized pericardial effusion. There are no
echocardiographic signs
of tamponade.
.
CT torso: 1. No evidence of acute pulmonary embolism within the
main, lobar or
segmental branches of the pulmonary arteries bilaterally.
Evaluation of the
subsegmental pulmonary arteries is limited secondary to bolus
timing.
2. Moderate-sized pericardial effusion with interval increase in
enhancement
of the pericardium suggestive of pericarditis.
3. Ground-glass opacity in the left apex again identified and
may be
infectious in nature. Followup to resolution is recommended.
Large right and
moderate left-sided pleural effusion with adjacent compressive
atelectasis.
4. Multiple low-density lesions within the kidneys bilaterally
which most
likely represent renal cysts. Confirmation may be obtained with
renal
ultrasound when the patient is clinically able.
.
C-spine films:
1. Sclerotic C6 vertebral body of unclear etiology. Correlate
with MRI.
Multilevel discogenic disease with secondary degenerative
changes and
multilevel neural foraminal narrowing. MRI would be more helpful
to further
assess.
.
CXR: 1. Bilateral stable moderate pleural effusions with
associated bibasilar
dependent atelectasis.
2. Subtle ground-glass opacity at the left lung apex, new since
last CXR,
but evident on recent CT, could suggest early developing focus
of infection.
3. Cardiac silhouette is suboptimally evaluated due to summation
of shadows
with pleural effusions.
.
LABORATORY DATA:
Trop-T: <0.01
.
Chem 7
131 99 16 116 AGap=15
5.7 23 0.7
K on recheck = 4.7
Lactate 2.0
.
CBC
85
40.1 > 14.5 < 405
43.1
N:90 Band:3 L:6 M:1 E:0 Bas:0
.
PT: 12.2 PTT: 22.7 INR: 1.0
Brief Hospital Course:
65 year old woman with history of hypertension, hypothyroidism,
hyperparathyroidism and recent pericarditis, felt likely viral,
s/p drainage of pleural effusion (pericardial effusion not
drained) and CDiff infection who presents with dyspnea on
exertion and returning pleural effusions.
# Pleural Effusions: Patient arrived with SOB and CXR revealed
pleural effusion bilaterally. Each side was tapped on different
days and patient was symptomatically better and hypoxia
resolved. Pulmonary, ID, and Rheumatology were consulted but no
clear diagnosis was made. She was started on a prednisone taper
which will be managed by her PCP. [**Name10 (NameIs) **] will be following up
with her as an outpatient.
# Leukocytosis: On admission, patient had a WBC of 40.0.
Initially it was thought to have been contributed by prior
C.Diff infection. Was initially on broad spectrum abx and was
ultimately placed on 250mg PO Vanco QID for a 14 day course.
Hematology/Oncology was consulted, however no concrete diagnosis
was made. Hematology/Oncology is interested in following up with
her in one month. Will need repeat CBC prior to appointment.
# AVnRT: Patient developed with AVnRT to during last admission
and was placed on diltiazem. Patient had intermittent AVnRT
episodes but remained stable and was discharged on her home
dose.
# Diarrhea: Patient experienced daily loose green BM for
multiple days. Initially it was thought that she redeveloped
C.diff, as she had a corresponding WBC. However stool analysis
was negative for C.diff toxins. Colchicine was then discontinued
and the diarrhea subsided.
# Hematuria: On U/A, patient had microscopic blood. No further
investigation was completed at this time. However, patient would
benefit from a follow-up U/A as outpatient.
# Hypothryoidism: Patient remained on home dose of Lexovyl. No
changes were made to regimen.
# Anxiety: Patient remained on home doses of Ambien and Lexapro.
No changes were made to regimen.
Medications on Admission:
1. Escitalopram 10 mg Tablet Sig: 0.25 Tablet PO QHS
2. Levothyroxine 88 mcg daily
3. Zolpidem 5 mg QHS
4. Multivitamin daily
5. Colchicine 0.6 mg daily
6. Metronidazole 500 Q8H
7. Diltiazem HCl 240 mg SR daily
8. Omeprazole 20 mg daily
9. Ativan 0.5 mg Q4H:PRN anxiety
10. Indomethacine 25mg TID
11. Alendronate 70 mg Qweek -?left off Discharge Med List
Discharge Medications:
1. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Escitalopram 10 mg Tablet Sig: 0.25 Tablet PO QHS (once a day
(at bedtime)).
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
8. Diltiazem HCl 240 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO once a day.
9. Prednisone 10 mg Tablet Sig: see instructions Tablet PO once
a day for 14 days: [**7-16**]: take 4 pills;[**7-17**]: take 4 pills;[**7-18**]:
take 3 pills;[**7-19**]: take 3 pills;[**7-20**]: take 3 pills;[**7-21**]: take 3
pills;[**7-22**]: take 2 pills;[**7-23**]: take 2 pills;[**7-24**]: take 2 pills;[**7-25**]:
take 2 pills;[**7-26**]: take 1 pill;[**7-27**]: take 1 pill;[**7-28**]: take 1
pill;[**7-29**]: take 1 pill.
Disp:*32 Tablet(s)* Refills:*0*
10. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 5 days: [**Month (only) 116**] give liquid.
Disp:*20 Capsule(s)* Refills:*0*
11. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
12. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Primary: Bilateral pleural effusions
Secondary: Pericardial effusion, Hypertension, Anxiety,
Hyperparathyroidism, Hypothyroid, Osteoporosis, recent
Clostridium difficile infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Vital Signs stable and ambulating with difficulty on room air.
Discharge Instructions:
-You were admitted with shortness of breath and found to have
reaccumulation of fluid in your lungs. The fluid around your
heart remained stable. You underwent drainage of the fluid in
your lungs, with improvement in your symptoms. You were also
started on Steroids to help your condition.
.
-It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> STOPPED Colchicine
--> STOPPED Flagyl
--> STARTED Vancomycin. It is important for you to take this
medication four times a day for 5 ADDITIONAL days. Your last
dose will be on [**7-20**].
--> STARTED Reglan and Zofran for nausea. Please take these
medications with meals if you feel nauseous.
--> STARTED Prednisone. Please adhere to the following:
On [**7-16**], take 4 (four) tablets
On [**7-17**], take 4 (four) tablets
On [**7-18**], take 3 (three) tablets
On [**7-19**], take 3 (three) tablets
On [**7-20**], take 3 (three) tablets
On [**7-21**], take 3 (two) tablets
On [**7-22**], take 2 (two) tablets
On [**7-23**], take 2 (two) tablets
On [**7-24**], take 2 (two) tablets
On [**7-25**], take 2 (one) tablet
On [**7-26**], take 1 (one) tablet
On [**7-27**], take 1 (one) tablet
On [**7-28**], take 1 (one) tablet
On [**7-29**], take 1 (one) tablet-- THIS WILL BE YOUR
LAST DAY OF STEROIDS.
.
-Contact your doctor or come to the Emergency Room should your
symptoms return. Also seek medical attention if you develop any
new fever, chills, trouble breathing, chest pain, nausea,
vomiting or unusual stools.
Followup Instructions:
Please call Dr.[**Name (NI) 15895**] office next week to make an
appointment.
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2107-8-18**] at 2:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: THURSDAY [**2107-8-18**] at 2:30 PM
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2107-8-18**] at 2:30 PM
With: DR. [**Last Name (STitle) 4013**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES/Hematology
When: FRIDAY [**2107-8-19**] at 3:00 PM
With: DR. [**Last Name (STitle) 16481**] [**Telephone/Fax (1) 16482**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]
Completed by:[**2107-7-15**]
|
[
"008.45",
"252.00",
"599.72",
"428.0",
"401.9",
"733.00",
"427.31",
"416.2",
"427.89",
"244.9",
"300.00",
"486",
"518.0",
"787.91",
"423.9",
"420.91",
"511.9",
"275.3",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
24073, 24136
|
20082, 22051
|
13962, 13980
|
24360, 24360
|
17412, 20059
|
26294, 27451
|
16286, 16521
|
22456, 24050
|
24157, 24339
|
22077, 22433
|
24575, 26271
|
16536, 16536
|
13865, 13924
|
14008, 15826
|
24375, 24551
|
15848, 16134
|
16150, 16270
|
16562, 17393
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,657
| 125,544
|
13517
|
Discharge summary
|
report
|
Admission Date: [**2145-2-18**] Discharge Date: [**2145-2-27**]
Date of Birth: [**2112-11-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Watermelon / Almond Oil
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
Nausea/vomiting, diarrhea --> DKA
Major Surgical or Invasive Procedure:
PICC line placement
Initiation of hemodialysis
History of Present Illness:
Mr. [**Known lastname 21822**] is a 32 year-old man with a history of HTN, type 1
diabetes with gastroparesis, CKD stage V and recently s/p AV
fistula [**2145-1-22**] in anticipation of HD, and anemia who presents
with profuse watery vomiting and watery diarrhea for last 2
days. No blood or mucus. No fevers but did have night sweats and
chills. He also has crampy abdominal pain improved with bowel
movements. He has only been able to keep down sips. He denies
any lightheadedness. He does still make urine and has not noted
any change in UOP, dysuria, or hematuria. He denies any sick
contacts but did just return to work yesterday after recovering
from placement of a RUE graft on [**1-26**]. He denies any recent
travel or antibiotics use. He states his BS have been in 100s
and he has been taking his lantus 15 in AM, but states this is
what his DKA has felt like in the past.
Past Medical History:
- HTN
- DM I since age 19, seen at [**Last Name (un) **]. Complicated by nephropathy,
gastroparesis, proteinuria and possibly retinopathy.
-CKD: thought to be related to HTN and longstanding DMII.
Underwent RUE fistula placement on [**1-26**] for planned HD
initiation. Being considered for liver-pancreas transplant
- Anemia: Thought to be combination of iron deficiency and CKD,
still taking iron
- Depression
- S/p appendectomy [**7-/2144**]
Social History:
Lives with his girlfriend. [**Name (NI) 1403**] in a clerical setting. Quit
smoking 2 days ago, 5 pk year history. Occasional ETOH. No
illicit drugs.
Family History:
Diabetes and heart trouble in grandfather
Physical Exam:
Physical Exam (on Admission)
Vitals: T 99.2, HR 100, BP 171/90, RR 12, O2sat 97RA.
General: Uncomfortable appearing young man, recently vomited
small amount of nonbloody nonbilous emesis
HEENT: NCAT, MMM, oropharynx clear
Neck: Supple, LAD
Pulm: CTA B
CV: Tachycardic but regular, promienent P2, no m/r/g
Abd: BS hyperactive but not high-pitched, diffuse tenderness
without guarding or rebound, nondistended
Extrem: No LE edema, DP pulses 2+
Neuro: AAOx 3, grossly nonfocal, no asterixis
Derm: No rash
Pertinent Results:
On admission to MICU:
pH 7.27 pCO2 24 pO2 233 HCO3 12 BaseXS -13
140 107 100 AGap=26
-------------<305
5.1 12 15.2
Ca: 8.3 Mg: 2.0 P: 8.0
ALT: 62 AP: 77 Tbili: 0.1
AST: 33 [**Doctor First Name **]: 93 Lip: 59
Osms:346
Serum Acetmnphn Negative
MCV 88
wbc 8.2
plts 272
hct 20.0
N:87.2 L:8.7 M:3.1 E:0.8 Bas:0.1
Lactate: 0.8
EKG: NSR at 97 bpm, nl axis and intervals, no ST-T wave changes
Chem ([**2-27**]): 140/4.1 101/29 31/8.7 < 70 Ca=8.0 Mg=1.8
P=4.1
CBC ([**2-27**]): 6.4 > 22.1 < 233
Blood culture [**2-24**] and [**2-27**]: Final read negative
Brief Hospital Course:
In the ER on [**2-18**], his vitals were: T 100.1, P 98, BP 164/90, RR
16, O2 sat 100%. He had abdominal pain, and he was guiac
negative. His initial creatinine was 15.3, his glucose was 162,
and he had a metabolic acidosis with an anion gap of 24 (up from
his baseline of 19, due to his chronic kidney disease). He was
given 2L IVF for hydration, and his anion gap closed to 20. He
was given morphine 4 mg IV x 2 and zofran 4 mg IV x 2, and
admitted to medicine. On transfer to the floor his vitals were:
T 99.2, HR 100, BP 171/90, RR 12, O2sat 97% on room air.
.
On the medicine floor he had worsening nausea, vomiting and
abdominal pain, his glucose rose to 305, his gap increased to 21
and his pH was 7.27. He received another 2 liters of normal
saline, but become tachypneic. His tachypnea resolved with
diuresis (Lasix 20 mg IV). On [**2-19**] the patient was transferred
to the MICU for an insulin drip and management of DKA. He
received 2 liters of D5W in normal saline, then 1 liter of D5W
with 3 amps of bicarb, then 1 liter of D5W with K+. For his
hematocrit of 20 he received 1 unit of pRBCs. His gap was back
down to 21 by 23:00 that evening.
On [**2-20**] the patient had his first session of hemodialysis. He
declined his renal diet all day, then at midnight had [**State 19827**]
Fried Chicken brought in from outside. In the early AM of [**2-21**]
he developed nausea, vomiting, a glucose of 436 and DKA. He had
an EKG that showed no ischemia, and morphine for pain. For
systolic blood pressures from 190-210 he received IV doses of
his home PO antihypertensives (Hydralazine and Metoprolol). The
patient was refusing his calcium capsules because they were too
big to swallow, and tried to order a pizza in instead of
hospital food.
By [**2-24**] he had been transitioned from insulin drip to insulin
boluses. On [**2-25**] he had his 4th session of dialysis. He wanted
to leave that evening AMA (felt he had lost his freedom), but
was convinced to stay. On [**2-26**] he again wanted to leave AMA but
was again convinced to stay one more day for a 5th dialysis
session and to arrange optimal outpatient followup. He was
transferred out of the ICU to the medicine floor.
Overnight on [**3-31**], he [**Date Range 28316**] a fever to 100.9. Blood
cultures were sent and he underwent his 5th dialysis session.
Following his HD session, he was seen by the medical team and
advised to stay in the hospital for one more day to assess for
an infection, given his overnight fever and recent initiation of
hemodialysis. He was advised to stay to ensure he remained
afebrile for 24 hours. Mr. [**Known lastname 21822**] refused this advise and
decided to sign out AGAINST MEDICAL ADVICE, despite repeated
discussions with him regarding our decision and desire to
monitor him for another day.
By problem:
Anion gap metabolic acidosis/hyperglycemia/DKA. Increased above
baseline on presentation probably due to uremia in setting of
dehydration. It slightly improved s/p 2L IVF near baseline gap
of 19. But after brief stay on the regular medicine floor, his
blood sugar elevated into the 200-300s and anion gap increased;
acetone found in serum and ketones seen in urinalysis,
concerning for DKA. Lactate was normal. In the MICU, patient was
started on an insulin gtt and started on intravenous fluids. In
total, patient received 2L D51/2NS, then D5W with 3 amps bicarb
in 1L, then D5W with potassium. He had a PICC placed for regular
(every 4 hour) electrolyte checks. Patient's anion gap decreased
to baseline ~17, given patient's underlying end-stage renal
disease/uremia. Insulin gtt was discontinued and [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recs, patient was started on a fixed Lantus and Humalog sliding
scale. Of note, on [**2-20**], patient refused hospital diet
and had his girlfriend bring him [**State 19827**] Fried Chicken; his
blood sugars and anion gap increased. Patient required
resumption of insulin gtt briefly; he was resumed on insulin
sliding scale and fixed dose, with Nutrition Consult and Social
Work following for coping/management of his long-standing,
complicated Type 1 Diabetes Mellitus.
N/V/D, abdominal pain. Given low grade fever and acute onset,
most c/w viral gastroenteritis although possible that this was
exacerbated by uremia. Also, patient has a hx of gastroparesis.
Abdominal exam nonfocal but with tenderness initially that
resolved. Did have an episode of resumed, increased abdominal
pain after consumption of KFC, likely due to brief opening of
anion gap and underlying gastroparesis. Lipase was normal. Mild
elevation of LFTs gradually resolved. Pt did not appear fluid
overloaded on exam. Patient's diarrhea resolved while in MICU
and as per above, developed appetite and was able to tolerate PO
medications/diet. Clostridium difficile toxin was sent and
negative
Acute on chronic renal failure. Pt was already in end stage
renal disease (stage 4) on admission. AV fisulta had been
recently placed for initiation of hemodialysis. In the setting
of profuse nausea, vomiting and diarrhea, there was also likely
a prerenal component to the bump in creatinine. Patient received
2L intravenous fluids in the ED and then approximately 4L to
manage his DKA. Patient did become hypertensive likely in this
setting. Patient was continued on calcitriol, calcium acetate,
and nephrotoxic medications were avoided. Renal followed the
patient during this admission and initiated hemodialysis with
good effect on his creatinine and volume status.
Anemia. Initially on arrival to the MICU, hematocrit was 20,
mildly below baseline of 25 and felt due to the combination of
iron deficiency and CKD. Patient did not have emesis or blood in
his stools. Patient was transfused one unit of pRBC with good
effect. He was continued on iron supplements and may benefit
from Epogen with hemodialysis in the future.
HTN. Poorly controlled, likely in the setting of initial acute
discomfort and later due to volume overload in the setting of
his ESRD and intravenous fluids for DKA. Patient was ultimately
transitioned to a regimen of Metoprolol 100mg twice daily,
Amlodipine 10mg daily and Hydralazine 50mg three times daily.
Fever. Mr. [**Known lastname 21822**] [**Last Name (Titles) 28316**] a fever to 100.9 on the night of
[**3-31**]. As discussed above, in the setting of recent
initiation of hemodialysis and pending blood cultures, the
patient was advised to remain in the hospital to be sure he was
afebrile for 24 hours, without signs or symptoms of infection,
and that his blood cultures remained negative. Mr. [**Known lastname 21822**]
refused, and signed out AGAINST MEDICAL ADVICE.
Medications on Admission:
Calcium Acetate 667 mg 2 tabs tid w/ meals
Amlodipine 10mg daily
Metoprolol succinate 100mg daily
Ferrous sulfate 1 tab daily
Calcitriol 0.25mcg daily
Hydralazine 25mg tid
Humalog SS
Lantus 15 units qAM
.
Allergies: Penicillins, Watermelon, Almond Oil
Discharge Medications:
1. Calcium Acetate 667 mg Capsule [**Known lastname **]: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
2. Amlodipine 5 mg Tablet [**Known lastname **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Hydralazine 25 mg Tablet [**Known lastname **]: Two (2) Tablet PO TID (3 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 50 mg Tablet [**Known lastname **]: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Insulin regimen
Please follow printout of insulin dosing (Humalog)
6. Insulin Glargine 100 unit/mL Solution [**Known lastname **]: Fifteen (15) units
Subcutaneous at bedtime.
Disp:*1 month supply* Refills:*2*
7. Calcitriol 0.25 mcg Capsule [**Known lastname **]: One (1) Capsule PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Viral Gastroenteritis
Diabetic Ketoacidosis
Diabetes Mellitus type 1
CKD stage V, requiring initiation of hemodialysis
Discharge Condition:
The patient is leaving AGAINST MEDICAL ADVICE given his recent
fevers, pending blood cultures, and recent initiation of
hemodialysis.
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
*LEAVING AGAINST MEDICAL ADVICE*
You were admitted to the hospital for nausea and vomiting.
While in the hospital, your sugars were elevated and you were
found to have Diabetic Ketoacidosis (DKA). You were treated
with an insulin drip and your DKA initially resolved. However,
you were not compliant with your diabetic diet and after eating
fried chicken you redeveloped signs of DKA requiring a second
insulin drip. You developed further episodes of DKA during your
hospitalization and each required insulin drip in the intensive
care unit. Additionally, during this hospitalization you were
initiated on hemodialysis which you will require three times a
week. You [**Known lastname 28316**] a fever on [**2-24**] and again on [**2-27**], and blood
cultures were taken to evaluate for any signs of blood
infection. These must be followed by your primary care doctor
or your outpatient nephrologist. Given your recent initiation
of hemodialysis and lengthy hospital course, we advise you to
remain in the hospital while we await the results of these
cultures. As you have decided to leave, it will be AGAINST
MEDICAL ADVICE as we strongly believe that you should continue
to be evaluated for signs and potential sources of infection
given your recent fevers. We want to ensure that you did not
have an active infection and do not have fevers over the next 24
hours.
We made the following changes to your home medications:
Hydralazine 50 mg TID (you were taking 25 mg TID prior)
Metoprolol Tartrate 100 [**Hospital1 **] (you were on a long acting
metoprolol once daily prior)
Please also follow the attached printout of sliding scale
insulin dosing based on your blood sugars.
Followup Instructions:
Appointment #1
MD: [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] ([**Company 191**] Post [**Hospital **] Clinic)
Specialty: Internal Medicine
Date/ Time: Monday, [**3-1**], 8:15am
Location: [**Location (un) **], [**Hospital Ward Name 23**] Building, [**Location (un) **] Central
Suite
Phone number: [**Telephone/Fax (1) 250**]
.
Appointment #2
MD: [**First Name8 (NamePattern2) 7208**] [**Last Name (NamePattern1) 978**]
Specialty: Endocrinology
Date/ Time: Tuesday, [**3-2**], 9 am
Location: [**Hospital **] Clinic
Phone number: [**Telephone/Fax (1) 2490**]
Apt # 3:
Social Work:
[**3-24**] at 12PM with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10927**], LICSW in [**Company 191**]
Please call [**Telephone/Fax (1) 250**] to cancel or change if needed
|
[
"250.43",
"V58.67",
"311",
"403.91",
"536.3",
"280.9",
"362.01",
"585.6",
"276.51",
"250.63",
"285.21",
"588.81",
"250.13",
"584.9",
"250.53",
"008.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10924, 10930
|
3117, 9782
|
333, 381
|
11112, 11246
|
2526, 3094
|
13103, 13909
|
1946, 1989
|
10084, 10901
|
10951, 10951
|
9808, 10061
|
11391, 12806
|
2004, 2507
|
12824, 13080
|
260, 295
|
409, 1294
|
10970, 11091
|
11260, 11367
|
1316, 1762
|
1778, 1930
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,122
| 109,038
|
20155
|
Discharge summary
|
report
|
Admission Date: [**2122-11-23**] Discharge Date: [**2122-12-6**]
Date of Birth: [**2050-8-14**] Sex: M
Service: CARDIAC
HISTORY OF PRESENT ILLNESS: This is a 72 year old white
male who has a new onset of left arm pain and nausea and
ruled out for an myocardial infarction. He was transferred
from the cardiac catheterization laboratory. He has a
history of hypertension and presented to the [**Hospital6 3426**] on [**11-21**] with left arm pain associated with nausea,
belching and flatus. He reports the pain awoke him from
sleep. He denies shortness of breath or palpitations. He
became pain free in the Emergency Room without intervention.
Initial enzymes were negative and the electrocardiograms had
no ischemic changes.
He underwent a spec MIBI on [**11-22**] which was suggestive of
infarction along the inferior wall. The patient remained
pain free and was transferred to [**Hospital1 190**] for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Status post excision of melanoma from the chest.
2. History of borderline hypertension.
3. History of gout.
4. History of allergic rhinitis.
5. Status post appendectomy.
6. Status post left hernia repair.
7. Status post bilateral rotator cuff surgery.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q. day.
2. Hydrochlorothiazide 25 mg p.o. q. day.
3. Protonix 40 mg p.o. q. day.
4. Probenecid 250 mg p.o. q. day.
5. Chondroitin.
REVIEW OF SYSTEMS: His review of systems is unremarkable.
SOCIAL HISTORY: He drinks three to four drinks per night.
He lives at home with his wife. [**Name (NI) **] smoked half a pack a day
and quit forty years ago.
PHYSICAL EXAMINATION: On physical examination, he is a well
developed, well nourished white male in no apparent distress.
Vital signs were stable. HEENT examination normocephalic,
atraumatic. Extraocular movements intact. Oropharynx
benign. Neck was supple, full range of motion, no
lymphadenopathy or thyromegaly. Carotids were two plus and
equal bilaterally without bruits. Lungs were clear to
auscultation and percussion bilaterally. Cardiovascular was
regular rate and rhythm with normal S1, S2 with no rubs,
murmurs or gallops. Abdomen was soft, nontender, with
positive bowel sounds, no masses or hepatosplenomegaly.
Extremities without cyanosis, clubbing or edema.
Neurological examination was non-focal. Pulses were two plus
and equal bilaterally throughout.
HOSPITAL COURSE: The patient underwent cardiac
catheterization on [**11-23**], which revealed that left ventricle
had one plus mitral regurgitation and had a normal ejection
fraction. The left main had a 60 to 70% ostial lesion and a
60% distal lesion. Left anterior descending had an ostial of
30% lesion, mid of 60% lesion, left circumflex was calcified
and occluded at the mid vessel and the right coronary artery
had proximal tapering with diffuse luminal irregularities to
a maximum stenosis of 30%.
Dr. [**Last Name (STitle) 70**] was consulted and on [**2122-11-25**], the patient
underwent a coronary artery bypass graft times two with left
internal mammary artery to the left anterior descending and
reverse saphenous vein graft to obtuse marginal 1.
Crossclamp time was 37 minutes. Total bypass time 52
minutes. He was transferred to the CSRU on Neo-Synephrine
and Propofol in stable condition.
He had a stable postoperative night and he was extubated. He
became confused on postoperative day number two. He was on
neo-synephrine which was weaned off. He also had a
temperature to 101.8 F. He was cultured. He was started on
beer. On postoperative day three, he had his chest tubes
discontinued. He also was in atrial fibrillation.
He had a tachy-brady syndrome and they recommended observing
him. He also had some atrial fibrillation and was started on
amiodarone no acute distress converted to sinus rhythm. He
was transferred to the floor on postoperative day number five
and electrophysiology saw him again and recommended
discontinuing the amiodarone due to his bradycardic episodes,
and he also was anti-coagulated with heparin and then
Coumadin. He had his wires discontinued on postoperative day
number six.
He continued to slowly progress. He had some nausea from
percocet and was changed to Dilaudid and tolerated that
better and worked with Physical Therapy, and was discharged
to home on postoperative day number ten in stable condition.
His labs on discharge were white blood cell count of 15,600,
hematocrit of 27.8, platelets 787,000. Sodium 136, potassium
4.6, chloride 101, carbon dioxide 27, BUN 16, creatinine 1.2,
blood sugar 111. His INR was 3.5.
DISCHARGE MEDICATIONS:
1. Lasix 40 mg p.o. twice a day.
2. KayCiel 20 mEq p.o. twice a day.
3. Colace 100 mg p.o. twice a day.
4. Aspirin 325 mg p.o. q. day.
5. Zantac 150 mg p.o. q. day.
6. Thiamine 100 mg p.o. q. day.
7. Folate 1 p.o. q. day.
8. Multivitamin one p.o. q. day.
9. Coumadin 2 mg and titrate for an INR of 2.0 which will be
followed by Dr. [**Last Name (STitle) 18323**].
DISCHARGE INSTRUCTIONS:
1. The patient will be seen in one to two weeks by Dr.
[**Last Name (STitle) 18323**].
2. The patient will be seen in six weeks by Dr. [**Last Name (STitle) 70**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 50176**]
MEDQUIST36
D: [**2122-12-4**] 19:07
T: [**2122-12-4**] 20:13
JOB#: [**Job Number 54178**]
|
[
"427.81",
"E878.2",
"414.01",
"599.0",
"427.31",
"E849.7",
"274.9",
"401.9",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.56",
"36.11",
"36.15",
"37.22",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
4703, 5077
|
1317, 1477
|
2496, 4680
|
5101, 5572
|
1722, 2477
|
1497, 1537
|
171, 960
|
982, 1291
|
1554, 1698
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,776
| 137,906
|
14586
|
Discharge summary
|
report
|
Admission Date: [**2129-10-23**] Discharge Date: [**2129-11-22**]
Date of Birth: [**2057-10-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tegretol / Spironolactone
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
urinary retention x 1 week
fevers x 2 days
Major Surgical or Invasive Procedure:
[**11-3**] Left septic hip wash out
[**11-3**] Intubation
[**11-16**] Extubation
[**11-18**] Thoracentesis
History of Present Illness:
72 year-old male with diastolic heart failure, AVR, AF on
coumadin, CAD, pulmonary hypertension, CHB s/p PPM, and severe
COPD admitted with weight gain, urinary retention, and fever.
Son at bedside provides majority of history. Famiy noted weight
up to be up by approximately 5lb yesterday morning (baseline
~148) - discussed with patient's PCP, [**Name10 (NameIs) 1023**] recommended metolazone
2.5mg IV x1 with Lasix. Also, difficulty with Lasix
administration time - receiving 2 doses 5 hours apart rather
than every 12 hours over past 1 week. Patient with no salt diet,
and strict fluid restriction to 1.75 liter per day.
.
Over past day had increasing difficulty with urination.
Yesterday took [**7-16**] attempts at a time before he was able to
urinate, and then only small amounts. Also with fever to 100.8
this morning. Decreased PO intake today. Patient presented to ED
for further evaluation.
.
Of note, inpatient [**Date range (1) 43020**] with COPD exacerbation and acute
on chronic diastolic heart failure. Received
steroids/antibiotics; Lasix 120mg IV BID (continued at
discharge). Medication changes included adding prednisone taper,
azithromycin, and ipratropium.
.
In the ED, 100.7 63 99/44 16 97% 2L NC. Physical examination
notable for midline site without erythema; well-appearing male.
Sons at bedside. Laboratory data significant for creatinine 1.9,
hematocrit 36.4, WBC 7.9 with left shift, lactate 2.6; UA within
normal limits. Urine culture, blood culture x2 sent. CXR 2V with
with fluid overload, ?RLL pneumonia. EKG with v-paced, similar
to prior. Discussed with cardiology; troponin elevation likely
related urinary retention; recommend no intervention at this
time. Foley placed with 600cc 0> 1L output. Received Lasix 120mg
IV per home regimen, vancomycin IV, and levofloxacin IV. On
transfer to medicine service, 102.3, 117/66, 74, 20, 100% 2L.
.
On the floor, patient able to participate in full review of
systems. Reports feeling relief after Foley placement. He is
without night sweats, headache, visual changes, sinus
congestion, cough, sore throat, chest pain, palpitations,
abdominal pain, nausea, vomiting, dysuria. He has constipation.
No skin rashes.
Past Medical History:
CADs/p 2V CABG
HTN
HLD
Severe diastolic CHF (EF >60% [**2129-2-7**])
Pulmonary Hypertension
A fib on coumadin
Hx of 3rd degree block s/p PPM, currently V-paced
Hx of AS s/p AVR with [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] Mechanical Valve ([**2116**])
COPD
Hx of CVA c/b seizure DO, on lamictal
Diet-controlled DM
Chronic Kidney Injury
-Chronic lethargy and confusion with concern for Dementia
-Focal disection of abd aorta - noted CT abdomen [**2126-10-16**]-
unchanged from [**2124**]
-BPH (no difficulty voiding)
-s/p L ORIF and THR [**9-/2128**]
Social History:
He currently lives with wife and son in a two story home. He is
a retired newpaper journalist; He moved to the U.S.A. in [**2098**],
but returned to [**Country 11150**] to work. He returned here permanently in
[**2120**]. He does not currently smoke, but quit 10 years ago with an
80 pack year history.
Family History:
There is a family history of CAD. All sisters and brothers are
deceased.
Physical Exam:
Admission PE:
99.6, 120/59, 65, 18, 97%3L
General: Alert; comfortable; at times with pain when moving left
leg (he and son report chronic after hip surgery last year)
HEENT: Sclera anicteric, dry mucous membranes
Neck: Supple - flexion, extension without difficulty; bounding
venous pulsation
Lungs: Crackles to mid-lung fields bilaterally; no wheezes or
rhonchi appreciated
CV: Irregularly irregular; normal S1; pronounced S2; no murmurs
appreciated
Abdomen: Hypoactive bowel sounds; soft, nontender, and not
distended
Ext: Thin; venous stasis changes; faint lower extremity pulses;
no lower extremity edema; no erythema or swelling noted at left
hip
Neuro: No facial droop noted; squeezes both hands equally,
reduced ([**4-11**]); moves lower extremities
Skin: No erythema/drainage noted at RUE midline site
.
Discharge PE:
98.6, BPs ranging from high 70s systolic to 120s with diastolics
ranging from 40s-60s, HR=60s, RR=20, POx=100% 3L NC
General: Confused at times, A+Ox1-2 (person and sometimes place)
Pertinent Results:
Pertinent Labs:
[**2129-11-22**] 02:40AM BLOOD WBC-12.7* RBC-2.72* Hgb-7.9* Hct-24.5*
MCV-90 MCH-29.0 MCHC-32.2 RDW-20.1* Plt Ct-201
[**2129-11-22**] 02:40AM BLOOD PT-16.8* PTT-40.0* INR(PT)-1.5*
[**2129-11-22**] 02:40AM BLOOD Glucose-60* UreaN-83* Creat-2.9* Na-138
K-3.5 Cl-100 HCO3-31 AnGap-11
[**2129-11-22**] 02:40AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.1
[**2129-11-22**] 05:59AM BLOOD Vanco-14.2
.
[**11-4**] ECHO: The left atrium is markedly dilated. The right
atrium is markedly dilated. The estimated right atrial pressure
is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. The
right ventricular free wall is hypertrophied. The right
ventricular cavity is mildly dilated with depressed free wall
contractility. A bileaflet aortic valve prosthesis is present.
The transaortic gradient is higher than expected for this type
of prosthesis. The mitral valve leaflets are mildly thickened.
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. 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.
.
[**11-20**] Left shoulder and elbow X-ray:
CLINICAL INFORMATION: Limited shoulder motion after extubation
FINDINGS:
Four total images are obtained including the humerus and elbow.
There are
mild degenerative changes of the acromioclavicular joint and
glenohumeral
joint. No fracture is identified in the humerus. Within the
elbow, there are mild degenerative changes without fracture
noted.
.
[**11-21**] CXR: FINDINGS: In comparison with the study of [**11-20**],
there is again a tiny right apical pneumothorax. The overall
appearance of heart and lungs is essentially unchanged. The
nasogastric tube has been removed.
Brief Hospital Course:
Medical Floor Course [**Date range (1) 43021**]:
#. MRSA bacteremia:
Mr. [**Known lastname 43019**] was started on vancomycin and cefepime on arrival to
the floor [**10-24**]. Infectious source was considered [**Last Name (un) **] PNA vs.
sacral and LE ulcers. He was found to have high grade MRSA
bacteremia with 6/6 positive blood cultures from the ED ([**10-23**],
19/18, and [**10-25**]). ID was consulted and the midline was pulled
on hospital day 2 ([**10-25**]). Daily blood cultures were drawn for
evidence of clearing of infection. Bacteremia was thought to be
due to a transietn bacteremia likely from his sacral stage IV
decubitus ulcer or other cutaneous entry point, with the midline
serving as a nidus for rapid replication. Pneumonia was
considered to be another, less likely source of bacteremia. On
the evening of [**10-25**] cefepime was stopped due to low suspicion
for pneumonia and he was started on gentamycin at 0.5mg/kg ([**1-8**]
normal dose due to chronic kidney disease) for empiric
endocarditis treatment. TEE was performed on [**10-27**] to look for
valvular vegetations and showed no vegetations, and left atrial
appendage thrombus could not be ruled out. CT chest was
performed to look for evidence of pneumonia. Given back and hip
pain, plain XRay of his hip was performed on admission and
showed no obvious fracture, though could not rule out fracture
of greater trochanter. CT back and hip were performed [**10-26**] to
look for evidence of osteomyelitis or spinal cord compression
given urinary retention and back pain (though neuro exam showed
intact, symmetric reflexes and strength and normal perianal
sensation), or florid abnormality of hip prosthesis, as Mr.
[**Known lastname 43019**] was not a candidate for MRI due to pacemaker and not
considered candidate for joint aspiration given multiple medical
comorbities, fragile skin, and florid bacteremia. Vancomycin was
continud for the MRSA.
.
# Left hip pain:
Mr. [**Known lastname 43019**] reported intermittent left hip and leg pain and muscle
spasms. Plain x-ray on admission negative for fracture though
left trochanter could not be evaluated. CT on [**10-27**] no obvious
fluid collection, unable to evaluate hip given streak. Could
not get MR due to pacemaker. On [**10-28**] he was evaluated by his
orthopedic surgeon Dr. [**Last Name (STitle) **] and his team and it was decided
that he should undergo emergent aspiration of his left hip joint
due to concern for septic joint. His left hip was aspirated
under IR guidance on [**10-28**] and showed MRSA. He was taken to the
OR by orthopedic surgery for prosthetic hip replacement on [**11-3**]
and tolerated the procedure but was unable to be extubated and
was transferred to the ICU Please see MICU course below.
.
# Urinary retention: U/A and urine culture were negative. Known
BPH + retention likely precipitated by ipratropium (new med as
of 1 month prior admission) and lasix dosing every 5 instead of
[**8-16**] hours. continued on home flomax. Hold anticholinergics.
Foley placed ([**10-24**] - ). Home Lasix; Cr and BUN bump with
diuretics. CTM.
.
#. Decompensated diastolic heart failure: Lasix 120mg IV BID
goal 500cc to 1L daily, beta-blocker, aspirin, statin
.
#. CAD: s/p 2V CABG. Troponin above baseline at admission,
trending down, decreased clearance.
.
#. Atrial fibrillation s/p PPM placement for 3rd degree CHB: Mr.
[**Known lastname 43019**] was maintained on coumadin and heparin gtt drip for
coumadin. b-blocker held due to SBPs in 90s. She was seen by
electrophysiology on [**10-25**] who interrogated his pacemaker and
reset it so that it would have decreased variation with
activity, as it had detected his tremors and artificially
elevated his heart rate. On the morning after it was reset,
Creatinine improved to 1.7 from 1.9 despite aggressive diuresis
with lasix and an increase in his sodium to a max of 148. TTE
was performed on [**10-26**] to look for preliminary signs of
endocarditis while awaiting TEE and also to assess for
improvement in EF s/p pacemaker adjustment.
.
#. Aortic stenosis s/p AVR: INR subtherapeutic on admission.
Heparin gtt was started with goal PTT 60-100.
.
# COPD: O2 was weaned. O2 sats ranged from 96-100% on room air.
Holding anticholinergics
.
MICU course [**Date range (1) 43022**]:
.
# Respiratory failure: He was intubated for his left septic hip
washout and could not be extubated after the surgery for several
reasons. The cause was likely bacteremia with ARDS as well as
multifocal pneumonia, diastolic heart failuure (volume
overload), and COPD. Vancomycin was continued, ceftazidime, and
metronidazole were added. Sputum also grew mutli drug resistant
pseudomonas initially susceptible to ceftazidime. He was
intermittently able to tolerate pressure support ventilation,
but his poor mental status remained a barrier to extubation.
Later, his daily CXR started to improve, and his mental status
cleared. He remained net quite positive for his length of stay
in the ICU, so aggressive diuresis with a lasix drip was begun
to improve his chances for a successful extubation. He was
extubated on [**11-16**] without difficulty with good O2 Sats on 2-3L
NC. He was also changed lasix 80mg [**Hospital1 **] IV dosing. He completed
a 14 day course of the ceftazidime which was then stopped.
.
# Hypotension: While intubated on a lasix gtt, norepinephrine
gtt was started to support blood pressure. He continued to
require this after extubation while on a lasix gtt, but it was
discontinued once the lasix drip was stopped. When the Lasix
drip was titrated off, he continued to have ample urine output
on [**Hospital1 **] Lasix IV bolus doses despite systolic blood pressures
that occasionally fell into the 70s.
# Prevotella bacteremia: He grew [**4-10**] blood cultures positive
for prevotella. Flagyl was continued for a total 14 day course
and then stopped.
.
#. Acute renal failure: Baseline creatinine 1.5 to 2.0. BUN
high. ACEi held on admission. Creatinine slowly climbed to 3.9.
Renal was consulted and felt that this was likely ATN from his
previous hypotension. He was started on levophed to increase
MAPs while on lasix gtt. He put out copious amounts of urine
and creatinine downtrended on the lasix gtt and continued to
trend down after it was stopped. Creatinine was down to 2.9
upon discharge and has been improving slowly with diuresis. His
vanco levels should be monitored frequently given his improving
renal function and his vanco should be dosed to keep his levels
between 15-20.
.
#. Aortic stenosis s/p AVR: INR subtherapeutic on admission.
Heparin gtt was started with goal PTT 60-100. Later, he was
bleeding slightly into his lung and into his GI tract, and his
PTT goal was adjusted to 40-60. When he stabilized, coumadin
was restarted at a lower dose with a goal INR 1.8-2.2. His goal
PTTs on his heparin drip should remain in the 50-70 range until
his INR becomes therapeutic.
.
# COPD: He was given a steroid course for the COPD component of
his respiratory failure. These were tapered and stopped. Upon
discharge, his home inhaled steroids were restarted.
.
# Goals of care: After extensive discussions, Mr. [**Known lastname 43023**]
family decided that he would be DNR but OK to re-intubate.
Medications on Admission:
Metolazone 2.5mg IV prn - last dose yesterday morning
Aspirin 81mg PO daily
Dorzolamide 2% One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day)
Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day)
Furosemide Sig: 120 mg Intravenous twice a day.
Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
Potassium Chloride 20 mEq Packet Sig: Two (2) PO twice a day.
Sildenafil 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4PM:
please alternate with 3 mg (dosing varies with INR).
Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO bid ().
Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet
PO DAILY (Daily).
Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One
(1) Cap Inhalation DAILY (Daily).
Multivitamin Oral
Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: 2
puffs Inhalation four times a day as needed for shortness of
breath or wheezing - has not used over past 24 hours
Travatan Z 0.004 % Drops Sig: One (1) drop Ophthalmic at
bedtime: into each eye.
Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day)
as needed for constipation
Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig:
One (1) Tablet Sustained Release 24 hr PO once a day.
Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet
PO BID (2 times a day).
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. sildenafil 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. lamotrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
9. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
11. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) g PO DAILY (Daily) as needed for constipation.
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB/wheeze.
13. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
14. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
15. quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia, agitation.
16. Furosemide 80 mg IV BID
17. heparin drip
Please continue at 800 units per hour and adjust for goal PTT
50-70
18. insulin
Please use attached humalog sliding scale.
19. Labs
Please do CBC with differential and basic metabolic panel faxed
to [**Telephone/Fax (1) 1419**] on [**11-27**], two days prior to his infectious
disease appointment.
20. vancomycin 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous every other day: Please adjust dosing for goal level
15-20. This will continue at least until he follows up with
infectious disease clinic on [**11-29**].
21. Flovent HFA 220 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day.
22. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a
day.
23. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
24. multivitamin Tablet Sig: One (1) Tablet PO once a day.
25. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: One (1) Inhalation four times a day as needed for
shortness of breath or wheezing.
26. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
27. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: MRSA and Prevotella bacteremia, Pseudomonas pneumonia,
MRSA prosthetic joint infection s/p surgical washout, COPD
exacerbation, Diastolic CHF
.
Secondary: Atrial fibrillation, pulmonary hypertension, CAD s/p
CABG, type II diabetes mellitus, chronic kidney injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You came to the hospital because of an infection in your hip and
your blood. You were treated with antibiotics and required a
surgery to wash out the infection from your prosthetic hip.
After the surgery, you were unable to be extubated for a
prolonged period of time until your lung status was optimized
from an infection, fluid, and COPD perspective. Your kidneys
also suffered injury due to your infections which continues to
improve slowly.
Followup Instructions:
Please follow up with all of your outpatient medical
appointments listed below:
.
1) Cardiology: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2129-11-28**] 2:30
.
2) Infectious Disease: Dr [**Last Name (STitle) 2688**] Phone([**Telephone/Fax (1) 43024**] - [**Hospital **]
medical building basement. [**11-29**] at 3:10 PM. Please do CBC
with differential and basic metabolic panel faxed to
[**Telephone/Fax (1) 1419**] two days prior to this appointment.
.
3) Orthopedics - ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2129-12-6**] 12:40. Then follow up with provider: [**First Name11 (Name Pattern1) 2191**]
[**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2129-12-6**] 1:00
|
[
"518.5",
"996.66",
"491.21",
"V02.54",
"600.01",
"V43.64",
"999.31",
"V53.31",
"482.1",
"511.9",
"416.8",
"E878.1",
"038.12",
"933.1",
"250.02",
"V43.3",
"V45.81",
"995.92",
"585.9",
"707.07",
"348.31",
"584.5",
"707.03",
"564.00",
"428.0",
"428.33",
"788.20",
"441.02",
"E912",
"707.24",
"707.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"88.72",
"80.05",
"96.72",
"33.24",
"84.56",
"38.97",
"34.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
18323, 18393
|
6632, 13926
|
344, 453
|
18710, 18710
|
4726, 4726
|
19361, 20185
|
3609, 3683
|
15764, 18300
|
18414, 18689
|
13952, 15741
|
18890, 19338
|
3698, 4510
|
4524, 4707
|
262, 306
|
481, 2673
|
18725, 18866
|
4742, 6609
|
2695, 3272
|
3288, 3593
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,413
| 136,989
|
36254
|
Discharge summary
|
report
|
Admission Date: [**2136-5-6**] Discharge Date: [**2136-5-9**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo M s/p unwitnessed fall at home fell down approximately 5
stairs. Lives at home with his wife. Reportedly these was + LOC.
Patient has a history of mild dementia, but appeared to be at
his basline after his fall per family reports. He was
transported to [**Hospital1 18**] Emergency room where he complained shoulder
and neck pain.
Past Medical History:
Diabetes mellitus
Hypertension
Dementia
Social History:
Lives at nursing home
Family History:
Noncontributory
Physical Exam:
Upon admission:
T:98.3 BP: 185/99 HR:82 R:20 O2Sats: 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic, atraumatic. Well-healed scar to the left
neck(?CEA). No hemotympanum
Pupils: PERRL EOMs intact
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, not date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,5mm to
3 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-1**] throughout. Unable to perform
pronator drift secondary to left shoulder pain
Sensation: Intact to light touch
Pertinent Results:
[**2136-5-7**] 01:38AM BLOOD WBC-11.0 RBC-3.41* Hgb-10.7* Hct-30.0*
MCV-88 MCH-31.4 MCHC-35.7* RDW-12.8 Plt Ct-262
[**2136-5-7**] 01:38AM BLOOD PT-14.3* PTT-25.0 INR(PT)-1.2*
[**2136-5-7**] 01:38AM BLOOD Glucose-167* UreaN-14 Creat-1.0 Na-138
K-3.6 Cl-99 HCO3-27 AnGap-16 Calcium-9.0 Phos-2.7 Mg-2.0
CT Head [**2136-5-6**]
IMPRESSION:
Small left frontoparietal subarachnoid hemorrhage and tiny
amount of
intraventricular hemorrhage within the occipital [**Doctor Last Name 534**] of the
right lateral
ventricle. No mass effect or shift of normally midline
structures.
Repeat CT head [**2136-5-7**]
IMPRESSION:
1. No interval change in small amount of subarachnoid hemorrhage
within the left frontal and parietal cortical sulci with
layering hemorrhage within the occipital [**Doctor Last Name 534**] of the right
lateral ventricle.
2. Increased prominence of the left extra-axial space compared
to prior
study, may represent a hygroma.
Brief Hospital Course:
He was admitted to the Trauma surgery service with a small
subarachnoid hemorrhage with intraventricular hemorrhage; left
scapular fracture and multiple rib fractures. He was transferred
to the Trauma ICU for close monitoring.
He was evaluated by Neurosurgery, serial head CT scans were
followed and remained stable. It was recommended that the
aspirin he was prescribed be withheld for 1 month. Follow up in
4 weeks with Neurosurgery in clinic; repeat head CT scan will be
done prior to this appointment.
Orthopedics was consulted as well for evaluation of his scapular
fracture and recommended non-operative management. A sling is to
be worn for comfort and he is to remain non weight bearing on
that extremity. Follow up in 2 weeks in [**Hospital 5498**] clinic.
He was transferred from the ICU to the floor on hospital day 2.
Physical therapy evaluated him and recommended rehabilitation
after discharge.
Geriatrics was consulted and guided a syncope workup, which was
negative. Several medication recommendations were made which
included Tylenol, low dose prn Oxycodone for pain and bowel
regimen.
Medications on Admission:
ASA 162 mg, Centrum, Metformin 50 mg [**Hospital1 **], Lisinopril 20 mg,
Aricept 5 mg, Lumigan 0.003% OU HS, Trusopt 2% OU [**Hospital1 **]
Discharge Medications:
1. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Aricept 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
bowel movements.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain.
11. Oxycodone 5 mg/5 mL Solution Sig: 2.5-5 MG PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
Ledgewood
Discharge Diagnosis:
s/p Fall
Subarachnoid hemorrhage and intraventricular hemorrhage
Left acromial fracture
Left sided rib fractures
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
Hold aspirin for one month secondary to subarachnoid hemorrhage.
DO NOT bear any weight on your left arm. Wear sling for comfort
on left arm.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery in 2 weeks for
evaluation of your rib fractures. Please call [**Telephone/Fax (1) 2359**] for
an appointment.
Follow up with Dr. [**First Name (STitle) **] (neurosurgery) in 4 weeks. You will
need a repeat head CT prior to your visit so please inform the
office of this. Call ([**Telephone/Fax (1) 88**] to set up the appointment.
Follow up with Orthopedics in 4 weeks. You will need repeat
x-rays of your shoulder prior to your visit. Call ([**Telephone/Fax (1) 15940**] to set up an appointment.
Completed by:[**2136-6-12**]
|
[
"276.51",
"250.00",
"401.9",
"807.03",
"294.8",
"811.01",
"E880.9",
"564.09",
"852.02",
"V12.54",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5212, 5248
|
2943, 4054
|
267, 274
|
5405, 5486
|
1978, 2920
|
5679, 6277
|
775, 792
|
4244, 5189
|
5269, 5384
|
4080, 4221
|
5510, 5656
|
807, 809
|
219, 229
|
302, 657
|
1286, 1959
|
824, 1034
|
1049, 1270
|
679, 720
|
736, 759
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,071
| 169,620
|
33960
|
Discharge summary
|
report
|
Admission Date: [**2103-4-4**] Discharge Date: [**2103-4-7**]
Date of Birth: [**2053-11-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
1. Colonoscopy
History of Present Illness:
49 y.o. M with no PMHx here with sudden GIB @ 5 pm today.
Describes acute onset of stomach grumbling which progressed to
gross blood per rectum. Episode resolved but then recurred
second time so patient presented to [**Location (un) **] ED where he was
having profuse LGIB. Denies any h/o previous GI bleeding,
melena, recent sick contacts, aspirin use, personal or family
history of IBD, abdominal pain, fevers or other complaints.
Took couple days of motrin couple weeks ago for neck pain.
.
At [**Location (un) **], BP 180/109, HR 92. Hct 42 on presentation. Given 3
units PRBC's and additional 2L IVF's with repeat hct of 40.
Course notable for transient non-responsiveness for 1-2 minutes
in setting of bradycardia to 30's. This occurred while at rest
1-2 minutes after moving his bowels. Patient describes feeling
nauseated and then light headed and then syncopized - aroused
with sternal rub. Given atropine for bradycardia and improved
accordingly. Not hypotensive at any point. Started on IV PPI.
Transferred to [**Hospital1 18**] for management.
.
In ED 99.2, 95, BP 161/107, RR 25, O2 93% RA. Patient given one
additional Liter NS. Anoscopy demonstrated blood in rectal
vault, fresh clot, internal hemorrhoids but no active bleeding
lesion. Admitted to ICU for management.
.
EKG nl, CXR normal, 3 PIV, PPI [**Hospital1 **] today (one at [**Location (un) **]).
Past Medical History:
None
Social History:
Software engineer, no-tobacco, 2 glasses wine per day.
Family History:
No family history of crohn's, UC, early colon cancer.
Physical Exam:
Vital Signs as of [**2103-4-5**] 02:35 AM
Tmax: 36.1 ??????C (97 ??????F)
Tcurrent: 36.1 ??????C (97 ??????F)
HR: 73 (69 - 73) bpm
BP: 151/35(67) {136/35(67) - 151/87(100)} mmHg
RR: 19 (15 - 19) insp/min
SpO2: 95%
Heart rhythm: SR (Sinus Rhythm)
Height: 64 Inch
O2 Delivery Device: Nasal cannula
SpO2: 95%
Physical Examination
General Appearance: Well nourished
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t)
S3, No(t) S4, (Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Wheezes : )
Extremities: Right: Absent, Left: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): X 3, Movement: Not assessed,
Tone: Normal
Pertinent Results:
[**2103-4-4**] 09:15PM BLOOD WBC-12.2* RBC-4.67 Hgb-14.6 Hct-40.3
MCV-86 MCH-31.3 MCHC-36.2* RDW-13.0 Plt Ct-168
[**2103-4-4**] 09:15PM BLOOD Neuts-86.8* Bands-0 Lymphs-9.2* Monos-3.6
Eos-0.3 Baso-0.1
[**2103-4-4**] 09:15PM BLOOD PT-13.1 PTT-20.9* INR(PT)-1.1
[**2103-4-4**] 09:15PM BLOOD Glucose-127* UreaN-18 Creat-0.9 Na-141
K-4.2 Cl-110* HCO3-21* AnGap-14
[**2103-4-4**] 09:15PM BLOOD ALT-16 AST-15 LD(LDH)-169 AlkPhos-55
TotBili-1.2
[**2103-4-4**] 09:15PM BLOOD Lipase-37
[**2103-4-4**] 09:15PM BLOOD Calcium-7.5* Phos-3.5 Mg-1.8
==========
Colonoscopy [**2103-4-6**]
Indications: Lower GI bleed
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. The
efficiency of a colonoscopy in detecting lesions was discussed
with the patient and it was pointed out that a small percentage
of polyps and other lesions can be missed with the test. A
physical exam was performed. The patient was administered
conscious sedation. The patient was placed in the left lateral
decubitus position and the colonoscope was introduced through
the rectum and advanced under direct visualization until the
cecum was reached. Careful visualization of the colon was
performed as the colonoscope was withdrawn. The colonoscope was
retroflexed within the rectum. The procedure was not difficult.
The quality of the preparation was good. The patient tolerated
the procedure well. The digital exam was normal. There were no
complications.
Findings:
Protruding Lesions Small grade 2 internal hemorrhoids were
noted.
Excavated Lesions Multiple non-bleeding diverticula were seen
in the sigmoid colon.Diverticulosis appeared to be of moderate
severity.
Impression: Grade 2 internal hemorrhoids
Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum
Recommendations: 1. No active bleeding noted.
2. Follow Hct
Additional notes: The efficiency of colonoscopy in detecting
lesions was discussed with the patient. It was explained that
colon cancer and colon polyps on rare occasions may be missed
during a colonoscopy.The procedure was done with attending
physician and GI fellow.
Brief Hospital Course:
49 yom presents with lower GIB c/w diverticulosis and syncopal
episode in [**Location (un) **] ED.
Gastrointestinal bleed - Hct of 40 s/p 3 units suggests patient
had significant bleed as did not bump. Most likely Lower
diverticular GIB, or internal hemorrhoidal bleeding. Less
likely colitis given absence of abdominal pain, and benign exam.
Possibly angiodysplasia of the colon. Agree with plan for
colonoscopy to evaluate for source of bleeding and control of
any active bleeding source. Would continue to monitor with
serial hct's overnight although patient stable on exam now, w/o
tachycardia, orthostasis, or other signs of volume depletion.
- check hct q4hours
- 2 large bore IVs
- active type and screen
- appreciate GI recs
- prep tonight for scope w/ Golytely
- Transfuse for Hct < 30
- Patient underwent colonoscopy [**4-6**] without evidence of active
bleeding, both simoid diverticulosis and internal hemorrhoids
were noted, etiology of GI bleed unclear.
- [**Name2 (NI) **] advised to start daily aerobic exercise, fiber
supplements, and plenty of water for both diverticulosis and
hemorrhoids.
Syncope - Apparent vagal episode that responded to atropine in
setting of bowel movement. Could also have been hypotensive
episode from acute bleed. Low suspicion for cardiac or
neurological cause such as seizure for syncopal episode.
- Monitor on telemetry.
- Not orthostatic by BP/HR on admission to ICU.
- Managemento of LGIB as above.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
1. Gastrointestinal bleeding
2. Sigmoid diverticulosis
3. Internal hemorrhoids
Discharge Condition:
Stable
Discharge Instructions:
Please contact your primary care physician if you develop any
bleeding in your stool, lightheadedness, palpitations, or
shortness of breath.
You can try to reduce the chances of another episode of
gastrointestinal bleeding by taking fiber supplements (to a goal
of 30 grams of fiber per day), plenty of fluids for the fiber,
and also daily aerobic exercise.
Followup Instructions:
Make a follow up appointment with your primary care physician,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12982**] ([**Telephone/Fax (1) 78441**].
|
[
"780.2",
"455.0",
"285.1",
"578.1",
"562.10",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
6741, 6747
|
5198, 6657
|
320, 337
|
6870, 6879
|
2965, 5175
|
7286, 7488
|
1868, 1923
|
6712, 6718
|
6768, 6849
|
6683, 6689
|
6903, 7263
|
1938, 2946
|
275, 282
|
365, 1752
|
1774, 1780
|
1796, 1852
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,216
| 163,308
|
8817
|
Discharge summary
|
report
|
Admission Date: [**2154-4-30**] Discharge Date: [**2154-5-10**]
Date of Birth: [**2109-2-28**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
DM I, admitted for pancreas transplant
Major Surgical or Invasive Procedure:
[**2154-5-1**] Implantation of pancreatic allograft
[**2154-5-1**] Exploratory laparotomy, explantation of pancreatic
allograft
[**2154-5-1**] Right common iliac artery thrombectomy endarterectomy
and bovine patch angioplasty.
History of Present Illness:
44 y/o man with DM I with h/o ESRD who underwent a LRRT
from his father on [**2151-10-26**]. [**Name2 (NI) **] done well since that time.
Creatinine usually runs 1.7-2.2. He has been well. Glucoses have
been in 2-300s. Does experience hypoglycemic unawareness at
times. Did fall last Saturday while carrying packages and
scraped
left tibial area. Applied bacitracin to area. Now scabbed.
Denies infections, fever,chills, nausea, vomiting, chest pain,
sob, abd pain, dysuria, constipation, diarrhea. Last BM today.
NPO since 11am.
Past Medical History:
diabetes, retinopathy, vitrectomy, hypertension, and
hypercholesterolemia.
history of anxiety
history of pertoneal dialysis s/p cath placement, repostioning
and removal
Social History:
Lives with by himself. His mother and father help. [**Name2 (NI) **] a 4 y.o.
dtr. Currently not working
Smoking history, no other current substance abuse noted
Family History:
parents in their 60s: alive and well, father with hypertension
sister with hepatitis (HepC?)
Physical Exam:
98.4 HR 78 123/81 18 98%RA wt 70 kg
A&O, NAD
ENT: normal pharynx, dentition good
Neck no LAD
Lungs clear
Cor RRR, no murmur
abd well healed LLQ kidney transplant incision, non-tender,
non-distended, normal bowel sounds
ext no edema. 2 + DPs,
Skin L tibial area with scabbed areas and slight erythema at
border of scabs. No drainage
Labs: K 6.1 (not hemolyzed), creatinine 1.8, gluc 364
EKG : NSR (unchanged from previous)
CXR Pending
HLA spec sent to [**Hospital1 112**]
Stress Test [**11-16**] normal, EF 66%
Pertinent Results:
[**2154-5-10**] 04:45AM BLOOD WBC-8.6 RBC-3.41* Hgb-10.0* Hct-29.6*
MCV-87 MCH-29.3 MCHC-33.9 RDW-13.7 Plt Ct-636*
[**2154-5-6**] 04:00AM BLOOD PT-12.4 PTT-22.5 INR(PT)-1.0
[**2154-5-5**] 05:00AM BLOOD Glucose-259* UreaN-19 Creat-1.3* Na-134
K-4.0 Cl-98 HCO3-26 AnGap-14
[**2154-5-9**] 04:40AM BLOOD Glucose-58* UreaN-22* Creat-2.4* Na-138
K-3.9 Cl-97 HCO3-28 AnGap-17
[**2154-5-10**] 04:45AM BLOOD Glucose-101* UreaN-18 Creat-2.1* Na-141
K-4.2 Cl-102 HCO3-30 AnGap-13
[**2154-5-10**] 04:45AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2
[**2154-5-10**] 04:45AM BLOOD tacroFK-8.4
Brief Hospital Course:
He was admitted to the Transplant Service and underwent pancreas
transplant on [**2154-5-1**]. A drain was left in place. Surgeon was
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Postop, his foot became cool and pulseless over a
few hours and he was taken emergently back to the OR. Surgeon
was [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. The iliac artery was found to have thrombosed as
well as the pancreatic allograft. Transplant pancreatectomy with
jejuno-jejunostomy was performed then the case was turned over
to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] who performed right common iliac artery
thrombectomy endarterectomy and bovine patch angioplasty of RCIA
for cold right leg in setting of RCI dissection. Please refer to
operative notes for complete details. Postop, he was sent to the
SICU for management.
A heparin drip was started, but stopped for hct drop (35 to 23).
He was transfused with PRBC. Serial Hct then remained stable
and heparin drip was resumed on [**5-3**]. Right leg dorsalis pedis
was dopplerable, and PT/[**Doctor Last Name **] pulses were palpable. RLE NIAS
-demonstrated mod art outflow dx at SFA, mild to mod outflow dx
on Lt at [**Doctor Last Name **]
Angiography was considered, but then deferred as this was felt
to not be indicated. He was extubated with stable O2 sats on
nasal cannula.
CK was elevated due to ischemia and muscle necrosis. Hydration
continued and CKs were trended until peaks declined.
NGT was left to low to continuous suction and he was kept NPO.
Protonix was given for stress ulcer prophylaxis. NG tube
remained until [**5-6**]. Insulin gtt was required until diet was
advanced then SQ insulin was resume with [**Last Name (un) 9718**]
recommendations. Diet was slowly advanced. He did pass stool,
but then became distended again with nausea and vomiting on [**5-9**].
KUB showed nonspecific bowel gas pattern, no obstruction. Reglan
was started and he was able to tolerate diet advancement on [**5-10**].
He passed stool on [**5-10**].
Foley remained in place and urine output was adequate. Foley
was removed, but had to be replaced for urinary retention. He
failed to void after foley was removed a 2nd time. Foley was
replaced and Flomax was started. Creatinine increased on postop
day 2 then improved, but again increased to 2.4 on [**5-9**] from 1.8.
This was felt to be from elevated prograf level of 16.6. Prograf
dose was decreased. Creatinine then decreased to 2.1 on [**5-10**].
Foley care teaching was done with the patient.
Usual immunosuppession continued consisting of mycophenolate,
prednisone and tacrolimus doses for h/o renal transplant. Home
meds were resumed.
Physical therapy worked with him and declared him safe for
discharge to home. He was ambulating independently. Vital signs
remained stable.
Of note, on [**5-8**], he experienced left eye floater. Ophthalmology
was consulted and found a pre-retinal hemorrhage. Recommendation
was to have patient use two pillows when in bed. He was to avoid
lying flat on back or stomach. F/u with Dr. [**Last Name (STitle) **] on [**5-13**].
Heparin drip was stopped and home dose of [**Month/Day (4) **] 81 was started.
He was discharged to home on [**5-10**] in stable condition. Abdominal
incision remained intact without redness/bleeding/drainage.
.
Medications on Admission:
prograf 1.5 [**Hospital1 **], cellcept 500mg [**Hospital1 **], prednisone 5mg qd,
bactrim ss qd, fenofibrate 54mg qd, simvastatin 40mg qd, Levemir
30 units HS (took half), Humalog SS, Omeprazole 20mg qd
(sometimes 40mg qd if indigestion), Metoprolol 50mg qam/75mg HS,
citalopram 20mg [**Last Name (LF) **], [**First Name3 (LF) **] 81'
Discharge Medications:
1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*0*
2. Humalog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous four times a day.
Disp:*qs 1 month* Refills:*0*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 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. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
9. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for reflux.
13. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
14. Reglan 5 mg Tablet Sig: One (1) Tablet PO four times a day:
take 1/2 hr prior to meals.
Disp:*120 Tablet(s)* Refills:*2*
15. Levemir 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime: adjust as needed.
16. fenofibrate 54 mg Tablet Sig: One (1) Tablet PO once a day.
17. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
19. Outpatient Physical Therapy
Please evaluate and treat; using cane at time of discharge for
unsteadiness. patient not to lie flat on back or stomach must
have head up at least on 2 pillows given recent retinal bleed
(s/p pancreas trasplant then explant. R iliac artery dissesction
requiring endarterectomy, patch angioplasty and RCIA
Discharge Disposition:
Home
Discharge Diagnosis:
Type 1 diabetes, failed pancrease transplant, peripheral artery
disease
Right iliac artery dissection
left eye pre retinal hemorrhage
ARF, resolving
urinary retention
Ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the Transplant Surgery office at [**Telephone/Fax (1) 673**] if you
experience any of the following symptoms: fever (temperature of
101 or greater), chills, nausea, vomiting, increased abdominal
distension/pain, decreased urine output, right leg
swelling/discoloration/numbness/cold sensation
Empty foley bag and record outputs. [**Month (only) 116**] change bag to leg bag
for convenience
No heavy lifting/straining
Avoid sitting for longer than 1 hour to avoid flexion at right
groin
Followup Instructions:
Department: TRANSPLANT CENTER
When: [**Month (only) **] [**2154-5-13**] at 8:30 AM
With: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Dept: Ophthalmology
When: [**Last Name (LF) **], [**2154-5-13**] at 4:00 PM
With: Dr. [**Last Name (STitle) **], MD ([**Telephone/Fax (1) 30777**]
Building: [**Last Name (un) 3911**]
Department: VASCULAR SURGERY
When: WEDNESDAY [**2154-6-12**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1393**]
Building: [**Last Name (NamePattern1) **]; Suite 5C
Department: TRANSPLANT CENTER
When: THURSDAY [**2154-10-17**] at 10:00 AM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2154-5-10**]
|
[
"276.7",
"788.29",
"790.01",
"272.4",
"996.86",
"560.1",
"250.71",
"V58.67",
"599.70",
"362.01",
"785.0",
"401.9",
"867.0",
"584.9",
"997.79",
"362.81",
"300.00",
"250.51",
"E928.9",
"443.81",
"E878.0",
"272.0",
"444.81",
"443.9",
"443.22",
"V42.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.06",
"38.16",
"00.93",
"52.6",
"52.82",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
8607, 8613
|
2760, 6123
|
342, 571
|
8830, 8830
|
2167, 2737
|
9503, 10548
|
1521, 1615
|
6509, 8584
|
8634, 8809
|
6149, 6486
|
8981, 9480
|
1630, 2148
|
264, 304
|
599, 1134
|
8845, 8957
|
1156, 1326
|
1342, 1505
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,093
| 144,709
|
12634+56381
|
Discharge summary
|
report+addendum
|
Admission Date: [**2112-10-23**] Discharge Date: [**2112-11-25**]
Date of Birth: [**2045-8-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4421**]
Chief Complaint:
Right arm and leg weakness following fall .
Major Surgical or Invasive Procedure:
Cervical laminectomy
Halo collar
PEG tube placement
Tracheostomy
IVC filter placement
History of Present Illness:
The patient is a 67 yo R-handed woman with metastatic
endometrial cancer to multiple sites, including the C-spine, who
presents with weakness in her R-arm and leg following a fall 3
days prior to presentation.
She presented with metastatic disease in [**Month (only) 216**] and underwent
XRT to the C-spine, along with a dexamethasone taper (now
finished). This was associated with excellent pain relief and
good neurologic function. She was seen in oncology clinic
several weeks ago and was continued on Megace for control of
metastatic disease. At that time she was stable, ambulatory,
and feeling very well without neurologic complaints. The
patient was doing well at home until Thursday, when she got her
foot tangled and fell (i.e. a mechanical fall). She did not hurt
her head or lose consciousness. However, immediately following
the fall she experienced increased neck pain, mainly on the R,
and noted increased difficulties in ambulating, with weakness in
her right arm and right leg. She denies any numbness or
tingling. The weakness has not progressed over the last days.
Because she was concerned about lack of improvement, she
notified her physicians who advised her to be immediately
evaluated in the ED.
No bladder or bowel symptoms. Patient received decadron 10mg iv
x1 in ED. Ortho-spine and neurology were consulted as well.
Review of systems:
Denies fever, chills, weight loss, visual changes, hearing
changes, headache, nausea, vomiting, dysphagia, tingling,
numbness, bowel-bladder dysfunction, chest pain, shortness of
breath, abdominal pain, dysuria, hematuria, or bright red blood
per rectum.
Past Medical History:
-endometrial ca originally diagnosed in [**11-1**]; s/p TAH-BSO, XRT
and brachytherapy
-Endometrial cancer recurrence in [**Month (only) 216**]- diffusely metastatic
disease:
+cervical spine: C3 collapse with retropulsion, s/p XRT to spine
(Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]);
+also involvement of lymphnodes, iliac, scapula per PET study
-HTN
-arthritis
-nasal polyps
Social History:
Comes from [**Location 149**] and has been in the United States for many
years now. She has 3 children and four grandchildren, all in
good health. She lives in [**Location 583**] with her husband, [**Name (NI) **], who
is an electrical engineer and a professor [**First Name8 (NamePattern2) **] [**Last Name (Titles) 39035**]
Polytechnical Institute.
She does not smoke or drink.
Family History:
Father died at age 60 of CHF-hx diabetes. Mother died at 74 of
complicated pneumonia.
grandmother had a "bone cancer".
Physical Exam:
T99.5 BP135/82 RR18 HR87 sO294-95 RA
Gen: NAD
Neck: collar
Lungs: Clear to auscultation bilaterally
Cardiovascular: Regular rate and rhythm, normal S1 and S2, no
murmurs, gallops and rubs.
Abdomen: normal bowel sounds, soft, nontender, nondistended
Extremities: no clubbing, cyanosis, ecchymosis, or edema
Mental Status: Awake and alert, cooperative with exam, normal
affect.
Oriented to place, month, day, and date, person.
Attention: MOYbw to [**Month (only) 216**]; inattentive and lot of frustration
Memory: Registration: [**3-3**] items; Recall [**3-3**] at 5 min.
Language: fluent; repetition: intact; Naming intact;
Comprehension: intact; no dysarthria, no paraphasic errors.
[**Location (un) **]: intact; Prosody: normal. Fund of knowledge normal; No
Apraxia. No Neglect.
Cranial Nerves:
II: Visual acuity intact. Visual fields are full to
confrontation, pupils equally round and reactive to light both
directly and consensually, 2 mm bilaterally. Discs sharp.
III, IV, VI: Extraocular movements intact without nystagmus.
Fixation and saccades are normal.
V: Facial sensation intact to light touch and pinprick.
VII: Facial movement normal and symmetrical. Old ptosis R.
VIII: Hearing intact to finger rub bilaterally.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
Motor System: Normal bulk; tone decreased in R-arm and R-leg.
No
tremor.
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 4 4 +4 4 4+ 4 2 3 5 4 +4 5 4 5 4
Left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Very distinct pronator drift R.
Sensory system: Sensation intact to light touch, pin prick, and
proprioception in all extremities. Cold decreased distally in
RLE. Vibration decreased in both LE, but more in RLE.
Reflexes:
B T Br Pa Pl
Right 2 2 1 2 2
Left 2 2 1 1 1
Grasp reflex absent.
Toes: down on L; mute on right.
Coordination: FNF slight dysmetria on L; not able to do on R;
[**Doctor First Name **]
on L intact. HTS deferred.
Gait: deferred.
Pertinent Results:
[**2112-10-23**] GLUCOSE-104 UREA N-16 CREAT-0.4 SODIUM-132*
POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-24 ANION GAP-16
[**2112-10-23**] WBC-5.4 RBC-3.38* HGB-11.0* HCT-30.7* MCV-91
MCH-32.4* MCHC-35.7* RDW-13.6
[**2112-10-23**] NEUTS-79.1* LYMPHS-12.7* MONOS-5.4 EOS-2.3 BASOS-0.4
[**2112-10-23**] PLT COUNT-436#
[**2112-10-23**] PT-13.9* PTT-23.0 INR(PT)-1.3
IMAGING;
MRI of the head w/wo gad:[**2112-10-23**]
No new lesions are seen. The left parietal mass is
redemonstrated. While a metastatic neoplastic focus would seem a
reasonable consideration, given the widely metastatic disease
elsewhere, a resolving hemorrhage could be considered, with
infection being less likely.
CT of C-SPINE W/Contrast : [**2112-10-24**]
There is loss of vertebral body height at C3 with some
retropulsion of bone into the spinal canal. There is bone
destruction in the right side of the posterior elements
extending to the midline. There is a fracture of the spinous
process of C3. There is no significant displacement of the
fracture fragments. The vertebral body collapse is unchanged
from the prior plain film. There is stable appearance of the
compression fracture of the C5 vertebral body. The prevertebral
soft tissues are again prominent.
BILATERAL LOWER EXRTREMITIES DOPPLER [**2112-10-31**]:
No evidence of deep venous thrombosis in either lower extremity.
CTA OF THE CHSET W/CONTARAST AND RECONS;10/31/2205
1. Segmental and subsegmental pulmonary emboli involving the
pulmonary arterial branches supplying the left lower lobe.
2. Extensive mediastinal and right hilar lymphadenopathy, not
significantly changed since the prior examination.
3. Multiple nodular opacities are again demonstrated within both
lungs, with interval increase in the degree of cavitation
involving two left lower lobe nodular opacities. These findings
most likely represent pulmonary metastases.
4. Interval worsening of ill-defined left upper lobe nodular
opacity.
5. Minimal decrease in size of the right pleural effusion with
compressive right lower lobe atelectasis.
CARDIAC ECHO;11/03/2205
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Left ventricular
systolic function is hyperdynamic (EF>75%). No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. 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 pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
CT NECK W/ & W/O CONTRAST:[**2112-11-7**]
Postoperative changes including C3-6 corporectomy, allograft
insertion, and placement of anterior and posterior stabilization
hardware are again noted. The degree of prevertebral soft tissue
thickening has increased. The prevertebral fluid collection
extending anteriorly to the right has increased in size,
although less air is present at this surgical site. An air-fluid
level from secretions in the airway is noted above the balloon
of the tracheostomy tube. A nasogastric tube is noted. A fluid
level is again noted in the right maxillary sinus. An effusion
is visible in the right lung apex and associated with
atelectasis. Airspace opacities are noted in both lung apices,
greater on the right.
CTA OF THE CHSET W/CONTARAST AND RECONS [**2112-11-7**]
1. New multilobar consolidations as described in both upper
lobes and left lower lobe.
2. Interval increase in size of the right pleural effusion.
3. Unchanged extensive mediastinal and hilar lymphadenopathy.
4. Multiple nodular opacities within both lungs, some cavitary,
likely represent metastases.
5. Postobstructive right basal atelectasis.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 39033**] is a 67-year-old woman with recurrent, stage IC,
grade 3 endometrial cancer metastatic to multiple sites
including the C spine C2-5 and lung, s/p XRT to pelvis and C
spine, who presents with right arm and leg weakness following a
fall on [**10-20**]. MRI of the C spine revealed worsened C3 cord
compression. Radiation oncology felt that additional radiation
therapy would not be of benefit, and neurosurgery was consulted
in view of progressive cord compression precipitated by recent
neck trauma.
Dr. [**Last Name (STitle) **] from Neurosurgery and Dr. [**Last Name (STitle) 724**] from Neuro-oncology
felt that an operation to debulk cervical spine tumor and
stabilize the C-spine was reasonable under the circumstances.
The risks and potential benefits were explained to the patient
and her husband, and she was interested in proceeding with
surgery. She operated on [**2112-10-28**] for posterior C3, partial
C2-4 Laminectomies with occiput C1-5-6 plates and screws, Halo,
and general surgery placed a tracheostomy at the same day.
Immediate postop patient was opening eyes to voice, following
commands, moves left upper and lower extremity purposefully, no
movement on the right upper extremity, slight movement on the
right lower extremity to noxious stimuli. She remained in the
PACU overnight and was eventually transferred to the neuro
step-down unit for close monitoring. PICC line placed for
parenteral nutrition and dexamethasone weaned. On [**2112-10-30**] her
oxygen saturation decreased, chest radiograph showed increased
left sided opacification and large pleural effusion. A CTA of
the chest revealed segmental and subsegmental pulmonary emboli
involving the pulmonary arterial branches supplying the left
lower lobe. Patient started on heparin gtt for anticoagulation
and then transferred to Neuro-ICU.
Infectious disease was consulted on [**2112-10-31**] and continued to
follow her throughout her hospital stay. In the setting of PE
Vascular surgery consulted for IVC filter. Prior to IVC filter
placement, a bilateral lower extremity Doppler study showed no
evidence of DVT.
The patient's affect appeared to change over time, and she
became less communicative and more withdrawn, despite being
alert. Given her complicated disease course and understandable
emotional/physical stress, a psychiatry consult was obtained.
Psychiatry recommended continuing lorazepam for anxiety/sleep,
and ongoing support for family. If a clearer picture of
depression emerged, they would consider an antidepressant.
[**2112-11-4**] patient underwent an anterior corpectomy C3-4-5-6 with
allograft, as a planned second step in an attempt to stabilize
her cervical spine. Heparin drip was resumed 48 hours after the
surgery, as well as Dexamethasone 4mg every 6 hours for 48 then
gradually tapered to off. Postoperatively her neuro exam has
been waxing and [**Doctor Last Name 688**], and the patient was inconsistently
following commands. On [**2112-11-9**] neuro exam; opens eyes to
voice, moves left upper and lower extremities to command.
ID reconsulted regarding cellulitis on the posterior wound site
started on Vancomycin and meropenem, discontinued ceftriaxone.
MRSA and VRE screen returned positive therefore contact
precaution [**Name2 (NI) 39036**]. Stool sent for C-diff which also came
back positive, and she started on Metronidazol for C-diff
coverage. Endocrine consulted for hyponatremia, started on
initailly to 1000ml/24 then 1500cc/24 fluid restriction, check
serum Na level twice a day and continued with sodium tabs via
NG-tube.
On [**2112-11-19**], the patient was transferred out of the ICU and back
to the OMED service. At that time, she was in a halo cast,
immobilized in bed, without good recovery of function on her
right side. Given the extensive nature of her metastatic
disease, her poor performance status, and the low likelihood of
obtaining meaningful neurological recovery, the patient and her
husband expressed the desire that she be transferred to home
with hospice care. Her chest tube was removed after
pleurodesis. Neurosurgery removed halo collar and placed hard
cervical collar. She will continue to be treated for her
pneumonia and c.diff colitis for two weeks. She will also
continue to receive tube feedings. Per the patients request, the
tracheostomy tube will be left in place. She has a known
pulmonary embolism and will continue to be treated with lovenox.
Medications on Admission:
Atenolol 50 [**Hospital1 **], megace 40 [**Hospital1 **], protonix 40 [**Hospital1 **],
lisinopril 20 [**Hospital1 **], norvasc 5 [**Hospital1 **], colace [**Hospital1 **], senna [**Hospital1 **], oscal
[**Hospital1 **], tylenol #3 prn.
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 5-40 mg PO q1hr
as needed for pain.
Disp:*150 ml* Refills:*0*
2. Opium Tincture 10 mg/mL Tincture Sig: 10 drops PO every [**4-6**]
hours as needed for diarrhea.
Disp:*1 bottle* Refills:*0*
3. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4-6H (every 4 to 6 hours) as needed for FEVER/HA/PAIN.
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 mdi* Refills:*0*
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
6. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
7. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM AND
Q1PM ().
Disp:*60 Tablet(s)* Refills:*0*
8. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours).
Disp:*1 month supply* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
10. Lorazepam 0.5 mg Tablet Sig: 1-4 Tablets PO Q4-6H (every 4
to 6 hours) as needed for anxiety/nausea.
Disp:*120 Tablet(s)* Refills:*0*
11. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*90 Tablet(s)* Refills:*2*
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO BID (2 times a day).
Disp:*1 bottle* Refills:*2*
13. equipment
Tube feed pump
14. equipment
IV pole
15. equipment
feeding bags
16. equipment
60cc catheter tip syringes
17. Respalor Liquid Sig: Sixty (60) ml PO q1h.
Disp:*1 month supply* Refills:*2*
18. equipment
tracheostomy dressing changing supplies
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
endometrial cancer
MRSA pneumonia
clostridium difficile colitis
pulmonary embolism
cervical cord compression
hyponatremia
Discharge Condition:
Stable but guarded.
Discharge Instructions:
Home hospice arrangements have been made- a hospice nurse will
meet you at home. Equipment will be provided at home, including
a hospital bed. Please call Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] at
([**Telephone/Fax (1) 28919**] if you have questions or problems.
Followup Instructions:
With hospice as needed.
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2113-1-9**]
1:00
Completed by:[**2112-11-25**] Name: [**Known lastname 7045**],[**Known firstname 1715**] Unit No: [**Numeric Identifier 7046**]
Admission Date: [**2112-10-23**] Discharge Date: [**2112-11-25**]
Date of Birth: [**2045-8-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7047**]
Addendum:
Mrs[**Known lastname 7048**] blood pressure was consistently in the range of
90-100 systolic and did not require anti-hypertensive
medications.
.
Mrs.[**Known lastname 7049**] prescription for Megace was inadvertantly omitted
from her discharge planning. A prescription for this was called
in to her local pharmacy.
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 5548**]
[**First Name11 (Name Pattern1) 499**] [**Last Name (NamePattern4) 7050**] MD [**MD Number(1) 7051**]
Completed by:[**2112-11-25**]
|
[
"251.8",
"V10.42",
"253.6",
"682.1",
"198.3",
"198.4",
"415.19",
"285.1",
"198.89",
"197.0",
"197.2",
"198.5",
"518.5",
"438.21",
"E932.0",
"482.41",
"733.13",
"336.3",
"008.45"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"96.6",
"97.23",
"02.94",
"03.53",
"93.41",
"34.04",
"81.63",
"81.02",
"99.04",
"31.1",
"80.51",
"43.19",
"81.01"
] |
icd9pcs
|
[
[
[]
]
] |
17221, 17460
|
9214, 13689
|
360, 448
|
15922, 15944
|
5232, 9191
|
16281, 17198
|
2939, 3059
|
13976, 15655
|
15777, 15901
|
13715, 13953
|
15968, 16258
|
3074, 3384
|
1846, 2103
|
277, 322
|
476, 1827
|
3876, 5213
|
3399, 3860
|
2125, 2524
|
2540, 2923
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,977
| 169,632
|
30944
|
Discharge summary
|
report
|
Admission Date: [**2125-9-29**] Discharge Date: [**2125-10-4**]
Date of Birth: [**2072-9-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hepatic encephalopathy
Major Surgical or Invasive Procedure:
Central Venous Catheterization
Endotracheal Intubation
History of Present Illness:
53 year-old man transferred from the [**Location 1268**] VA with
hepatic encephalopathy for consideration of a liver transplant.
He was admitted there for increasing abdominal girth and dyspnea
on exertion. There he underwent diagnostic paracentesis which
was negative for sbp. An ultrasound revealed normal portal
flow. He was started on diuretics with minimal effect. He
underwent therapeutic paracentesis but only 2 liters could be
removed. He developed altered mental status and was transferred
to [**Hospital1 18**] for evaluation of a transplant.
Past Medical History:
Hepatitis C
Cirrhosis
SBP
Hiatal Hernia
Depression
UGIB from esophageal varices
Social History:
Lives with mother. Brother is health care proxy. [**Name (NI) **] smoking or
alcohol on admission.
Family History:
NC
Physical Exam:
Physical Exam on Admission:
Vitals: 97.5 130/60 94 16 100%RA
Gen: Cooperative. Confused, no acute distress.
HEENT: Icteric sclerae. PERLL. MMM.
Neck: No JVD.
Chest: Minimal crackles.
CVS: Slightly tachycardc. Regular. No M/R/G.
Abdomen: Mild distention. Soft. Non-tender. No rebound or
guarding.
Extremities.2+ pitting edema to calves bilaterally.
Pertinent Results:
CT Abdomen and pelvis [**2125-10-3**]- IMPRESSION: Limited evaluation
secondary to lack of intravenous contrast administration.
Markedly distended, predominantly air-filled, small bowel in
addition to mildly distended colon. No evidence of pneumatosis.
Given the underlying liver disease and moderate amount of
ascites present, spontaneous bacterial peritonitis should be
considered as a potential etiology. Clinical correlation
recommended.
Chest [**2125-10-3**]- SINGLE AP VIEW OF THE CHEST PERFORMED AT 1800
HOURS. New ET tube tip is 3.4 cm above the carina. NG tube tip
is in the stomach. There are low lung volumes. Cardiomediastinum
is unchanged. Ill-defined opacities in the left perihilar and
left lower lobe regions are new. Given the clinical history is
consistent with aspiration, there is no pneumothorax or pleural
effusion.
Abdominal ultrasound [**2125-10-1**]-IMPRESSION:
1. Sludge-filled non-distended gallbladder without evidence of
cholecystitis.
2. Findings consistent with known cirrhosis.
3. Mild amount of perihepatic ascites.
Brief Hospital Course:
# Hepatic Encephalopathy: 53 year-old man with cirrhosis due to
hepatitis C and alcohol, with history of encephalopathy,
varices, ascites, poor synthetic function, initially transferred
from [**Location 1268**] VA with hepatic encephalopathy for
consideration of liver transplant. While at the VA, he underwent
diagnostic paracentesis which was negative for SBP. He was
placed on ciprofloxacin for SBP prophylaxis and started on
lactulose. He was initially admitted to MICU on [**9-29**] with
improved mentation and decreasing bilirubin and he was
transferred to the floor and was put on the transplant list.
# Abdominal pain: He subsequently developed acute abdominal
pain and distension. NG tube was placed with copious [**Location (un) 2452**]
output. He became increasingly obtunded, and was sent to CT with
ceftriaxone for presumed SBP. After CT, pt. became increasingly
tachypneic and was being readied for transfer to MICU when a
code was called for respiratory distress.
# PEA Arrest: Mr. [**Known lastname 73154**] was tachypneic, desaturating to the
70s, so he was urgently intubated at that time. He almost
immediately went into wide complex PEA arrest, after which CPR
was initiated immediately. He received chest compressions for 15
minutes with epinephrine x 3 cycles, insulin, D50, bicarbonate X
2, calcium, with return of bradycardic pulse. Then received
atropine X 2 and returned to PEA, then to pulseless ventricular
tachycardia. Dopamine was started, and patient was shocked X 1
with return of spontaneous pulse and SBP 180. Initial ABG in
code 7.28/53/216, lactate 8.4, K was 6.4. He was transferred to
the ICU, where he was noted to have bleeding from rectum, from
nares, and from endotracheal tube. Coags increasingly elevated.
Initial ABG was 7.18/47/71/18 on 100%fi02, AC ~500/10/8. Was
started on vasopressin, levophed, neosynephrine at masximum
doses with BPs dipping into 70s, continued bleeding despite FFP,
cryoprecipitate, and ddAVP. Pt. continued to have difficulty
being ventilated. As sedatives increased, so did pressor
requirements, and pt. continued to poorly oxygenate. Team
planned to paralyze pt. to allow for better ventilation, but
given continued hypotension and poor prognosis, family meeting
with 3 daughters, youngest of whom was hcp was arranged and
determination was made that consistent with pt.'s wishes, he
would want to be made confortable given grim prognosis. Decision
was made by family to continue fentanyl drip, remove pressors,
and extubate with family at bedside. He was pronounced dead at
12:50 AM. Family consented for autopsy.
Medications on Admission:
Lactulose
Ceftriaxone
Protonix
Folic Acid
Propranolol
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
End-stage liver disease
Hepatic Encephalopathy
Cardiopulmonary arrest
Discharge Condition:
Expired
|
[
"571.2",
"789.59",
"584.9",
"311",
"785.52",
"572.3",
"427.41",
"286.6",
"038.9",
"577.0",
"995.92",
"287.5",
"276.1",
"070.44",
"560.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.60",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5411, 5420
|
2681, 5278
|
336, 392
|
5533, 5543
|
1605, 2658
|
1216, 1220
|
5382, 5388
|
5441, 5512
|
5304, 5359
|
1235, 1249
|
274, 298
|
420, 979
|
1264, 1586
|
1001, 1083
|
1099, 1200
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,442
| 122,144
|
52763+52764
|
Discharge summary
|
report+report
|
Admission Date: [**2152-1-24**] Discharge Date: [**2152-2-1**]
Service: Vascular Surgery
HISTORY OF PRESENT ILLNESS: An 81-year-old male with a
history of peripheral vascular disease status post a left leg
revascularization x3 presenting with a new left fifth
metatarsal dry gangrene x2 weeks. He has been followed by
Dr. [**Last Name (STitle) 3925**] of Podiatry for chronic first toe MTP ulcer,
which is now resolving. Patient denies any fevers, chills,
nausea, vomiting, or diarrhea. He also denies any
claudication symptoms, any history of DVT, or rest pain.
Patient has had no bowel changes. He denies any chest pain,
palpitations, orthopnea, or edema. Patient denies any
history of CVA, TIA, headache, or syncope.
INCOMPLETE DICTATION
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 28130**]
MEDQUIST36
D: [**2152-2-1**] 12:39
T: [**2152-2-1**] 12:42
JOB#: [**Job Number 108824**]
Admission Date: [**2152-1-24**] Discharge Date: [**2152-2-1**]
Service: Vascular Surgery
HISTORY OF PRESENT ILLNESS: Patient is an 81-year-old male
with a history of peripheral vascular disease, who is status
post left lower extremity revascularization x3. He now
presents with a new left fifth MTJ gangrene, which has gotten
progressively worse over the past two weeks. He is followed
by Dr. [**Last Name (STitle) 3925**], who is a podiatrist for his chronic first
MTJ ulcer, which was resolving. Patient denies any fevers,
chills, any nausea, vomiting, or diarrhea. He also denies
any claudication symptoms or rest pain. He denies any chest
pain, palpitations, orthopnea. Patient states that he can
climb [**12-28**] flights of stairs without any difficulty. He
denies any history of CVA, TIA, loss of vision, or headache,
or seizures.
PAST MEDICAL HISTORY:
1. Diabetes.
2. CAD.
3. Hypertension.
4. Aortic stenosis.
5. Diabetic retinopathy.
6. Carotid stenosis.
7. Colonic polyps.
8. Small bowel obstruction.
9. Dyslipidemia.
10. Kidney stones.
PAST SURGICAL HISTORY:
1. AVR.
2. CABG.
3. He has had a left SFA to posterior-tibial bypass.
4. He has also had a left SFA to posterior-tibial PTCA and
stent.
5. Left SFA-PT jump graft with a vein.
MEDICATIONS AT HOME:
1. Aspirin 325.
2. Lopressor 50 b.i.d.
3. Metformin 500 b.i.d.
4. Zocor 20 mg q.d.
5. Synthroid 0.05 mg q.d.
6. He takes insulin NPH 18 q.a.m. and 14 q.h.s.
7. He is on a regular insulin-sliding scale.
8. Lisinopril 2.5 mg.
9. He also takes 70/30 insulin 53 units q.a.m. and p.m.
PHYSICAL EXAM: On physical exam, patient is afebrile. His
vital signs were stable on admission. Blood pressure 112/56,
heart rate of 68, respiratory rate of 18, and O2 saturations
of 92%. Patient is in no apparent distress. There is no
evidence of JVD. There are no carotid bruits. Neck is
supple, there is no evidence of lymphadenopathy. His lungs
are clear to auscultation bilaterally. His rhythm and rate
are regular with a systolic ejection murmur that radiates to
his carotids. His abdomen is benign, soft, nontender, and
nondistended. There are no bruits. Lower extremities: He
has a bilateral palpable femoral pulse, biphasic popliteal
Dopplerable only and no evidence of DP or PT pulses
bilaterally.
LABORATORIES ON ADMISSION: White count of 12.9, hematocrit
35.7, platelets of 193. His PT was 12.9, PTT 29.9, INR of
1.1. Chemistry: Sodium 135, potassium 4.8, chloride 100,
bicarb 27, BUN 26, creatinine of 1.0, and his glucose was
233. His urinalysis was negative.
HOSPITAL COURSE: The patient was admitted to the Vascular
Surgery service and put on IV antibiotics. He was also
prepped for an angio. He was hydrated adequately. Podiatry
was consulted. Patient was made nonweightbearing on the left
foot and wet-to-dry dressings were applied to the ulcers.
Patient had bilateral upper and lower extremity vein mapping
and the right arm was instructed to be saved. Patient was on
vancomycin, levofloxacin, and Flagyl for antibiotics, and
vancomycin levels were drawn and vancomycin was dosed
appropriately.
On the day of the angiogram, patient was not feeling well.
Resident was called to see the patient and patient was
diaphoretic and complained of lightheadedness while he was
having a bowel movement in the bathroom. EKG showed no
significant changes. Cardiac enzymes were negative x3 and
Cardiology was consulted. Patient was transferred to the
VICU for closer management.
On hospital day five, Persantine MIBI stress test was
ordered. Patient had a new systolic dysfunction showing
decrease in ejection fraction and new left ventricular
dilation and a lateral partially reversible defect with
multiple fixed defects in the inferior wall. Cardiology felt
that this signaled an internal progression of the CAD, and
patient was taken to cardiac catheterization laboratory that
afternoon. A stent was placed in the distal RIMA with good
result.
Cardiology recommended also delaying any elective surgery for
at least six weeks to minimize the risk of acute stent
thrombosis. Also Cardiology recommended Plavix and aspirin.
The rest of the hospital course is otherwise unremarkable.
The patient post catheterization was doing fine. There was
no evidence of any hematoma in the right groin. He was
tolerating a regular diet without any nausea or vomiting. He
was out of bed and ambulating without any difficulty.
Cardiology cleared the patient for an angiogram during the
admission. Patient was carefully hydrated pre-angiogram. He
was continued on Plavix.
On hospital day eight and post catheterization day three,
patient had an angiogram, which showed bilateral femoral
pulses and bilateral Dopplerable DP post procedure which was
unchanged compared to pre-procedure.
Patient returned to the floor, where his post-angio check was
unremarkable. He was tolerating p.o. His groin had no
evidence of a hematoma. His BUN and creatinine the next
morning were within normal limits. Patient denied any chest
pain or shortness of breath. He was afebrile. His vital
signs were stable. He was deemed safe for discharge to home
with followup of his angio.
DISCHARGE DIAGNOSES:
1. Peripheral vascular disease.
2. Diabetes.
3. Coronary artery disease.
4. Hypertension.
4. Aortic stenosis.
5. Dyslipidemia.
DISCHARGE STATUS: To home with services.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Aspirin 325 one tablet p.o. q.d.
2. Lopressor 50 mg one tablet p.o. b.i.d.
3. Simvastatin 10 mg two tablets p.o. q.d.
4. Levothyroxine sodium 50 mcg one tablet p.o. q.d.
5. Percocet 5/325 1-2 tablets p.o. q.4-6h. for pain.
6. Levofloxacin 500 mg one tablet p.o. q.d. for two weeks.
7. Plavix 75 mg tablets one tablet p.o. q.d.
8. Lisinopril 5 mg 0.5 tablet p.o. q.d.
9. Linezolid 600 mg tablets one tablet p.o. b.i.d. for two
weeks.
10. Patient is to resume his insulin orders as prior to
admission.
RECOMMENDED FOLLOWUP: Patient is to followup with his
cardiologist. He is also to followup with Dr. [**Last Name (STitle) 1391**] in
one month with the results of angiogram, further
determination of any possible revascularization will be
determined. Patient is to finish his course of antibiotics.
He is instructed to return to the Emergency Room with any
sudden onset of uncontrollable pain in his left foot, or
chest pain, or shortness of breath. He is also to followup
with his podiatrist, Dr. [**Last Name (STitle) 3925**] in [**11-26**] weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 28130**]
MEDQUIST36
D: [**2152-2-1**] 16:28
T: [**2152-2-1**] 16:37
JOB#: [**Job Number 108825**]
(cclist)
|
[
"996.74",
"V45.81",
"E878.2",
"414.01",
"996.72",
"785.4",
"707.15",
"V42.2",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.01",
"88.55",
"99.20",
"88.48",
"36.07",
"86.22",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
6426, 6435
|
6233, 6404
|
6458, 7801
|
3619, 6212
|
2326, 2607
|
2129, 2305
|
2623, 3342
|
1167, 1896
|
3357, 3601
|
1918, 2106
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,712
| 126,464
|
29935
|
Discharge summary
|
report
|
Admission Date: [**2195-4-1**] Discharge Date: [**2195-4-10**]
Date of Birth: [**2146-5-1**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Adnexal masses discovered during work-up for liver transplant
Major Surgical or Invasive Procedure:
Diagnostic laparoscopy, exploratory laparotomy, lysis of
adhesions, bilateral salpingo-oophorectomy.
History of Present Illness:
Patient has been undergoing liver transplant evaluation for ETOH
cirrhosis and Hepatitis C and was discovered to have an adnexal
mass. Initially admitted to GYN/Onc for removal and potential
staging of the mass
Past Medical History:
Hep C Cirrhosis
Asthma: no intubations
Broken Jaw requiring surgery
Ankle surgery
Social History:
Currently living with sister, currently unemployed
ETOH: drank heavily for 20 years. Last drink was in [**Month (only) 547**] of
[**2193**]. She does not attend any counseling at this time.
Smokes 2 PPW, used to smoke 1 PPD
Family History:
Father with prostate CA
Physical Exam:
VS: 98.3, 106/64, 95, 18, 96%RA
Gen: NAD, A+Ox3, speech somewhat slow and slurred
Neuro: CN II-XII intact, no gross neuro defects
Lungs: CTA bilaterally
Card: RRR
Abd: Obese, soft, non-tender
Pertinent Results:
On Admission: [**2195-4-1**]
WBC-3.6* RBC-2.87* Hgb-9.3* Hct-28.1* MCV-98 MCH-32.3* MCHC-33.0
RDW-15.6* Plt Ct-42*
PT-16.0* PTT-38.3* INR(PT)-1.5*
Glucose-114* UreaN-13 Creat-1.0 Na-139 K-4.0 Cl-110* HCO3-22
AnGap-11
ALT-20 AST-55* LD(LDH)-263* AlkPhos-86 TotBili-2.3*
Albumin-2.9* Calcium-8.6 Phos-4.4 Mg-2.1
On Discharge:[**2195-4-10**]
WBC-3.6* RBC-2.54* Hgb-8.2* Hct-24.0* MCV-94 MCH-32.1* MCHC-34.0
RDW-16.6* Plt Ct-35*
PT-20.1* PTT-56.8* INR(PT)-1.9*
Glucose-90 UreaN-15 Creat-1.0 Na-136 K-3.1* Cl-101 HCO3-30
AnGap-8
ALT-10 AST-38 AlkPhos-59 TotBili-2.3*
Calcium-7.6* Phos-2.4* Mg-1.7
Albumin-2.7*
Brief Hospital Course:
Patient with Hep C/ETOH cirrhosis on transplant list with
adnexal masses found during transplant workup. Patient admitted
day before surgery for prep. In addition she received blood
products (6 u plt, 1u FFP prior to surgery and intra-op; 1u plt,
2u FFP)
Surgery was performed by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2028**]. Please see the
operative note for details. In summary: she underwent a
diagnostic laparoscopy, exploratory laparotomy, lysis of
adhesions, bilateral salpingo-oophorectomy. There were no
palpable vaginal or parametrial nodularity noted. On exploratory
laparoscopy,
there was about a liter and a half of ascites on entering the
abdomen. The liver edge was cobblestone. There were no adhesions
in the upper abdomen . The only adhesions within the abdomen or
pelvis were in the posterior cul-de-sac where both ovaries
adhered the rectosigmoid to the posterior surface of the uterus.
These were extremely dense adhesions that did not come down
easily and could not be removed
laparoscopically, laparotomy performed. Patient was extubated in
the OR, stable on transfer to the PACU.
Post op the patient had low urine output. Given history of
ascites and elevated INR she was receiving albumin and FFP.
Urine output would increase transiently following colloids and
then fall back.
Patient was transferred to the SICU on [**4-5**] (POD 3) and started
on Midodrine, Octreotide and albumin. Urine output at 20-40
cc/hr but also recorded at < 10cc/hr. Creatinine stable at 1.2
(baseline 0.9) Transferred to Transplant and Hepatology until
time of discharge, with GYN following.
Patient had periods of slow speaking, somnolence both prior to
and following surgery. Lactulose was restarted for
encephalopathy in addition to Lasix for fluid management.
Patient stabilized, urine output improved and patient
transferred to [**Hospital Ward Name 121**] 10 on [**4-8**]. She continued to be follwed by
GYN, who removed staples on [**4-9**].
Abdominal wound opened and decision made to initiate NS wet to
dry dressings which the patient will continue at home.
She will complete a 10 day course of Augmentin and then switch
back to her prophylactic Cipro at home.
Biopsy shows:
- Right ovary and fallopian tube: Ovary with endometrioma,
simple cysts and multiple adhesions; no malignancy is
identified. Unremarkable fallopian tube.
- Left ovary and fallopian tube: Ovary with endometriosis, focal
adhesion formation and simple cyst. Fallopian tube with rare
endometriotic implants.
Since no malignancy is identified she will be placed back on
liver transplant waiting list.
Medications on Admission:
cipro 500', neomycin 500', lasix 40', lactulose 30"", folate T'
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: 5-10 MLs PO QID (4
times a day).
Disp:*500 ML(s)* Refills:*2*
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
6. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
9. Neomycin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 10 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
11. Cipro 500 mg Tablet Sig: One (1) Tablet PO once a day: Start
back on Cipro once Augmentin is completed in 10 days.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Home Care Services
Discharge Diagnosis:
Endometriosis, no malignancy seen from adnexal masses
Discharge Condition:
Good
Discharge Instructions:
Please call Dr[**Name (NI) 27357**] office at [**Telephone/Fax (1) 7614**] if you experience
fever, chills, drainage, bleeding or extension of the abdominal
wound.
You will be having twice a day dressing changes to the abdominal
wound
Complete 10 day course of Augmentin, THEN resume your Cipro.
Continue the Neomycin.
Follow-up appointments with Dr [**Last Name (STitle) 497**] and Dr [**Last Name (STitle) 2028**] Weds [**4-15**].
Followup Instructions:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2195-4-15**] 9:40
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 7614**] Date/Time:[**2195-4-15**]
2:15
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2195-4-10**]
|
[
"571.2",
"789.5",
"493.90",
"070.54",
"V49.83",
"276.52",
"617.1",
"V64.41",
"572.2",
"614.6",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.05",
"65.61",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
5842, 5908
|
1962, 4574
|
373, 476
|
6006, 6013
|
1333, 1333
|
6494, 6893
|
1080, 1105
|
4688, 5819
|
5929, 5985
|
4600, 4665
|
6037, 6471
|
1120, 1314
|
1656, 1939
|
272, 335
|
504, 716
|
1347, 1643
|
738, 821
|
837, 1064
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,454
| 161,983
|
28877
|
Discharge summary
|
report
|
Admission Date: [**2176-8-10**] Discharge Date: [**2176-8-16**]
Date of Birth: [**2095-7-9**] Sex: F
Service: MEDICINE
Allergies:
Epinephrine
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
transferred from OSH for [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
cardiac cath
pericardiocentesis
History of Present Illness:
The pt is a 81 yo F w/ ho of HTN, hyperlipidemia, no CAD, ?TIA
presented to the OSH after developing SSCP and dizziness this
am, found to have inferior lateral [**First Name3 (LF) **] with tropinin of 11.1
transferred to [**Hospital1 18**] for further management. Pt developed an
episode, without any radiation, N/V/Diapheresis three days prior
to admission when temp was about 100F, resolved spontaneously
thought was heat related. She has subsequently been doing until
late this morning after breakfast, when she felt dizzy, per pt
no chest pain at the time, fell to the floor and remained there
for some time. per daughter, she found her on the floor,
diaphoretic, but alert, no nausea and vomiting, complaining of a
sudden onset of [**7-15**] SSCP, no radiation at the time, and no N/V,
called EMS.
.
EMS gave her sl nitroglycerin for CP ([**10-15**]) enroute to OSH
([**Hospital3 **]), not relieved. later relieved with morphine IV x 2.
.
At the OSH [**Name (NI) **], pt had EKG showed ST elevation in inferior
lateral leads (II, III, aVF, V5, V6) and corresponding ST
depression in V1 V2, right sided ECG not showing ST elevation in
V4R. Pt was started on integrllin, heparin, but was D/C'ed when
pt developed acute onset of L sided hemiparesis (arm and leg
only), no change in speech or MS, spontaneously resolved after
1-2 hrs, head CT negative. per daughter, she also had an echo
at OSH, ? pericardial effusion. At the ED, she was given 5mg IV
lopressor, BP dropped to 60's, started with fluid resuscitation
5L [**Hospital **] transferred to [**Hospital1 18**] for further management.
.
Intially, chest pain free, T 94.6, BP 98/54, cool mottled
skin,likely cardiogenic shock, and started dopamin 5->7.5mg/kg.
pt went to the Cath lab, which showed right dominant, LMCA mild
disease, LAD serial 80% stenosis, LCX 50-60% proximal, diffuse
70% OM1, and occluded OM2->stented->0% residual; RCA 90%
mid->stented->0% residual. At the time of the cath, PCW mean
26, PA mean 22, PA (36/23) mean 28, RV (34/22) end 24, HR 75-77,
CI 1.76, given equalization of filling pressure across the
[**Doctor Last Name 1754**] worrisome for found tamponade, echo was done which
showed moderate size pericardial effusion. Patient underwent a
fluoro guided pericardiocentesis with peridcardial pressure of
20mmHg, localized effusion with 150cc of bloody drainage with
Hct of 34) worrisome for pericarditis vs localized sealed
myocardial rupture. Cardiac surgery was consulted at the time,
for likely retamponade in the future. She was back onto the CCU
floor, type and crossed 6 units of blood and off pressors, put
on ASA, plavix 75mg x 12 months, echo in 1 hour showed minimal
effusion localized to RV (total output ~100cc), keep SBP<110
given likely rupture, hemodynamic monitoring with A-line and PA.
Past Medical History:
HTN
Hyperlipidima
?TIAs
Asthma
bronchitis (recent excerbation two weeks ago, was on levaquin x
7 days, and steroids x 2weeks, last dose three days prior)
Glaucoma
osteoprosis
h/o TB in [**2120**]'s treated
Reflux s/p slasky's ring dilation
Social History:
Lives with one of her daughters, former nurse, still works at
store (cashier), widowed (2 daughters), no smoking (but a lot of
second hand smoking from husband), no ETOH or drugs
Family History:
+ CAD, +DM
Physical Exam:
Admission:
Vitals: T 94.6, BP 94/51, HR 88, RR 21, 98% on 4L, Ht 5'1'',
130lbs
Gnl: NAD, Alert and oriented x 3
HEENT: PERRLA, EOMI, MM slightly dry, OP clear, JVP difficult to
assess.
CV: RRR, Normal S1 + S2, no m/r/g, distant heart sounds; 1+
femoral, carotid, dP, Pt pulses bilaterally
Resp: mild bibasilar crackles
Abd: Soft, Nontender, NABS, No hepatosplenomegaly
Extremities: 1+ pulses bilaterally, cool mottled skin, no c/c/e
Neuro: A&O x 3, CN II-XII WNL, strenth 5-/5 thoughout, no focal
neural signs.
Pertinent Results:
Admission Labs:
.
[**2176-8-10**] 03:58PM BLOOD WBC-11.8* RBC-3.56* Hgb-11.1* Hct-33.5*
MCV-94 MCH-31.1 MCHC-33.1 RDW-13.5 Plt Ct-360
[**2176-8-10**] 03:58PM BLOOD PT-12.5 PTT-27.1 INR(PT)-1.1
[**2176-8-10**] 03:58PM BLOOD Glucose-158* UreaN-14 Creat-0.7 Na-141
K-4.5 Cl-112* HCO3-19* AnGap-15
[**2176-8-10**] 03:58PM BLOOD CK(CPK)-158*
[**2176-8-10**] 03:58PM BLOOD CK-MB-13* MB Indx-8.2* cTropnT-1.38*
[**2176-8-10**] 03:58PM BLOOD Calcium-6.8* Phos-3.6 Mg-1.9
.
ECG ([**2176-8-10**]): ST at 106, Left axis deviation, ST elevation 2mm
at II, III, AvF, V5, V6, ST depression V1-V2, q waves II, III,
AVF;
Right sided ECG: decreased voltage v4-V6
.
Cardiac Cath ([**2176-8-10**]):
1. Selective coronary angiography revealed a right dominant
sytem with
three vessel coronary artery disease. LMCA had mild disease. The
lAD had
sequential 80% lesions in the proximal and mid vessel. LCX had
an ostial
60% lesion and diffused 70% OM1 diseease. dital LCx and OM2 were
occluded. The RCA had moderate proximal disease and 90% mid
vessel
lesion.
2. Left ventriculography was deferred.
3. Hemodynamic assessment showed elevated and equalised RA
pressure,
RVEDP and PCWP at 23 mm Hg. There was 15 mm Hg pulsus on aortic
pressure
tracing. Pericardial pressure was 23 mm Hg. Drainage of 150 cc
of bloody
pericardial fluid (hct 33) decreased the pericardial pressure to
10 mm
Hg. the blood pressure increased and pulsus resolved. The
patient was
weaned off Dopamin and cardiac index improved.
4. the RCA lesion was predilated with a 2.0 balloon and stented
with two
overlapping 3.0 Cypher stents with lesion reduction from 90 to
0%. The
final angiogram showed TIMI III flow with no dissection and no
embolisation. (see PTCA comments)
5. The LCX lesion was predilated with a 2.0 balloon and stented
with a
2.5 stent with lesion reduction to 0%. The final angiogram
showed TIMI
III flow with no dissection or embolisation. (see PTCA comments)
6. The moderate pericardial effusion was drained with
improvement of her
hemodynamic status. The drain was left in situ for overnight
drainage.
(see PTCA comments)
.
Serial Echo post cath showed stable and progressively decreasing
pericardial effusion.
.
Echo ([**2176-8-12**]): Regional left ventricular systolic dysfunction
c/w multivessel CAD. Prominent anterior fat pad (vs.
hemorrhagic effusion without hemodynamic compromise). Mild
pulmonary artery systolic hypertension. LVEF 40-45%
.
Carotid Doppler ([**2176-8-14**]): Minimal plaque with bilateral less
than 40% carotid stenosis.
.
Other Labs:
.
[**2176-8-10**] 03:58PM BLOOD CK-MB-13* MB Indx-8.2* cTropnT-1.38*
[**2176-8-11**] 01:59AM BLOOD CK-MB-14* MB Indx-7.4* cTropnT-1.86*
[**2176-8-11**] 09:29PM BLOOD CK-MB-14* MB Indx-3.8
[**2176-8-11**] 01:59AM BLOOD Triglyc-86 HDL-57 CHOL/HD-2.7 LDLcalc-82
.
Discharge Labs:
.
[**2176-8-16**] 06:15AM BLOOD WBC-6.9 RBC-3.68* Hgb-11.1* Hct-33.1*
MCV-90 MCH-30.2 MCHC-33.6 RDW-14.4 Plt Ct-428
[**2176-8-16**] 06:15AM BLOOD Plt Ct-428
[**2176-8-16**] 06:15AM BLOOD Glucose-100 UreaN-12 Creat-0.5 Na-139
K-4.2 Cl-103 HCO3-28 AnGap-12
[**2176-8-16**] 06:15AM BLOOD ALT-59* AST-47* LD(LDH)-265* AlkPhos-80
TotBili-0.7
[**2176-8-16**] 06:15AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.1
Brief Hospital Course:
81 yo F w/ HTN, hyperlipidemia, no CAD, p/w inferoposterior
[**Month/Day/Year **], likely occured prior to acute presentation, Q waves
present in inferior leads, now in cardiogenic shock s/p cath and
pericardiocentesis. Her hopsital course for this admission is
as follows:
.
1. [**Month/Day/Year **]/pericardial effsuion/hypotension - IMI with posterior
extension s/p cath (three vessel disease, LAD 80% stenosis not
intervened, 50-60% proximal Lcx, 70% OM1, occluded OM2 stented,
mid RCA 90% stenotic, stent placed), possible small rupture
causing tamponade s/p 150cc bloody pericardial drainage, likely
causing cardiogenic shock. PA cathether and A line were placed
to assess CI and pressures. Patient was placed on ASA 325',
Plavix 75', lipitor 80' decreased to 10' due to intoleration,
captopril 6.25''' initially. Pericardail drain placed and
followed--collected 100 cc yesterday afternoon but no further
drainage past 1600 yesterday. Likely clotted off. Per
instructions from placing attending, no saline or heparin flush
started, as hoping not to dislodge clot and that effusion no
longer collecting. Patient's pressures appear to be equalizing
this morning again, with CVP approaching PA diastolic. However,
patient not demonstrating hypotension. CI remains above 2
although down slightly. Echo on [**8-12**] to measure for effusion will
help to evaluate whether the pressure equalizing is due to
volume overload or reaccumulation of fluid, which showed 1 cm
pericardial effusion: appears stable, more likely due to fluid
overload. pericardial drain pulled on [**8-12**] and repeat echo
showed stable pericardial effusion. Patient was treated with
lasix prn for fluid overload, and started with metoprolol after
her BP stabilized. We continued monitoring her CVP and PAP
which remained stable and her PA catheter was pulled on [**2176-8-14**],
we increased her metoprol dose to 12.5mg tid and her captopril
to 25mg tid. On [**2176-8-15**], her A-line was pulled, and her bblock
was converted to atenolol 25' and her ACEI was converted to
lisinopril 5mg', she was called out to the step down unit, and
continued to do well without symptoms of SOB, chest pain, or
dizziness.
.
2. Tachycardia: Patient developed atrial bigeminy on the night
of [**8-11**], and the morning of [**8-12**] at roughly at 730am developed
tachycardia to 140s. Rate was predominantly regular, although
P-waves were difficult to ascertain. She had another episode of
SVT (likely A tach) in th 120s in the afternoon of [**8-13**], which
she was treated with lopressor 5mg IV x 1, and increased her
metoprolol PO 12.5 bid to tid, which did not slow down her HR;
she was given Ditilzam 10mg IV x 1 and continued her with
ditilzam IV infusion, which brought her HR to 70's and back to
NSR. Tachycardia likely secondary either to post MI fluid
overload or irritation from pericardial effusion. She was given
lasix IV prn for fluid overload and kept her on lopressor PO
12.5 tid which was converted to atenolol 25mg PO qday for rate
control. Her tachycardia resolved after diuresis and increased
bblock dosage and her HR has been mainly in the 70-80's since
[**8-14**].
.
3. SOB: Patient tend to be short of breath in the morning.
Likely her underlying COPD. CXR relatively clear SOB resolved
rapidly with atrovent nebs. We continued advair and atrovent
nebs PRN and diuresed her prn to prevent fluid overload.
.
4. Hyperlipidemia - Her lipid panel showed Triglyc-86 HDL-57
CHOL/HD-2.7 LDLcalc-82; we initially increased her statin from
10->80mg s/p [**Name (NI) **], pt unable to tolerate it, went back to 20mg
PO qday which she was able to tolerate.
.
5. COPD/Asthma- continued her advair, atrovent nebs. Wean her
supplemental O2 to RA. She was able to ambulate without any
difficulty.
.
6. Glaucoma- continued her xalatan eye drops
.
7. GERD - on protonix 40mg PO qday.
.
8. Prophylaxis - ASA, plavix, SQ heparin, bowel reg prn, PPI
.
9. Code- Full but does not want prolonged life support, both
daughters her healthy care proxy, social work consult
Medications on Admission:
Meds at home: (per daughter, not very compliant with meds,
except albuterol, advair)
verapamil SR 240mg PO qday
lipitor 10'
ASA 81'
HCTZ 12.5'
nexium
albuterol
adavir
xalatan eye drops
Ca
Vitamin D
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain: hold
for oversedation or RR<12.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**]
Discharge Diagnosis:
Primary diagnosis
ST elevation MI s/p stents (mid RCA stent and OM2 stent)
placement
pericardial effusion s/p pericardiocentesis
.
Secondary diagnosis
HTN
Hyperlipidemia
TIAs
Asthma
bronchitis (recent excerbation two weeks ago, was on levaquin x
7 days, and steroids x 2weeks, last dose three days prior)
Glaucoma
osteoprosis
h/o TB treated
Reflux
Discharge Condition:
stable in good condition, no fever, chest pain, SOB, Nausea or
vomiting, good PO intake, ambulating
Discharge Instructions:
You had an episode of MI (blockage of your heart vessels) with
cardiac cath and stents placement which opened up your blockage.
It is essential that you take all your medications as
prescribed, in pariticular your cardiac medications (ASA,
plavix, atenolol, lisinopril, and atorvostatin).
.
You have been started in plavix and aspirin. You MUST take these
two medications without fail. If you stop taking these
medications even for one day, you are at high risk for having
your stent close off and causing a heart attack.
.
If you experience chest pain, shortness of breath or fevers, or
any other serious medical conditions, please go to the emergency
room immediately
.
You should follow a cardiac healthy diet.
.
Please call your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] at [**Telephone/Fax (1) 57826**]
for a follow up appointment within one week of discharge (his
office already know that you are getting discharged today and
needs a follow up appointment).
Followup Instructions:
Please follow up with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**]
([**Telephone/Fax (1) 57826**] talk to the charge nurse [**First Name4 (NamePattern1) 717**] [**Last Name (NamePattern1) 69685**]) to schedule
an follow up appointment within a week of discharge (I already
spoke with her, and she need to discuss with Dr. [**First Name (STitle) 1075**] to see
when he can see you next week)
Completed by:[**2176-8-16**]
|
[
"414.01",
"272.4",
"427.89",
"401.9",
"410.31",
"423.9",
"785.51",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"37.23",
"88.56",
"00.41",
"37.0",
"00.66",
"00.46",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
13106, 13246
|
7452, 11494
|
319, 352
|
13638, 13740
|
4221, 4221
|
14798, 15267
|
3660, 3673
|
11743, 13083
|
13267, 13617
|
11520, 11720
|
13764, 14775
|
7033, 7429
|
3688, 4202
|
231, 281
|
380, 3183
|
4237, 6744
|
3205, 3447
|
3463, 3644
|
6756, 7017
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,270
| 176,402
|
24941
|
Discharge summary
|
report
|
Admission Date: [**2108-9-5**] Discharge Date: [**2108-10-6**]
Date of Birth: [**2049-12-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Intubation, esophageal baloon
History of Present Illness:
HPI: Pt is a 58 y/o f with htn, dm2, hypercholesterolemia who
presented to an OSH with increasing sob and cxr/chest CT
infiltrates felt to respresent an ILD, was transferred to [**Hospital1 18**]
floor for further work-up, underwent VATS 1 day prior to MICU
admission, and developed hypoxemia and respiratory distress on
the night of admission, prompting micu transfer and intubation.
Apparently she first began developing sx one month prior to
presenting to the OSH with increasing sob, attributed at first
to a pneumonia that did not respond to antibiotics. Her sx
worsened and her doctor got a chest CT with diffuse bilateral
interstitial and ground glass opacities. At OSH, was ruled-out
for MI, negative stress test, echo with decreased e/a ratio, cta
without pe. She was transferred to [**Hospital1 18**] and underwent VATS one
night prior to MICU transfer, with the chest tube removed the
day of transfer. Overnight, she was seen by the nightfloat for
hypoxia and tachypnea, transferred to the MICU, and intubated.
.
Past Medical History:
1.)HTN
2.)DM2
3.)Hypercholesterolemia
4.)Hypothyroidism
Social History:
SocHx: Married. Lives with her husband and children. Works as a
manager for an outside vendor at [**Company 22916**] company. Quit smoking
20 years ago, had smoked 1ppd x 10 years. No hx EtOH or drug
abuse.
Family History:
Fhx: Mother had MI in her 70's - now with a pacemaker, also
currently being treated for lymphoma. Father has died, but had
lupus and had CABG at age 70. Brother had an MI and CABG at age
55.
Physical Exam:
PE: t 97.8, bp 96/50, hr 88, rr 20, spo2 97%
vent- a/c vt 400/rr 16/peep 10/fio2 1.00
gen- anxious-appearing female, looks age, mod distress
cv- rrr, s1s2, no m/r/g
pul- moves air well, clear anteriorly, velcro rales [**12-18**] way both
lung fields
abd- soft, nd, nabs
extrm- no cyanosis/edema, warm/dry
nails- no clubbing, painted
neuro- sedated, intubated, perrl
Pertinent Results:
DATA:
.
Non Contrast CT chest [**9-6**]
IMPRESSION: Diffuse lung disease with a basal predominance. The
differential diagnosis include NSIP, UIP, or COP. The less
likely differentials are chronic hypersensitivity pneumonitis,
sarcoidosis and drug related lung disease. If the patient is
immunocompromised, atypical infection such as PCP could be [**Name Initial (PRE) **]
possibility.
2) Mediastinal lymphadenopathy.
3) Innumerable small sub cm axillary lymph nodes and a 10 mm
right
prepectoral enlarged node.Clinical correlation recommended.
.
Bronch [**9-10**]: showed no DAH and had no complications.
.
VATS DATA ([**9-7**]):
Right middle lobe, wedge biopsy:
a. Acute and organizing interstitial pneumonitis with features
of bronchiolitis obliterans/organizing pneumonitis (BOOP).
b. Intraparenchymal lymph node.
Right lower lobe biopsy:
a. Acute and organizing interstitial pneumonitis with features
of bronchiolitis obliterans/organizing pneumonitis (BOOP).
b. Subpleural fibrosis and pleural adhesions.
Note: Stains for bacteria and fungi are negative.
.
Other Lab Data: +[**Doctor First Name **] (1:80), -ANCA, Neg Anti GBM.
.
CT Scan of Chest [**10-4**]
There are multiple subcentimeter right and left paratracheal,
prevascular, precarinal, and subcarinal lymph nodes measuring up
to 7 mm in diameter that do not individually meet criteria for
pathologic enlargement. There are no pathologically enlarged
axillary lymph nodes. There is a tiny left pleural effusion,
decreased in size from the previous examination. In comparison
with the examination of [**2108-9-17**], there is mild increase
in consolidative opacity within the airspaces at the lung bases
bilaterally and within the superior segment of the left lower
lobe. There is additional increase in air space consolidation at
the lung apices bilaterally, with patchy foci of dense
consolidation at the right lung apex and in left perihilar and
apical location. The distribution and extent of patchy
geographic ground-glass opacity throughout the remainder of the
lungs is probably not significantly changed in the interval.
Sutures are again seen at the right lung base. There is no
pneumothorax. Limited images of the liver, spleen, adrenal
glands, upper poles of the kidneys, appear unremarkable. There
is a small amount of dependent density within the gallbladder
suggestive of small stones or milk of calcium. BONE WINDOWS:
Bone windows demonstrate multiple right-sided rib deformities
consistent with old healed fractures. No suspicious lytic or
sclerotic osseous lesions are identified. IMPRESSION: 1.
Interval progression of bilateral airspace consolidation, most
prominent at the lung bases and within the superior segment of
the left lower lobe, and additionally involving the lung apices
and central perihilar regions. The geographic patchy ground
glass opacity appears approximately unchanged in distribution.
2. Decrease in size of small left pleural effusion. 3. Probable
gallstones or milk of calcium.
Brief Hospital Course:
AA/P: 58 y/o f with htn, DM2 and newly diagnosed ILD 1 day s/p
[**Hospital **] transferred to MICU and intubated for hypoxic respiratory
failure. Extubated and improved for 5 days, then required
reintubation and remains intubated with increasing O2
requirements with a diagnosis of PCP [**Name Initial (PRE) 11091**] (by BAL) superimposed
on her BOOP diagnosis.
.
1) Hypoxic respiratory failure -- Chest x-ray, discussed with
radiology, had appearance of progressive disease. Final results
of VATS consistent with organizing interstitial pneumonitis with
features of BOOP. She progressed on antibiotics in the past,
had no fever/wbc, all making an overlying infectious process
seem unlikely at the time. Pt had fairly normal echo at the
OSH, making failure also seem to be an unlikely candidate. Pt
was on high dose solumedrol during this time. Pts repiratory
function improved, and she was extubted on [**9-12**]. She remained
on high flow mask until [**9-18**] but was very anxious with
occasional desats and CT chest on [**9-17**] showed worsening
bilateral infiltrates. BAL was done [**9-18**] and she was paralyzed
with cisatracurium at 0.16mg/kg/hr and an esopageal baloon was
placed and she was reintubated on APRV and then PC ventillation.
BAL micro data grew PCP pneumonia and IV Bactrim was started.
The question remains whether this was in the setting of high
dose steroids (only short course prior to diagnosis) or due to
an underlying immunocompromised condition. ID was consulted
after several days of continued inability to wean with high
loading pressures (>30). Several fungal studies were negative
as were autoimmune serologies except for [**Doctor First Name **] which was positive
(RF negative). Steroids were dosed at 60mg IV BID starting
[**9-20**]. On [**9-25**], she was reintubated over a guidewire for cuff
leak. For the next several days, all attempts to wean
ventillation were unsuccessful. The patient remained fluid
overloaded and daily I/O goals were net negative. She received
fluids with antibiotics, etc. that made this difficult to attain
and lasix drip was used intermittently. In addition, the
patient has an underlying anxiety disorder and required
increasing amounts of sedation of both Fentanyl and Versed. As
soon as sedation began to wean, BP was >185 systolic with
apparant distress. Several times, during daily sedation weans,
we asked the pt to report on any pain. She responded with head
nods or shakes appropriately to questions and denied any pain or
other known sources of what could have been contributing to her
elevated BP. She did admit to being anxious. Starting around
[**9-30**], discussions about trach began with the family. Per IP,
given her high PEEP requirement on AC (>10), a surgical should
be considered as well. Between [**Date range (1) 11301**], she required
occasional increased in FiO2 requirement and on the morning of
[**10-5**], on 100% FiO2 and PEEP of 12, O2 sats were in the mid 80's
after one desat to the mid 70s. Bronch revealed no plugging.
Given high FiO2, no BAL was performed. Secretions have been
bloody at times, but no visible trauma on BAL. In addition,
occasional blood in NG residuals had persisted since [**10-3**], but
negative NG lavages. At this time, discussions with the family
re: this turn for the worse began. On [**10-5**], Md. [**Known lastname 1637**] is on
PC with an FiO2 of 100%, PEEP 18, PIP 33, RR 20, MAP 22. Her
CXRs for the past few days have been significantly worse. We
started vancomycin and meropenam on [**10-4**] for Coag + Staph
aureus in the sputum from [**10-2**] ([**Last Name (un) 36**] pending) and worsening
CXRs. CT done yesterday was consistent with worsening
infiltrates.
.
2) PCP [**Name Initial (PRE) **]: Pts repiratory function took a turn for the
worse several days ago requiring re-intubation due to PCP PNA
determined to have PCP PNA on BAL.
- IV Bactrim Q8 dosing for PCP PNA in setting of steroids.
.
3) Anxiety and sedation: Underlying anxiety disorder. There is
a clear relationship between elevated BP and anxiety. Sedation
resolves both issues for now.
Sedation switched a few times during the admission from
fentanyl/versed to propofol. Most recently, this is being done
on [**10-5**].
.
4) DM -- Ins gtt.
.
5) Anemia - HCT stable in mid 20's. Had anemia of chronic dz
per data this admission.
.
6) Hyponatremia- persists. Changed bactrim to be loaded in NS
instead of D5 (>1L daily fluid) on [**10-4**] with some improvement.
Had ranged 128-134.
.
7) Gut immobilization/FEN- For several weeks, the patient has
had high rediduals with tube feeding. She has had enemas QID
with lactulose as well as a full complement of PO bowel
medications and IV erythromycin (due to residuals on PO). TPN
was commenced on [**10-4**]. See hyponatremia above. Repleating
other lytes as necessary. She had a contraction alkalosis with
hypochloridia due to diuresis as well.
.
8) Ppx -- Sc heparin, pneumoboots, PPI
.
9) Access -- R subclavian (placed [**9-17**]), peripherals, A line
(placed [**2108-9-21**])
.
10) Comm -- with husband and PCP(Dr. [**Last Name (STitle) 48223**]
.
11) Code -- full
.
12) Disp -- On [**10-6**], due to a family meeting where the fact
that the patient had previously expressed no desire to be in a
long term ventillated state was revealed, she was made CMO and
died quickly after she was extubated. Morphine was titrated to
comfort. The family was present for the extubation.
Medications on Admission:
Levothyroxine 100mcg QD
Glyburide 5mg [**Hospital1 **]
Glucophage 500mg [**Hospital1 **]
ASA 325 QD
Cozaar 50mg QD (per pt, on Diovan?)
?Detrol LA (per patient. Not per doctor)
?Lipitor 10mg QD (per doctor. Not per patient)
recent Levaquin
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"482.41",
"516.8",
"401.9",
"244.9",
"285.29",
"428.0",
"518.84",
"564.00",
"136.3",
"515",
"250.00",
"300.00",
"272.0",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.38",
"93.90",
"33.24",
"33.22",
"04.81",
"96.72",
"96.6",
"38.93",
"96.04",
"38.91",
"99.15",
"33.28"
] |
icd9pcs
|
[
[
[]
]
] |
11119, 11128
|
5354, 10828
|
343, 374
|
11179, 11188
|
2344, 5331
|
11244, 11254
|
1749, 1942
|
11149, 11158
|
10854, 11096
|
11212, 11221
|
1957, 2325
|
276, 305
|
402, 1428
|
1450, 1508
|
1524, 1733
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,123
| 116,395
|
54468
|
Discharge summary
|
report
|
Admission Date: [**2135-1-6**] Discharge Date: [**2135-1-12**]
Date of Birth: [**2049-11-26**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
[**2135-1-6**] open repair infrarenal AAA
[**2135-1-7**] ex lap/cholecystectomy, Bilat [**Doctor Last Name **] embolect, Bilat
fasciotomies
[**2135-1-8**] [**Doctor Last Name **] cutdown, embolectomy, AT embolectomy
[**2135-1-9**] ex-lap (neg), open abdomen
History of Present Illness:
85-year-old female presented for elective repair of an
infrarenal abdominal aortic aneurysm initially found on CT chest
for routine follow-up of a lung mass.
Past Medical History:
5.8-cm abdominal aortic aneurysm, smoker, hypertension, LLE DVT,
COPD, arthritis, hammertoe deformities, major depression, a
pulmonary nodule in RUL, cataracts, footdrop of the right foot,
diastolic dysfunction by echo from [**2117**], chronic kidney disease
stage III, mitral valve prolapse, degenerative disc disease,
hearing loss, hyperlipidemia, urge incontinence, osteopenia.
PFTs from [**2128**] showed FEV1 93% predicted and FEV1/FVC ratio 84%
predicted. colonoscopy: consistent with colitis/IBD; scoliosis;
varicose veins.
Social History:
Significant history of tobacco use. Denied EtOH abuse. Denied
recreational drug use.
Family History:
Unknown.
Physical Exam:
Pre-op exam:
T 98.9 P 68 BP 137/79 RR 20 O2sat 97% on RA
Awake, alert, NAD, anxious
Heart RRR
Lungs no respiratory distress, normal excursion/effort
Abdomen soft, NT, ND
Extremities WWP, bilateral hammertoe deformities
Brief Hospital Course:
On [**2135-1-6**], the patient was admitted post-operatively after
open AAA repair. She produced 2 guaiac positive stools, raising
concern for mesenteric ischemia. In addition, dopplerable
signals were lost in bilateral lower extremities, raising
concern for showered emboli from the aneurysmal thrombus. The
patient was taken back to the OR on [**2135-1-7**] for bilateral
popliteal artery exploration with embolectomy of the tibial
vessels bilaterally, exploratory laparotomy with cholecystectomy
and evacuation of hematoma. The right DP became dopplerable,
but signals remained absent on the left DP/PT. Pt was
transfused with blood to maintain hematocrit above 30. On
[**2135-1-8**] the patient underwent re-exploration at left
popliteal fossa with left anterior tibial artery thrombectomy.
The patient was started on an argatroban drip out of concern for
HIT. She went into rapid afib and was cardioverted x2. The
patient returned to the OR [**2135-1-9**] for exploratory laparotomy
which was unremarkable, and she was left with an open abdomen.
She remained intubated and sedated since the initial surgery.
She became hypotensive requiring vasopressor drips. She
developed anuric renal failure, requiring CVVHD. She developed
progressive acidosis and hemodynamic instability requiring
pressors. She returned to the OR for exploration on [**2135-1-11**] at
which time diffuse ischemia of all abdominal contents was noted
and it was deemed inappropriate to procede with bowel resection
based on the patient's previously stated wishes and a discussion
with the son.
After many family discussions, final decision was to render the
patient CMO on [**2135-1-11**]. Medications were stopped. The patient
expired on [**2135-1-12**] at 0250.
Medications on Admission:
Atenolol 25 mg daily, Lisinopril 10 mg daily, and Aspirin 81 mg
daily.
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Abdominal aortic aneurysm, s/p open repair
Bilateral popliteal artery embolism
Cholecystitis
Bilateral lower extremity ischemia
Acute kidney injury, requiring hemodialysis
Chronic kidney disease
Discharge Condition:
Expired.
Discharge Instructions:
None.
Followup Instructions:
None.
Completed by:[**2135-1-12**]
|
[
"287.5",
"585.3",
"440.20",
"570",
"276.2",
"403.90",
"998.09",
"296.20",
"788.31",
"272.4",
"496",
"789.59",
"518.51",
"424.0",
"584.5",
"997.2",
"286.6",
"E878.2",
"427.31",
"998.12",
"736.79",
"557.0",
"V49.86",
"V66.7",
"575.0",
"441.4",
"444.22",
"733.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44",
"39.95",
"38.08",
"99.61",
"51.22",
"54.12",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
3628, 3637
|
1721, 3477
|
329, 588
|
3875, 3885
|
3939, 3975
|
1449, 1459
|
3598, 3605
|
3658, 3854
|
3503, 3575
|
3909, 3916
|
1474, 1698
|
264, 291
|
616, 775
|
797, 1329
|
1345, 1433
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,147
| 192,527
|
43301
|
Discharge summary
|
report
|
Admission Date: [**2177-12-31**] Discharge Date: [**2178-1-17**]
Date of Birth: [**2118-12-13**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Ceftriaxone / Flagyl / Levofloxacin / Iodine Strong /
Unasyn / Bactrim / Vancomycin
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Abdominal pain, melena, seizure
Major Surgical or Invasive Procedure:
Colonoscopy
Upper endoscopy
Ultrasound guided paracentesis
History of Present Illness:
This is a 59 year-old female with history of hepatitis C
cirrhosis, hypertension, cryoglobulinemia, who presented with
abdominal pain. She had been having nausea, vomiting, diarrhea,
and abdominal pain for 3 days prior to presentation. In the
emergency department, she had a focal seizure that generalized
in the setting of hypertension to the 200s systolic. She
responded to ativan and returned to her baseline mental status.
.
Review of systems was notable for burning with urination. She
denies any fevers, chills, fatigue, weakness, lightheadedness,
dizzyness, or headaches.
Past Medical History:
1. Hepatitis C: She is followed in liver clinic, but declined
any interventions. She has evidence of cirrhosis and ascites.
This is believed to have resulted from transfusion 20 years ago
following an ectopic pregnancy
2. Hypertension
3. Cryoglobinemia diagnosed in [**3-23**]
4. Varicose veins status post stripping in [**5-27**] and [**12-29**]
5. Vasculitis: Leukocytoblastic diagnosed on biopsy from [**2-21**]
following 3 year history of difficulty walking and leg pain and
swelling.
6. Hypothyroidism
7. Cholecystectomy in [**2174**] that is thought to be due to chronic
vasculitis from untreated Hepatitis C.
Social History:
She came to the US from [**Country 532**] about 15 years ago. She lives
with her son and ex-husband. She is independent in daily
activities. She denies alcohol or tobacco use.
Family History:
Her mother died of coronary arterty disease and hypertension at
the age of 72
Physical Exam:
Vitals: Temperature:96.9 Blood Pressure:127/48 Pulse:95
Respiratory Rate:14 Oxygen Saturation:99% on room air
General:Lying in bed no acute distress.
HEENT: Pupils equal and reactive, moist mucous membranes,
extraoccular movements intact.
Cardiac: Regular rate and rhythm no murmurs, rubs, gallops.
Pulmonary: Clear to auscultation bialterally.
Abdomen: Normoactive bowel sounds, distended, nontender.
Extremities: Warm and well perfused, no edema, surgical scars on
anterior right shin.
Neuro: Cranial nerves II-XII grossly intact, strength and
sensation symmetric
Pertinent Results:
Hematology:
WBC-6.0 HGB-10.9 HCT-31.5 PLT COUNT-243
NEUTS-86.7 BANDS-0 LYMPHS-11.6 MONOS-1.1 EOS-0.1 BASOS-0.4
.
Chemistries:
SODIUM-138 POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-19 UREA N-16
CREAT-0.9 GLUCOSE-181
.
Liver Function:
ALT(SGPT)-27 AST(SGOT)-34 ALK PHOS-85 AMYLASE-74 TOT BILI-1.1
LIPASE-22
ALBUMIN-4.3
.
Urinalysis: [**10-12**] RBC, [**5-2**] WBC, few bacteria, 0-2 epithelial
cells.
.
Lactate:6.7
CRP: 6.7
SED-Rate: 5
.
Imaging:
1. Head CT: No evidence of intracranial hemorrhage or acute
intracranial pathology. Bilateral occipital encephalomalacia
consistent with chronic infarct. Please note that noncontrast CT
scan cannot exclude acute infarction. MRI with
diffusion-weighted images is more sensitive for evaluation of
this entity.
2. Abdominal CT: Small amount of intra-abdominal and pelvic
ascites.Thsi maybe secondary to teh background of liver disease
or low protein state but acute intraabdominal process cannot be
excluded. No pneumoperitoneum or localized collection
demonstrated. No evidence of bowel obstruction on the current
study. Some localised fluid in the gallbladder fossa remains
unchanged to the previous CT. Small right basal pleural
effusion, minimal rim of fluid at the left lung base. A 1.6 cm
densely calcified right splenic artery aneurysm, 1-cm pancreatic
head lipoma unchanged. Mild sigmoid diverticulosis.
Brief Hospital Course:
This is 59 year-old female with hepatitis C, cryoglobulinemia,
and hypertension who presented with nausea, vomiting, abdominal
pain who had a witnessed seizure in the ED in the setting of
hypertensive urgency.
.
1. Seizure: In the Emergency department, she had a seizure in
the setting of blood pressure to 214/82. A head CT was
unrevealing for an acute bleed or mass effect. It is unclear
the etiology of her seizure, although it is likely that it was
triggered by hypertensive changes. She was evaluated by
neurology. The patient, however, refused further diagnostic
work-up including and MRI/MRA, lumbar puncture, and EEG. She
also refused empiric antibiotics. She was monitored in the
intensive care unit immediately post-seizure. She did not have
any further seizures during this admission.
.
2. Urinary tract infection: She had a positive urinalysis and
her urine culture grew out e.coli. Initially, she refused
antibiotic treatment for several days. She then accepted
antibiotic treatment and was treated with Bactrim for 3 days.
She refused repeat urine culture to see if the bacturia had
cleared.
.
3. GI bleed: She was guaiac positive and had an episode of
melena in the intensive care unit. Initially, she refused
evaluation with an upper endoscopy but was willing to undergo
colonoscopy. The colonoscopy did not show any source of
bleeding. Several days later, she consented to an upper
endoscopy that showed 4 grade III varices with stigmata of
recent bleed. Three bands were placed and she was told that she
would need repeat banding every 3 weeks until her varices were
resolved. She was started on nadolol, which she took for a few
days until she started refusing. Per her request, she was
switched to propranolol, which she tolerated on previous
admissions. However, she never took this medication and refused
to take it throughout the remainder of the admission. The
endoscopy also showed gastritis and she was started on
pantoprazole twice daily as well as sucralfate.
.
4. Spontaneous bacterial peritonitis (SBP): On admission, she
had abdominal pain. An ultrasound did not show adequate ascites
to tap. A few days post-endoscopy, she began having worsening
abdominal pain with fevers to 102. A repeat ultrasound showed
significant ascites, and a paracentesis under ultrasound
guidance drained about 2L of fluid. The ascites had greater
than 4000 neutrophils. Gram stain and culture were both
negative; however, the patient had recently completed a course
of Bactrim for her urinary tract infection. In it unclear that
inciting factor for her SBP whether it was her urinary tract
infection or recent variceal bleed without prophylactic
antibiotics as she refused. She was started on Unasyn for her
SBP. After 2 doses, she developed a macular papular blanching
rash over her flexor and extensor surfaces of her elbows and
over her groin bilaterally. Dermatology felt that her rash was
consistent with a drug hypersensitivity reaction from either
Bactrim or Unasyn. At that point she refused to take any
medications saying that all medications were hurting her and
causing the rash. After several long discussion with the
patient and interpreter, she agreed to take aztreonam. She took
1 dose and then refused to take them again since she was not
improving. Over the course of several days, she would refuse
antibiotics and then take a single dose and then refuse them
again for several days. A repeat paracentesis under ultrasound
guidance was done after she had been off of antibiotics for
several days. The fluid again had about 4,000 neutrophils and
the fluid culture continued to not grow anything. Finally, with
the help of her daughter, she agreed to take the aztreonam on
schedule. After 3 days of antibiotics, she was convinced that
they were not helping despite her pain improving and her fever
curve trending down. At one point during the admission, she
requested to be diuresed for comfort. She received 2 days of
Bumex. Her creatinine, however, increased, so the diuresis was
stopped.
.
5. Possible small bowel obstruction: Her abdomen became
progressively more tympanic with increased abdominal pain. An
abdominal plain film was suggestive of an early small bowel
obstruction. She was made NPO until her symptoms improved. Her
diet was advance to soft solids as she tolerated. Towards the
end of the admission, she began having worsening abdominal pain
and a repeat x-ray showed another early small bowel obstruction.
However, the patient left AMA before that could be resolved.
.
6. Rash: She developed a drug hypersensitivity reaction to
either Unasyn or Bactrim. Her rash progressed to her whole
body, and she developed urticaria. She refused Benadryl
initially. She did agree to take 1 dose of Benadryl late in her
hospital stay. Initially, she also refused topical steroid
creams and Sarna lotion, but then agreed to them intermittently.
Her rash improved after about 1 week.
.
7. Hypertension: She has a long standing history of hypertension
and will only take clonidine patch at home. Her hypertension
was poorly controlled on the clonidine patch initially. Once
she was started on the nadolol, her blood pressure improved
transiently. Her blood pressure also improved with diuresis
.
8. Hepatitis C: The patient and family are in denial of her
hepatitis and therefore do not want to pursue any treatment.
The have the fixed false belief that she was given an infection
in her liver at the time of her cholecystectomy in [**2174**] despite
documentation that she had hepatitis C in [**2172**].
.
9. Anemia: Her anemia is secondary to anemia of chronic disease
and blood loss from probable variceal bleed. She did except 1
transfusion but refused all other suggestions for transfusion.
When she left AMA, her hematocrit was 22.
.
10. FEN: Initially, she was maintained on a low sodium diet.
She was NPO for early small bowel obstruction and her diet was
advanced as above. She persistently refused repletion of all
electrolytes.
.
11. Access: She had peripheral IVs.
.
12. Code: Full. Her code status was readdressed when she was
persistently refusing treatments.
.
13. Dispo: Throughout this admission, she intermittently refused
antibiotics and other medical treatments. Towards the end of
the admission, she persistently refused all treatment. Ethics
and legal were involved and felt that the patient could not be
forced to take medications. Psychiatry evaluated the patient
and felt that she had capacity to make her own decisions.
Numerous discussions were held with the patient with an
interpreter present. During these discussion, she demonstrated
that she understood the risks of refusing treatments. She
clearly stated that she would rather be home. Her son came to
take her home against medical advice. Her daughter could not be
reached at the time that the son was taking her home. The
patient and her son refused to sign the AMA form. She was given
prescriptions for her medications in case she decided to take
them. She was told to follow-up with her primary care physician
or return to the emergency room (even if at another hospital)
for worrisome symptoms.
Medications on Admission:
Medications on Admission:
Roxicet
Clonadine patch 600 mcg qweek
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Urinary tract infection
Spontaneous bacterial peritonitis
Esophageal varices
GI bleed
Hypertension
Hepatitis C with cirrhosis
Discharge Condition:
Patient is leaving against medical advice.
Discharge Instructions:
Please take all medications as prescribed and keep all follow-up
appointments.
.
At the present moment you are leaving against medical advice.
On x-ray you have a small bowel obstruction. This could become
fatal. Please seek medical services if you having worsening
abdominal pain, fevers or chills. Only eat if you are passing
gas and/or having bowel movements.
Followup Instructions:
You should follow-up with your primary care physician:
[**Name Initial (NameIs) 2169**]: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2178-2-6**] 1:30
.
You also have the following appointments:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2178-1-7**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2178-4-1**] 10:00
Completed by:[**2178-1-18**]
|
[
"280.0",
"584.9",
"599.0",
"780.39",
"571.5",
"567.23",
"456.0",
"560.1",
"E931.0",
"693.0",
"789.5",
"401.9",
"070.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"42.33",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
11263, 11269
|
3973, 11148
|
389, 450
|
11447, 11492
|
2597, 3039
|
11906, 12504
|
1917, 1996
|
11290, 11426
|
11200, 11240
|
11516, 11883
|
2011, 2578
|
318, 351
|
478, 1064
|
3048, 3950
|
1086, 1705
|
1721, 1901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,402
| 106,278
|
2660
|
Discharge summary
|
report
|
Admission Date: [**2156-6-4**] Discharge Date: [**2156-6-30**]
Date of Birth: [**2084-3-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Aleve / Codeine / Depakote
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hypotension after hemodialysis
Major Surgical or Invasive Procedure:
R IJ central line placement
Hemodialysis
History of Present Illness:
Chief Complaint:
Hypotension
.
History of Present Illness:
72F with a history of type II DM, ESRD on HD, GAVE, HTN, MR,
CAD, CHF w/ RV failure and seizure disorder with recent
hospitalization from [**5-5**] to [**6-3**] with culture negative sepsis
with MS change and c.diff colitis, who presents to the ED on
[**6-4**] for HD. Pt was discharged on [**6-3**] and was due for her HD
today per her MWF schedule. She was sent from rehab to the
[**Hospital1 18**] ED for HD due to her current diarrhea from c.diff colitis
and concerns about her volume status. She was seen in the ED
then sent for HD with 2.5 fluid removed. Prior to HD, in ED BP
131/76 RR 16 92% 4L.
.
Following her ultrafiltration, she returned to the ED for likely
discharge back to rehab. However, both during HD and on return
to the ED, she was noted to be hypotensive, to as low as SBP
60s. She received 2 L total IVF in ED with minimal response.
She had a RIJ placed for access. Her BP has since been labile
and she has had BP to 67/42 with HR 89 at time of transfer to
the floor. The only laboratory sent at the time of admission to
floor were CBC and chem 10.
.
Allergies: Aspirin / Aleve / Codeine / Depakote
Past Medical History:
* Chronic Gastric Angiodysplasia (GAVE)and consequent chronic
low-grade UGIB, and has therefore been advised not to take
aspirin or other antiplatelet agents.
* DM type II: c/b nephropathy and neuropathy - currently not on
diabetic meds, has hypoglyemia [**12-27**] poor nutritional stores
* ESRD: HD MWF has fistula L arm
* CAD
* CHF, R-sided, diastolic EF 50-55% with 4+ TR 2+ MR [**8-/2155**]
TTE
* Anemia: multifactorial (ESRD + iron deficiency [**12-27**] GIB)
* colon polyps (hyperplastic) [**7-/2153**] colonoscopy
* gastritis and duodenitis [**7-/2153**] EGD
* gout
* pleural effusion s/p thoracentesis [**8-/2153**] negative cytology,
.
Social History:
Pt lives at [**Location **]. No ETOH, tobacco, or drugs.
Pt has four children, all involved in her care. There were
several family meetings during this admission with all her
children. They are very supportive and close family. No health
care proxy is assigned at this time ([**2156-5-31**]). She is aware that
she needs to choose one.
.
Family History:
[**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. Her mother
had an MI in her 80s.
Physical Exam:
VS: T: 95 BP: 78/48 HR: 112 RR: 16
Gen: Elderly woman in apparent distress, intermittently
responsive and awake, at times combative and agitated
HEENT: NCAT. Mucous membranes slightly dry
Neck: Supple, no JVD, RIJ dressing c/d/i
CV: RRR normal s1 s2
Chest: Poor air movement
Abd: Soft, NT/ND. No HSM or tenderness. +BS, umbilical hernia
Pertinent Results:
[**2156-6-3**] 05:13AM BLOOD WBC-5.6 RBC-2.63* Hgb-9.5* Hct-30.8*
MCV-117* MCH-36.3* MCHC-30.9* RDW-25.9* Plt Ct-76*
[**2156-6-24**] 04:16AM BLOOD WBC-6.4 RBC-2.35* Hgb-8.5* Hct-27.3*
MCV-116* MCH-36.3* MCHC-31.3 RDW-20.3* Plt Ct-129*
[**2156-6-30**] 07:18AM BLOOD WBC-6.1 RBC-2.53* Hgb-8.9* Hct-28.3*
MCV-112* MCH-35.3* MCHC-31.5 RDW-18.8* Plt Ct-142*
.
[**2156-6-3**] 05:13AM BLOOD Glucose-70 UreaN-10 Creat-2.6* Na-141
K-3.9 Cl-102 HCO3-30 AnGap-13
[**2156-6-24**] 04:16AM BLOOD Glucose-161* UreaN-8 Creat-2.2* Na-133
K-3.6 Cl-97 HCO3-30 AnGap-10
[**2156-6-30**] 07:18AM BLOOD Glucose-85 UreaN-11 Creat-3.0* Na-133
K-3.6 Cl-95* HCO3-27 AnGap-15
.
[**2156-6-5**] 02:25AM BLOOD ALT-16 AST-32 AlkPhos-147* Amylase-59
TotBili-2.5*
[**2156-6-6**] 05:31AM BLOOD ALT-19 AST-44* LD(LDH)-439* AlkPhos-133*
TotBili-2.4*
[**2156-6-21**] 05:58AM BLOOD ALT-12 AST-29 LD(LDH)-309* TotBili-6.1*
DirBili-4.5* IndBili-1.6
.
[**2156-6-28**] 06:13AM BLOOD ALT-19 AST-50* AlkPhos-189* TotBili-9.6*
.
[**2156-6-5**] 05:16AM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2156-6-5**] 11:49PM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2156-6-6**] 09:06PM BLOOD CK-MB-NotDone cTropnT-0.18*
.
[**2156-6-16**] 05:11AM BLOOD Ammonia-69*
[**2156-6-17**] 05:05AM BLOOD Ammonia-52*
[**2156-6-21**] 04:03PM BLOOD Ammonia-16
[**2156-6-23**] 06:12AM BLOOD Ammonia-53*
[**2156-6-14**] 04:22AM BLOOD Digoxin-0.9
[**2156-6-15**] 06:53AM BLOOD Digoxin-1.8
.
Imaging:
Echo - The left atrium is elongated. The right atrium is
moderately dilated. A secundum type atrial septal defect is
present. The estimated right atrial pressure is 10-15mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) There is no ventricular
septal defect. The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. 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. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral regurgitation is seen. The tricuspid valve leaflets
fail to fully coapt. Severe [4+] tricuspid regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
CT abdomen and pelvis -
CT OF THE ABDOMEN WITHOUT CONTRAST: There is a moderate-to-large
left
effusion, simple in attenuation, increased in volume from the
prior study.
There is a small right pleural effusion, also increased since
the prior exam.
There is bilateral lower lobe atelectasis versus consolidation.
There are
coronary artery calcifications and calcifications of the aortic
valve.
The non-contrast appearance of the liver, gallbladder, spleen,
pancreas and
adrenal glands is unremarkable. The known enlarged common bile
duct is not
well assessed on this examination. The kidneys are atrophic.
There is no
hydronephrosis. A moderate amount of ascites is again seen.
There is no free
intra-abdominal air.
There is circumferential wall thickening of the colon, most
marked from the
cecum through the hepatic flexure. The transverse, descending,
and sigmoid
colon is not well distended though it may be thickened to a
lesser degree.
Small bowel loops are normal in caliber and appearance, without
evidence of
obstruction. The abdominal aorta is normal in caliber, with
atherosclerotic
calcifications. Patency of the mesenteric vessels cannot be
assessed without
IV contrast; no air is seen within them. There is no mesenteric
or
retroperitoneal lymphadenopathy. There is extensive subcutaneous
edema
bilaterally, similar to that seen on the prior study. A 2.4 x
1.3 cm nodule
is seen in the subcutaneous fat of the left lower abdomen,
possibly related to
an injection.
CT OF THE PELVIS WITHOUT CONTRAST: Oral contrast reaches the
rectum, which is
normal in appearance. There are calcifications of the uterine
vessels. The
bladder is likely collapsed and not well assessed. There is a
moderate-to-
large amount of free pelvic fluid, slightly increased from the
prior exam. No
enlarged pelvic or inguinal nodes are seen. Again extensive
subcutaneous
edema is appreciated.
No suspicious osseous lesions are detected.
Multiplanar reformatted images were essential in delineating the
anatomy and
pathology in this case.
IMPRESSION:
1. Interim development of circumferential wall thickening of the
colon, most
pronounced in the cecum through the hepatic flexure. The
remainder of the
colon is likely thickened to a lesser degree. While
infectious/inflammatory
colitis such as C. Diff remain in the differential, ischemic
colitis is of
concern, given the vascular distribution of the findings (right
sided
predominance and elevated lactate) . The patency of the
mesenteric vessels was
not assessed on this non- contrast exam. No free air, portal
venous gas or
obstruction.
2. Extensive third spacing of fluid including subcutaneous
fluid, pleural
effusions and ascites.
3. Known enlargement of the common bile duct is not well
assessed on this
study. Followup imaging was advised on the prior exam.
4. Atrophic kidneys.
5. Moderate-to-severe atherosclerotic calcification of the
abdominal
vasculature.
6. Nodule of the subcutaneous fat of the left lower abdomen.
This could be
related to injections. Attention on followup studies will be
helpful.
Brief Hospital Course:
71 yo F with DM, ESRD on HD, GAVE, HTN, CHF w/ RV failure,
c.diff colitis and persistent diarrhea admitted for hypotension,
also noted to be persistently hypoglycemic. Was in the unit on
pressors, then was able to be weaned off. Waxing and [**Doctor Last Name 688**]
encephalopathy while on floor, contributing to hypoglycemia and
aggitation.
.
# Hypotension: Coagulopathy, thrombocytopenia, hypothermia and
hypotension was concerning for sepsis. Her BP was not
responsive currently to IVF, she received total of 1.5 L in ED
and 1 L on floor, she was started on neo (did not tolerate
levophed) and started on broad spectrum antibiotics including
vancomycin IV and cefepime IV as well as vancomycin po and
flagyl iv for her c.diff. There was also likely component of
hypovolemia in setting of diarrhea and poor POs. She as weaned
off of neo, but continue to have intermittent low blood
pressures to the high 80's and 90's. This is likely secondary to
her c.diff infection. She was mentating at her baseline
throughout these hypotensive periods. She received her usual
dialysis, but did not tolerate much fluid removal. She was
eventually weaned off of her pressors. For several dialysis
sessions, she was unable to have a high enough BP for adequate
fluid removal, but BPs started to improve and patient was
tolerated dialysis with approx 2-3L removal per session. When
transferred to the floor, patient had moderately low BPs while
she was in aflutter/afib. Patient evenutally converted with HRs
in 80-100s and BPs improved. Likely due to improved heart
function with slower rhythm. BPs on discharge in 120s and
stable.
.
# Atial tachycardia: Intermittent bursts of atrial tachycardia -
afib vs. aflutter. HRs in 120s-140s during these epsisodes.
Low BPs but had normal perfusion. Electrophysiologists were
consulted and started 4 week amiodarone load with 400 mg daily.
Then will start 200 mg amiodarone daily indefinitely. Also on
digoxin 0.125 mg every other day. Pt was not on beta blocker
during this time because blood pressure were unable to tolerate.
While on floor, after approx 1-1.5 weeks of amio load,
patient's aflutter/fib resolved. Was in NSR and telemetry was
discontinued. She was noted to have several runs of
asymptomatic NSVT to about 10 beats while on telemetry. Will
continue amio 400 mg until [**7-10**], then switch to 200 mg
daily.
.
# Encephalopathy - likely related to toxic metabolite buildup,
probably hepatic failure is biggest contributor. Would wax and
wane between confusion and lucidness. Would treat aggitation
with SL zyprexa. Avoided sedating meds. Pt was refusing
narcotics for pain control because she could feel herself not
thinking clearly. Upon discharge, patient has appropriate
mental status for several days and was able to understand her
situation. Likely has depression contributing at some level,
too. Often is sad and crying in the morning when family is not
around.
.
# Hypoglycemia: Pt has history of diabetes, but is no longer on
any diabetic meds because of these low blood sugars. Is likely
due to poor nutritional stores in setting of hepatic failure
with poor gluconeogenesis. Endocrinology was consulted during
previous admission and did not feel insulinoma was a
possibility. C peptide was likely only elevated because it is
renally cleared. Pt FS was as low as 15 while in the MICU. Pt
was able to resume her diet and then have appropriate blood
sugars. She does need encouragement to keep appropriate PO
intake. While on the general medicine floor, had a period ofo
altered mental status in which she was too somnolent to eat, and
to maintain sugars, we had her on a d10W gtt at 500cc/hr for
about 3 days. She became hyponatremic at that time. Her mental
status improved, we were able to stop the drip and keep her on
her normal PO diet and her sugars did much better. Her
hyponatremia also resolved. We started her on scheduled glucose
tabs, but she does not take them regularly because she does not
like the taste.
.
# ESRD/HD: On HD MWF. Needs to continue this schedule as an
outpatient.
.
# Thrombocytopenia/coagulopathy: Initially ther was concern for
DIC. She was given vitamin k initially, however her coagulopathy
is likely [**12-27**] to her hepatopathy [**12-27**] to right heart failure. Her
coags were followed as well as monitoring for signs of bleeding.
No further intervention was necessary. Her INR is high at 2.5.
She does not have any active signs of bleeding and has stable
anemia with a hemoglobin between 8 and 9.
.
# Hyperbilirubinimia: Thought to be associated with congestive
hepatopathy from RV hypokinesis. We monitored her liver
functions were showed increasing bilirubin. She became more
jaundiced throughout her stay. Her belly exam remained
intermittently tight and distended, worsening at time, but
improves often after dialysis. She is asymptomatic. We
discussed possibly doing a therapeutic paracentesis, but with
her his risk and lack of symptoms, we decided against it.
.
# Peripheral Vascular Disease - the patient developed what
appears to be arterial ulcers on her Bilateral big toes. They
do not seem infected, but she has symptoms of pain in her heels,
occassionally her hands. We did ultrasounds studies of her ABIs
which were 0.4 and 0.6 in R and L respectively. We tried to
control her pain with oxycodone, but patient refusing narcotic
meds. Tylenol up to 2 gms daily can be used for symptom relief.
.
# C.diff - was admitted with a c.diff infection. Was treated
with appropriate course of PO vanco and PO flagyl. Diarrhea is
now only mild and not voluminous like it previously had been.
Does not need any more treatment on discharge.
.
# Hx of siezures - on prior admission, had a seizure while
hypotensive and in the MICU. Is now on keppra for siezure
prophylaxis. Will continue keppra as outpatient. She has an
appointment with neurology is late [**Month (only) 216**] in which they may
cchoose to discontinue this med.
.
# Pleural effusions - patient has a stable pleural effusion,
unknown etiology. A thoracentesis was attempted previously, but
unsuccessful. There has been a question of possible lymphoma
seen on prior imaging studies, but no diagnosis has been made.
Her breathing is stable on room air and she is not dyspneic on
the mild exertion she is able to do.
.
# Deconditioning - has been in and out of the hosptial since
about [**Month (only) 956**], does not get out of bed much. Needs extensive
PT work to improve her strength.
.
# Code - patient is now DNR/DNI as CPR is not medically
indicated in her case. Palliative care knows the patient and
the family well. There were many family meetings during the
time of her care about the patient's poor prognosis.
.
# Contact: son [**Name (NI) **], [**Telephone/Fax (1) 13227**]
Medications on Admission:
Camphor-Menthol 0.5-0.5 % Lotion QID (4 times a day) as needed.
Omeprazole 40 mg Capsule PO DAILY
Metronidazole 500 mg PO TID for 10 days from [**6-3**]
Keppra 100 mg/mL 250 mg PO BID
Ergocalciferol (Vitamin D2) 50,000 unit PO 2X/WEEK (MO,TH) for 2
months
Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day: Start after 2 months of 50,000u twice weekly is completed.
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 10 days: Please finish taking amiodarone 400 mg daily until
[**7-10**]. Then start taking 200 mg daily.
4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed: Do not exceed 2 grams daily.
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day).
7. Dextrose (Diabetic Use) 300 mg Tablet Sig: Two (2) Tablet PO
TID (3 times a day).
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
PLEASE DO NOT START THIS DOSAGE UNTIL [**7-11**]. Thanks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**]
Discharge Diagnosis:
Primary diagnosis:
1. Hypotension
2. C. diff
3. Altered mental status secondary to multiorgan failure
4. ESRD on HD
5. Liver dysfunction
6. Right heart failure
7. Peripheral Vascular disease
8. Hypoglycemia
Discharge Condition:
vitals signs stable, SBPs in 110s-120s, HR 80s-90s. Afebrile.
Somewhat delerious, but waxing and [**Doctor Last Name 688**]. Continues to have
mild diarrhea 2-4x a day. Able to get from bed to chair with
assistance. Tolerating ground solids.
Discharge Instructions:
You were admitted for low blood pressures after a dialysis
session. You were in the MICU for several days on a vasopressor
medicine that kept your blood pressure at a high level. We had
a difficult time removing fluids from your body during dialysis
while you had this low blood pressure.
.
Eventually we were able to wean you off the vasopressors. You
were treated for a possible infection with strong antibiotics.
None of the cultures came back, so we do not know if there was
an infection causing you to have these low pressures.
.
These pressures also affected your mental status. Some days you
were very delerious from having low pressures and having toxic
metabolic buildup in your blood from your multiorgan failure.
We monitored your electrolytes and liver function tests. You
started to improve over time but still have some good days and
bad days.
.
You had a bowel infection called c.diff this whole time. It
causes chronic diarrhea. We treated you with anitbiotics called
vanco and flagyl, both of which are taken by mouth. You stopped
taking these medicines on [**6-24**].
.
You also had heart problems during this hospitalization. For a
while, you were in a rhythm called atrial flutter. It caused
your heart rate to go very high, which is unsafe for your body.
We were able to start controlling it with medicines called
digoxin and amiodarone. The electrophysiologists helped us
choose and then further manage these medicines.
.
You also had some problems keeping you blood sugars high enough,
especially on days when you were confused and not eating well.
We treated you with IV fluids that had sugar in them. You did
well and when your mental status improved, we were able to take
that off. You should continue to try and eat as much as
possible several times a day to help your nutrition and blood
sugars.
.
You continued dialysis MWFs while an inpatient.
.
You will be discharged to a rehabilitation facility to start
working on your strength. You will need to continue dialysis.
You should come back to the hospital for any chest pain,
shortness of breath, dizziness, fainting, or other concerns.
Followup Instructions:
Neurology:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2156-7-19**] 4:30
.
PCP:
[**Name10 (NameIs) 357**] call [**Known firstname 2048**] [**Last Name (NamePattern1) 4223**] at [**Telephone/Fax (1) 7976**] to make an
appointment as needed once at rehabilitation.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2156-6-30**]
|
[
"250.42",
"427.32",
"250.62",
"261",
"250.82",
"038.9",
"707.15",
"349.82",
"008.45",
"428.0",
"274.9",
"285.21",
"357.2",
"428.32",
"424.0",
"585.6",
"276.52",
"572.8",
"287.5",
"995.92",
"440.23",
"403.91",
"345.90",
"785.52",
"458.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16669, 16716
|
8581, 15389
|
326, 369
|
16967, 17215
|
3115, 8558
|
19394, 19903
|
2637, 2740
|
15821, 16646
|
16737, 16737
|
15415, 15798
|
17239, 19371
|
2755, 3096
|
414, 428
|
456, 1589
|
16756, 16946
|
1611, 2260
|
2276, 2621
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,816
| 148,880
|
8474
|
Discharge summary
|
report
|
Admission Date: [**2200-1-5**] Discharge Date: [**2200-1-8**]
Date of Birth: [**2134-2-11**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 year-old male with a complicated history transferred from
[**Hospital3 2783**] where he presented following a syncopal
episode and left hand pain. Per patient he went to the bathroom
and on his way back to his room, he felt lightheaded and had a
syncopal episode and fell on his left hand. He denies preceding
chest pain, SOB or palpitations. His wife heard some noise,
found him on the floor, and helped him back to his room. He
denies post-event confusion. He has a history of similar
syncopal events with dizziness with standing. For this reason he
uses a wheelchair. He is usually able to make the trip to the
bathroom by walking unassisted.
.
This morning, he awoke with pain in his left hand, with swelling
and redness. The swelling worsening significantly during the
course of the day, and he presented to [**Hospital3 2783**].
There his was INR 4.7 and his hand X-ray negative. With concern
for compartment syndrome, and he was transferred to [**Hospital1 18**] for
further evaluation.
.
Initial [**Hospital1 18**] ED eval notable for VS T 98.3, HR 90, BP 140/70,
RR 18, Sat 100% on 2L. He was seen by Plastic surgery, who did
not feel that he was having a compartment syndrome. He was also
seen by the medicine consult service and cleared for OR if
needed. He was admitted to the medical service for serial exams
and monitoring.
.
In the am of [**1-6**] pt was noted to have SBP in the 60's, O2 sat
90's this AM when being evaluated by short call team. Pt was put
on 4L NC with improvement of sat to mid 90's, and ABG
7.32/50/71. He was bolused 2L NS with slight improvement of
blood pressure to 80's systolic (from 140's at admission). He
got 2 units of FFP and 5 SQ Vit K to correct his INR of 6. Pt
remaines AAO x 3. Ddx included hypotension related to narcotics
(2 mg morphine + percocet, w/ h/o low BP to narcs per his
wife/PCP), hypovolemia (but not fluid responsive), sepsis (given
granulating abdominal wound), and blood loss given elevated INR.
No pressors were given. 1 dose of Narcan was given with
improvement in SBP's to 100's. Pt was subsequently transferred
to the [**Hospital Unit Name 153**] where he was observed for a day and found to have
improved hypotension, an INR of 2.2, an ABG was done and found
to be 7.32/50/71. The patient mentated at baseline and had no
increase in O2 requirement. He is subsequently being transferred
back to the floor.
Past Medical History:
1. Left circumflex stent in 3/[**2194**].
2. Catheterization in [**10-4**] with three vessel disease.
3. Status post coronary artery bypass graft x 3.
4. s/p catheterization [**12-5**]- with stent to native right
coronary artery with an occluded saphenous vein graft.
5. Insulin dependent diabetes mellitus.
6. CRI with a baseline creatinine of 1.1 to 1.3.
7. Hypothyroidism
8. COPD
9. ? PE in [**2196**]
10. History of ETOH.
11. Pancreatitis.
12. s/p CABG [**11-3**] complicated by osteomyelitis of the sternum.
The
patient had a left hemisternectomy in [**2197-1-1**] due to
infection. Sternal debridement rectus flap and bilateral
pectoralis flaps. Still open wound.
13. History of lens transplant in right eye secondary to
cataract.
Last cath in [**2-/2198**]: LMCA normal. LAD occluded . The LCX was
widely patent and the stented sites were open. At the origin of
the OM3, there was 50% restenosis. The RCA stents were widely
patent. LIMA-LAD patent.
Cath ([**12-5**])
The LAD had a proximal 60% lesion, a mid 80% lesion, and distal
competitive flow from the LIMA-LAD. The LCX stents were widely
patent with normal flow. The RCA had a proximal 60% lesion at a
[**Last Name (un) 29846**] crook, with diffuse mid disease up to a sub-total
occlusion in the mid vessel. The distal vessel supplied a lower
AM/PDA and a RPL branch. 2. Successful stenting of the RCA was
performed with overlapping 2.5 x 28 mm and 3.0 X 13 mm Cypher
(drug-eluting) stents, post-dilated using 2.5 and 3.25 mm NC
balloons respectively. There was <10% residual stenosis, no
angiographically-apparent dissection, and normal flow (see
PTCA Comments).
Social History:
He lives with his wife. They have 4 children and 18
grandchildren. Ex-smoker, quit 6 months ago. Has 150 pack-year
smoking history. Prior EtOH use. History of addiction to
narcotics.
Family History:
F: died at 63 of MI
Physical Exam:
VITALS: T 97.2 , HR 96 , BP 134/80 , RR 22 , Sat 94% on 2L
GEN: Caucasian male, in NAD.
HEENT: Anicteric.
RESP: CTAB.
CVS: RRR. Normal S1, S2. No S3, S4. No murmur or rub.
GI: Obese abdomen. Soft, non-tender, ND, BSNA.
SKIN: Chronic wound on abdomen, about 10 cm long, with
granulating base.
EXT: Left hand swelling of left hand and forearm, wrapped in a
dressing
VASC: Palpable radial and ulnar pulses (per plastics).
Pertinent Results:
[**2200-1-5**] 06:45PM GLUCOSE-344* UREA N-23* CREAT-1.6* SODIUM-139
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
[**2200-1-5**] 06:45PM CK(CPK)-71
[**2200-1-5**] 06:45PM CK-MB-NotDone cTropnT-0.01
[**2200-1-5**] 06:45PM CALCIUM-9.5 PHOSPHATE-2.5* MAGNESIUM-1.9
[**2200-1-5**] 06:45PM WBC-9.8 RBC-3.91* HGB-11.5* HCT-33.5* MCV-86
MCH-29.5 MCHC-34.4 RDW-15.6*
[**2200-1-5**] 06:45PM NEUTS-56.3 LYMPHS-34.5 MONOS-6.3 EOS-2.0
BASOS-0.9
[**2200-1-5**] 06:45PM MICROCYT-1+
[**2200-1-5**] 06:45PM PLT COUNT-417
[**2200-1-5**] 06:45PM PT-27.3* PTT-41.8* INR(PT)-5.5
.
[**2200-1-8**] 07:00AM BLOOD WBC-12.6* RBC-3.60* Hgb-10.7* Hct-32.5*
MCV-90 MCH-29.8 MCHC-33.0 RDW-15.1 Plt Ct-401
[**2200-1-8**] 07:00AM BLOOD Plt Ct-401
[**2200-1-8**] 07:00AM BLOOD Glucose-72 UreaN-22* Creat-1.3* Na-140
K-4.5 Cl-109* HCO3-23 AnGap-13
[**2200-1-8**] 07:00AM BLOOD Calcium-9.5 Phos-2.3* Mg-2.1
[**2200-1-6**] 06:40AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2200-1-7**] 11:46AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
[**2200-1-6**] 08:30AM BLOOD Type-ART pO2-71* pCO2-50* pH-7.32*
calHCO3-27 Base XS-0 Intubat-NOT INTUBA Comment-NC
[**2200-1-6**] 08:30AM BLOOD Lactate-1.6
.
L Wrist X rays [**1-5**]: IMPRESSION: 1. No fracture or dislocation
within the hand. 2. Diffuse soft tissue swelling involving the
dorsum of the hand. Focal round lesion noted within the
subcutaneous tissues of the dorsal aspect of the left hand,
which may represent a hematoma or focal lesion such as a
sebaceous cyst.
.
Ct head [**1-5**] IMPRESSION: No evidence of acute intracranial
hemorrhage.
.
CXR [**1-6**] The left ventricle is enlarged. No overt CHF or active
infiltrates. No pneumothorax identified
Brief Hospital Course:
ASSESSMENT AND PLAN: 65 yo male with [**Hospital 23789**] transferred from OSH
following a syncopal event and ? compartment syndrome in left
hand is setting of supratherapeutic INR, now with hypotension.
.
HYPOTENSION: Intial ddx included hypotension related to
narcotics (2 mg morphine + percocet), hypovolemia, sepsis, and
blood loss given elevated INR. He did not have evidence of GIB,
is afebrile, and continued to make good urine output (although
evidence of urinary retention w/ foley placement). Given his
clear history of low BP in setting of narcotics and improvement
with Narcan, this seemed like the most likely etiology. We held
further antihypertensives and narcotics. His BP remained stable
and he was discharged a day after transfer back to the floor
without any new symptoms. He was discharged off home BP meds
with planned follow up with PCP.
.
LEFT HAND HEMATOMA: Seen by plastics, and the patient appeared
to have improvement in swelling and had no evidence of
compartment syndrome. We continued dressing changes per
plastics, and OT followed. We followed INR s/p Vit K and FFP
were given (see HPI), which remained WNL. He was discharged
with a stable hematoma and no evidence of compartment syndrome.
.
SYNCOPE: By history pt had post-micturitional syncope, with
history of prior similar episodes. Suspect vasovagal syncope.
Not orthostatic at OSH. EKG without acute changes, 2 sets of
enzymes negative with >1 day prior. CT head negative.
He had no syncopal events after transfer to the floor.
.
CAD: s/p CABG/PTCA, and s/p r/o ROMI as noted above. We
continued cardiac meds once BP stabilized.
.
DM type 2: Continued outpatient regiment with Lantus 40 units
[**Hospital1 **] and Humalog SS. FS QID.
.
COPD: No acute issues during admission. Patient reportedly on
home oxygen, and we continued this as well as home
Albuterol/Atrovent inhalers prn.
.
SUPRATHERAPEUTIC INR: On Coumadin for unclear reasons. As per
above, this was reversed and remained WNL after Vit k and FFP.
Was discharged off Coumadin for planned follow up with PCP.
.
ACUTE ON CHRONIC RENAL FAILURE: Likely due to obstruction, as pt
had 1400 CC urine out when foley placed on floor. Also had to
place coudet as regular foley did not pass prostate. He trended
down to a creatinine of 1.3 by time of discharge with good urine
output.
.
HYPOTHYOIDISM: Continued outpatient Levoxyl.
.
Communication: with PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 29848**] [**Telephone/Fax (1) 29849**]. Gets
majority of care at [**Hospital3 **]. Wife - [**Name (NI) **]
[**Telephone/Fax (1) 29850**]
.
Disp: To home.
.
Medications on Admission:
- Cardura 4 mg PO QHS
- Flagyl 500 mg PO TID (Had C dif in [**Month (only) **]),
- Neurontin 600 mg PO TID
- Celexa 40 mg PO TID
- Lisinopril 20 mg PO QD
- Toprol XL 100 mg PO QD
- Remeron 30 mg PO QHS
- Protonix 40 mg PO QD
- ASA 81 mg PO QD
- Coumadin 5 mg PO QHS
- Synthroid 0.175 mg PO QD
- Lasix 40 mg PO QD
- Humalog SS TID [**1-21**] with meals
- Lantus 40 units [**Hospital1 **]
- Lipitor 10 mg PO QD
Discharge Medications:
1. aquacel AG dressings Sig: One (1) Dressing once a day.
Disp:*QS * Refills:*2*
2. Adaptic Bandage Sig: One (1) Bandage Topical once a day.
Disp:*QS Bandage* Refills:*2*
3. Normal Saline Sig: Ten (10) ml Topical (hair, nails and
skin) once a day: To dressing.
Disp:*1 Bottle* Refills:*2*
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
5. Mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Atorvastatin 10 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. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
14. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical DAILY (Daily).
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*33 Tablet(s)* Refills:*0*
16. Keflex 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
17. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
18. Lantus 100 unit/mL Cartridge Sig: Forty (40) units
Subcutaneous twice a day.
19. Humalog 100 unit/mL Cartridge Sig: One (1) Subcutaneous
four times a day: Per Sliding SCALE.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 2436**] Home Care
Discharge Diagnosis:
Hand hamatoma s/p Fall
Hypotension
CAD
DM 2
Discharge Condition:
Stable
Discharge Instructions:
Pls take all meds as prescribed. Complete the full course of
antibiotics. Call your doctor if hand swelling worsens, if you
experience any pain, fevers, nausea, vomiting, diarrhea, etc.
Follow up with your PCP and with cardiology as outlined below.
You should discuss your ongoing syncope (fainting) and falls
with your PCP and see [**Name Initial (PRE) **] cardiologist as soon as possible. Also,
wound nurse has recommended follow up with plastics. We are
discharging you off your home blood pressure medications.
Please do not take these until you discuss with your PCP. [**Name10 (NameIs) **]
are also discharging you off coumadin given recent falls and
elevations in INR. Please discuss with your PCP as well.
To the abdominal wound, use silver ion dressing (Aquacel AG or
equivalent) change every 2 days (keep dry so remove for
bathing). Clean open hand wounds on left hand, with NS and
apply Adaptic and use dry dressing/clean wrap and change once a
day.
Followup Instructions:
With your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Telephone/Fax (1) 29849**] on Monday, [**1-13**] @
1:15pm
Call your Cardiologist, Dr. [**Last Name (STitle) **] in [**Hospital1 2436**] as soon as
possible for a follow up appointment.
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1429**] (plastics) for follow up
appointment for your abdominal wound
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"914.2",
"E937.9",
"250.60",
"008.45",
"V58.67",
"496",
"780.2",
"790.92",
"428.0",
"V45.82",
"585.9",
"V45.81",
"923.20",
"V15.88",
"584.9",
"458.29",
"333.0",
"600.01",
"458.0",
"276.51",
"E888.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
11712, 11773
|
6781, 9401
|
277, 284
|
11861, 11870
|
5039, 6758
|
12889, 13422
|
4563, 4584
|
9861, 11689
|
11794, 11840
|
9427, 9838
|
11894, 12866
|
4599, 5020
|
226, 239
|
312, 2694
|
2716, 4347
|
4363, 4547
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,842
| 186,772
|
54037
|
Discharge summary
|
report
|
Admission Date: [**2155-10-29**] Discharge Date: [**2155-11-5**]
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**Doctor First Name 1402**]
Chief Complaint:
chestpain/nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]yo Russian speaking only F with MI x 3, s/p RCA hepacoat
stents
x5 [**8-24**] and RCA Cypher stents x 5 in same location on [**10-12**] for
STEMI who presents with chest pain from [**Hospital 100**] Rehab. The pain
radiates from her back to her L axilla or starts in her L axilla
and radiates to her L shoulder blade. It is not assoc with
diaphoresis, is +/- assoc with SOB, is not associated with
exercise. It comes more often in the morning and lasts for 2
hours. Is not assoc with moving her arm. Nitro has tended to
improve it. It is sometimes assoc with eating. The pain has
been going on for days, but on day of presentation, the pain was
not relieved with 3 nitro. She describes the pain as very
different than the pain that brought her in recently with an MI.
.
In ED, her intial vitals were HR 60's BP 194/83 and EKG showed Q
in III and aVF and inverted T's in II, III, aVF and V4-V6 with
no ST changes. It looked improved from her recent D/C EKG. HCT
was 25, decreased from 32.8 on [**10-15**]. In the ED she got BB,
MSO4 2mg, ASA, and a nitro drip with resolution of her CP. She
was then transferred to F3 for further management.
Past Medical History:
1. Coronary artery disease.
2. Pacemaker (Pacesetter A-V pacer) placement for sick sinus
syndrome (installed for bradycardia)
3. Hypertension.
4. Hypercholesterolemia.
5. Gastroesophageal reflux disease.
6. Chronic renal insufficiency with a baseline creatinine of
1.4 to 1.7.
7. Anemia secondary to renal disease.
8. Constipation.
9. Hypothyroidism.
Social History:
The patient lives alone, but has been at [**Hospital 100**] Rehab since her
prior admission. Her daughter is involved with her care. She
denies EtOH, Illicits, Tobacco.
Family History:
Non-contributory
Physical Exam:
VS in ED: AF, SBP 190-204, HR 60-70, Sat 97% on 4L
VS on floor: 98, 181/62, 55, 16, 100% on 4L (SBP then 160)
Gen: NAD, lying comfortably in bed, conversant through her
daughter, who translated. Pale
HEENT: Some scleral pallor, NCAT, OP clear, Neck supple, No
bruit, No JVD visible, No LAD
CV: RRR, nml S1/S2, no extra heart sounds, II/VI SEM at USB with
some radiation to axilla (holosystolic). Pacer is in place over
L shoulder and is mildly TTP. Palpation over lateral chest wall
on L reproduces pain.
Lung: Crackles at bases initially that clear with deep
inspiration. No dullness to percussion.
Abd: Soft, NT, ND, nml BS, small ecchymosis over RLQ
Ext: no clubbing, cyanosis, nor edema. 2+ DP bilaterally, 1+
PT bilaterally. groin: no hematoma
Neuro: AAO x 3, No facial droop, palate and smile symmetric
elevation, shrug intact bilat, MAE against gravity, FNF intact
bilat, Gait deferred.
Pertinent Results:
[**2155-10-29**] 09:33PM CK(CPK)-49
[**2155-10-29**] 09:33PM CK-MB-NotDone cTropnT-0.05*
[**2155-10-29**] 04:00PM CK(CPK)-50
[**2155-10-29**] 04:00PM cTropnT-0.07*
[**2155-10-29**] 04:00PM WBC-7.3 RBC-2.68*# HGB-8.7* HCT-25.0* MCV-94
MCH-32.6* MCHC-34.9 RDW-14.3
[**2155-10-30**] 10:45AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2155-10-30**] 06:35AM BLOOD WBC-6.3 RBC-3.50*# Hgb-11.3*# Hct-32.0*
MCV-91 MCH-32.3* MCHC-35.4* RDW-14.7 Plt Ct-327
.
CTA: IMPRESSION:
1. No evidence of intrathoracic aortic dissection.
2. Dense atherosclerotic changes, including coronary artery
calcifications, with multiple areas of ulcerated plaque.
3. Patchy opacity within the superior aspect of left lower lobe
concerning for pneumonia.
4. Tree-in-[**Male First Name (un) 239**] opacities within the right lower lobe. Multiple
3 mm
noncalcified pulmonary nodules bilaterally, increased in number
since prior exam dated [**2150-3-4**].
5. Several calcified pulmonary nodules scattered bilaterally.
.
CXR: IMPRESSION: Unchanged appearance of the chest with mild
cardiomegaly. No overt congestive failure or pneumonia.
.
CT Abd: No RP bleed. Normal except some high density [**Year (4 digits) **] in
sigmoid colon. ? blood in sigmoid. Clinical correlation
required.
.
EKG: Atrial paced at 60 with Q waves in III and aVF and TWI in
inferior leads and V4-V6, no ST changes. Improved from EKG on
discharge ([**2155-10-15**]).
Brief Hospital Course:
BRIEF OVERVIEW: [**Age over 90 **] yo F h/o 3VD s/p stenting x 2 with a total of
10 stents in RCA. Last stenting [**10-12**] for STEMI. Presented with
atypical CP in setting of anemia and hypertension. She was
admitted to the cardiology service after a CT that was negative
for dissection and a non-contrast abd CT that revealed no
intraperitoneal process. The patient complained of nausea and
had some vomiting in the hospital. She also complained of a
number of different types of chest pain over her first 24 hours
of hospitalization. Repeated EKG's showed no changes c/w
ischemia. N/V was controlled acutely with anzemet. CP was
reproducible by palpation. Pt was discovered to have had
longstanding N/V at home with a negative upper endoscopy in [**2153**]
per her daughter. She was started on reglan with some relief.
.
HOSPITAL COURSE BY SYSTEM:
#Cardiac:
a) Ischemia: The patient had a history of thrombus to RCA with
TO of RCA and 5
hepacoat stents. 2 weeks prior to this admission, she was taken
to the cath lab for STEMI and had 5 Cypher stents to same area
of RCA for restenosis. She was also known to have diffuse 3VD
on catheterization. EKG at this admission showed improvement
from EKG at discharge from last admission. She continuee to have
inverted T's inf and lat, and q's inf, but no ST changes. Three
sets of enzymes were negative. Her pain was not consistent with
typical CP (reproduced with palpation, not assoc with exercise).
However, pt was anemic and hypertensive, and may have had some
ongoing ischemia. She had had a recent cath with known 3VD. She
was not a surgical candidate and a repeat cath was thought to be
unlikely to have been helpful. Therefore, she was to be
medically optimized at this hospitalization. CP could also have
been explained to some degree by her recent PNA. She was
continued on aspirin, plavix, and statin. Because she had CP in
the ED, she was started on a nitro drip to make her pain free.
This was weaned off overnight. Because her BP was 190-200 in
the ED, she was started on an increased dose of metoprolol and
hydralazine was added to her regimen. Her BP was brought to the
120's overnight and in the morning, when the patient was seen to
have had a baseline creatinine even after the dye load she
received with her CTA in the ED, she was restarted on valsartan
80 (which was held at her last hospitalization for low BP).
Imdur was restarted at 120 qd after the nitro drip was weaned
off. During the first 2 days, the patient complained of mild
TTP over her L chest wall, but no spontaneous chest pain. The
waxing/[**Doctor Last Name 688**] nature of this chest pain and its lack of
associated symptoms and its chronicity (from her last
hospitalization until now) with hours of pain that can be
reproduced is c/w atypical CP. While there may be a component
of angina, given her known 3VD, it will be managed medically.
.
b) pump: The patient has a known HTN history with known
diastolic CHF. Her EF in [**1-25**] was >65%, however her estimated EF
in bedside echo at last admission immediately post-MI was around
50%. Echo will need to be repeated as an outpatient in [**1-24**]
weeks to evaluate her true EF post-MI. The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] was
held at her last hospitalization for rising creatinine and low
BP as stated above. As above, valasartan was restarted the
morning after admission to control the pt's BP, however with
worsening [**Doctor First Name 48**] this was discontinued. Pt had one episode of
flash pulm edema in setting of high BP in the morning. She was
diuresed aggresively and this resolved. On day of discharge she
had an episode of some lightheadedness with SBP of 76. She had
received BB, Imdur and Lasix earlier in the morning. She was
not taking enough fluids and was given a small bolus of 250cc.
Her symptoms resolved. She was likely dry at this time and
further diuresis should be held. She is likely to need lasix at
small dose as an outpatient. This should be evaluated carefully
and instituted at the [**Hospital 100**] Rehab Facility.
- Her BP should be monitored, as should her electrolytes (chem
7).
.
c) rhythm- The patient has a h/o a/v pacemaker placement in [**2144**]
for sinus
brady. The patient is atrial paced, and therefore it was felt
to be safe to titrate up her BB to increase BP control without
great concern for HR. Her QRS remained narrow on her EKG. She
had one episode of A. fib with RVR upto 140s she was hypotensive
to 70s and was transferred to CCU for cardioversion. After 2
shocks she remained in A. fib and was started on Amiodarone.
Over the next few hours she flipped back into sinus rhythm.
Following day she underwent AV node ablation to prevent her from
becoming tachycardic. She should also be continued on
amiodarone with goal of amiodarone down to 200mg in 1 month time
and decreasing the dose to 100mg in 6 months. Pt had history of
nosebleeds in coumadin however after contacting Dr. [**Name (NI) **], pt's
outpt cardiologist, she was started on coumadin. She should
have INR checked frequently initially until her coumadin dose is
set.
.
# Renal: The patient has a h/o CRI due to hypertensive
nephropathy. All medications were renally dosed. Creatinine on
admission was better than baseline for the patient and did not
rise significantly on the day after admission. [**Last Name (un) **] was thought
to be renal protective in this patient. However with diuresis
her creatinine increased and [**Last Name (un) **] was again discontinued. Her
[**Doctor First Name 48**] was thought likely secondary to aggresive diuresis and
further diuresis should be held until repeat electrolytes show
improvement in creatinine.
.
# Heme: The patient's anemia was previously thought to be [**1-22**]
CKD and anemia of chronic disease. However, based on her
relatively acute drop in HCT, it appeared that she may have been
dropping HCT too quickly to be explained by this. CT abd showed
no RP bleed. No evidence of hematoma in groin was observed on
exam. W/U for iron deficiency, vitamin deficiency, and
hemolysis were sent. Anemia previously thought to be [**1-22**] CKD.
Ferritin low, TIBC low, Transferrin low - likely mixed chronic
dz, chronic kidney dz, and iron deficiency. All stools were
guaiaced and were negative. The patient could have had a small
GI source to her bleed. She was started on [**Hospital1 **] PPI in case of
an upper GI bleed. The pt was transfused with 2 units of blood
and had an appropriate HCT increase. The patient should be
started on EPO as an outpatient. She may also need repeated
blood transfusions to maintain her HCT given her history of low
HCT and 3VD. She should have periodic monitoring of her HCT.
.
# Podagra: Pt had an episode of toe pain, consistent with
classic gout. Likely due to aggressive diuresis. Colchicine
and NSAIDS are contraindicated in renal failure. Consider
checking uric acid if this recurs as outpt off diuretics.
Started on prednisone taper - 30, 20, 10, 10, 5, 5. - Hold ASA
until acute gouty attack has resolved.
.
# Nausea: Pt has chronic hx of nausea with upper GI negative in
[**2153**] per pt's daughter. Responded to compazine and anzamet
somewhat. Will start reglan and cont as OP - this may decrease
her feeling of incomplete swallowing and address her nausea.
Started on reglan 5 PO AC TID.
.
# Endocrine: Pt has a history of hypothyroidism, she was
continued on synthroid.
.
# Prophy - the pt was maintained on sq heparin at this
hospitalization
.
# Code: Full code was continued initially, however on the
morning after hospitalization she was changed to DNR/DNI after
discussion with assistance of an interpreter.
Medications on Admission:
1. ASA 325
2. Plavix 75
3. Simvastatin 80
4. Tylenol PRN
5. Synthroid 25
6. Protonix 40
7. Metoprolol 50 TID
8. Docusate
9. Heparin 5,000 unit/mL
10. Imdur 120
11. Ambien 5 PRN
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please hold during the patient's acute attack of gout. Tablet(s)
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
1.5 Tablet Sustained Release 24HRs PO HS (at bedtime): Please
give 75mg po qhs.
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
11. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 days.
12. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 days.
13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO ONCE (once)
for 1 doses.
14. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day) for 2 days: After 2 days, the dose should be changed to
400mg daily for one week followed by 200mg daily thereafter.
15. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime): Dose will need to be adjusted based on INR testing.
16. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day) as needed for AC.
17. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
18. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
19. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
20. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Atypical chest pain
Nausea
CAD
CHF
Flash pulmonary edema
gout
Coronary artery disease.
A fib
Hypertension.
Hypercholesterolemia.
Gastroesophageal reflux disease.
Chronic Kidney disease
Anemia secondary to renal disease and blood loss and chronic
illness.
Constipation.
Hypothyroidism.
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
[**Name8 (MD) 26975**] [**Name8 (MD) **]:1500 cc.
.
Please continue to take all your medications as directed and
follow up with all your appointments. If patient complaints of
any further chest pain associated with shortness of [**Name8 (MD) 1440**]
please have the patient evaluated again by a physician at [**Hospital 100**]
rehab or return to the emergency room.
Followup Instructions:
The patient has an appointment to follow-up in Device Clinic for
her pacemaker in one month with Dr. [**Last Name (STitle) **], device clinic
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2155-12-10**]
1:30
.
Please call your cardiologist Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D.
Phone:[**Telephone/Fax (1) 127**] to setup an appointment.
.
Please follow up with your PCP at [**Hospital **] rehab after discharge.
Completed by:[**2155-11-5**]
|
[
"280.0",
"414.01",
"428.0",
"V45.01",
"244.9",
"428.33",
"274.9",
"272.0",
"585.9",
"285.21",
"530.81",
"V45.82",
"786.59",
"401.9",
"578.9",
"413.9",
"410.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"99.62",
"37.34",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
14317, 14390
|
4428, 5261
|
243, 250
|
14719, 14728
|
2980, 4405
|
15244, 15774
|
2026, 2044
|
12359, 14294
|
14411, 14698
|
12157, 12336
|
14752, 15221
|
5288, 12131
|
2059, 2961
|
187, 205
|
278, 1450
|
1472, 1824
|
1840, 2010
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,168
| 153,885
|
11660
|
Discharge summary
|
report
|
Admission Date: [**2110-12-2**] Discharge Date: [**2110-12-24**]
Date of Birth: [**2036-4-3**] Sex: M
Service: CARDIOTHOR
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname 36950**] is referred
by Dr. [**Last Name (STitle) **]. The patient is a 74-year-old gentleman
who had an outpatient cardiac catheterization for anginal
symptoms and a positive stress test. The patient's history
is such that he complained of chest pain below the chin,
while he was on his roof blowing leaves. He was admitted to
[**Hospital3 3583**] on [**2110-11-25**] for rule out MI protocol. The
CKs subsequently were negative, but the troponin I peaked at
.18. He ultimately got a stress test and had 3.2 minutes of
the [**Doctor First Name **] protocol stopped secondary to his shortness of
breath, claudications in the bilateral lower extremities.
the EKG on the [**Doctor First Name **] Protocol showed inferolateral changes.
As a consequence, he was referred for cardiac catheterization
here at the [**Hospital1 69**] on
[**2110-12-2**]. The patient's previous cardiac workups, included
echocardiogram on [**2110-4-21**], which at that time showed
mild-to-moderate aortic sclerosis, no significant aortic
stenosis, 1+ MR, 2+ TR, and 1+ PR. He had evidence of
[**Hospital1 **]-atrial enlargement at that time and EF measured at 40% to
45%. Additionally, the patient had an EKG, which showed
atrial fibrillation at rate of 83. There were Q waves seen
in leads 3 and AVF. There were no ST or T changes seen.
Given this profile, the patient was subsequently referred for
cardiac catheterization.
Other medical history: Paroxysmal atrial fibrillation, which
the patient underwent cardioversion two years ago. He
suffered from paroxysmal atrial fibrillation times three
years. He had a history of congestive failure,
hypothyroidism, coronary artery disease, hyperlipidemia, and
inguinal hernia on the left.
PAST SURGICAL HISTORY: History includes bilateral vein
ligations, hemorrhoid operation, as well as a tonsillectomy
and adenoidectomy. He had no history of TIA, no history of
stroke, no history of melena or GI bleeding. Cardiac risk
factor profile is notable for hypertension, 65 to 70 pack
year smoking history, and hyperlipidemia. He has no history
of diabetes mellitus. He has had a borderline hypertension.
LABORATORY DATA: Labs, prior to cardiac catheterization on
[**2110-12-2**] revealed a hematocrit of 39, white count of 7,000,
platelet count of 219,000. Chemistries were notable for BUN
creatinine of 24 and 1.5.
SOCIAL HISTORY: History was remarkable for the patient being
recently widowed in [**2110-9-6**] and certainly has events
of clinical depression.
ALLERGIES: The patient is allergic to DRAMAMINE.
MEDICATIONS ON ADMISSION:
1. Amiodarone 200 mg p.o.q.d.
2. Levoxyl 75 mcg p.o.q.d.
3. Nitropaste q 6 hours p.r.n.
4. Aspirin 81 mg p.o.q.d.
5. Zestoretic 10/12.5 mg q.a.m.
6. Lipitor 20 mg p.o.q.d.
On [**2110-12-2**], the patient underwent cardiac catheterization
when he was admitted to the [**Hospital1 188**] which showed an EF of 55%. He had mild inferior
hypokinesis. There is evidence of the left main coronary
artery being long and serpiginous in nature. There was an
80% proximal right coronary artery lesion and 80% proximal
LAD lesion and serial 40% and 60% stenoses seen in the left
circumflex artery. Given the patient's significant
three-vessel coronary artery disease and subjective symptoms
of exertional angina increasing in frequency, he was admitted
for unstable angina, cardiac consultation and ultimately for
assessment for elective coronary artery bypass graft.
He was admitted to the C-Med Service and in the first couple
days of his admission, he had the development of chest pain
requiring IV nitroglycerin and heparinization. Consultation
was carried out to Dr. [**Last Name (STitle) 70**] of the Cardiothoracic
Surgery Service for an elective CABG, who assessed the
patient as appropriate candidate. However, given his
paroxysmal atrial fibrillation and hypercholesterolemia and
hypothyroidism history, preoperative workup including chest
x-ray was completed, which showed the diffuse reticular
nodular infiltrate, chronic in nature, certainly evidentiary
changes for COPD also seen, but no significant
pneumothoraces, no bullae identified, and no failure seen.
EP consultation was obtained. Their recommendations
preoperatively were that the patient should be anticoagulated
and have beta blockers and Amiodarone utilized for rate
control. Heparin was to be continued with Coumadin
postoperatively, particularly given this, since the left
atrial diameter was about 4.9 as previously measured by
echocardiogram in [**2108-4-5**]. Additional preoperative
workup included a bilateral carotid ultrasound, which showed
no significant disease, stenoses less than 40%. The patient
has never had a history of TIA. Given the previously
mentioned workup, the patient was brought to the operating
room on [**2110-12-5**], where he underwent a CABG times three
including a LIMA graft to the LAD, right less saphenous vein
graft to the right coronary artery and a right radial artery
graft to the oblique marginal I. Because of the
electrophysiology consultation obtained two days
preoperatively, it was agreed upon between Dr. [**Last Name (STitle) 70**] and
the EP Service that a left atrial cryoablation and Mays
procedure would be carried out, which was also done
intraoperatively.
Postoperatively, the patient was intubated on propofol drip
and Neo-Synephrine for blood pressure support. He was
brought to the Cardiac Surgery Recovery Unit, where he
remained intubated. He was transfused one unit of packed red
blood cells, postoperatively for a hematocrit of 25 and low
filling pressures of 10. The BUN and creatinine were noted
to be 31 and 1.4. He was being maintained at this time on a
milrinone drip at .5, Neo-Synephrine drip of 3.2,
nitroglycerin drip of .5 for the radial artery graft, as well
as a propofol drip of 10.
The patient was kept in the Cardiac Intensive Care Unit. The
patient was noted, on postoperative day #2, to go in atrial
fibrillation with a rapid ventricular response. This was
controlled using IV Amiodarone a 1 mg per minute. The
Milrinone drip was at .5 mcg per hour, Neo-Synephrine drip
was at 3.75 mcg per kilo per minute. The Nitroglycerin drip
was still at 1.5 and the propofol was utilized for sedation.
Ultimately, he was retransfused two packed cells on
postoperatively day #7 for hematocrit of 26. By
postoperative day #3, the patient's FIO2 was weaned as
tolerated and the chest tubes were removed due to the
patient's poor oxygenation. He was kept intubated. He was
given DVT prophylaxis and started on Heparin therapy and
maintained on Amiodarone for the atrial fibrillation issues.
He had no evidence of clinical bleeding at this time.
By postoperative day #4, he was hemodynamically stable.
However, he continued to have a slight respiratory and
metabolic acidosis. He was started on Lopressor for rate
control. He was maintained on Amiodarone as well. He was
switched over from the Nitroglycerin drip to Imdur for his
radial artery graft. Ultimately, he was transferred one unit
again on postoperative day #4 for hematocrit of 27, with goal
of 30. Repeat chest x-rays were done during this time.
Because of the patient's inability to wean from the
ventilator, it was seen that he had bilateral fluffy
infiltrates with the reticular nodular infiltrates as well,
which looked like an acute and chronic process. Certainly,
the patient had elements of obstructive pulmonary disease by
his failure to wean and this made it difficult for him to
progress postoperatively. As a consequence, SICU
consultation was obtained on postoperative day #6.
Bronchoscopy was carried out, which showed very thick
secretions. He is a smoker. He did grow out evidence of a
Hemophilus species, which were ultimately treated with a
two-week course of Levofloxacin.
He was noted to have some low-grade temperatures on
postoperative day #7, where sputum cultures, chest x-ray,
urine cultures, blood cultures, were sent. White count at
this time was 13.6, hematocrit 32, platelet count 115, BUN
and creatinine of 34 and 1.2. He was started on tube feeds
and tolerated the tube feeds a this time.
Ultimately, the patient was extubated by postoperative day
#8. He was subsequently transferred to the floor by
postoperative day #10. Nitrates were decreased to 30 because
of low blood pressures. Chest x-ray had shown again issues
of this bilateral infiltrates with reticular interstitial
pattern. The hematocrit at this time was 32. The BUN and
creatinine were 40 and 1.4. Heparin was infusing.
By postoperative day #11, however, suffered a bright red
blood per rectum bowel movement. He was treated for GI
bleed. NG tube lavage from above was negative. Hematocrit
was 33 and stable. He was given a bowel prep after GI
consultation. They stressed the need for colonoscopy, which
he underwent on postoperative day #13. This showed evidence
of ulceration of the splenic flexure consistent with the
clinical picture of ischemic colitis, thought to be secondary
to hypotensive episodes he must has suffered during his
perioperative course. The hematocrit at this time was 31,
BUN and creatinine were 25. and .9. General Surgical
consultation was obtained, which recommended NPO IV fluids,
broad spectrum antibiotics, which he was given and serial
hematocrits. The patient did not have any return of his
large bright red blood per rectum bowel movements, but he did
have guaiac-positive stools postoperatively. The hematocrit
remained stable throughout the entire postoperative course.
He was maintained on Levaquin and Flagyl for broad-spectrum
coverage for the presumed ischemic colitis. Blood pressure
remained stable. He had no more hypotensive episodes. Heart
rate was well controlled in and out of atrial fibrillation
and sinus rhythm.
By postoperative day #17, the patient was ambulating at a
level 4 with physical therapy assistance. His Coumadin
therapy had not been restarted. The BUN and creatinine were
35 and 1.5. The hematocrit was 36.
By postoperative day #18, the patient was deemed appropriate
for discharge to rehabilitation. Vital signs were 96.0,
pulse 62, sinus 116/71. Blood pressure was 20. He did have
a high O2 requirement postoperatively because of the
aforementioned interstitial lung disease. He was 90%
room-air saturation on 2 to 4 liters nasal cannula and 79%
room-air saturation.
DISCHARGE LABS: As stated. Examination was notable for a
stable sternum, no evidence of erythema or exudate. The
right artery harvest site was clean, dry, and intact with no
erythema. The right lesser saphenous vein graft site was
also well approximated with no evidence of cellulitis or
infection. No peripheral edema was present. Lung
examination was notable for distant breath sounds
bilaterally. Heart examination was regular with no murmur.
DISCHARGE MEDICATIONS:
1. Imdur 30 mg p.o.q.d.
2. Coumadin 2 mg p.o.q.d.
3. Lopressor 25 mg p.o.q.d.
4. Lasix 20 mg p.o. q.a.m.q. Monday, Wednesday, and Friday.
5. [**Doctor First Name 233**]-Dur 20 mEq p.o.q.d.q. Monday, Wednesday, and Friday.
6. Protonix 40 mg p.o. q.d.
7. Combivent MDI 2 puffs q.4 to 6 p.r.n.
8. Colace 100 mg p.o. b.i.d.
9. Amiodarone 400 mg p.o.q.d.
10. Levaquin 500 mg p.o.q.d.
11. Flagyl 500 mg p.o. q.8h.
Both the Levaquin and Flagyl are to end on [**2111-1-1**] to
complete a total of a two-week course for the ischemic
colitis.
12. Aspirin 81 mg p.o.q.d.
13. Tylenol 650 mg p.o.q.4 to 6h.p.r.n.
14. Maalox 15 to 30 cc p.o. q.6h.p.r.n.
DISCHARGE INSTRUCTIONS: The patient is to be discharged to
rehabilitation in [**Location (un) **] and to followup with
Dr. [**Last Name (STitle) 70**] in 30 days. The patient should see his
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 36951**] in approximately 3-4
weeks.
DISCHARGE STATUS: The patient is to be discharged to
rehabilitation.
DIAGNOSES:
1. Significant three-vessel coronary artery disease status
post coronary artery bypass graft times three.
2. Postoperative ischemic colitis lower GI bleed.
3. Postoperative atrial fibrillation.
4. History of chronic paroxysmal atrial fibrillation
requiring anticoagulation.
5. Coronary artery disease.
6. Hypertension.
7. Hypothyroidism.
8. Hypercholesterolemia.
The patient did well from the delirium postoperatively
requiring self restraints and p.r.n. Haldol. At present, the
patient is alert and oriented times three and has not had any
issues in mental status for the last 72 hours.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2110-12-23**] 14:13
T: [**2110-12-23**] 14:22
JOB#: [**Job Number 36952**]
|
[
"496",
"414.01",
"557.9",
"411.1",
"482.2",
"440.0",
"427.31",
"424.0",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"36.12",
"45.25",
"99.62",
"96.72",
"36.15",
"37.23",
"33.24",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
11045, 11700
|
2773, 10567
|
11725, 12996
|
10585, 11022
|
1942, 2549
|
2566, 2747
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,473
| 124,934
|
41974
|
Discharge summary
|
report
|
Admission Date: [**2189-8-17**] Discharge Date: [**2189-9-8**]
Date of Birth: [**2114-6-4**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
polytrauma s/p fall
Major Surgical or Invasive Procedure:
[**2189-8-17**]
Splenectomy and hepatorrhaphy
[**2189-8-18**]
1. Open reduction and internal fixation right olecranon
fracture.
2. Washout and debridement open fracture to bone.
[**2189-8-18**]
1. Exploratory laparotomy.
2. Removal of 3 intraperitoneal lap pads.
3. Insertion of inferior vena cava filter with fluoroscopy.
[**2189-8-28**]:
Interventional radiology drainage of left upper quadrant fluid
collection
[**2189-8-31**]
Esophagogastroduodenoscopy with repair of gastric perforation
[**2189-9-7**]
I&D for R elbow wound dehiscence
History of Present Illness:
Mr. [**Known lastname **] is a 75 year old male who presented via [**Location (un) **] on
[**2189-8-17**] s/p 15 foot fall from roof of RV. He was reportedly found
by EMS and following commands on the scene. He was taken to
[**Hospital 8641**] Hospital where head CT revealed subarachnoid
hemorrhage/intraventricular hemorrhage and was subsequently
intubated at the outside hospital. He was subsequently
transferred to [**Hospital1 18**] for further evaluation and management of
his injuries.
Past Medical History:
PMH: hyperlipidemia, possible seizures
PSH: hip and knee replacement, open cholecystectomy
Social History:
Lives in [**State 15946**], in [**Location (un) 3844**] for summer, staying in RV at
a camping area. Was planning to start trip home the day after he
fell. Married and was traveling with wife, who has family in
area.
Family History:
Noncontributory
Physical Exam:
On arrival to [**Hospital1 18**]:
Temp 97 BP: 119/60 HR: 99 RR 16 O2 Sats 99%
Constitutional: Intubated
HEENT: Pupils equal, round and reactive to light
C. collar in place
Chest: Breath sounds bilaterally, crepitus right chest,
right sided chest tube in place
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, distended
Pelvic: Stable
Rectal: Normal tone, no gross blood
Skin: Large laceration over right elbow, compartments soft
Neuro: Sedated
Pertinent Results:
LABORATORIES:
IMAGING:
[**8-17**] torso CT- chest: 1. 50% R anterior PTX w/ mediastinal
shift and compressive effects on both lungs; R chest tube enters
low and is oriented in posterior pleural space (away from PTX).
2. no L PTX. 3. no aortic or injury. 4. extensive R chest wall
emphysema. 5. R posterolateral rib fx [**3-24**]; L posterolateral rib
fx [**8-24**]; R clavicle fx. abdomen/pelvis: 1. worsening hepatic
and splenic lacerations w/ growing perihepatic and perisplenic
hematomas - active extrav around spleen; small amt blood
tracking along B paracolic gutters. 2. prominent R adrenal gland
- ? hematoma. 3. no free intraabdominal air. 4. extensive R
abd/flank wall emphysema extending into R groin; early R flank
hematoma. 5. no spine or pelvic fx.
CT A/P [**8-21**]: 1. Given consideration of persistent leukocytosis,
findings suggest this to be the result of scattered ill-defined
pulmonary infiltrates as described as well as bibasilar
consolidation versus collapse. 2. Expected fluid in the splenic
bed, overall benign appearance.
3. Hence, no findings within the abdomen or pelvis to explain
leukocytosis. 4. No change in multiple right-sided rib
fractures, decrease in subcutaneous air, only small residual
right pneumothorax remaining with decrease in mediastinal shift,
decrease in subcutaneous air, no change in hepatic contusions.
CT A/P [**8-26**]: 1. Extraluminal location of oral contrast adjacent
to the fundus of stomach is concerning for a contained leak. No
change in the size of a 6 x 10 cm splenic bed fluid collection
which is now better organized and has new rim enhancement
concerning for abscess. This is amenable to percutaneous
drainage. 2. Multifocal ground-glass opacities could likely
represent infection or inflammation, possibly related to
aspiration. 3. Numerous right and left-sided rib fractures,
right clavicular fracture are unchanged.
MICROBIOLOGY:
Sputum Cx [**8-21**]: Pan sensitive Klebsiella pneumoniae, Klebsiella
oxytoca, Enterobacter cloacae
BCx [**8-22**]: Enterobacter cloacae
Sputum Cx [**8-25**]: Stenotrophomonas maltophilia, Serratia marascens
- pan sensitive
Abscess Cx [**8-28**]: Polymicrobial
PATHOLOGY:
[**8-17**]: Spleen, splenectomy: Splenic tissue with focal capsular
disruption and hemorrhage, consistent with laceration.
[**2189-8-17**] 03:35PM ASA-NEG ETHANOL-111* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-8-17**] 03:35PM WBC-15.7* RBC-3.07* HGB-10.8* HCT-30.7*
MCV-100* MCH-35.3* MCHC-35.3* RDW-13.1
[**2189-8-17**] 03:35PM NEUTS-87* BANDS-1 LYMPHS-5* MONOS-7 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2189-8-17**] 03:35PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2189-8-17**] 03:35PM PLT SMR-NORMAL PLT COUNT-216
[**2189-8-17**] 03:35PM PT-14.8* PTT-27.7 INR(PT)-1.3*
[**2189-8-17**] 03:35PM FIBRINOGE-140*
[**2189-8-17**] 03:35PM LIPASE-67*
[**2189-8-17**] 03:42PM TYPE-ART TIDAL VOL-500 PEEP-5 PO2-51*
PCO2-56* PH-7.15* TOTAL CO2-21 BASE XS--9 -ASSIST/CON
INTUBATED-INTUBATED
[**2189-8-17**] 03:51PM LACTATE-3.2*
Brief Hospital Course:
As per above the patient was transferred from OSH via [**Location (un) **]
to [**Hospital1 18**] for trauma management. He arrived intubated and
sedated. STAT trauma protocol was activated on arrival and
patient was evaluated by acute care surgery service. In the
trauma bay there was concern for a tension pneumorthorax as
patient was hypotensive with mediastinal shift on trauma bay
chest xray despite right chest tube at outside hospital.
Malpositioned chest tube was removed and R chest tube was
re-positioned with good effect. Further imaging was obtained in
the ED showing extravasation from injured spleen and liver.
Patient was brought emergently to the OR for exploratory
laparotomy, splenectomy and repair of small hepatic defect.
Patient was then transferred to the TSICU with an open abdomen
for further management.
TSICU COURSE:
Neuro: Patient was admitted to TSICU intubated with sedation
regimen. Pain/sedation was initially controlled with
fentanyl/propofol while patient was intubated and subsequently
transitioned to PCA on extubation with good effect and adequate
pain control. When tolerating oral intake, the patient was
transitioned to oral pain medications.
CV: The patient arrived to the ICU hemodynamically stable with
single [**Doctor Last Name 360**] vasopressor support, subsequently successfully
weaned following abdominal closure HD 2 with intermittent use
until HD 6
Pressors: Single-[**Doctor Last Name 360**] vasopressor support was utilized for
blood pressure support during immediate post-operative period
and subsequently weaned without issue. The patient was
transferred to floor hemodynamically stable without pressor
requirement.
Pulmonary: The patient arrived to the ICU intubated and sedated.
Patient was kept intubated with increasing ventilatory
requirement 9/6-7. CTA chest [**8-21**] was negative for PE. Concern
for pulmonary edema with prn lasix and adequate diuresis on
follow-up CXR. Serial CXR were obtained given presence of R
chest tube without evidence of reaccumulation. Following
extubation, R chest was removed with stable post-pull CXR.
Concern for VAP was successfully treated with VAP protocol
antibiotics prior to transfer to floor.
GI/GU/FEN: Postoperatively patient arrived to TSICU with open
abdomen and packing in place. On [**8-18**] patient was taken back to
OR for removal of packing and abdominal closure which went well
without issue (reader referred to operative note for details.
During work-up for persistent leukocytosis, CT was obtained
which demonstrated fluid collection in LUQ which was
subsequently drained by IR. Subsequent fluoroscopic examination
of this collection demonstrated a small gastric perforation
communicating with aforementioned fluid collection which was
subsequently repaired endoscopically. Initially pt tolerated
tube feeds via IR advanced dobhoff which was subsequently
discontinued. Pt was transferred to floor NPO with IR drain in
place. Post-splenectomy vaccines were administered prior to
transfer to floor. Patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Wound care: Incisional wounds were regularly monitored for
signs of infection of which there were none.
Antibiotics: Patient was started on vancomycin for open
fracture of R olecranon given penicillin allergy. Pt was also
treated for VAP per [**Hospital1 18**] protocol and fluconazole was
empirically added given concern for gastric perforation with
subsequent discontinuation following confirmation of the
integrity of endoscopic repair. At time of transfer to floor,
pt remained on antibiotics for UTI infection, empiric treatment
for H.pylori as well as R elbow ORIF per orthopedic surgery.
Endocrine: The patient's blood sugar was monitored throughout
this admission. Insulin dosing was adjusted accordingly.
Hematology: The patient was found to be hypotensive on arrival
to [**Hospital1 18**] and large amount free hemorrhage was found in abdomen
on exploratory laparotomy [**8-17**]. 13 units pRBCs were administered
on [**8-17**] with flat hct in mid 30s. Six units FFP and 2 platelets
were administered per massive transfusion protocol. Following
operative intervention, the patient's complete blood count was
examined routinely with single transfusion requirement [**8-30**] for
asymptomatic anemia. No further transfusions were required at
time of transfer to floor. Given patient's antibody
cross-reactivity, blood bank staff was involved early in the
post-operative care of this patient. Please see relevant notes
for pertinent work-up and recommendations. Please see
Prophylaxis section for anticoagulation.
MSK: Patient was found to have open fracture of R olecranon on
presentation and was taken to the OR with orthopedics [**8-18**] for
ORIF. At time of transfer to floor, patient remained stable with
orthopedic surgery following.
Prophylaxis: Heparin was not utilized on initial presentation as
there was significant concern for intra-abdominal hemorrhage.
An IVC filter was placed [**8-18**] for this reason.
The patient received subcutaneous heparin and venodyne boots
during this admission and was encouraged to get up and ambulate
as early as possible.
FLOOR course: Mr. [**Known lastname **] was transferred to the floor on [**2189-9-2**].
Neuro: While on the floor, Mr. [**Known lastname **] complained of minimal pain
which was well controlled with tylenol only. His mental status
began to improve. By the day of discharge he was alert, oriented
to self, place and situation. He was following commands and his
speech was clear. A follow up head CT in 6 weeks was initially
recommended by neurosurgery, who had signed off after multiple
stable head CT's and improvement in mental status.
CV: His vital signs were monitored routinely while on the floor
and remained stable and afebrile.
Pulm: He finished the course of antibiotics for VAP while on the
floor. He remained on room air with stable oxygen saturations
and no respiratory compromise.
GI/GU: The patient had a formal speech and swallow evaluation as
well as a video swallow study. Pureed solids and nectar
thickened liquids were recommended. The patient was able to
tolerate this diet without difficutly. H. pylori treatment was
continued on the floor with flagyl and pantoprazole.
Electrolytes were continually monitored and repleted as needed
throughout his hospitalization. On [**9-4**] he was found to have a
UTI and was started on a 7 day course of ciprofloxacin to be
completed on [**9-10**]. On [**9-5**] the patient failed his void trial
after his foley catheter was removed and the catheter was
replaced and kept in for the remainder of his hospital stay.
Heme/ID: Mr. [**Known lastname **] [**Last Name (NamePattern1) **] blood cell count began to trend
downward appropriately throughout his floor course, from 24.7 on
[**9-2**] to 11.6 on [**9-8**]. His hematocrit remained stable. SC heparin
was initiated for prophylaxis on [**9-7**] given the stability of his
TBI. In addition to the cipro for UTI, he remains on keflex
through [**9-10**] for RUE cellulitis and flagyl through [**9-11**] for h.
pylori treatment. Incisions were continually monitored for
signs and symptoms of infection.
MSK: On [**9-7**] the patient's RUE incision was noted was noted to
have dehisced, and the patient was taking to the operating room
by orthopedics for an I&D and closure of the wound. His course
of antibiotics was completed as described above for the
cellulits. He had a physical therapy and occupational therapy
evaluation, who recommended rehab for the patient. Fall
precautions were maintained and he remained nonweightbearing on
his right arm, with a sling for comfort.
Endocrine: His blood sugars were monitored while on the floor
and remained within normal limits with no need for coverage with
insulin sliding scale, which was d/c'd on [**2189-9-8**].
By the day of discharge, his neuro status was stable and he was
tolerating PO intake. He was hemodynamically stable. He was
discharged to rehab.
Medications on Admission:
asa, pravastatin
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: Five Hundred
(500) units Injection TID (3 times a day).
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
3. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for sob/wheeze.
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day) as needed for agitation.
9. cephalexin 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 2 days: last dose 9/29.
10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 3 days: last dose 9/30.
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days: last dose 9/28.
12. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Levothyroxine Sodium 25 mcg IV DAILY
14. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. pantoprazole 40 mg Susp,Delayed Release for Recon Sig: Forty
(40) mg PO Q24H (every 24 hours).
16. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
s/p 15 foot fall
Injuries:
1. Left temporal traumatic SAH
2. Right tension pneumothorax
3. Hepatic laceration
4. Splenic laceration
5. Right posterolateral rib fractures [**3-24**]
6. Left posterolateral rib ffractures [**8-24**]
7. Right clavicle fracture
8. Right adrenal hematoma
9. Right olecranon fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after falling from the roof of
an RV. You sustained multiple injuries including a head bleed,
collapse of your right lung, liver and spleen injuries, multiple
rib fractures, a right clavicle fracture and a right elbow
fracture.
You sustained rib fractures which can cause sever pain and
subsequently cause you to take shallow breaths because of the
pain.
You should take your pain medicine as as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths.
If the pain medication is too sedation, take half the dose and
notify your physician.
[**Name10 (NameIs) **] is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the samll
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Thefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
If your doctor allows, non steriodal anti-inflammatory drugs are
very effective in controlling pain (i.e. Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than 20-25 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing, and also because of the
drain in place in hour abdomen. Ask your doctor when you can
resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
Followup Instructions:
Please follow up for a repeat CT scan of the head in 4 weeks
with
Dr. [**Last Name (STitle) 739**] in the [**Hospital 4695**] clinic. Call [**Telephone/Fax (1) 1669**]
upon discharge to schedule an appointment an appointment.
Please follow up in the [**Hospital **] clinic in one week. Call
[**Telephone/Fax (1) 1228**] upon discharge to schedule an appointment.
Please follow up in the Acute Care Surgery Clinic in [**1-15**] weeks.
Call [**Telephone/Fax (1) 600**] upon discharge to schedule an appointment.
Completed by:[**2189-9-8**]
|
[
"810.00",
"868.01",
"272.4",
"807.08",
"E878.8",
"512.0",
"868.03",
"998.33",
"998.6",
"E884.9",
"813.11",
"864.05",
"V43.65",
"567.22",
"998.59",
"V43.64",
"865.04",
"852.00",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.63",
"54.19",
"54.92",
"45.13",
"50.61",
"96.07",
"79.62",
"77.63",
"38.7",
"79.32",
"41.5",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
15158, 15205
|
5384, 8669
|
288, 835
|
15561, 15561
|
2242, 5361
|
18149, 18692
|
1725, 1742
|
13657, 15135
|
15226, 15540
|
13615, 13634
|
15714, 18126
|
1757, 2223
|
229, 250
|
8682, 13589
|
863, 1358
|
15576, 15690
|
1380, 1474
|
1491, 1709
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,746
| 121,647
|
36899
|
Discharge summary
|
report
|
Admission Date: [**2163-1-16**] Discharge Date: [**2163-1-18**]
Date of Birth: [**2113-11-18**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Codeine Phos/Acetaminophen
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Lightheadedness, nausea, progressive anemia, and melena.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Pt is a 49yo woman with h/o severe GERD, h/o morbid obesity s/p
Roux-en-Y gastric bypass [**11/2161**], iron-deficiency anemia,
presenting with lightheadedness, nausea, progressive anemia, and
melena. Pt noted onset of heartburn towards the end of [**11/2162**],
with epigastric discomfort and heartburn after eating. This was
different from her prior GERD, which manifested more as reflux
and throat burning. Diet adjustment was advised, including Stage
III diet and avoiding nuts, and she was started on Pepcid AC.
With these changes she felt significantly better almost
immediately. She was doing well until Saturday [**1-15**], when she
developed new dizziness. She has had occasional episodes of
dizziness over the last year, but they were always transient and
resolved quickly, but yesterday her dizziness persistent and she
began to feel more faint and nausous. She found her BP to be
lower than usual (SBP 90s), so she went to [**Hospital1 34**] where she was
found to be orthostatic and Guaiac positive on rectal exam. Hct
returned at 23 (most recent values here >30), so she was started
on IV fluids and a PPI gtt and transferred to [**Hospital1 18**].
She does recall a black tarry stool on Friday [**1-14**], but didn't
think much of it. She denies any recent abdominal pain, emesis
or
hematemesis, diarrhea, constipaion, or BRBPR. She did not have
any associated chest pain or dyspnea, but did have palpitations.
She denies any recent aspirin or NSAID use, or any significant
EtOH intake. She was recently on an unknown antibiotic for a
dental infection, and has been on Pepcid AC for her heartburn
and
epigastric discomfort.
On arrival to ED, VS: Temp 100.2F, HR 94, BP 98/66. Labs here
remarkable for Hgb 7.0 & Hct 19.9 (H&H 12.6 & 36.9 in [**11-21**]),
INR
1.3, BUN 23 (baseline 12), Cr 0.5 (at baseline), normal LFTs,
lipase, and albumin, and UCG negative. Rectal exam notable for
melena. Concern was raised for upper GI bleeding, but NG lavage
was deferred given her gastric bypass. She is admitted to the
SICU and has received 2units of PRBCs, without change in her Hct
after the first transfusion, but continues to have stable VS.
Past Medical History:
1. Depression and anxiety On medications Resolved
2. Hypertension No medications required currently
3. Type 2 diabetes mellitus- Resolved
4. Hyperlipidemia with delineated triglycerides- resolved
5. Obstructive sleep apnea requiring BiPAP- No symptoms
6. Severe gastroesophageal reflux-Resolved
7. Fatty liver.
8. Iron deficiency anemia.
9. Stress urinary incontinence- No recent episodes
10. Low back pain.
PAST SURGICAL HISTORY:
1. Wisdom tooth extraction ([**2132**]).
2. Tubal ligation ([**2149**]).
3. Laparoscopic Roux-en-Y Gastric Bypass in [**2161-11-12**].
Social History:
Former smoker, quit many years ago. Does not
drink excessively or use drugs. Homemaker, marries, lives with
husband. [**Name (NI) **] two sons.
Family History:
Stroke, obesity, hyperlipidemia.
Physical Exam:
VS: Afebrile, VSS
General: WA woman in NAD, comfortable, appropriate
HEENT: NC/AT, PERRL/EOMI, sclerae anicteric, + conjunctival
pallor, MMM, OP clear
Neck: supple, no LAD
Lungs: CTA bilat, no r/rh/wh
Heart: RRR, nl S1-S2, no MRG
Abdomen: +BS, soft/NT/ND, no palpable HSM
Extrem: WWP, no c/c/e
Skin: no rash or lesions
Neuro: A&Ox3, intact and non-focal
Pertinent Results:
Labs on Admission:
[**2163-1-16**] 12:20AM BLOOD WBC-4.3 RBC-2.24*# Hgb-7.0*# Hct-19.9*#
MCV-89 MCH-31.2 MCHC-35.0 RDW-13.4 Plt Ct-197
[**2163-1-16**] 12:20AM BLOOD Neuts-70.2* Lymphs-25.9 Monos-2.5 Eos-0.6
Baso-0.7
[**2163-1-16**] 12:20AM BLOOD PT-14.8* PTT-27.8 INR(PT)-1.3*
[**2163-1-16**] 12:20AM BLOOD Glucose-96 UreaN-23* Creat-0.5 Na-140
K-3.7 Cl-109* HCO3-24 AnGap-11
[**2163-1-16**] 12:20AM BLOOD ALT-21 AST-20 LD(LDH)-139 AlkPhos-44
TotBili-0.3
[**2163-1-16**] 06:00AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.7
[**2163-1-16**] 11:40AM BLOOD freeCa-1.17
[**2163-1-16**] 11:40AM BLOOD Type-[**Last Name (un) **] Temp-37.4 pH-7.40
Brief Hospital Course:
Mrs. [**Known lastname 9241**] presented to an outside hospital on [**2163-1-16**] after experiencing persistent dizziness accompanied by
nausea and hypotension. Upon presentation, she was guaiac
positive and orthostatic. Her hematocrit returned at 23, so she
was started on IV fluids and a PPI gtt and transferred to [**Hospital1 18**]
for further management. Upon arrival to the Emergency
Department, she was found to have melena on rectal exam. Given
suspicion for an active upper GI bleed, the patient was
transferred to the medical intensive care unit where she
received multiple blood transfusions and remained on a PPI gtt.
On hospital day #1 on endoscopy revealed showed clean-based 7 mm
ulcer at gastro-jejunal anastomosis, without evidence of active
bleeding. Her hematocrit, which was monitored serially,
stabilized without further blood transfusions. She subsequently
transferred to the general surgical [**Hospital1 **] where she remained
stable. The PPI gtt was discontinued and changed to intravenous
and then oral pantoprazole per the recommendation of GI. Her
last colonoscopy results were obtained from her primary care
provider at the request of GI. These results showed only
internal hemorrhoids, which were communicated to GI. She was
maintained on a stage 3 bariatric diet, which was well
tolerated. Her vital signs and urine output remained stable as
did her hematocrit.
Mrs. [**Known lastname 9241**] was discharged on hospital day #2 in good
condition. She will have her hematocrit checked and follow-up
in clinic on [**2163-1-20**]. Additionally, she will follow-up
with GI later this month. She was instructed to return to the
Emergency Department if she should experience any signs and
symptoms of bleeding, which were reviewed with her with
perceived excellent understanding.
Medications on Admission:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO three times a day.
4. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
5. Iron High Potency 240 mg (27 mg Iron) Tablet Sig: Two (2)
Tablet PO once a day.
6. multivitamin Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO once a day.
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Outpatient Lab Work
Hematocrit, hemoglobin, platelets, white blood cell count
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Two (2)
Tablet PO three times a day.
6. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
7. Iron High Potency 240 mg (27 mg Iron) Tablet Sig: Two (2)
Tablet PO once a day.
8. multivitamin Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO once a day.
9. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a
day.
Disp:*500 ml* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital for dizziness and progressive anemia.
While you were here, you underwent an endoscopy which showed an
acute ulcer. You were treated with iv Protonix with good
results. You were also transfused blood products while you were
in the hospital.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You see blood or dark/black material when you vomit or have a
bowel movement.
*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 experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-21**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2163-1-20**] 9:45
Provider: [**Name10 (NameIs) 11170**] [**Last Name (NamePattern4) 11171**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2163-2-2**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2163-5-2**] 8:30
Completed by:[**2163-1-20**]
|
[
"211.1",
"534.00",
"571.8",
"276.52",
"455.0",
"280.9",
"724.2",
"V45.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7550, 7556
|
4408, 6230
|
358, 366
|
7623, 7623
|
3751, 3756
|
9511, 10018
|
3328, 3362
|
6728, 7527
|
7577, 7602
|
6256, 6705
|
7774, 9488
|
3012, 3151
|
3377, 3732
|
262, 320
|
394, 2548
|
3771, 4385
|
7638, 7750
|
2570, 2989
|
3167, 3312
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,113
| 186,650
|
23698
|
Discharge summary
|
report
|
Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-27**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Amiodarone
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
OUTPATIENT CARDIOLOGIST: Dr. [**First Name (STitle) **] [**Name (STitle) **]
.
Chief Complaint: chest pressure
Major Surgical or Invasive Procedure:
cardiac catheterization
femoral line placement
History of Present Illness:
87 y.o afib, TIA, temporal arteritis, hypothyroidism, HTN,
discharged from [**Hospital1 **] [**Location (un) 620**] on [**11-29**] with viral
tracheobronchitis and MRSA who presented to OSH this morning
with chest pressure that started last night. CP located in
central chest w/o radiation. Pt had [**8-23**] pressure for a couple
of hours. It came on at rest. It was relieved somewhat with
nitroglycerin. She has had this pressure to a lesser extent
throughout the night. Her chest pressure was associated with SOB
and lightheadedness. She does not currently have chest
pressure/pain.
.
Pt reported the CP this morning. When EMS arrived she was found
to be in AFib with HR max 130s. Pt given nitro x3 with
resolution of CP. Pt uncertain if she is [**Last Name (un) 26886**] in AFib; she
cannot tell when she is in or out of AFib. Came into OSH with
"rapid afib to 132" with reported lateral STD and trop 0.16 at
[**Location (un) 620**]. [**Location (un) 620**] ED gave diltiziam 5mg IV for HR 130s came down
to 80s. She was also given aspirin. In the ED here she was not
given any medications Her vitals signs were: BP 126/54 HR 82,
sat 98% ra.
.
During the [**11-29**] admission to [**Location (un) 620**] she was treated for PNA
and possible COPD with antibiotics and prednisone. Pt then
developed diarrhea, C.diff negative but treated with flagyl.
Cough still present but improving. Diarrhea resolved.
.
.
On review of systems, he denies any prior deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, hemoptysis, black stools or red stools.
He denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for ankle edema. Pt denies
chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, palpitations, syncope or presyncope.
.
Past Medical History:
Atrial Fibrillation-on amiodarone, s/p cardioversion which held
for 9months, amio dc/d on [**11-29**]. current regimen atenolol
started at 50mg and increased to 100mg, Cardizem started at
240mg and increased to 360mg. Has seen Dr. [**First Name (STitle) **] at [**Hospital1 2025**].
TIA
hypothyroid
HTN
depression
melanoma
s/p appendectomy
s/p hysterectomy
.
Cardiac Risk Factors: -Diabetes, -Dyslipidemia, +Hypertension
Cardiac History: CABG, n/a
Percutaneous coronary intervention: n/a
Pacemaker/ICD: in ? [**2137**] for slow heart rate.
Social History:
Pt lives in a NH. Pt is a never smoker. Reports rare EtOH. There
is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - T 96.9 BP 107/ 85 HR 81 R 18 O2sat 97% ra wt 74.7 kg
Gen: WDWN female in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 6 cm. no LAD
CV: irreg irreg, normal S1, S2. + 2/6 systolic murmur heard at
RUSB. No thrills, lifts. No S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: + 3pitting edema from ankle to mid-tibia bilat. No c/c. No
femoral bruits.
Skin: Right lower ext with 3cm laceration on tibia.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2141-12-18**] 07:10PM CK(CPK)-178*
[**2141-12-18**] 07:10PM CK-MB-20* MB INDX-11.2* cTropnT-0.90*
[**2141-12-18**] 01:37PM GLUCOSE-89 UREA N-25* CREAT-1.1 SODIUM-143
POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-31 ANION GAP-10
[**2141-12-18**] 01:37PM estGFR-Using this
[**2141-12-18**] 01:37PM CK(CPK)-164*
[**2141-12-18**] 01:37PM CK-MB-18* MB INDX-11.0* cTropnT-0.79*
[**2141-12-18**] 01:37PM TSH-3.3
[**2141-12-18**] 01:37PM DIGOXIN-2.1*
[**2141-12-18**] 01:37PM WBC-5.9 RBC-3.32* HGB-10.2* HCT-31.2* MCV-94
MCH-30.7 MCHC-32.7 RDW-17.4*
[**2141-12-18**] 01:37PM NEUTS-81.2* LYMPHS-13.6* MONOS-4.3 EOS-0.8
BASOS-0.1
[**2141-12-18**] 01:37PM PLT COUNT-183
[**2141-12-18**] 01:37PM PT-25.9* PTT-30.9 INR(PT)-2.6*
.
ECHO-The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. An eccentric, posteriorly directed jet of mild
to moderate ([**12-15**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a fat pad.
.
EKG [**2141-12-19**]-
Atrial fibrillation
Delayed R wave progression with late precordial QRS transition
Diffuse ST-T wave abnormalities
These findings are nonspecific but clinical correlation is
suggested
Since previous tracing of the same date, no significant change
.
CXR-FINDINGS: No previous images. The cardiac silhouette is
mildly enlarged in
this patient with a dual-channel pacemaker device in place.
Pulmonary vessels
are essentially within normal limits and there is no definite
pleural effusion
or acute pneumonia.
.
Cardiac Cath [**2141-12-22**]
FINAL DIAGNOSIS:
1. 2 vessel coronary artery disease.
2. Normal ventricular function.
3. Unsccessful attempt to cross the LCX CTO.
4. Successful rotablation, PTC and stenting of the RCA.
.
CT SCAN TORSO [**2141-12-23**] -
IMPRESSION:
1. Left inner thigh hematoma. No evidence of retroperitoneal
bleed.
2. Significant coronary artery calcification.
3. Age-indeterminate compression fracture of L4; in the right
clinical
context further imaging such as edema-sensitive MR [**First Name (Titles) **] [**Last Name (Titles) 9304**].
4. Left adrenal adenoma.
5. Left pleural effusion and atelectasis.
Brief Hospital Course:
In summary, Ms [**Known lastname 10148**] is an 87 yo F w afib, TIA, temporal
arteritis, hypothyroidism, HTN who presented to OSH with chest
pain, was transferred to [**Hospital1 18**] for cath for NSTEMI, and is now
s/p CCU stay.
.
#. NSTEMI: The patient was found to have a NSTEMI given the
patient's symptoms and elevation in cardiac enzymes. She did
not have any changes in her EKG. She was treated with a heparin
drip, integrillin and plavix while we waited for her INR to
drift down to an acceptable level. She underwent cardiac
catheterization and was found to have 2 vessel coronary artery
disease. The interventional cardiologists were unable to treat
the LCX lesion, but stents were placed in the right coronary
artery. The patient's hospitalization was complicated by a
bleeding and hypotension after her catheterization. She was
given 2 units of PRBCs and a CT scan of the torso revealed left
inner thigh hematoma. A femoral line was place for access and
she was transferred to the CCU for more intensive monitoring.
She received fluids to maintain her blood pressure. She was
started on prednisone because of concern of adrenal
insufficiency since the patient had recently been taken off
steroids. She is being discharged on a steroid taper. After 2
days in the CCU, she was hemodynamically stable and Hct was
stable ~30. The [**Hospital 228**] medical therapy was adjusted to
better control her heart rate and blood pressure. We recommend
that she continue to take plavix and apirin 325 mg daily on
discharge.
.
#. PUMP: The patient has normal systolic EF (>55%). [**Month (only) 116**] have
diastolic dysfunction as previously had volume overload on last
hospitalization requiring lasix. The patient was only slightly
edematous on admission, but she became very edematous after the
colloid and crystalloid resusitation she recieved after her
acute blood loss. There was some concern about an allergy to
lasix but it seemed unlikely since the patient had been taking
the medication for such a long period of time. Bumex (which
also contains sulfa) was used for diuresis with good effect and
no evidence of allergic reaction. She will be restarted on
lasix on discharge. Please monitor for evidence of rash or
reaction to lasix. The patient's cardiologist or primary care
will have to adjust the patients lasix dosing going forward.
The patient will need continued diuresis at her rehab facility.
.
#. Rhythm: The patient was found to be in atrial fibrillation on
admission. Initially, her heart rate was elevated to the 120s.
Her heart rate was better controlled with an increased dose of
metprolol. Her diliatem was continued and her digoxin dose was
decreased due to an elevated drug level. The patient was
restarted on coumadin the night of discharge and will need her
INR followed.
.
# SKIN RASH: The patient has several areas of skin rash and
necrosis after her catheterization. Derm consult was obtained
due to concern re: possible vasculitis. It was felt unlikely to
be a drug reaction to lasix. The lasix was restarted. She was
started on prednisone. Her ESR and CRP and rheumatoid factor
were negative. The skin biopsy was negative for vasculitis,
clot or emboli. The patient is being discharged on a steroid
taper.
.
#. Anemia, acute blood loss on chronic anemia - The patient's
hematocrit slowly drifted down this admission and was due to
repeated phlebotomy. After the patient's catheterization she had
hemorrhage into her thigh. She was resuscitated with PRBC and
IV fluids.
.
#. Hypothryoidism - continue synthroid 125 mcg daily
.
#. GERD - continue PPI.
.
#. COPD - stable. will cont duonebs prn.
Medications on Admission:
KCL SR 20 mEq a day
calcium 500 mg TID
vitamin D 400 International Units twice a day,
Coumadin 2 mg a day,
nitroglycerin 0.4 mg q5 minutes sublingual p.r.n.,
Tylenol 650 every 6 hours as needed,
multivitamin 1 tab daily
Prilosec 20 mg a day
vitamin B12 1,000 mcg a day
Synthroid 125 mcg daily
Cardizem CD 360 daily
Ensure 1 can 3 times a day
Lasix 40 mg a day,
DuoNebs q.4 hours p.r.n.,
digoxin 0.125 mcg a day
coated aspirin 81 mg a day,
Toprol XL 150 mg daily.
Benzonatate 100 mg [**Hospital1 **]
Meclizine 25 mg Q8 hr prn
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Cyanocobalamin 250 mcg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1)
neb Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual Q 5 minutes as needed for pain: Maximum of 3 tablets.
.
11. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
14. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Digoxin 125 mcg Tablet Sig: [**12-15**] tab Tablet PO once a day.
16. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
17. Warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
18. Prednisone 5 mg Tablet Sig: see below Tablet PO once a day:
Take 20mg [**12-28**];
take 15mg [**12-29**];
take 10mg [**12-30**];
take 5mg [**12-31**];
take 2.5 mg [**1-1**];
stop on [**1-2**].
19. Cardizem CD 360 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
20. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
NSTEMI
Anemia, acute blood loss
minor:
Atrial Fibrillation
History of TIA
hypothyroid
Hypertension
depression
Discharge Condition:
stable.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with chest pressure and you were
found to have a small heart attack called an NSTEMI. We
preformed a cardiac catheterization which showed some blockages
in your heart. One blockage was appeared old and could not be
intervened upon. However, the other blockage was openned and
stents were placed to keep it open. Your cardiac
catheterization was complicated by bleeding into the muslce in
you left leg which has now stabilized.
Please take your medications as prescribed.
The following changes has been made to your medications:
- We have increased your metoprolol to 150mg tablet by mouth
twice daily.
- We have decreased your digoxin to 0.0625 mg tablet by mouth
daily.
- Please start taking aspirin 325 mg daily for secondary
cardiovascular prevention (to prevent another heart attack)
- Please start taking atorvastatin 80mg daily for your heart and
for your cholesterol.
- Please continue to take your coumadin 3mg tablet, 1 tablet
every evening.
- Please start taking clopidogrel (Plavix) 75 mg daily to keep
stents open.
- Please taper the prednisone as instructed.
If you develop chest pain, jaw pain, or chest pressure, chest
pain with pain radiating into arm, shortness of breath or
decreased urine output or if you for any reason become concerned
about your medical condition please call 911 or present to
nearest ED.
- We also gave you Nitroglycerin tablets to take if you
experience chest pain, please call 911 or your doctor if chest
pain recurs even if it dissapears with nitroglycerine.
**DO NOT STOP TAKING THE ASPIRIN OR PLAVIX UNLESS INSTRUCTED TO
DO SO BY YOUR CARDIOLOGIST EVEN IF ANOTHER DOCTOR TELLS YOU TO**
Followup Instructions:
Please schedule an office visit with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 4248**]
[**Last Name (NamePattern1) 60567**], in the 1-2 weeks after being discharged.
We have made a follow up appointment for you with your
Cardiologist, Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2142-2-7**] at 1:30am.
His telephone number is [**Telephone/Fax (1) 18278**].
Completed by:[**2141-12-28**]
|
[
"414.01",
"V88.01",
"428.0",
"244.9",
"V45.02",
"V45.79",
"428.31",
"V12.04",
"311",
"285.1",
"V12.54",
"401.9",
"V58.61",
"998.12",
"E879.0",
"446.5",
"427.31",
"496",
"782.1",
"V45.01",
"410.71",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"99.20",
"37.22",
"36.06",
"86.11",
"99.04",
"00.40",
"00.66",
"38.93",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
12915, 12994
|
6826, 10483
|
367, 415
|
13149, 13159
|
3948, 6205
|
14888, 15324
|
3046, 3128
|
11059, 12892
|
13015, 13128
|
10509, 11036
|
6222, 6803
|
13183, 14865
|
3143, 3929
|
312, 329
|
443, 2352
|
2374, 2916
|
2932, 3030
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,860
| 129,644
|
53011+53054
|
Discharge summary
|
report+report
|
Admission Date: [**2157-2-12**] Discharge Date: [**2157-3-11**]
Date of Birth: [**2118-9-29**] Sex: F
Service:
woman with a history of crack-cocaine abuse. On [**2-12**] she was
found at home responsive. She had vomited and aspirated.
She was brought to [**Hospital 47**] Hospital, where a head CT
subarachnoid bleed and left anterior communicating artery
[**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] on [**2157-2-12**]. She went to the
communicating aneurysm.
Please see other dictation summary
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
D: [**2157-3-14**] 11:59
T: [**2157-3-14**] 12:03
JOB#: [**Job Number **]
Admission Date: [**2157-2-12**] Discharge Date: [**2157-3-11**]
Date of Birth: [**2118-9-29**] Sex: F
HISTORY OF PRESENT ILLNESS: The patient is a 38 year old
female with a history of crack cocaine abuse, on [**2-12**], found
at home unresponsive; had vomited and aspirated. She was
brought to [**Hospital 47**] [**Hospital 107**] Hospital where a head CT scan
transferred to [**Hospital1 69**] on [**2-12**],
for further management.
HOSPITAL COURSE: On [**2-13**], the patient underwent
arteriogram which showed a ruptured left fetal PCA aneurysm. On
[**2157-2-13**] at 11PM, the patient went to the Operating Room for a
clipping of a left PCA aneurysm without interoperative
placed on admission on [**2157-2-13**].
Postoperatively, the patient remained intubated and remained
in the Intensive Care Unit for close monitoring with
ventricular drain in place. Neurologically, pupils 2.5 down
to 2 bilaterally, moving everything spontaneously, following
commands, wiggling fingers and toes to commands immediately
postoperatively. The patient has transcranial Dopplers done
on [**2157-2-17**], which showed significant increase in flow
velocity in the left middle cerebral artery with mild
increase in flow velocity in the right middle cerebral
artery, ACA and left ACA consistent with possible vasospasm.
The patient also had repeat head CT scan on [**2157-2-17**], which
showed no significant change.
On [**2157-2-18**], the patient's examination showed a decrease in
movement of the right upper extremity. Dr. [**Last Name (STitle) 1132**] was
notified and the patient had an arteriogram which showed mild
left middle cerebral artery vasospasm. The patient did not
receive any interventional treatment at that time due to high
ICP. The patient intermittently spiking temperatures,
however, all cultures sent were negative to date. The
patient is currently on Kefzol for brain prophylaxis.
On [**2157-2-22**], the patient continued to neurologically be
following some commands; pupils equal and reactive to light,
moving the left side spontaneously. The right upper
extremity continued to move only to pain. She returned to
angiography on [**2157-2-22**], and underwent intracranial angioplasty
of the left internal cerebral artery with infusion of Papaverine
into the left middle cerebral artery and left internal
cerebral artery without complication.
Post-procedure, the patient's vital signs were stable. She
was afebrile. She remained intubated, off sedation,
squeezing fingers in the left hand to command; not showing
two fingers on the left hand. Pupils were 5 down to 3 mm
bilaterally. She moved the left side spontaneously,
continued to have no movement in the right upper extremity.
The patient ruled in for an myocardial infarction on
01/32/[**2157**], and was seen by the Cardiology Service and placed
on Lopressor for rate control. The patient was extubated on
[**2157-2-26**], and continued on a Neo-Synephrine drip to
keep her systolic blood pressures greater than 150. At this
point, she was moving all extremities within normal limits
including her right upper extremity. She continued to have
periods of agitation requiring a bedside sitter and weaned
off her intravenous Neo-Synephrine on [**2157-3-2**]. Her
ventilator was discontinued and the patient was transferred
to the floor on [**2157-3-3**].
The patient remained neurologically stable with some periods
of agitation and confusion requiring sitters until
[**2157-3-9**]. The patient was discontinued off sitters and was
neurologically stable and ready for discharge to home. The
patient was seen by Physical Therapy and Occupational Therapy
while she was on the floor and felt to require 24 hour
supervision but safe for discharge to home.
DISPOSITION: The patient left the hospital on [**2157-3-10**],
prior to being officially discharged.
DISCHARGE MEDICATIONS: Prescriptions for medications, for
Lopressor for her blood pressure, was called in to the
Pharmacy.
Her mother was notified of her leaving the hospital before
official discharge.
A pain medication was also prescribed.
DISCHARGE INSTRUCTIONS:
1. The patient was to follow-up for outpatient Occupational
Therapy on [**2157-3-15**], all of which her family was notified
of after her discharge.
CONDITION AT DISCHARGE: The patient was stable at the time
of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2157-3-14**] 12:14
T: [**2157-3-14**] 12:34
JOB#: [**Job Number **]
|
[
"401.9",
"285.9",
"518.5",
"430",
"331.4",
"304.20",
"410.21",
"507.0",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"39.50",
"02.39",
"96.6",
"99.29",
"96.72",
"39.51",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4658, 4879
|
1239, 4634
|
4903, 5064
|
5080, 5380
|
914, 1220
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,197
| 184,819
|
47677
|
Discharge summary
|
report
|
Admission Date: [**2140-9-11**] Discharge Date: [**2140-9-19**]
Date of Birth: [**2076-2-1**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
SOB, cough, fever
Major Surgical or Invasive Procedure:
Decubitus ulcer debriedment
History of Present Illness:
64M CHF, DM and peptic ulcer, s/p UGIB, PEA arrest now trach
dependent pw necrotic sacral ulcer and intermittent oozing from
GI tube site sent in from [**Hospital **] rehab with unclear history. Per
EMS, at [**Hospital **] rehab EKG done with STE in inferior leads after
saw ST changes on tele. Given asa and nitro, BP 134/75 after
nitro and then called EMS later. Never had chest pain. Found to
be diaphoretic by EMS; no STE found on EKG. Fever to 101.2 on
arrival to [**Hospital1 18**] ED. Patient denies CP. Reports SOB but this has
been since trach placement- has not recently worsened. NO abd
pain. Pain in sacral ulcers. Had some bleeding from area around
g-tube yesterday.
In ED, initial VS were: 101.2 84 130/70 100%. Evaluation
revealed ?RLL opacity. Labs were significant for lactate of 3.5,
troponin 0.09, INR 1.6 and UA. 2L IVF.
On arrival to the MICU, HD stable, on FiO2 35% and mentating
well.
Past Medical History:
Recent hospitalized: [**Date range (1) 100709**]/12: UGIB [**3-17**] gastric ulcers, s/p
PEA arrest, couldn't wean from vent-->tracheostomy performed on
[**8-12**]
PEG placed [**2140-8-17**]
- NIDDM
- hx of UGIB [**3-17**] peptic ulcer ([**2124**])
- CHF
- HTN
- CAD s/p MI
Medications HOME:
- amitriptyline 25mg hs
- amlodipine 5mg
- furosemide 40mg
- glipizide 5mg
- losartan 25mg
- Metoprolol succinate 100mg
Allergies: PCN, ACE inhibitors
Social History:
Lives at [**Hospital 100**] rehab
Family History:
unable to obtain
Physical Exam:
On admission:
Vitals: T BP 119/62 HR60 RR25 SpO2 95% CMV FiO2 35%
General: Alert, oriented, no acute distress, trach
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD, trach site benign
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: rhonchorous breath sounds bilaterally, slight crackles in
RLL
Abdomen: soft, obese, non-tender, bowel sounds present, no
organomegaly, g-tube site with open wound, no active bleeding or
discharge, no surrounding erythema.
GU: Foley and flexiseal draining
Skin: 8x5cm sacral decub, unstageable ulcer with mildly
erythematous rim, no appreciable warmth, not inappropriately
tender around wound.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; no calf tenderness or asymmetry
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, interacting
appropriately
On discharge:
VS: 97.8 153/74 84 19 95 T mist
General: Alert, oriented, no acute distress, trach
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, trach site benign
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: rhonchorous breath sounds bilaterally, slight crackles in
RLL
Abdomen: soft, obese, non-tender, bowel sounds present, no
organomegaly, g-tube site with open wound, no active bleeding or
discharge, no surrounding erythema.
GU: Foley and flexiseal draining
Ext: warm, well perfused, covered in brace, 2+ pulses, no
clubbing, cyanosis or edema; no calf tenderness or asymmetry
Neuro: grossly normal sensation, gait deferred, interacting
appropriately
Pertinent Results:
Admission labs:
[**2140-9-11**] 07:14PM BLOOD WBC-8.0 RBC-3.49* Hgb-9.7* Hct-30.8*
MCV-88 MCH-27.9 MCHC-31.6 RDW-19.0* Plt Ct-213
[**2140-9-11**] 07:14PM BLOOD Neuts-81.6* Lymphs-10.4* Monos-4.5
Eos-3.3 Baso-0.2
[**2140-9-12**] 01:47AM BLOOD PT-13.4* PTT-33.2 INR(PT)-1.2*
[**2140-9-11**] 07:14PM BLOOD Glucose-250* UreaN-55* Creat-1.0 Na-135
K-3.9 Cl-97 HCO3-26 AnGap-16
[**2140-9-12**] 01:47AM BLOOD ALT-33 AST-35 CK(CPK)-19* AlkPhos-418*
TotBili-1.1
[**2140-9-11**] 07:14PM BLOOD CK-MB-2 cTropnT-0.09*
[**2140-9-12**] 01:47AM BLOOD CK-MB-2 cTropnT-0.08*
[**2140-9-12**] 01:47AM BLOOD Calcium-7.6* Phos-4.4# Mg-2.3
[**2140-9-11**] 07:26PM BLOOD Lactate-3.5*
[**2140-9-11**] 09:05PM BLOOD Lactate-2.3*
[**2140-9-12**] 02:02AM BLOOD Lactate-1.9
Radiology
Echo [**2140-9-19**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated with severe global left ventricular
hypokinesis (LVEF = <20 %). The apical half of the heart is not
seen as there were no apical windows. The right ventricular
cavity is moderately dilated with moderate global free wall
hypokinesis. The ascending aorta is mildly dilated. The aortic
valve leaflets are mildly thickened (?#). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Left ventricular dilation
with severe global biventricular hypokinesis.Mild mitral
regurgitation. Pulmonary artery hypertension. No discrete
vegetations identified.
Compared with the prior study (images reviewed) of [**2140-8-3**],
biventricular systolic function is now more depressed, the left
ventricular cavity is more dilated, and the estimated PA
systolic pressure is lower (may reflect impaired right
ventricular systolic function). As viewed in the parasternal
windows, valve morphology and the severity of mitral
regurgitation are similar.
UNILAT UP EXT VEINS US LEFT [**2140-9-18**]
INDICATION: Patient with bacteremia secondary to line infection.
Assess for dvt. PRELIMINARY REPORT: [**Doctor Last Name **]-scale and color Doppler
images of bilateral subclavian, left internal jugular, axillary
vein demonstrate normal flow and compressibility. There is
non-occlusive thrombus involving the brachial vein. There is an
additional non-obstructive thrombus involving the basilic vein.
The cephalic vein demonstrates normal flow and compressibility.
IMPRESSION: Non-obstructive thrombus involving the left brachial
and basilic veins.
CXR
[**2140-9-11**] No significant interval change since prior. Pulmonary
vascular congestion. Bibasilar opacities potentially due to
atelectasis; however, infection is not excluded.
[**2140-9-12**]: In comparison with study of [**9-11**], the PICC extends only
to the left brachiocephalic vein before its junction with the
superior vena cava. Continued low lung volumes may account for
some of the prominence of the transverse diameter of the heart.
Bibasilar opacification most likely reflects atelectatic
changes. Possibility of supervening pneumonia would have to be
considered in the appropriate clinical setting. The pulmonary
vascular congestion is less prominent than on the prior study.
Micro
Blood culture [**2140-9-11**]: Acinetobcter, Klebsiella
Sputum culture [**2140-9-12**]: Acinetobcter, Klebsiella
Urine culture [**2140-9-12**]: Negative
PICC [**2140-9-14**]: Acinetobacter, klebsiella
Blood cx [**9-15**], [**9-16**]: NGTD
Blood Culture, Routine (Final [**2140-9-19**]): NO GROWTH.
WOUND CULTURE (Final [**2140-9-18**]):
ACINETOBACTER BAUMANNII COMPLEX. >15 colonies.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
KLEBSIELLA PNEUMONIAE. >15 colonies.
Piperacillin/tazobactam sensitivity testing available
on request.
CEFEPIME sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
| KLEBSIELLA PNEUMONIAE
| |
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- <=2 S =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R 4 S
CEFTAZIDIME----------- 16 I =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 1 S =>4 R
GENTAMICIN------------ =>16 R 8 I
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 0.5 S
MEROPENEM------------- <=0.25 S
TOBRAMYCIN------------ <=1 S 8 I
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
URINE CULTURE (Final [**2140-9-16**]): NO GROWTH.
C. DIFFICILE DNA amplification assay (Final [**2140-9-13**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
GRAM STAIN (Final [**2140-9-12**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2140-9-18**]):
SPARSE GROWTH Commensal Respiratory Flora.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
CEFEPIME: sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| ACINETOBACTER BAUMANNII
COMPLEX
| |
AMPICILLIN/SULBACTAM-- =>32 R <=2 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- I =>64 R
CEFTAZIDIME----------- =>64 R 8 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R 1 S
GENTAMICIN------------ <=1 S =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 0.5 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
FUNGAL CULTURE (Preliminary): YEAST.
MRSA SCREEN (Final [**2140-9-13**]): POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS.
Brief Hospital Course:
64M CHF, DM and peptic ulcer, s/p UGIB, PEA arrest now trach
dependent pw necrotic sacral ulcer and intermittent oozing from
GI tube site sent in from [**Hospital **] rehab with unclear history.
#Acinetobacter Bacteremia/Sepsis: Patient with acinetobacter
bacteremia. Had elevated lactate on admission which trended
downward with gentle fluid boluses and IV abx. Otherwise,
patient did not have fever or leukocytosis. ID was consulted and
patient had his PICC line removed and placed on line holiday.
He was initially placed on [**Hospital **]/cefepime which was narrowed to
cefepime when blood grew GNR, which was then switched to
Meropenem ([**Date range (1) 100710**]). The source of his bacteremia is
likely PNA or PICC line, however he also has a sacral decubitus
ulcer. As his abx therapy is 2 weeks, he does not require ID
follow up.
#Sacral Decubitus ulcer: Patient with worsening breakdown of
his decubitus ulcer. Wound care followed the patient while here
and recommended debridement. Patient went to OR on [**2140-9-15**] for
debridement of necrotic ulcer and wound vac was placed by ACS.
Bone biopsy was taken to see if he has osteomyelitis. Results
of bone biopsy are pending. He will require wound vac changes
every 3-5 days, and will need follow up with surgery in one
month.
#SOB: initially patient described dyspnea and was started on
HCAP coverage. He grew acinetobacter and klebsiella in his
sputum. he was initially placed on [**Date Range **]/cefepime and then
meropenem as GPC was thought to be contaminant/colonization. He
had no episodes of dyspnea and tolerated trach mist for most of
his hospitalization.
#Decreased Urine Output: patient has episodes of oliguria
(UOP<30cc/hr) periodically during admission. Attempts were made
to flush foley and obtain bladder ultrasound (which showed
minimal urine) with no improvement. He received periodic fluid
boluses. His FeNa and FeUrea indicated a pre-renal azotemia, so
he was subsequently given additional fluid boluses. Nephrology
was consulted and they recommended IV lasix, which he was
started on with good effect.
#CAD: per records, had ST elevations at [**Hospital 100**] rehab. EKG here
shows RBBB, no STE and no chest pain. Elevated tropsx 2 however
all troponins were stable, risk factors for repeat STEMI:
previous MI, HTN, CHF.
#sCHF: systolic dysfunction. last echo [**2140-8-4**] showed EF 15-20%.
Fluid was given in small boluses due to his sCHF, however he had
no acute exacerbation of CHF while hospitalized.
#Elevated INR: patient had INR elevated on admission with no
subsequent change throughout his hospitalization. Likely causes
include malnutrition versus liver disease versus antibiotic
interaction. He had no episodes of bleeding while in house.
#Anemia: normochromic. No acute blood loss. Has had anemia with
hct in low 30s in last hospitalization when had GIB due to
peptic ulcers. He had guaiac negative stools and had stable HCT
throughout hospitalization.
#DM: on glipizide, amitriptyline presumably for neuropathic
pain. He was placed on ISS and had no issues in house.
#HTN: baseline 120-130s. In house he was initially normotensive
with no medications, on discharge his metoprolol and losartan
were re-started at half their normal dose. he should follow up
with his pcp at [**Name9 (PRE) **] to check blood pressure and better titrate
his anti-htn regimen.
Transitional issues:
-He should see his PCP regarding his [**Name9 (PRE) 100711**] medications
-He should follow up with Surgery in 1 month.
-He should finish a 14 days course of meropenem ([**Date range (1) 96317**])
-PCP should follow up on bone biopsy results
-Goals of care should be re-evaluated.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. Amitriptyline 25 mg PO HS
2. Amlodipine 5 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. GlipiZIDE XL 5 mg PO DAILY
5. Losartan Potassium 25 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Losartan Potassium 12.5 mg PO DAILY
hold for sbp<100 or hr<60
RX *losartan 25 mg 0.5 (One half) tablet(s) by mouth once a day
Disp #*15 Tablet Refills:*0
2. Amitriptyline 25 mg PO HS
3. GlipiZIDE XL 5 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*15 Tablet Refills:*0
5. Albuterol Inhaler [**2-15**] PUFF IH Q6H:PRN Wheeze/sob
6. Meropenem 500 mg IV Q6H Duration: 9 Days
RX *meropenem 500 mg every six (6) hours Disp #*54 Unit
Refills:*0
7. Furosemide 40 mg IV DAILY
RX *furosemide 10 mg/mL 4ml once a day Disp #*15 Unit Refills:*0
Discharge Disposition:
Expired
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Acinetobacter/Klebsiella bactermia/pneumonia
Sacral Decubitus ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 1728**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were brought to the hospital for concerns
of a heart attack, but we do not think you had a heart attack.
You were admitted due to an infection in your blood and lungs
and a blocked gastric tube. You were treated with antibiotics
and had surgery to debride the large ulcer on you lower back.
After surgery, your blood pressure dropped and you needed 30
seconds of chest compressions. Your blood pressure was improved
after this. Your gastric tube is now working.
Followup Instructions:
Please follow up with LTAC PCP regarding blood pressure
medications
Please have your PCP follow up on bone biopsy performed here of
your sacral decubitus ulcer
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"285.9",
"V55.1",
"428.0",
"414.01",
"707.25",
"V44.0",
"518.83",
"482.0",
"707.03",
"682.2",
"041.3",
"790.92",
"038.49",
"427.5",
"584.9",
"428.22",
"412",
"425.4",
"995.91",
"250.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"96.6",
"96.36",
"77.69",
"96.71",
"77.49"
] |
icd9pcs
|
[
[
[]
]
] |
15209, 15269
|
10502, 13888
|
313, 342
|
15382, 15382
|
3540, 3540
|
16143, 16443
|
1819, 1838
|
14570, 15186
|
15290, 15360
|
14217, 14547
|
15558, 16120
|
1853, 1853
|
10384, 10479
|
2805, 3521
|
13909, 14191
|
256, 275
|
370, 1282
|
3556, 10354
|
1867, 2791
|
15397, 15534
|
1304, 1751
|
1767, 1803
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,579
| 194,906
|
38818
|
Discharge summary
|
report
|
Admission Date: [**2195-8-3**] Discharge Date: [**2195-9-18**]
Date of Birth: [**2131-7-13**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Cefepime / Aztreonam
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Elective admission for alloSCT
Major Surgical or Invasive Procedure:
Stem cell transplant
History of Present Illness:
Mr [**Known lastname **] is a 63 yo male with history of DM, hyperlipidemia,
and HTN who was diagnosed with AML after routine labs showed
pancytopenia. Bonemarrow biopsy at that time showed 50% blasts.
He was treated with one cycle of 7+3 and 2 cycles of decitabine,
with the last cycle [**2195-6-8**]. He is admitted for allogenic
stem cell transplant. Today, he is without complaints. He is
goal oriented and looking forward to beginning therapy. He
reports good appetitie. Denies F/C, N/V/D, Headache, Cough,
hematemesis, SOB, Chest Pain, Abdominal pain, dysuria.
.
Patient reports severe medication reaction on last admission and
states that it was due to "one of the four chemotherapy agents I
was given" descrivbing the reaction as erythemia that covered
his legs/arms/torso. According to the discharge summary from
[**Hospital1 18**] [**2195-5-2**] Allergy was consulted who believed that the rash
was from either Cefepime or Aztreonam and recommended avoiding
all cephalosporins avoid all cephalosporins (in particular
Cefepime and Ceftazidime) and Aztreonam.
Past Medical History:
- AML:
[**2195-3-27**]: Sent to [**Hospital6 33**] by PCP for
pancytopenia - WBC: 0.7, Hb: 7, HCT:19.8, PLT: 8.
[**2195-3-31**]: Bone marrow biopsy that showed 50% blasts.
Transferred to [**Hospital1 18**] for treatment of acute leukemia.
[**2195-4-2**]: 7+3 chemo
[**2195-4-4**]: Febrile neutropenia. Developed significant rash from
drug allergy
[**2195-4-15**]: Day 14 7+3 bone marrow demonstrated hypocellularity,
but persistence of AML
[**2195-4-21**]: fungal pneumonia, had bronchoscopy on [**2195-4-24**]
[**2195-4-22**]: Repeat marrow again showed persistent disease
[**2195-5-2**]: Discharged from [**Hospital1 18**]
[**2195-5-11**]: C1D1 Dacogen
[**2195-6-8**]: C2D1 Dacogen
- Hypertension
- Hyperlipidemia
- Non-insulin dependent diabetes
- Tubular adenoma in [**1-/2191**]
- BPH
- Back surgery following MVA in [**2187**]
Social History:
- Divorced, lives with son, who is a senior in high school.
- Smokes 1.5 packs of cigarettes/daily.
- Drinks 1-2 drinks / wk with no heavy drinking in the past.
- No recreational drug use.
Family History:
- Diabetes and breast cancer in mother
- brother died at age 23 of brain tumor.
- Has 3 sisters all in good health.
- Daughter age 31 and son in high school in good health.
Physical Exam:
Temp: 97.1 BP 108/68 P: 75 RR: 14 SaO2:98% on RA
GEN: a middle aged male laying in bed pleasant and talkative in
NAD
HEENT: MMM, no OP lesions, Non elevated JVP, neck is supple, no
cervical, supraclavicular, or axillary LAD
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or HSM, no stigmata of chronic
liver disease
LIMBS: No LE edema, no tremors or asterixis, no clubbing
SKIN: No rashes or skin breakdown
NEURO: CNII-XII nonfocal, strength 5/5 of the upper and lower
extremities, reflexes 2+ of the upper and lower extremities,
toes down bilaterally
Pertinent Results:
ADMISSION LABS:
.
[**2195-8-3**] 09:03AM BLOOD WBC-1.4* RBC-2.89* Hgb-10.9* Hct-31.0*
MCV-107* MCH-37.6* MCHC-35.1* RDW-16.2* Plt Ct-28*
[**2195-8-3**] 09:03AM BLOOD PT-11.9 PTT-25.9 INR(PT)-1.0
[**2195-8-4**] 12:00AM BLOOD Gran Ct-412*
[**2195-8-3**] 09:03AM BLOOD UreaN-16 Creat-0.9 Na-139 K-4.3 Cl-106
HCO3-27 AnGap-10
[**2195-8-3**] 01:55PM BLOOD Glucose-110* UreaN-16 Creat-1.0 Na-138
K-4.3 Cl-105 HCO3-27 AnGap-10
[**2195-8-3**] 09:03AM BLOOD ALT-32 AST-19 LD(LDH)-130 AlkPhos-60
TotBili-0.2
[**2195-8-20**] 12:05AM BLOOD proBNP-[**Numeric Identifier 86155**]*
[**2195-8-3**] 09:03AM BLOOD Albumin-4.7 Calcium-9.0 Phos-2.8 Mg-1.9
.
DISCHARGE LABS:
.
[**2195-9-18**] 12:00AM BLOOD WBC-2.2* RBC-2.56* Hgb-7.9* Hct-23.0*
MCV-90 MCH-31.0 MCHC-34.5 RDW-14.8 Plt Ct-30*
[**2195-9-18**] 12:00AM BLOOD Gran Ct-1716*
[**2195-9-18**] 12:00AM BLOOD Glucose-105* UreaN-15 Creat-1.4* Na-139
K-3.8 Cl-104 HCO3-24 AnGap-15
[**2195-9-18**] 12:00AM BLOOD ALT-6 AST-13 LD(LDH)-263* AlkPhos-82
TotBili-1.1
[**2195-9-18**] 12:00AM BLOOD Calcium-8.2* Phos-4.0 Mg-1.7
[**2195-9-18**] 09:49AM BLOOD Cyclspr-261
Brief Hospital Course:
63 yo male recently diagnosed with AML s/p 7+3 induction and 2
cycles of Decitabine, last cycle on [**2195-6-8**]. He was admitted
for double cord transplant with Day 0 on [**8-10**].
#AML: He had neutropenic fever, which is why he is on Meropenem,
Vancomycin. The patient has had rashes to aztreonam and
cefepime. He takes Atovaquone, Acyclovir, and Voriconazole for
prophylaxis. He was afebrile for 10 days, and was thus taken
off the Meropenem and Vancomycin prior to discharge, during
which he remained afebrile. His counts improved, and his ANC
remained above 1500 off Neupogen, indicating that he was
successfully engrafted. He will be discharged to the apartments
and will come in daily to the heme/onc clinic.
.
His course has been complicated by a visit for the ICU from
which he returned approximately 1 week ago; he had been in the
ICU after having an increased oxygen requirement on the floor,
[**Last Name (un) **], and noted decrease in his ejection fraction on Echo. His
echo revealed cardiomyopathy, with a depressed EF of 30%, but
the source of his cardiomyopathy is unclear at this time. He was
intubated, but following diuresis and initiation on imdur,
beta-blockade, and hydralazine improved. He returned to the
floor on room air.
BRIEF [**Hospital Unit Name 13533**]:
Respiratory Distress / Heart Failure - Patient was transferred
to the [**Hospital Unit Name 153**] for respiratory distress in the setting of mild bump
in cardiac enzymes (Troponin peak 0.11), new effusions on CXR,
and non-specific Twave changes on EKG. Echo demonstrated
decreased poor systolic function (EF 35%). The patient required
imediate intubation for hypoxic respiratory failure. The
diagnostics and imaging point to pulmonary edema [**1-13**] to CHF in
the setting of ACS, although given the patient's neutropenic
status infection was also considered. The patient was gently
diuresed and weaned from the ventilator. PNA was covered by the
patient's existing broad neutropenic prophylaxis (vanco, [**Last Name (un) 2830**],
micafungin). He was extubated and was weaned from supplemental
O2. At the time of his transfer out of the ICU, he was stable
on room air.
HTN - On transfer to the [**Hospital Unit Name 153**], the patient's antihypertensives
had been held given his low blood pressure. Following the
patient's extubation, the patient became hypertensive to SBP
160s-180s. He was started on hydralazine, carvedilol and imdur
to reduce afterload. He also had a vasovagal bradycardic
episode and triggered for HRs in the 40s. He was monitored on
tele with no further events. He was seen by cardiology, who
recommended patient be restarted on metoprolol and diovan for
treatment of hypertension and non-ischemic cardiomyopathy. He
will follow-up with cardiology after discharge.
.
[**Last Name (un) **] - On transfer to the [**Hospital Unit Name 153**], the patient's Creatinine was
elevated to high 2s, from baseline of 0.9. This was thought to
be multifactorial, [**1-13**] to to nephrotoxic chemotherapeutics and
due to poor renal perfusion in the setting of heart failure /
ACS. His cyclosporin was held pending improvement in the
patient's renal function. He did not have any metabolic
derangements and his renal function gradually improved to 1.3
by the time of his transfer back to the BMT service. On
discharge, his Cr was 1.4.
Medications on Admission:
Glyburide 5 mg daily
Metformin 1,000 mg daily
Discharge Medications:
1. ursodiol 300 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO QAM (once a
day (in the morning)).
Disp:*30 Capsule(s)* Refills:*2*
2. ursodiol 300 mg Capsule [**Month/Day (2) **]: Two (2) Capsule PO qPM.
Disp:*60 Capsule(s)* Refills:*2*
3. atovaquone 750 mg/5 mL Suspension [**Month/Day (2) **]: Two (2) PO DAILY
(Daily).
Disp:*60 suspension* Refills:*2*
4. mycophenolate mofetil 500 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
5. voriconazole 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
6. acyclovir 400 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
7. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
[**Month/Day (2) **]: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
9. folic acid 1 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
11. valsartan 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. vancomycin 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO every six
(6) hours.
Disp:*120 Capsule(s)* Refills:*2*
13. Neoral 25 mg Capsule [**Last Name (STitle) **]: [**12-14**] Capsules PO once a day: Do not
substitute
Take as directed.
Disp:*180 Capsule(s)* Refills:*2*
14. Neoral 100 mg Capsule [**Month/Day (3) **]: One (1) Capsule PO once a day: Do
not substitute
Take as directed.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
AML
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for a bone marrow transplant.
Your white blood cells have recovered and you were clinically
stable for discharge. You will still have to come back to the
clinic on a daily basis in order to receive platelets.
.
CYCLOSPORIN: You should take 125 mg twice a day in the morning
and at night until otherwise directed. This is 1 100 mg pill
and 1 25 mg pill twice a day. This dose may change based on
your Cyclosporin level in your blood. We will tell you what
dose to take when you return in the clinic.
.
On discharge, we STOPPED Glyburide and Metformin. Do not take
these medications until you discuss further management of your
diabetes with your Primary Care Physician.
Followup Instructions:
Provider: [**Name Initial (NameIs) 455**] 5-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2195-9-19**] 9:30
Provider: [**Name Initial (NameIs) 455**] 5-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2195-9-20**] 9:30
Provider: [**Name Initial (NameIs) 455**] 5-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2195-9-21**] 9:30
|
[
"305.1",
"272.0",
"E933.1",
"780.61",
"410.91",
"428.21",
"401.9",
"428.0",
"276.2",
"584.9",
"205.00",
"425.4",
"600.00",
"518.81",
"250.00",
"288.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"99.25",
"38.97",
"96.72",
"41.06",
"99.15",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9910, 9962
|
4473, 7838
|
325, 347
|
10010, 10010
|
3355, 3355
|
10889, 11219
|
2569, 2743
|
7934, 9887
|
9983, 9989
|
7864, 7911
|
10161, 10866
|
4009, 4450
|
2758, 3336
|
255, 287
|
375, 1445
|
3371, 3993
|
10025, 10137
|
1467, 2346
|
2362, 2553
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,861
| 195,025
|
33673
|
Discharge summary
|
report
|
Admission Date: [**2121-2-2**] Discharge Date: [**2121-2-8**]
Date of Birth: [**2060-7-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Bright Red Blood Per Rectum
Major Surgical or Invasive Procedure:
Upper Endoscopy
Colonoscopy
Right IJ central line
History of Present Illness:
Mr. [**Known lastname **] is a 60 year old male with a history of coronary
artery disease s/p CABG, hypertension, [**Last Name (un) **] esophagus and
chronic abdominal pain who presented to [**Hospital3 417**] hospital
on [**2121-2-1**] with melena and syncope. The patient has had a
history of chronic diffuse abdominal pain for the past [**1-19**]
years. The pain is centrally located and he describes it as a
gnawing sensation assocaited with gas. The pain worsens when he
eats food. It is present, however, regardless of PO intake.
The pain does not wake him up from sleep. He has had an
extensive workup including upper and lower endoscopies, CT scans
and SBFTs which have all been negative. The patient reports
that two days prior to presentation to Good Samaratan's he
noticed a black quality to his stools. He has never had black
stools in the past. He called his gastroenterologist at [**Hospital1 2025**] who
saw him urgently and scheduled an outpatient upper endoscopy.
Two days after this appointment he was eating dinner with his
wife when he began to have diffuse abdominal pain similar in
quality to his chronic pain. It was associated with gas and an
urge to move his bowels. He went to the restroom and had gross
red blood per rectum. He then recalls standing up and feeling
week and passing out. He hit the front of his head with the
fall. He does not think that he lost consciousness but felt
lightheaded. He was taken by ambulance to [**Hospital3 417**]
hospital. On admission to [**Hospital3 417**] his hemoglobin was
11.5. NG lavage performed in the ER was guaiac positive and
rectal exam was notable for bright red blood per rectum. He
initially had a colonscopy which showed diverticulosis with
active bleeding. EGD showed minimal erythema in the duodenal
bulb suggestive of duodenitis. He initially had a tagged red
blood cell scan without evidence of active bleeding. He was
stable until the morning of [**2-2**] at which time he began to pass
large amounts of blood per rectum. Repeat tagged red blood cell
scan at that time revealed active small bowel bleeding in the
left lower quadrant. Per the patient he was transiently
hypotensive to the 90s systolic. In total he recevied 9 units
of packed red blood cells prior to transfer. He was transferred
to [**Hospital3 **] for further management.
The patient was initially admitted to the MICU. He initially
underwent tagged red blood cell scan which showed tracer uptake
in the colon from prior study indicating interval GI bleeding
but no new tracer accumulation indicating no evidence of active
bleeding. He was transfused two additional units of packed red
blood cells. He underwent upper endoscopy on [**2121-2-4**] which
showed nodularity and thickened folds in the stomach body and
fundus which were biopsied. There was erythema in the antrum
and duodenal bulb compatable with mild gastritis and duodenitis
as well as an esophageal ring. He was unable to undergo
colonoscopy secondary to poor prep. For the past 24 hours he
has been noted to be hemodynamically stable. He has continued
to have melena but no further BRPBR. He was felt to be stable
for transfer to the floor for further management including
colonoscopy in the morning.
On questioning this evening the patient relates the same story.
He says that he has never had GI bleeding such as this before.
He has had small hemorrhoidal bleeds but no melena or BRBPR. He
denies recent fevers or chills. He denies any chest pressure or
dyspnea. He describes chronic abdominal pain as above s/p
extensive workup with no etiology found. He denies dysuria or
hematuria. He denies current lightheadedness or dizziness. He
does report swelling of his hands and feet since being in the
MICU secondary to aggressive hydration with crystalloid. He has
had yearly EGDs for his history of Barrett's esophagus which
have been stable. He takes aspirin 81 mg daily but no other
NSAIDs. He drinks [**12-18**] alcoholic beverages per week.
Past Medical History:
1. HTN - diovan 320 and atenolol
2. CAD - 3-vessel CABG - [**2113**], anginal equivalent substernal
chest discomfort. Report of 3 stents in place. [**2-/2120**] mibi
scan showing mild fixed inferior wall defect, no ischemia noted.
3. Hypothyroidism
4. Carotid artery disease - left carotid endarterectomy
5. Barrett's esophagus
Social History:
Lives at home with wife, has no children. Close social support
with sisters-in-law. Drinks 1-2 drinks/week, quit tobacco 30
years ago, denies IVDU. Works as a public utilities worker,
deals with drains and water pipes.
Family History:
Non contributory
Physical Exam:
T 98 BP 190/70 HR 95 lying, 112 sitting, RR 18 99%2l
Gen - NAD, A/Ox3, lying in bed, conversant, cooperative.
HEENT - no conjunctival pallor, no scleral icterus appreciated,
dry MM, no posterior pharyngeal erythema appreciated.
NECK - no posterior/anterior LAD, no JVD on R appreciated, L
anterior chain scar in place, ?of JVD elevation at L earlobe vs.
anatomical change from scar.
CV - RRR, S1+S2+S3-S4+, 2/6 SEM 2nd intercostal space,
holosystolic. PMI at mid-clavicular line.
LUNGS - CTAB, good air movement bilaterally, no crackles
appreciated, no wheezes appreciated
ABD - NABS, soft, mildly tender mid-epigastrium. non-distended.
No organomegaly appreciated.
EXT - no lower extremity edema. 2+ palpable pulses bilaterally
dorsalis pedis, posterior tibial, radial, ulnar, all 2+.
SKIN: No rashes/lesions, ecchymoses.
NEURO - A&Ox3, seems apropriate. CN 2-12 grossly intact, did not
do fundoscopy. Preserved sensation throughout. MSK 4+/5
bilaterally, upper extremities and lower extremities. 1+
reflexes L4 bilaterally.
PSYCH - Listens and responds to questions appropriately
Access - 1 RIJ with no erythemia, 2 22g pIVs R arm, 1 18g L arm.
Pertinent Results:
Hematology:
[**2121-2-2**] 05:27PM WBC-8.9 RBC-3.90* HGB-11.7* HCT-33.0* MCV-85
MCH-30.0 MCHC-35.4* RDW-14.1
[**2121-2-2**] 05:27PM NEUTS-69.6 LYMPHS-20.4 MONOS-9.6 EOS-0.2
BASOS-0.3
[**2121-2-2**] 05:27PM PLT COUNT-85*
[**2121-2-2**] 05:27PM PT-13.2 PTT-31.6 INR(PT)-1.1
[**2121-2-2**] 11:49PM HCT-28.2*
[**2121-2-7**] 06:22AM BLOOD WBC-5.7 RBC-3.49* Hgb-10.4* Hct-30.2*
MCV-86 MCH-29.7 MCHC-34.3 RDW-15.0 Plt Ct-228
Chemistries:
[**2121-2-2**] 05:27PM BLOOD Glucose-106* UreaN-16 Creat-1.0 Na-141
K-4.2 Cl-113* HCO3-23 AnGap-9
[**2121-2-2**] 05:27PM BLOOD Calcium-6.3* Phos-2.4* Mg-2.2
[**2121-2-7**] 06:22AM BLOOD Glucose-87 UreaN-9 Creat-0.9 Na-142 K-4.0
Cl-107 HCO3-27 AnGap-12
[**2121-2-7**] 06:22AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.9
[**2121-2-5**] 05:41AM BLOOD Albumin-2.9*
CXR [**2121-2-2**]: There are low lung volumes that accentuate the
cardiac silhouette which appears to be mildly enlarged. Patient
is post CABG. Right IJ catheter tip is in the right
brachiocephalic vein. There are low lung volumes. The lungs are
clear. There is no pneumothorax or sizable pleural effusion.
Tagged RBC scan [**2121-2-4**]: Following intravenous injection of
autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and
dynamic images of the abdomen for 90 minutes were obtained. A
left lateral view of the pelvis was also obtained. Initial
static image demonstrates tracer uptake throughout the colon,
consistent with residual activity from prior study.
Blood flow images show normal flow in the aorta. Dynamic blood
pool images show no evidence of active bleed.
Upper Endoscopy [**2121-2-4**]: Nodularity and thickened folds in the
stomach body and fundus (biopsy). Erythema in the antrum
compatible with mild gastritis (biopsy). Erythema in the
duodenal bulb compatible with mild duodenitis. Esophageal ring
Gastric Biopsies [**2121-2-4**]:
A) Body biopsy: Prominent parietal cells without inflammation.
B) Antrum biopsy:Within normal limits.
Colonoscopy [**2121-2-5**]: Several diverticula were seen in the
sigmoid colon. Diverticulosis appeared to be of mild severity.
Normal terminal ileum
Capsule Endoscopy [**2121-2-6**]: results pending at time of discharge
EKG Sinus rhythm at a rate of about 90 beats per minute.
Baseline artifact. Non-specific ST-T wave changes. Delayed
precordial transition. QRS duration at upper limits of normal.
Minuscule R waves in leads III and aVF. No previous tracing
available for comparison.
Brief Hospital Course:
Mr. [**Known lastname **] is a 60 year old male with CAD s/p CABG,
hypertension, Barrett's esophagus who presented to [**Hospital 6451**] with melena and BRBPR transferred here for
angiography.
Gastrointestinal bleeding: The patient was transferred to this
hospital from [**Hospital3 417**] with gastrointestinal bleeding.
Upper endoscopy performed prior to transfer showed no active
bleeding. Colonoscopy revealed gross blood in the colon. He
had two tagged red blood cell scans. The first did not show any
signs of active bleeding. The second was concerning for a small
bowel etiology. Prior to transfer he had received 9 units of
packed red blood cells. On arrival here his hematocrit was
33.0. Over the next two days he received two additional units
of blood with eventual stabilization of his hematocrit at 30.
He underwent a repeat tagged red blood cell scan which showed no
signs of active bleeding. He had a push enteroscopy and repeat
colonoscopy which also did not reveal the site of bleeding. His
upper endoscopy was notable for a nodular contour of his stomach
and biopsies were taken which revealed prominent parietal cells
without inflammation. Prior to discharge he underwent a capsule
endoscopy study the results of which were pending at time of
discharge. Prior to discharge his hematocrit had been stable
for 72 hours as were his hemodynamics. At the time of discharge
he was tolerating a regular diet. Capsule endoscopy results
will be available next week. His aspirin was held throughout
this hospitalization and was held at the time of discharge. He
was discharged on his outpatient proton pump inhibitor. He will
follow up with his primary care physician within one week for
repeat hematocrit as well as with his primary
gastroenterologist.
Hypocalcemia: On arrival the patient's serum calcium was noted
to be low at 6.3. It was thought that this was likely secondary
to EDTA administration in his numerous blood transfusions.
Albumin was measured at 2.9. His calcium was monitored during
his hospitalization and improved to 8.2 on discharge.
Coronary Artery Disease: The patient is s/p CABG. He had no
evidence of coronary ischemia during this hospitalization.
Given his active gastrointestinal bleeding his aspirin was
discontinued. His antihypertensive agents were initially held
and restarted prior to discharge with no evidence of hemodynamic
instability. He will follow up with his primary care physician.
Hypertension: On transfer to this hospital the patient's
antihypertensive agents were initially held out of concern for
hemodynamic instability. He did not have any documented
hypotension during this admission but originally was orthostatic
by heart rate criteria. His antihypertensive agents were
restarted prior to discharge. On his home regimen his blood
pressures ranged from the 120s to 150s systolic with transient
increases to as high as 170s systolic. The patient will be
following up with his primary care physician in one week for
repeat blood pressure check.
Thrombocytopenia: On transfer the patient had evidence of
thrombocytopenia with platelet counts of 85. This was thought
to be secondary to receiving multiple blood transfusions in the
absence of platelet transfusions. His platelet count improved
to 228 without intervention.
Prophylaxis: He received IV protonix [**Hospital1 **] throughout his
hospitalization
Code: Full Code
Medications on Admission:
1. Atenolol 25mg
2. HCTZ 25mg
3. Diovan 320 mg qd
4. aspirin 81mg
5. nexium 40mg
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
2. Diovan 320 mg Tablet Sig: One (1) Tablet PO once a day.
3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Gastrointestinal Bleeding
Hypertension
Secondary:
Coronary Artery Disease
Discharge Condition:
Stable. Ambulating without assistance. Breathing comfortably
on room air.
Discharge Instructions:
You were seen and evaluated for your gastrointestinal bleeding.
You received two units of blood. You had an upper endoscopy and
colonoscopy which did not locate the site of bleeding. You had a
capsule endoscopy performed and the results will be available
next week.
Please take all your medications as prescribed. The following
changes were made to your medication regimen.
1. Please hold your aspirin until told to resume this medication
by your gastroenterologist.
Please keep all your follow up appointments.
Please seek immediate medical attention if you experience any
lightheadedness, dizziness, chest pain, difficulty breathing,
black stools, bloody stools, or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician within one
week of your discharge. Your primary care physician should
check your blood counts at this appointment.
Please follow up with your gastroenterologist Dr. [**Last Name (STitle) 77952**] within
2-3 weeks of this admission.
Please call Dr. [**Last Name (STitle) 1407**] in the department of gastroenterology
within 7-10 days for the results of your capsule endoscopy. Her
phone number is [**Telephone/Fax (1) 11048**].
|
[
"562.10",
"578.9",
"287.5",
"V45.81",
"401.9",
"275.41",
"244.9",
"285.1",
"530.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"38.93",
"45.23",
"45.19",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12622, 12628
|
8742, 12164
|
340, 392
|
12756, 12834
|
6248, 8719
|
13586, 14070
|
5040, 5058
|
12301, 12599
|
12649, 12735
|
12190, 12278
|
12858, 13563
|
5073, 6229
|
273, 302
|
420, 4425
|
4447, 4784
|
4800, 5024
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,757
| 103,697
|
17330
|
Discharge summary
|
report
|
Admission Date: [**2113-6-24**] Discharge Date: [**2113-7-31**]
Date of Birth: [**2083-4-5**] Sex: M
Service: PLASTICS
HISTORY OF PRESENT ILLNESS: Patient is a 30-year-old
diabetic male admitted to Dr.[**Name (NI) 18870**] team on [**2113-6-24**]. Patient had a history of major trauma to the dorsum of
the right foot, which resulted in major wound complications
including major deformity and bone loss secondary to
infection in the last several days prior to admission. The
wound had expressed increasing purulent discharge over the
last few days prior to admission, and the patient reported
chills and nausea. The patient denied any fever, vomiting,
or diarrhea. Patient was admitted for IV antibiotics and
wound debridement as well as ex-fix removal of the right
foot.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes mellitus type 1.
3. Deep corneal abrasions.
MEDICATIONS ON ADMISSION:
1. NPH 18 units q am, 10 units q hs.
2. Humalog sliding scale.
3. OxyContin 10 mg twice a day.
4. Percocets 5/325 one tablet po q4-6h.
5. Trandolapril 2 mg po q day.
6. Artificial Tears for both eyes.
PHYSICAL EXAMINATION: On examination, the patient's vital
signs were temperature of 98.7, blood pressure 132/70, heart
rate of 96, respiratory rate of 18, and patient's O2
saturation was 98% on room air. Patient was alert and
oriented times three. Cardiovascular examination revealed a
regular, rate, and rhythm, S1, S2, no S3, S4. Respiratory
examination revealed clear to auscultation bilaterally.
Gastrointestinal examination revealed positive bowel sounds,
soft, nontender, nondistended, and soft. Lower extremities
revealed palpable pulses bilaterally with an ex-fix in place
in the right dorsal foot. There was a deep wound with
purulent discharge and erythema and edema in the surrounding
wound area and granular bone exposed. There was positive
sensation and positive movement in both foot digits
bilaterally.
SIGNIFICANT LABORATORY WORK: One wound culture revealed
oxacillin-resistant Staphylococcus aureus, Enterococcus
species, and Staphylococcus-coagulase negative.
HOSPITAL COURSE: Patient was admitted on [**6-24**], and was
started on Unasyn 3 grams IV q6h. On [**6-26**], the patient
was taken to the operating room by Dr. [**Last Name (STitle) **] for right
foot wound debridement and injection of 5 cc of Vancomycin
plus OsteoSet Vancomycin beads which were inserted into the
wound. Patient's external fixation on the right foot was
also removed and patient was also placed on Vancomycin 1 gram
IV q12h.
On [**6-28**], [**Last Name (un) **] was consulted for diabetic care. [**Last Name (un) **]
had known the patient since the patient was 15 years old, and
was well known to the clinic. Ophthalmology was also
consulted for general eye care of retinopathy and deep
corneal abrasions. Patient's hematocrit returned at 22.6 and
the patient was consequently, transfused with 2 units of
packed red blood cells.
On [**6-30**], the Vancomycin dose was changed to 1 gram IV
q24h from q12h. Patient was taken to the operating room on
[**7-6**] by Dr. [**Last Name (STitle) 13797**] for right foot wound debridement and
a right radial cutaneus free flap to the right foot. Patient
also had a left thigh split thickness skin graft to the right
radius and a VAC dressing was also placed on the right
forearm. Patient was started on aspirin 300 mg per rectally
and enoxaparin 60 mg subQ q12h. Patient tolerated the
procedure well, but had continuing hypertension and
tachycardia. The patient was consequently, given labetalol
10 mg IV x1.
While in the PACU, patient's right foot flap was thought to
be occluded venously, and the patient was returned to the
operating room for revision of the right foot flap. Patient
was also placed on continuous venous monitoring. Patient was
admitted to the Intensive Care Unit later that day.
On [**7-9**], patient's right foot flap lost venous signally
while in the Intensive Care Unit. Dr. [**Last Name (STitle) 13797**] decided to
take the patient back to the operating room for removal of a
venous thrombus. Patient tolerated both revisions of the
right foot flap well, despite elevated blood pressures and
tachycardia. This was thought to be due to poor pain
control. Patient was started on OxyContin 40 mg q12h and
Dilaudid PCA.
Patient's right foot continued to drain serosanguinous fluid,
saturating the patient's foot dressings. Patient was
consequently, transfused 2 units of packed red blood cells
for falling hematocrit to 22.2. At this time, the patient
was decided to be stable enough to be returned to the floors.
On [**7-13**], patient continued to have increase in
serosanguinous drainage from the right foot, with blood
pressures decreasing. Patient was given 2 liters of normal
saline to maintain pressures, transfused 2 units of packed
red blood cells for a hematocrit of 19.4, and 2 units of
frozen plasma. Patient's enoxaparin was discontinued and
vitamin K was administered.
Patient was taken to operating room again for wound
exploration of the right foot. Dr. [**Last Name (STitle) 13797**] found a small
arterial branch on the right foot flap and hemostasis was
performed. Patient was admitted to the SICU temporarily and
then transferred to floor on [**7-14**]. Patient was much
improved postoperatively with less serosanguinous drainage
from the right foot. Patient did well and on [**7-17**],
central line was discontinued.
On [**7-19**], medical consult was ordered for continued
persisting hypertension. Their recommendations eventually
led to an increase of metoprolol 100 mg po bid and
trandolapril 4 mg q day.
Acute Pain Consult service was also ordered for improved pain
management. The patient was eventually placed on OxyContin
30 mg tid and Percocets 1-2 tablets po q4-6h with improved
pain control.
Ophthalmology was also concerned of neovascular glaucoma of
the left eye due to slightly increased pressures. Patient
was started on Xalatan and Cosopt on the left eye. Physical
Therapy saw the patient on [**7-24**] for foot dangling five
minutes three times a day for increasing venous congestion in
the right foot. Patient was much improved by the end of the
week, and was ready for discharge.
CONDITION ON DISCHARGE: Good.
FINAL DIAGNOSES:
1. Cellulitis/osteomyelitis of the right foot.
2. Venous stasis of the right foot.
3. Coronary artery stenosis.
4. Benign hypertension.
5. Diabetes mellitus type 1.
DISCHARGE MEDICATIONS:
1. Keflex one capsule po qid for seven days.
2. OxyContin 40 mg tablets sustained release one tablet twice
a day for 10 days.
3. Percocet 5/325 mg tablets 1-2 tablets po q4-6h as needed
for pain for 10 days.
4. Erythromycin paste 5 mg/gram ointment 1.5" paste qid for
seven days.
5. Bacitracin 500 unit/gram ointment 1" paste topical [**Hospital1 **] for
seven days on the right foot.
6. Xalatan 0.005% drops one drop q hs for seven days to the
left eye only.
7. Cosopt 0.5-2% drops one gtt. [**Hospital1 **] for seven days to the
left eye only.
8. Metoprolol tartrate 100 mg tablet po bid for two weeks.
9. Trandolapril 4 mg one tablet po q day for two weeks.
10. Tears Naturale 1-2 drops qid for two weeks in the right
eye.
11. Tears Naturale 1-2 drops q3h for two weeks in the left
eye.
12. Colace 100 mg one capsule po bid as needed for
constipation for seven days.
RECOMMENDED FOLLOWUP: The patient is to followup with Dr.
[**Last Name (STitle) 13797**] in seven days. Patient is to call ([**Telephone/Fax (1) 48506**] to
make an appointment. Patient is also to followup with Dr.
[**Last Name (STitle) **] in seven days. Patient is to followup with
Ophthalmology in seven days. Patient is also to followup
with [**Hospital **] [**Hospital 982**] Clinic within two weeks. Patient is to
followup with Cardiology within two weeks. Patient is to
followup with Chronic Pain Service within seven days.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19095**], M.D. [**MD Number(1) 19096**]
Dictated By:[**Name8 (MD) 3430**]
MEDQUIST36
D: [**2113-7-31**] 12:28
T: [**2113-8-10**] 12:19
JOB#: [**Job Number 48507**]
|
[
"E878.2",
"998.11",
"459.81",
"682.7",
"362.01",
"250.51",
"996.52",
"730.17",
"707.14"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.69",
"78.68",
"86.75",
"77.68",
"86.22",
"77.73",
"78.08"
] |
icd9pcs
|
[
[
[]
]
] |
6486, 8162
|
917, 1119
|
2125, 6248
|
6297, 6463
|
1142, 2107
|
165, 795
|
817, 891
|
6273, 6280
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,800
| 104,090
|
46361
|
Discharge summary
|
report
|
Admission Date: [**2161-11-29**] Discharge Date: [**2161-12-10**]
Date of Birth: [**2096-5-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2474**]
Chief Complaint:
CC: shortness of breath
Major Surgical or Invasive Procedure:
Intubation, Arterial Blood Gases
History of Present Illness:
This is a 65 year old with mental retardation, severe COPD and
recent admission with COPD exacerbation treated with intubation
presents with SOB. The patient normal has oxygen sats in the
high 80s on RA, however today he was noted to be 72% on RA. He
uses 2L of oxygen at home at night. He complains of SOB. He has
had cough with clear sputum production for the last 3 weeks. He
denies chills or fevers. He restarted smoke 3 weeks ago. He was
brought to the ED by EMS.
.
In the ED, initial vs were: T 99 P 80 BP 117/78 R 22 O2 sat 98%
NRB. A CXR showed a questionable LLL PNA. Patient was given
Albuterol and ipratropium nebs, Levofloxacin 750mg IV,
Prednisone 60mg, and 1L NS. ABG showed respiratory acidosis with
pCO2 of 88 (baseline 70s) and preserved oxygenation. The patient
was clearly against intubation in the ED. CPAP was started in
the ED prior to transfer. VS prior to transfer were 97, HR 75,
98/60, 50, 95%3L. PIV x 2 were placed in the ED. The patient
received 15 min of BiPAP in the ED with improvement in
mentation.
.
On the floor, patient [**Last Name (un) **] tachypneic, with cynanotic lips but
felt that his breathing is improved from the ED.
.
Past Medical History:
1) COPD: FEV1 23% predicted, home 1.5-2L O2 at night only
2) Secondary Pulmonary Hypertension (51-66 mm Hg on ECHO
[**2159-9-18**])
3) Schizophrenia
4) Hx GI bleeding
5) Mental Retardation
6) Pulmonary Hypertension
7) s/p tonsillectomy
Social History:
Lives in [**Location **] with brother and brother-in-law. On
disability since [**2149**] for mental health issues. Has home nurse
visit every morning and evening. Reports ~50 pack-year smoking
and has now cut down to 3 cigs/day. Denies any ETOH/drug use.
Family History:
Patient unable to provide.
Physical Exam:
Physical examination:
- Gen: Well-appearing in NAD.
- [**Year (4 digits) 4459**]: Conj/sclera/lids normal, PERRL, EOM full, and no
nystagmus. Hearing grossly normal bilaterally. Sinuses
non-tender. Nasal mucosa and turbinates normal. Oropharynx clear
w/out lesions.
- Neck: Supple with no thyromegaly or lymphadenopathy.
- Chest: Normal respirations and breathing comfortably on room
air. Lungs clear to auscultation bilaterally.
- CV: PMI normal size and not displaced. Regular rhythm. Normal
S1, S2. No murmurs or gallops. JVP <5 cm. 2+ carotids. No
carotid bruits.
- Abdomen: Normal bowel sounds. Soft, nontender, nondistended.
Liver/spleen not enlarged.
- Rectal: No external lesions. Normal tone, stool guaiac
negative.
- Extremities: No ankle edema.
- MSK: Joints with no redness, swelling, warmth, tenderness.
Normal ROM in all major joints.
- Skin: No lesions, bruises, rashes.
- Neuro: Alert, oriented x3. Good fund of knowledge. Able to
discuss current events and memory is intact. CN 2-12 intact.
Speech and language are normal. No involuntary movements or
muscle atrophy. Normal tone in all extremities. Motor [**6-10**] in
upper and lower extremities bilaterally. Gait normal. DTRs 2+ at
brachioradialis and patella bilaterally. Plantar reflex down
(neg Babinski). Finger-to-nose and heel-to-shin normal. Romberg
and pronator drift negative. Sensation to light touch intact in
upper and lower extremities bilaterally.
- Psych: Appearance, behavior, and affect all normal. No
suicidal or homicidal ideations.
Pertinent Results:
[**2161-12-8**] 06:03AM BLOOD WBC-9.3 RBC-4.13* Hgb-12.6* Hct-37.7*
MCV-91 MCH-30.5 MCHC-33.3 RDW-13.5 Plt Ct-267
[**2161-11-29**] 09:40PM BLOOD WBC-11.4* RBC-4.16* Hgb-12.7* Hct-39.9*
MCV-96 MCH-30.4 MCHC-31.7 RDW-14.0 Plt Ct-412#
[**2161-12-9**] 06:05AM BLOOD Glucose-182* UreaN-17 Creat-0.7 Na-145
K-3.6 Cl-101 HCO3-40* AnGap-8
[**2161-11-29**] 09:40PM BLOOD Glucose-173* UreaN-19 Creat-1.0 Na-146*
K-4.1 Cl-101 HCO3-40* AnGap-9
[**2161-12-8**] 06:03AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.9
[**2161-11-30**] 05:05AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.8
.
Blood Gases
[**2161-12-8**] 04:36PM BLOOD Type-ART pO2-60* pCO2-62* pH-7.43
calTCO2-43* Base
[**2161-12-8**] 04:36PM BLOOD Type-ART pO2-60* pCO2-62* pH-7.43
calTCO2-43* Base XS-13
[**2161-12-5**] 04:42AM BLOOD Type-ART pO2-129* pCO2-60* pH-7.45
calTCO2-43* Base XS-15
[**2161-12-2**] 12:42PM BLOOD Type-ART Rates-16/ Tidal V-500 PEEP-8
FiO2-21 pO2-58* pCO2-45 pH-7.49* calTCO2-35* Base XS-9
-ASSIST/CON Intubat-INTUBATED
[**2161-12-2**] 10:37AM BLOOD Type-ART Temp-36.3 Rates-16/ Tidal V-500
PEEP-8 FiO2-35 pO2-115* pCO2-66* pH-7.41 calTCO2-43* Base XS-14
-ASSIST/CON Intubat-INTUBATED Vent-IMV
[**2161-12-2**] 09:27AM BLOOD Type-ART FiO2-35 pO2-94 pCO2-97* pH-7.28*
calTCO2-48* Base XS-14 Intubat-NOT INTUBA
.
[**2161-12-1**] 12:41PM BLOOD Type-ART pO2-101 pCO2-89* pH-7.28*
calTCO2-44* Base XS-11 Intubat-NOT INTUBA
[**2161-11-30**] 12:31AM BLOOD Type-ART pO2-84* pCO2-88* pH-7.32*
calTCO2-47* Base XS-14
[**2161-12-6**] 06:21PM BLOOD Lactate-0.9 K-4.2
[**2161-12-6**] 02:17PM BLOOD Lactate-1.0 K-3.5
[**2161-12-1**] 12:41PM BLOOD Glucose-202* Lactate-1.2 K-5.0
[**2161-12-5**] 01:34PM BLOOD freeCa-1.15
.
[**2161-11-29**] CXR
IMPRESSION: Findings suggestive of early left lower lobe
pneumonia.
.
CXR [**2161-12-8**]
IMPRESSION: AP chest compared to chest radiographs since [**2159**],
most recently
[**12-6**]:
Aeration at the base of the right lung has improved, with
remission of
peribronchial opacification. The discrete flame-shaped lesion in
the left mid lung whch appeared on [**11-30**] is smaller,
probably atelectasis in a region of an acute infection or
infarction. No indication of current pneumonia or cardiac
decompensation. Heart size normal. Of note prior chest CT scans
have findings suggesting a propensity to tracheobronchomalacia,
as well as moderately severe emphysema.
Left PIC catheter ends in the upper SVC. No pneumothorax or
pleural effusion.
Brief Hospital Course:
65 y/o with severe COPD, mild mental retardation presented with
hypercarbic resp failure.
.
# Acute on Chronic Respiratory Failure: This patient has Co2
chronically in the high 80s and presented with worsening dyspnea
consistent with a COPD exacerbation in the setting of
Bronchitis, and resuming smoking was likely. This patient has
been hospitalized with multiple prior intubations during the
past year. After some respiratory distress on HD 3 he was put
on BIPAP and did not tolerate it well with a high amount of
respiratory secretions which could not be suctioned. He was
transferred to intensive care unit where he remained tachypneic
and in respiratory distress and therefore was intubated. He
completed a complete 7 day course of levofloxacin for COPD
exacerbation. He was diuresed 2.5 liters while in the intensive
care unit. He was successfully extubated HD 8, and tolerated
nasal cannula well. He was continued on prednisone 60mg and
started a slow taper after transfer to the floor when he was
clinically stable from a respiratory standpoint. He was
continued on aggressive Albuterol and Atrovent nebulizer
treatment. On the floor he had an episode of transient
unresponsiveness and was found to be in hypoxic respiratory
distress on arterial blood gas. He recovered quickly with a
nebulizer treatment and was stable for the duration of his
hospitalization. He was discharged on the remainder of his
prednisone taper and on home 24 hour oxygen with nursing
services and close primary care follow-up.
.
#Hypotension - While in the intensive care unit, the patient
required Dopamine for few hours because of systolic pressures in
the 70??????s. After administration of 2 liters of normal saline
the patient was normotensive and blood pressures were stable
throughout the remainder of his hospitalization.
.
# Schizophrenia: The patient was continued on Zyprexa.
.
# Glucose intolerance. The patient was placed on an insulin
sliding scale due to elevated blood sugars in the setting of
prednisone. The patient declined insulin on discharge stating
he would not take it if prescribed, as he had not taken it in
the past. He will have close follow-up with his primary care
physician and will tolerated mildly elevated blood sugars given
the temporary duration of prednisone therapy.
.
# Anemia: HCT at baseline, normocytic. Trended HCT Q daily
Medications on Admission:
Zyprexa 7.5 mg daily
Advair Diskus 500 mcg-50 mcg inhaled twice daily
Spiriva 1 capsule inhaled daily
Aspirin 81 mg daily
Nicotine 14 mg/24 hr daily Patch
ProAir HFA 90 mcg/Actuation Aerosol Inhaler 2 puffs(s) inhaled
twice a day and q 4 hours prn wheeze
Multivitamin with Minerals daily
Famotidine 20 mg twice daily
Discharge Medications:
1. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every 4-6 hours as needed
for wheeze/sob.
Disp:*30 units* Refills:*0*
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day: Apply patch once a day for one month then switch to
7mg patch for one month then stop. (Continue as started on
[**11-17**]).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 1.5 Tablet, Rapid
Dissolves PO DAILY (Daily).
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation twice a day: Additional 2 puffs as
needed every 4 hours for SOB.
8. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day.
11. multivitamin Capsule Sig: One (1) Capsule PO once a day.
12. Home Oxygen
1- 2 liters nasal canula to keep O2 sat above 90%. Ambulatory
Saturation on Room Air is 86%. Ambulatory Saturation on 1L NC
is 88%. Please use nasal cannula during night and day to keep
saturations above 90%.
13. prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: Start friday [**2161-12-11**]. Take for three days.
Disp:*3 Tablet(s)* Refills:*0*
14. prednisone 10 mg Tablet Sig: as taper directs Tablet PO once
a day: start after 50mg prednisone, take 4 tablets daily for
three days, then take 3 tablets daily for 3 days, then take 2
tablets daily for 3 days then take 1 tablet daily for 3 days.
Disp:*40 Tablet(s)* Refills:*0*
15. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every
four (4) hours as needed for pain.
16. Home Nebulyzer Machine
Diagnosis: COPD
Discharge Disposition:
Home With Service
Facility:
[**Hospital 7272**] Health Systems
Discharge Diagnosis:
1. COPD exacerbation
2. Secondary pulmonary hypertension, DM2, schizophrenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for management of a chronic obstructive
pulmonary disease (COPD) exacerbation. Your ability to breathe
on your own was compromised such that you were intubated for
several days. You were treated with a complete antibiotic
course during your admission and were given steroids treat the
inflammation in your lungs. You required oxygen supplementation
throughout the day in addition to your nightly requirement.
In addition to your regular medications,
Please continue the prednisone taper as directed.
Please continue daytime home oxygen as directed until otherwise
insructed by your primary care physician.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2161-12-15**] at 9:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**]
|
[
"285.9",
"041.12",
"250.00",
"486",
"491.21",
"295.90",
"V46.2",
"518.84",
"458.9",
"305.1",
"416.8",
"401.9",
"276.0",
"319",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.97",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
10894, 10959
|
6154, 8521
|
340, 375
|
11080, 11080
|
3705, 6131
|
11884, 12318
|
2120, 2148
|
8890, 10871
|
10980, 11059
|
8547, 8867
|
11231, 11861
|
2163, 2163
|
2185, 3686
|
277, 302
|
403, 1570
|
11095, 11207
|
1592, 1830
|
1846, 2104
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,791
| 134,726
|
29292
|
Discharge summary
|
report
|
Admission Date: [**2124-11-25**] Discharge Date: [**2124-12-7**]
Date of Birth: [**2069-6-15**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal Pain
Jaundice
Nausea/Vomiting
Major Surgical or Invasive Procedure:
Small Bowel Resection; IOUS
Roux-en-Y Cholecysto-jejunostomy
Pseudocyst-Jejunosotmy
J-tube Placement
History of Present Illness:
This 55-year-old lady has a history of chronic alcoholic-induced
pancreatitis. She has had a pseudocyst problem in the past that
resolved over time
and has previously had an open J tube placement in the last year
for malnutrition during this period.
She recently presented with overt jaundice from bile duct
obstruction and a history of many weeks of decline. She has
only lost 4 pounds over this period of time, but has been
malnourished and unable to eat regular foods and has
sustained herself only on liquids because of gastric outlet
obstruction. She was transferred to our care for assessment
of her biliary obstruction and thoughts of therapeutic
approaches to this and the large pseudocyst that was
identified that was on the order of 10 x 10 cm in her mid-
abdomen. When we assessed her CAT scan, it was clear that she
had three problems.
1. Biliary obstruction from an obstructed bile duct.
2. Gastric outlet obstruction from the duodenum being
splayed across this large pseudocyst in the head of the
pancreas.
3. Sinistral hypertension from her pseudocyst as well.
It was clear that the whole upper abdomen was full of massive
venous collaterals in that in fact the superior mesenteric
vein drained into the splenic vein in order to drain her
bowels. The interface between the lower aspect of the portal
vein and the superior mesenteric vein was completely splayed
out and attenuated and probably thrombosed by the pseudocyst
mass effect. With Dr. [**First Name (STitle) **] [**Name (STitle) **], we decided that there was
no value in any endoscopic approaches to either the
pseudocyst or the biliary obstruction and it was clear that
an operative approach was the safest and only way to approach
this.
Past Medical History:
Alcoholic pancreatitis, hyperlipidemia, EtOH abuse (last drink
10 days ago), h/o regional thrombosis, cirrhosis, glaucoma
PSH: J-tube (removed [**6-13**]), C-section x2, tonsillectomy
Social History:
No tobacco
Last drink [**2124-11-15**]
Lives with Husband, 2 boys, and her mother
[**Name (NI) 1403**] as consultant
Family History:
Father with bladder CA
family HTN in f
Physical Exam:
VS: 100.6, 85, 140/80, 18, 96% RA
Gen: fatigued appearing, thin woman, NAD. Jaundice, Scleral
icteric
Chest: CTA bilat.
CV: RRR, normal S1, S2. No M/R/G.
Abd: soft, ND, +BS, TTP over epigastrim, no ascities.
Ext: 2+ DP pulses, warm, no C/C/E
Pertinent Results:
[**2124-11-30**] 02:43AM BLOOD WBC-10.3 RBC-3.85* Hgb-11.5* Hct-34.0*
MCV-88 MCH-29.8 MCHC-33.7 RDW-15.5 Plt Ct-389
[**2124-11-30**] 02:43AM BLOOD Glucose-156* UreaN-3* Creat-0.6 Na-138
K-4.5 Cl-105 HCO3-25 AnGap-13
[**2124-11-25**] 09:45PM BLOOD ALT-83* AST-55* AlkPhos-611* Amylase-58
TotBili-12.5* DirBili-9.4* IndBili-3.1
[**2124-11-29**] 08:28PM BLOOD ALT-43* AST-54* AlkPhos-311* Amylase-26
TotBili-10.1*
[**2124-11-30**] 02:43AM BLOOD Phos-4.5 Mg-1.7
CHEST PORT. LINE PLACEMENT [**2124-11-30**] 11:00 AM
CHEST PORT. LINE PLACEMENT
Reason: ? line position
[**Hospital 93**] MEDICAL CONDITION:
55 year old woman with cholecystojeje and pancreatic pseudocyst
jeje with new RIJ cvl
REASON FOR THIS EXAMINATION:
? line position
AP PORTABLE CHEST FOR LINE PLACEMENT ON [**2124-11-30**] AT 10:55 A.M.
HISTORY: New right internal jugular approach central venous
catheter.
COMPARISON: [**2124-11-29**].
FINDINGS: Patient has been extubated and the nasogastric tube
removed. The large right internal jugular sheath has been
removed as well. There is an indwelling right internal jugular
approach central line with the distal tip at the cavoatrial
junction. Lung volumes are markedly diminished, however, there
is no focal consolidation. Minimal left basilar atelectasis is
seen. No pleural effusion or pneumothorax is evident. There is
residual contrast within the colon. Midline surgical skin
staples are seen overlying the abdomen.
IMPRESSION: Central venous catheter as above. No pneumothorax.
Brief Hospital Course:
She was transferred here from an OSH with a larger pancreatic
pseudocyst. After reviewing the CT from the OSH, it was
determined that she will need a biliary drainage. An ERCP was
considered, but then felt that there was no value in any
endoscopic approaches to either the pseudocyst or the biliary
obstruction and it was clear that an operative approach was the
safest and only way to approach
this.
She was NPO, with an NGT and IV fluids. She was receiving a
Banana Bag for electrolyte replacement. She was receiving IV
antibiotics empirically. She received 2 days of vitamin K prior
to the OR.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
She went to the OR on [**2124-11-29**]. She tolerated the procedure
well. She had a feeding J-tube placed and Cyst J-tube to
gravity. She remained intubated overnight and was extubated in
the morning. She was slightly hypotensive post-operatively and
responded well to IV fluids.
Pain: She was receiving Dilaudid for pain control with good
effect. She continued on a PCA until she was tolerating clears
and then switched to PO pain meds on POD 6.
FEN: She initially was NPO, with IV fluids. She was started on
tube feedings at a slow rate and her rate was increased over the
next few days. She was started on sips on POD 4 and advanced to
clears, then fulls and a regular diet on POD 8. She had a
feeding J-tube in place and was tolerating 1/2 strength tube
feedings. The feedings were stopped on POD 9.
Abd: She had an ascitic abdomen that was very large, round, and
soft. The JP drain in the RLQ was draining large amounts of
sero-sanguinous fluid. A JP Amylase was 4 on POD 5. The drain
was D/C'd on POD 7 and a U-stitch placed. She was appropriately
tender with good bowel sounds. The staples were in place. These
were left in place due to her abdominal distension. The staples
will be removed at her follow-up appointment.
She had a Cyst J-tube to gravity that drained initially, but
there was no drainage by POD 4. The J-tube was capped and will
remain in place.
Activity: She was seen by PT and performed stairs without
difficulty. She was cleared to go home.
Medications on Admission:
Cosopt 1 gtt each eye [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Hydromorphone 2 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*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Abdominal Pain
Jaundice
Pancreatic Pseudocyst HOP
Biliary Obstruction
Portal Hypertension
Ascities
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.
Staples to be removed at follow-up appointment.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment.
.
Please follow-up with Dr. [**Last Name (STitle) 174**] (Pancreatologist). Call ([**Telephone/Fax (1) 70399**] to schedule an appointment.
Completed by:[**2124-12-7**]
|
[
"577.2",
"263.9",
"401.9",
"272.4",
"576.2",
"577.1",
"577.0",
"537.0",
"571.2",
"V12.51",
"572.3",
"789.5",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93",
"45.62",
"46.39",
"52.4",
"99.07",
"96.6",
"51.32"
] |
icd9pcs
|
[
[
[]
]
] |
7090, 7141
|
4384, 6565
|
320, 423
|
7283, 7290
|
2857, 3423
|
7669, 7968
|
2539, 2579
|
6654, 7067
|
3460, 3546
|
7162, 7262
|
6591, 6631
|
7314, 7646
|
2594, 2838
|
241, 282
|
3575, 4361
|
451, 2181
|
2203, 2389
|
2405, 2523
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,677
| 141,559
|
44468+58719
|
Discharge summary
|
report+addendum
|
Admission Date: [**2155-6-16**] Discharge Date: [**2155-6-25**]
Service: MEDICINE
Allergies:
Amoxicillin / Roxicet / Bactrim Ds / Ciprofloxacin Hcl /
Streptomycin Sulfate
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
CT head
TTE
History of Present Illness:
89 y/o womoan with diastolic CHF, moderate AS (1.0-1.2), AF on
coumadin, pulmonary HTN, and CKD who presents to [**Hospital1 18**] with
increasing shortness of breath in the 2 days prior to admission
and noted a 7lb weight gain in the last week (measured at ALF).
She has chronic dyspnea and orthopnea (sleeping on 3 pillows).
It is unclear what the exacerbating factor was in her
presentation. At baseline, she has a chronic cough with white
sputum and there has been no changes in quantity or quality.
She denied any sick contacts, fevers chills, chest pain.
.
Of note she is on home O2, 2-4L NC intermittently over the past
month. Prior to this she was on supplemental O2 for over two
years, but she was weakned to no oxygen for 4 months, until ~
1mo ago.
Past Medical History:
-Diastolic heart failure with preserved ejection fraction.
-Hypertension.
-Hyperlipidemia.
-Aortic stenosis with aortic valve area from 1-1.2.
-Pulmonary hypertension.
-Renal cell carcinoma s/p R nephrectomy '[**39**]
-Chronic kidney disease with baseline creatinine of 2.6.
-s/p cholecystectomy for porcelain gall bladder '[**39**]
-Restrictive lung disease.
-Chronic constipation.
-Degenerative joint disease.
-Atrial fibrillation.
-Renal artery stenosis.
-on home O2, 2-3 L as needed
-Cystic lesions on pancreas with chronic intra- and
extra-hepatic dilatation
Social History:
Russian speaking, son lives in [**Name (NI) 86**]. Lives at [**Hospital **] rehab.
She is a lifelong nonsmoker. She ambulates with a walker. She
denies any history of alcohol or drug use.
Family History:
NC
Physical Exam:
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Awake, alert, answers questions but visibly tachypneic
and uncomfortable, [**1-9**] word answers.
HEENT: Sclera anicteric, R eye w/ corneal opacification, L eye
pupil [**3-7**].
Neck: supple, JVP 9
Lungs: barrel chested, crackles bilatrally to apices, scant
ronchi
CV: Regular rate, normal S1 + S2, 2 RICS [**1-11**] SM.
Abdomen: soft, non-tender, distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, no edema.
Pertinent Results:
Labs:
[**2155-6-25**] 05:25AM BLOOD WBC-6.0 RBC-3.75* Hgb-11.8* Hct-36.6
MCV-98 MCH-31.5 MCHC-32.2 RDW-14.4 Plt Ct-187
[**2155-6-25**] 04:10PM BLOOD PT-34.9* PTT-36.0* INR(PT)-3.6*
[**2155-6-25**] 05:25AM BLOOD Glucose-109* UreaN-78* Creat-1.9* Na-143
K-3.9 Cl-97 HCO3-38* AnGap-12
[**2155-6-16**] 11:45AM BLOOD proBNP-8948*
[**2155-6-20**] 02:10AM BLOOD CK-MB-2 cTropnT-0.02*
[**2155-6-19**] 06:00PM BLOOD CK-MB-2 cTropnT-0.02*
[**2155-6-17**] 12:30AM BLOOD CK-MB-2 cTropnT-0.02*
[**2155-6-16**] 11:45AM BLOOD cTropnT-0.02*
[**2155-6-25**] 05:25AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.4
[**2155-6-25**] 05:25AM BLOOD TSH-1.4
[**2155-6-20**] 10:16AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2155-6-20**] 10:16AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2155-6-24**] 05:30AM BLOOD PT-31.3* PTT-34.9 INR(PT)-3.1*
[**2155-6-25**] 04:10PM BLOOD PT-34.9* PTT-36.0* INR(PT)-3.6*
.
PFTs:
SPIROMETRY 8:34 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 1.63 2.00 82
FEV1 1.25 1.31 95
MMF 1.02 1.71 60
FEV1/FVC 77 66 117
.
LUNG VOLUMES 8:34 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 2.95 3.55 83
FRC 1.42 2.11 67
RV 1.35 1.55 87
VC 1.59 2.00 80
IC 1.52 1.44 106
ERV 0.06 0.56 11
RV/TLC 46 44 105
He Mix Time 3.3
.
Imaging:
CXR PA&LAT ([**2155-6-16**]): Cardiomegaly, mild pulmonary vascular
congestion. Small right effusion.
.
CT Head w/o contrast ([**2155-6-19**]): No acute hemorrhage. No acute
intracranial process. Stable ventriculomegaly since 4/[**2153**].
.
ECHO ([**2155-6-20**]): There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 70%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated with depressed free wall
contractility. There are three aortic valve leaflets. The aortic
valve leaflets are moderately thickened. There is moderate
aortic valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. The tricuspid
valve leaflets are mildly thickened. There is severe pulmonary
artery systolic hypertension. There is a moderate sized
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
Echocardiographic signs of tamponade may be absent in the
presence of elevated right sided pressures. Compared with the
findings of the prior study (images reviewed) of [**2154-12-24**], the pulmonary artery systolic pressure is markedly further
increased, and the right ventricle is now dilated and
hypocontractile; pericardial effusion appears similar in size.
.
CXR PA&LAT ([**6-24**]): Improvement in the degree of pulmonary edema
with only mild pulmonary venous distension on the current
radiograph.
Brief Hospital Course:
89 y.o with dCHF presentes with dyspnea [**1-7**] to CHF exacerbation.
Treated with increased lasix. Course complicated by AMS,
requiring ICU admission. AMS thought secondary to respiradone,
MS improved with discontinuation.
.
# Acute on chronic diastolic CHF: BNP was 8948. Unclear what the
etiology for most recent exacerbation is, diastolic dysfunction
likely [**1-7**] HTN and AS. Echo on [**6-20**] showed pulmonary artery
systolic pressure is markedly further increased, and the right
ventricle is now dilated and hypocontractile; pericardial
effusion appears similar in size to echo done in [**Month (only) 404**]. ASA,
statin and isosorbide mononitrate were continued. Treated
briefly with lasix drip in MICU. On the floor Lasix was
increased to 80mg PO BID, however the bicarb and sodium have
been trending up. Today bicarb is 38 and sodium is 143.
Creatinine has been stable at 1.9 (the patient's baseline.)
Repeat CXR showed improvement in the degree of pulmonary edema
with only mild pulmonary venous distension. Pt is now euvolemic
on exam with improvement in SOB and O2 sats 99% on 2L (the
patient's baseline.)
- Continue furosemide 80mg PO BID
- Recheck electrolytes and Cr on [**6-27**]
.
# AMS. Devoloped somulance on the floor CO2 peak of 77.
Transfered to the MICU was BIPAP was briefly used. Thought
secondary to medication (resperidone) combined with mild
hypercarbia [**1-7**] CHF and underlying lung disease. Mentation
improved with discontinuation of risperidone, BIPAP, and Lasix
drip. After transfer to the floor MS remained at baseline,
confirmed by her son.
.
# Aortic stenosis: Moderate AS valve area 1-1.2, unchanged on
echo [**6-20**]
.
# Afib: Usually rate controlled, currently in sinus, HR in 80s.
INR subtherapeutic on admission (1.8), and home dosing was
unclear. We believe that her home dose was 2mg Sun/Mon/Tues/Wed
+ 3mg Thurs/Sat. We increased her dose to Warfarin 3 mg
Thurs/Sat + 4mg Sun/Mon/Tues/Wed. Her INR was therapeutic until
this morning when it was found to be high (3.6).
- Hold warfarin tomorrow ([**2155-6-26**]) and check INR on Friday and
then resume at 2mg daily; this may need to be further titrated.
.
# Chronic abdominal pain: Not active during hospitalization.
.
# CKD: Creatinine at baseline (1.9), remained stable with
diuresis.
.
# HTN: BP well controlled. Pt with RAS and R nephrectomy.
Amlodipine was continued.
.
# Gout: No active symptoms. We continued home doses of
allopurinol, tylenol PRN.
.
# Glaucoma: Stable
- Continue Dorzolamide/timolol (cosopt 2-0.5% opthalmic)
.
# Psych:
- Holding risperdal for somnolence
- Sertraline decreased to 50mg PO daily
.
# Code Status: DNR/DNI
Medications on Admission:
Heparin 5000 UNIT SC TID Order
Allopurinol 100 mg PO/NG DAILY Gout
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
Amlodipine 5 mg PO/NG DAILY
Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Artificial Tears 1-2 DROP BOTH EYES [**Hospital1 **]
Omeprazole 40 mg PO DAILY
Aspirin EC 81 mg PO DAILY
Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation
Bisacodyl 10 mg PO DAILY
Risperidone 0.25 mg PO BID Order
Calcium Carbonate 500 mg PO/NG [**Hospital1 **]
Sertraline 100 mg PO/NG DAILY
Docusate Sodium 200 mg PO BID
Simvastatin 80 mg PO/NG HS
Ferrous Gluconate 325 mg PO DAILY
Furosemide 60 mg PO/NG ONCE Duration: 1 Doses
Vitamin D 1000 UNIT PO/NG DAILY Order
Warfarin 4 mg PO/NG DAYS (TH,SA)
Warfarin 4 mg PO/NG DAYS ([**Doctor First Name **],MO,TU,WE)
Furosemide 80 mg IV DAILY
Warfarin 5 mg PO/NG ONCE Duration: 1 Doses
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Calcium Carbonate 650 mg (1,625 mg) Tablet Sig: One (1)
Tablet PO once a day.
10. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: goal
INR [**1-8**]. HOLD ALL COUMADIN ON [**2155-6-26**]. .
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5
Tablets PO DAILY (Daily).
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
15. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
16. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
17. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
18. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) drop
Ophthalmic twice a day: To right eye.
19. Potassium Chloride 20 mEq Packet Sig: One (1) PO twice a
day.
20. Ocuvite Tablet Sig: One (1) Tablet PO once a day.
21. Eucerin Cream Sig: One (1) application Topical at
bedtime.
22. Lidocaine HCl 3 % Cream Sig: One (1) application Topical at
bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Heart failure exacerbation
Delirium [**1-7**] resperidone
Aortic stenosis
Atrial fibrillation
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because of shortness of breath
and weight gain. We did lab tests, chest x-rays, and an ECHO
(ultrasound) of your heart and found that your syptoms were due
to a worsening of your heart failure.
You also became confused, we think this was from one of your
medications, Resperidone. This medicaiton was stopped and your
confusion resolved.
.
Please continue to take your home medications. We have made the
following changes:
- CHANGED warfarin. Hold it on [**2155-6-26**], then start 2mg daily.
- INCREASED furosemide to 80mg by mouth twice daily
- DECREASED sertraline to 50mg by mouth daily
- STOPPED risperidone
- STARTED metoprolol tartrate 12.5mg by mouth twice daily
.
Please follow up with your primary care doctor in the next 2
weeks.
Weigh yourself every morning and call your doctor if your weight
goes up more than 3 lbs.
Followup Instructions:
PCP in the next 2 weeks, [**Doctor Last Name **],[**Doctor First Name **] [**Telephone/Fax (1) 2634**]
Completed by:[**2155-6-25**] Name: [**Known lastname 15084**],[**Known firstname 1463**] Unit No: [**Numeric Identifier 15085**]
Admission Date: [**2155-6-16**] Discharge Date: [**2155-6-25**]
Date of Birth: [**2066-4-8**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Roxicet / Bactrim Ds / Ciprofloxacin Hcl /
Streptomycin Sulfate
Attending:[**First Name3 (LF) 2408**]
Addendum:
CHF: Pt started on low dose metoprolol tartrate (12.5mg [**Hospital1 **]) on
day of discharge for her diastolic heart failure. Given that
this is a new medication, please trend HR and BP carefully.
Further titration of the medication may be necessary.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - LTC
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2409**] MD [**MD Number(2) 2410**]
Completed by:[**2155-6-25**]
|
[
"V58.61",
"405.91",
"515",
"428.0",
"424.1",
"518.81",
"427.31",
"428.33",
"585.4",
"369.60",
"416.8",
"440.1",
"311",
"403.90",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12913, 13135
|
5371, 8023
|
293, 306
|
11044, 11044
|
2428, 5348
|
12085, 12890
|
1907, 1911
|
8909, 10789
|
10898, 11023
|
8049, 8886
|
11195, 12062
|
1941, 2409
|
246, 255
|
334, 1096
|
11059, 11171
|
1118, 1684
|
1700, 1891
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,587
| 128,715
|
23922
|
Discharge summary
|
report
|
Admission Date: [**2200-2-4**] Discharge Date: [**2200-2-7**]
Date of Birth: [**2153-10-29**] Sex: F
Service: NEUROLOGY
Allergies:
Reglan / Celebrex
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Headache, right hemiparesis, memory problems, nausea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 47 yo right-handed woman who was in an MVA on [**2200-1-15**].
She was the driver of the 3rd car in a 4-car back-to-front
collision, and she was wearing a seatbelt. She was able to get
out of the car independently and was able to walk; about 15
minutes afterwards, while the pt was seated, she reports
fainting and awaking 3-5 minutes later. She was taken by
ambulance to [**Hospital3 3583**] where a CT and Xrays were done. She
was told she had sinusitis and no serious trauma, and she was
sent home. Over the next two days she had several
symptoms including severe headache, shoulder pain, pain on neck
flexion and turning to the right, as well as nausea. She reports
three episodes of incontinence: once while sitting in a chair,
once while in the kitchen, and the last one was on [**2-2**], during
a period where she lost consciousness briefly. She recalls
waking and feeling confused for a few minutes, and noticing that
she had lost urine. Her son witnessed this event, but she has
never had
similar episodes before. She also notes that since the accident,
her memory has been failing, and she is not able to remember
phone calls and appointments as she used to.
On [**1-30**] she noticed that her right eye was blurry, but her left
eye was not. She also reports that her right side was weak, and
that she would have to perform tasks with her left hand in the
kitchen. On [**2-4**], her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 25786**], advised that she go to
[**Hospital3 3583**] to have further imaging to rule out stroke or
other causes of her weakness. She was at that time reported to
have a 3mm MCA aneurysm and brought to the [**Hospital3 **] Hospital.
In addition to this, she has had clear nasal discharge from her
right nostril, post-nasal drip and fluid in her right ear.
Incidentally, she also passed two large blood clots per vagina,
but notes that it was two weeks early for menstruation. She also
had diarrhea for the entire week following the accident.
Past Medical History:
[**2186**] "shattered disc" due to fall, treated with Phys Tx
[**2187**] molar pregnancy
Bilateral congenital collapsed eardrums
[**2179**] breast lumpectomy
?Laser treatment of uterus
Social History:
Lives in [**Location **] with husband and four children. No tob/etoh/IVDU
Family History:
Aneurysms (mother, maternal aunt and uncle); Hyperthyroidism,
Breast CA (mother, three maternal aunts)
Physical Exam:
Vitals: Temp: 97.8 BP: 141/88 Pulse: 74 RR: 16 O2sat:96suppO2
Gen: She is lying in bed, holding her head still, looking
exhausted
CV: RRR, nl S1 S1, no m/r/g
Resp: Bilaterally clear to auscultation
Abd: +BS, soft, non-tender, non-distended
Neuro
MSE: Alert and Oriented to person, "[**Hospital3 **]" and "[**2200-2-4**]". Able to say [**Doctor Last Name 1841**] backward, but misses [**Month (only) **].
Memory: [**1-23**] registration, only [**11-25**] recall at 5 minutes with
prompting.
Language: Fluency, comprehension, naming and repetition intact.
[**Location (un) **] intact.
CN: Pupil dilated at 6 mm bilaterally after eye exam, unable to
look up or down without converging, able to follow finger to
left side past midline but not fully to right, and eyes beat to
left as she attempts R gaze. Diplopia in Right gaze 2nd to right
lateral rectus. She has photophobia. Facial sensation reduced to
temp and LT on Right, normal on Left. Hearing intact. Tongue
midline. Uvula midline. Unable to test SCM/trap due to pain from
MVA.
Motor: Normal bulk and tone. She does not give full effort on
motor exam.
UE: D B T WE WF FF FE
L: 5 5 5 5 5 5 5
R: 4*5 5 5 5 5 5
LE: HF HE HA KF KE DF PF TE
L: 5 5 5 5 5 5 5 5
R: unable to test 2nd to femoral line but right TA, EDB, [**Last Name (un) 938**],
and toe/foot plantar 4*
*limited 2nd to giveway weakness
?right pronator drift
Sensation: Reduced to LT, temperature and pinprick on right
side. Decreased propioception on right.
Reflexes: [**12-27**] in arms, [**11-26**] at patellar, no ankle jerks. toes
equivocal bilaterally
Coordination: FTN slow, but accurate, bilaterally.
Gait: Not tested.
Pertinent Results:
[**2200-2-4**] 09:00PM PT-13.9* PTT-24.5 INR(PT)-1.2
[**2200-2-4**] 09:00PM PLT COUNT-201
[**2200-2-4**] 09:00PM WBC-6.7 RBC-4.27 HGB-12.6 HCT-35.2* MCV-82
MCH-29.4 MCHC-35.7* RDW-13.0
[**2200-2-4**] 09:00PM CALCIUM-8.0* PHOSPHATE-2.9 MAGNESIUM-1.8
[**2200-2-4**] 09:00PM GLUCOSE-91 UREA N-8 CREAT-0.6 SODIUM-142
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14
Brief Hospital Course:
The patient was admitted to the ICU and was followed by
Neurosurgery. Head CT, head MRI, and C-spine MRI did not reveal
an aneurysm; the only findings of note included sinusitis, C5-C6
left-sided neuroforaminal stenosis, and and C6-C7 bilateral
foraminal stenosis. Unasyn was started for sinusitis. The
patient was transferred to neuromedicine service, as there were
no neurosurgical issues. Upon further neurological examinations,
it was noted that the patient's gaze disturbance was a
convergence spasm rather than a 6th nerve palsy. Her sensory
exam revealed splitting of the forehead to vibration, as well as
splitting of the sternum to light touch and pinprick. Her motor
exam was notable for inconsistent effort all muscle groups
tested on the right upper and lower extremities. She also moved
the right leg well during distraction. She reacted to reflex
exam prior to the hammer strike. The team felt that a
neurological etiology of the patient's symptoms was unlikely.
This assessment was bolstered by the existence of significant
social stressors, including home-schooling four children and her
caring for a 45-year-old disabled adult living with the family.
On [**2200-2-7**], the patient was felt to be stable for discharge.
Medications on Admission:
Multivitamin.
Discharge Medications:
1. Imipramine HCl 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for headache and pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
3. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Muscle spasm
2. Transient weakness with no obvious neurological etiology
Discharge Condition:
Stable.
Discharge Instructions:
Take all medications as prescribed.
Follow-up with all scheduled outpatient appointments.
Call your PCP with any of the following symptoms: worsening
weakness, numbness, headache, or vision problems.
Followup Instructions:
Follow-up with your PCP [**Name Initial (PRE) 176**] 2 weeks of hospital discharge.
Call [**Hospital 878**] Clinic at [**Telephone/Fax (1) 541**] to schedule an outpt
appointment with Dr. [**Last Name (STitle) 51725**].
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"847.0",
"E812.0",
"427.1",
"784.0",
"473.9",
"389.9",
"787.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
6616, 6622
|
4889, 6126
|
330, 338
|
6742, 6751
|
4488, 4866
|
7001, 7317
|
2690, 2795
|
6190, 6593
|
6643, 6721
|
6152, 6167
|
6775, 6978
|
2810, 4469
|
238, 292
|
366, 2373
|
2395, 2582
|
2598, 2674
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,139
| 137,090
|
14236+14237
|
Discharge summary
|
report+report
|
Admission Date: [**2149-6-17**] Discharge Date: [**2149-6-26**]
Date of Birth: [**2090-5-1**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Percocet / Tetanus
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
diarrhea, fever and chest discomfort
Major Surgical or Invasive Procedure:
Bone marrow biopsy x2
History of Present Illness:
HPI: 59 y/o w/ HTN, HLD, psoriatic arthritis, h/o esophageal
leiomyomata s/p resection, and thrombocytopenia, presents w/
diarrhea, fever and chest discomfort. He was in his usual state
of health until 6 days prior to admission when he started having
diarrhea, approximately 4 loose BM/day. Denies associated
abdominal pain, nausea, vomitting, melena or hematochezia.
Endorses fever as high as 101 since onset of diarrhea. He has a
hoarse voice over the past several weeks and recently had break
out of hives 10 days ago. Recently traveled to [**State 1727**], but denied
eating raw foods or stream/river water. He has traveled to
[**Country 149**] and [**Doctor Last Name **] [**Country **] in past.
.
He initially presented today to his PCP where he endorsed
central to left sided chest discomfort, characterized as a
squeezing sensation, non-radiation to jaw/arm/back. No
associated SOB, diaphoresis, nausea or paresthesias. Pain is
slightly worsened by sitting forward. No known alleviating
factors. Pain is constant and is not related to exertion. He has
not had similar pain in the past. He has GERD treated with
prilosec. EKG in PCP office showed ST depressions laterally (I,
V2-V5) where were new since [**1-31**] and TWI in V2. He was given ASA
325mg and then sent to ED.
.
In the ED initial vitals were 98.4 96 148/96 18 97%. He received
a d-dimer that was positive and subsequent CT-A that showed NO
PE, but a 5mm lung nodule was identified requiring long term
f/u. Labs were also notable for leukocytosis 19.5 with abnormal
differential (bands, lymphs, atypicals and myelos). Trop was
<0.01. He received 1L NS and acetaminophen. 99.4 78 114/90 18 96
RA.
.
ROS: see HPI. On further questioning, he endorses recent night
sweats and weight loss of 6lb over the past week. He has diffuse
myalgias. Mild headache. Denies dysuria/hematuria.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- HTN
- HLD
- psoriatic arthritis - on Enbrel, but did not take most recent
dose due to diarrhea/not feeling well
- thrombocytopenia - unclear etiology, thought to be [**12-25**] PPI
-Leiomyomata: In [**2131**], he presented with midepigastric pain,
diagnosed as leiomyoma. The leiomyoma was surgically removed at
the [**Hospital1 112**] by Dr. [**Last Name (STitle) 8635**]. Over the last 10 years, he has had 5
leiomyomas removed: 3 from esophagus, one from right lung; and
one from right elbow. Last one was 3 years ago plus Nissen
fundaplication
- Recurrent skin abscess in the groins, treated with abx since
more than 20 years ago. Pt is MRSA carrier.
- Transient Ischemic Attack: [**2139**]
Social History:
lives with daughter and wife, employed as an attorney, on the
board at [**Hospital1 18**], no tob/ETOH/drugs.
Family History:
maternal grandmother with heart disease, mother w/ ovarian and
breast cancer died age 72, father died of cancer unknown type
Physical Exam:
PHYSICAL EXAM:
VS: 98.6 142/95 81 18 96% RA
GENERAL: NAD, comfortable, appropriate.
HEENT: PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no carotid bruits, no appreciable anterior or
posterior lymphadenopathy (note patient reported feeling nodes
earlier last week)
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no rh/wh, soft crackles left base
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: 2+ pulses throughout, no edema
SKIN: No rashes or lesions.
LYMPH: No cervical, axillary or inguinal LAD.
NEURO: A&Ox3, CNs II-XII grossly intact, muscle strength 5/5
throughout, sensation grossly intact throughout.
Pertinent Results:
ADMISSION LABS
[**2149-6-17**] 04:15PM BLOOD WBC-19.6*# RBC-5.18 Hgb-15.5 Hct-43.2
MCV-83 MCH-29.9 MCHC-35.9* RDW-15.9* Plt Ct-70*
[**2149-6-17**] 04:15PM BLOOD Neuts-42* Bands-4 Lymphs-13* Monos-19*
Eos-0 Baso-0 Atyps-5* Metas-0 Myelos-1* Blasts-8* Other-8*
[**2149-6-17**] 04:15PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Tear Dr[**Last Name (STitle) **]1+
[**2149-6-17**] 04:15PM BLOOD Glucose-116* UreaN-15 Creat-1.1 Na-135
K-3.9 Cl-99 HCO3-25 AnGap-15
[**2149-6-17**] 04:15PM BLOOD ALT-12 AST-28 LD(LDH)-359* AlkPhos-106
TotBili-0.6
[**2149-6-17**] 04:15PM BLOOD cTropnT-<0.01
[**2149-6-18**] 06:25AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.6
.
PERTINENT LABS
[**2149-6-18**] 10:55AM BLOOD Fibrino-773*
[**2149-6-17**] 04:15PM BLOOD ALT-12 AST-28 LD(LDH)-359* AlkPhos-106
TotBili-0.6
[**2149-6-18**] 06:25AM BLOOD CK-MB-5 cTropnT-0.09*
[**2149-6-19**] 09:05AM BLOOD CK-MB-3 cTropnT-0.12*
[**2149-6-17**] 04:18PM BLOOD D-Dimer-756*
[**2149-6-18**] 04:20PM BLOOD D-Dimer-2052*
[**2149-6-17**] 07:19PM BLOOD Lactate-1.2
[**2149-6-18**] 04:20PM BLOOD WBC-12.6* RBC-4.84 Hgb-14.7 Hct-40.8
MCV-84 MCH-30.4 MCHC-36.1* RDW-15.9* Plt Ct-48*
[**2149-6-20**] 05:30AM BLOOD WBC-14.2* RBC-3.97* Hgb-12.3* Hct-34.1*
MCV-86 MCH-31.0 MCHC-36.1* RDW-15.3 Plt Ct-40*
[**2149-6-21**] 05:40AM BLOOD WBC-12.8* RBC-4.03* Hgb-12.5* Hct-34.9*
MCV-87 MCH-31.0 MCHC-35.7* RDW-15.4 Plt Ct-42*
[**2149-6-21**] 03:00PM BLOOD WBC-14.6* RBC-4.30* Hgb-13.3* Hct-36.8*
MCV-86 MCH-30.9 MCHC-36.0* RDW-15.4 Plt Ct-46*
[**2149-6-23**] 07:55AM BLOOD WBC-10.0 RBC-3.84* Hgb-11.7* Hct-33.7*
MCV-88 MCH-30.4 MCHC-34.6 RDW-15.4 Plt Ct-56*
[**2149-6-24**] 06:30AM BLOOD WBC-11.0 RBC-3.88* Hgb-11.8* Hct-33.9*
MCV-88 MCH-30.4 MCHC-34.7 RDW-15.6* Plt Ct-56*
[**2149-6-25**] 06:05AM BLOOD WBC-8.8 RBC-3.62* Hgb-11.0* Hct-32.1*
MCV-89 MCH-30.4 MCHC-34.2 RDW-15.6* Plt Ct-67*
[**2149-6-26**] 06:10AM BLOOD WBC-10.2 RBC-3.82* Hgb-11.5* Hct-34.1*
MCV-89 MCH-30.3 MCHC-33.8 RDW-15.7* Plt Ct-79*
[**2149-6-20**] 05:30AM BLOOD Neuts-63 Bands-1 Lymphs-6* Monos-15*
Eos-1 Baso-0 Atyps-2* Metas-3* Myelos-4* Promyel-1* Blasts-4*
[**2149-6-21**] 05:40AM BLOOD Neuts-66 Bands-3 Lymphs-12* Monos-11
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-1* Promyel-1* Blasts-4*
[**2149-6-22**] 05:35AM BLOOD Neuts-69 Bands-4 Lymphs-7* Monos-11 Eos-0
Baso-0 Atyps-1* Metas-4* Myelos-2* Blasts-2* NRBC-1*
[**2149-6-22**] 02:45PM BLOOD Neuts-75* Bands-3 Lymphs-8* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-0 Blasts-4* NRBC-1*
[**2149-6-23**] 07:55AM BLOOD Neuts-55 Bands-3 Lymphs-11* Monos-6 Eos-0
Baso-0 Atyps-5* Metas-13* Myelos-2* Promyel-1* Blasts-4* NRBC-1*
[**2149-6-24**] 06:30AM BLOOD Neuts-58 Bands-1 Lymphs-20 Monos-9 Eos-0
Baso-0 Atyps-5* Metas-2* Myelos-1* Blasts-4*
[**2149-6-25**] 06:05AM BLOOD Neuts-55 Bands-3 Lymphs-20 Monos-11 Eos-0
Baso-0 Atyps-2* Metas-3* Myelos-3* Blasts-3* NRBC-2*
[**2149-6-26**] 06:10AM BLOOD Neuts-52 Bands-1 Lymphs-27 Monos-9 Eos-0
Baso-0 Atyps-5* Metas-1* Myelos-1* Blasts-4*
[**2149-6-26**] 06:10AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-1+ Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL
Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 15924**]
[**2149-6-26**] 06:10AM BLOOD Plt Smr-VERY LOW Plt Ct-79*
[**2149-6-26**] 06:10AM BLOOD PT-16.2* PTT-31.9 INR(PT)-1.4*
[**2149-6-25**] 06:05AM BLOOD Plt Smr-VERY LOW Plt Ct-67*
[**2149-6-25**] 06:05AM BLOOD PT-15.8* PTT-33.7 INR(PT)-1.4*
[**2149-6-24**] 06:30AM BLOOD Plt Smr-VERY LOW Plt Ct-56*
[**2149-6-24**] 06:30AM BLOOD PT-16.1* PTT-31.6 INR(PT)-1.4*
[**2149-6-23**] 03:20PM BLOOD Plt Ct-45*
[**2149-6-23**] 03:20PM BLOOD PT-16.0* PTT-30.0 INR(PT)-1.4*
[**2149-6-23**] 07:55AM BLOOD Plt Smr-VERY LOW Plt Ct-56*
[**2149-6-23**] 07:55AM BLOOD PT-16.6* PTT-32.3 INR(PT)-1.5*
[**2149-6-22**] 02:45PM BLOOD Plt Smr-VERY LOW Plt Ct-47*
[**2149-6-22**] 02:45PM BLOOD PT-17.2* PTT-34.0 INR(PT)-1.5*
[**2149-6-22**] 05:35AM BLOOD Plt Smr-VERY LOW Plt Ct-54*
[**2149-6-22**] 05:35AM BLOOD PT-16.8* PTT-35.9* INR(PT)-1.5*
[**2149-6-21**] 03:00PM BLOOD Plt Ct-46*
[**2149-6-21**] 03:00PM BLOOD PT-17.8* PTT-33.0 INR(PT)-1.6*
[**2149-6-21**] 05:40AM BLOOD Plt Smr-VERY LOW Plt Ct-42*
[**2149-6-21**] 05:40AM BLOOD PT-18.5* PTT-37.4* INR(PT)-1.7*
[**2149-6-20**] 06:20PM BLOOD Plt Ct-33*
[**2149-6-20**] 06:20PM BLOOD PT-19.6* PTT-33.9 INR(PT)-1.8*
[**2149-6-20**] 05:30AM BLOOD Plt Smr-VERY LOW Plt Ct-40*
[**2149-6-20**] 05:30AM BLOOD PT-19.2* PTT-37.6* INR(PT)-1.7*
[**2149-6-19**] 03:40PM BLOOD Plt Ct-48*
[**2149-6-19**] 03:40PM BLOOD PT-19.1* PTT-35.6* INR(PT)-1.7*
[**2149-6-19**] 09:05AM BLOOD Plt Smr-VERY LOW Plt Ct-42*
[**2149-6-19**] 06:15AM BLOOD Plt Ct-42*
[**2149-6-19**] 06:15AM BLOOD PT-17.2* PTT-36.0* INR(PT)-1.5*
[**2149-6-18**] 04:20PM BLOOD Plt Ct-48*
[**2149-6-18**] 04:20PM BLOOD PT-17.1* PTT-36.7* INR(PT)-1.5*
[**2149-6-18**] 10:55AM BLOOD Plt Smr-VERY LOW Plt Ct-54*
[**2149-6-24**] 06:30AM BLOOD Fibrino-900*#
[**2149-6-23**] 03:20PM BLOOD Parst S-NEGATIVE
[**2149-6-26**] 06:10AM BLOOD Glucose-108* UreaN-14 Creat-0.9 Na-139
K-4.3 Cl-103 HCO3-26 AnGap-14
[**2149-6-25**] 06:05AM BLOOD Glucose-117* UreaN-14 Creat-0.8 Na-138
K-3.8 Cl-102 HCO3-28 AnGap-12
[**2149-6-24**] 06:30AM BLOOD Glucose-127* UreaN-13 Creat-0.9 Na-137
K-3.5 Cl-100 HCO3-31 AnGap-10
[**2149-6-23**] 03:20PM BLOOD UreaN-14 Creat-0.8 Na-138 K-3.3 Cl-97
HCO3-31 AnGap-13
[**2149-6-23**] 07:55AM BLOOD Glucose-136* UreaN-14 Creat-0.8 Na-136
K-3.3 Cl-97 HCO3-31 AnGap-11
[**2149-6-22**] 02:45PM BLOOD UreaN-15 Creat-1.0 Na-138 K-3.5 Cl-101
HCO3-29 AnGap-12
[**2149-6-22**] 05:35AM BLOOD Glucose-120* UreaN-12 Creat-1.0 Na-137
K-3.8 Cl-100 HCO3-28 AnGap-13
[**2149-6-21**] 03:00PM BLOOD Glucose-124* Creat-1.1 Na-136 K-3.7 Cl-99
HCO3-28 AnGap-13
[**2149-6-21**] 05:40AM BLOOD Glucose-175* UreaN-12 Creat-1.0 Na-136
K-3.5 Cl-98 HCO3-28 AnGap-14
[**2149-6-20**] 06:20PM BLOOD UreaN-12 Creat-1.0 Na-139 K-3.2* Cl-101
HCO3-28 AnGap-13
[**2149-6-20**] 05:30AM BLOOD Glucose-147* UreaN-12 Creat-1.0 Na-138
K-3.2* Cl-100 HCO3-29 AnGap-12
[**2149-6-19**] 03:40PM BLOOD Glucose-151* UreaN-13 Creat-1.0 Na-136
K-3.4 Cl-101 HCO3-26 AnGap-12
[**2149-6-19**] 09:05AM BLOOD Glucose-170* UreaN-14 Creat-1.0 Na-137
K-3.4 Cl-101 HCO3-26 AnGap-13
[**2149-6-19**] 06:15AM BLOOD Glucose-150* UreaN-14 Creat-1.1 Na-135
K-3.8 Cl-98 HCO3-30 AnGap-11
[**2149-6-18**] 04:20PM BLOOD Creat-1.0 Na-136 K-3.5 Cl-101 HCO3-26
AnGap-13
[**2149-6-26**] 06:10AM BLOOD ALT-18 AST-24 LD(LDH)-301* AlkPhos-93
TotBili-0.4
[**2149-6-25**] 06:05AM BLOOD ALT-15 AST-24 AlkPhos-90 TotBili-0.4
[**2149-6-24**] 06:30AM BLOOD ALT-16 AST-26 LD(LDH)-279* AlkPhos-94
TotBili-0.6
[**2149-6-23**] 03:20PM BLOOD LD(LDH)-293* TotBili-0.7
[**2149-6-23**] 07:55AM BLOOD ALT-18 AST-27 LD(LDH)-277* AlkPhos-93
TotBili-0.7
[**2149-6-22**] 02:45PM BLOOD LD(LDH)-290*
[**2149-6-21**] 03:00PM BLOOD LD(LDH)-273* TotBili-0.8
[**2149-6-20**] 05:30AM BLOOD ALT-10 AST-16 LD(LDH)-237 AlkPhos-94
TotBili-0.6
[**2149-6-19**] 09:05AM BLOOD CK(CPK)-71
[**2149-6-18**] 04:20PM BLOOD LD(LDH)-235 CK(CPK)-76
[**2149-6-21**] 05:40AM BLOOD cTropnT-0.05*
[**2149-6-20**] 06:20PM BLOOD cTropnT-0.06*
[**2149-6-19**] 09:05AM BLOOD CK-MB-3 cTropnT-0.12*
[**2149-6-19**] 06:15AM BLOOD CK-MB-3 cTropnT-0.10*
[**2149-6-26**] 06:10AM BLOOD Albumin-3.3* Calcium-8.3* Phos-3.8 Mg-1.9
[**2149-6-25**] 06:05AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.8
[**2149-6-24**] 06:30AM BLOOD TotProt-5.8* Calcium-8.1* Phos-3.3 Mg-1.8
[**2149-6-23**] 03:20PM BLOOD Calcium-8.2* Phos-3.2 UricAcd-3.0*
[**2149-6-22**] 02:45PM BLOOD Calcium-8.3* Mg-1.8 UricAcd-2.9*
[**2149-6-21**] 03:00PM BLOOD Calcium-8.1* Phos-2.0* Mg-2.0
UricAcd-3.3*
[**2149-6-21**] 05:40AM BLOOD Albumin-2.8* Calcium-7.9* Phos-2.1*
Mg-2.1 UricAcd-3.8
[**2149-6-20**] 06:20PM BLOOD Calcium-7.7* Phos-2.2* UricAcd-4.0
[**2149-6-20**] 05:30AM BLOOD Albumin-3.0* Calcium-7.5* Phos-2.5*
Mg-1.6
[**2149-6-19**] 09:05AM BLOOD Calcium-8.0* Phos-2.3* Mg-1.4*
[**2149-6-18**] 04:20PM BLOOD Calcium-8.6 Phos-3.2 UricAcd-6.9
[**2149-6-23**] 07:55AM BLOOD VitB12-1523* Folate-6.6
[**2149-6-21**] 03:00PM BLOOD D-Dimer-895*
[**2149-6-20**] 06:20PM BLOOD D-Dimer-905*
[**2149-6-20**] 05:30AM BLOOD D-Dimer-1103*
[**2149-6-19**] 03:40PM BLOOD D-Dimer-1234*
[**2149-6-19**] 06:15AM BLOOD D-Dimer-1858*
[**2149-6-23**] 07:55AM BLOOD Homocys-12.8*
[**2149-6-26**] 06:10AM BLOOD TSH-2.4
[**2149-6-23**] 07:55AM BLOOD Vanco-6.6*
[**2149-6-19**] 08:16AM BLOOD Type-ART pO2-66* pCO2-36 pH-7.49*
calTCO2-28 Base XS-4 Intubat-NOT INTUBA
[**2149-6-26**] 06:10AM BLOOD BABESIA MICROTI DNA PCR-Test Name
[**2149-6-23**] 07:55AM BLOOD METHYLMALONIC ACID-Test
[**2149-6-22**] 05:35AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
[**2149-6-22**] 05:35AM BLOOD B-GLUCAN-Test
[**2149-6-21**] 05:40AM BLOOD SCHISTOSOMA ANTIBODIES-Test
[**2149-6-21**] 05:40AM BLOOD ANAPLASMA PHAGOCYTOPHILUM AND EHRLICHIA
CHAFFEENSIS ANTIBODY PANEL (IGM AND IGG) -Test
[**2149-6-21**] 05:40AM BLOOD STRONGYLOIDES ANTIBODY,IGG-Test Name
[**2149-6-20**] 11:30AM BLOOD QUANTIFERON-TB GOLD-Test
[**2149-6-19**] 03:40PM BLOOD B-GLUCAN-Test
[**2149-6-18**] 04:20PM BLOOD LYME BY WESTERN BLOT-Test Name
[**2149-6-22**] 06:20PM BONE MARROW [**Doctor Last Name 4427**]-DONE CD33-DONE CD41-DONE
CD56-DONE CD64-DONE CD71-DONE CD117-DONE CD45-DONE HLA-DR[**Last Name (STitle) 7735**]
[**Name (STitle) **] A-DONE Kappa-DONE CD2-DONE CD7-DONE CD10-DONE CD11C-DONE
CD13-DONE CD14-DONE CD15-DONE CD19-DONE CD20-DONE Lambda-DONE
CD5-DONE Iron St-DONE
[**2149-6-18**] 01:15PM BONE MARROW [**Doctor Last Name 4427**]-DONE Iron St-DONE
[**2149-6-18**] 09:39AM BONE MARROW CD33-DONE CD41-DONE CD56-DONE
CD64-DONE CD71-DONE CD117-DONE CD45-DONE HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) **]
A-DONE Kappa-DONE CD2-DONE CD7-DONE CD10-DONE CD11C-DONE
CD13-DONE CD14-DONE CD15-DONE CD19-DONE CD20-DONE Lambda-DONE
CD5-DONE
[**2149-6-18**] 09:39AM BONE MARROW CD34-DONE CD3-DONE CD4-DONE
CD8-DONE
[**2149-6-18**] 11:00AM BONE MARROW FLT3 MUTATIONS (ITD AND D835)-Test
[**2149-6-18**] 11:00AM BONE MARROW NPM (EXON 12) MUTATION ANALYSIS,
CELL BASED-Test
Brief Hospital Course:
Mr [**Known lastname **] is a 59 y/o man w/ h/o intrathoracic leiomyomata s/p
resection, HTN, HLD, who presented with a 6 day h/o diarrhea,
fever, nightsweats, and chest discomfort.
.
FEVERS of unclear etiology
The patient reported fevers up to 101F prior to admission,
associated with onset of diarrhea. During his hospitalization,
he remained febrile with temperatures reaching 103F. Given a
leukocytosis and the constellation of symptoms: hoarse voice,
rash, diarrhea, hypoxia, mildly increased troponins, and fever,
an infectious source, probably viral, seems likely. The patient
was started initially on empirical therapy for infectious
colitis with cipro and flagyl. Cefepime and vancomycin-(h/o
MRSA) were added due to concern for dysfunctional neutrophils.
Work-up included aerobic/anaerobic bacterial blood cultures,
fungal cultures, galactomannan/B-glucan, Lyme serologies,
[**Location (un) **], EBV PCR, and CMV viral load, enterovirus, adenovirus,
respiratory viruses, strongyloides, chagas disease,
schistosomiasis, and HIV. TTE was negative for endocarditis or
pleural effusion to suggest pericarditis, but mildly elevated
troponins and positional chest discomfort did support the
diagnosis. The patient completed a course of antibiotics and
was afebrile at the time of discharge.
.
LEUKOCYTOSIS with blasts in Smear and marrow
These findings were concerning for AML. The patient has a
history of thrombocytopenia with normal BM biopsy in [**2143**], but
no definitive cause found. In the setting of patient's
presentation, it is possible that patient had MDS for many years
and now with acute blast crisis. Findings from bone marrow
biopsy suggested infection in the setting of myelodysplastic
syndrome or RAEB type I, II or frank AML. Despite this
uncertainty, Heme/Onc was concerned enough to transfer patient
to BMT for further work-up. He had a repeat bone marrow biopsy
on [**2149-5-25**] which showed an increased population of CD34 negative
cells with an immature myeloid phenotype.
Immunohistochemistry performed on the core biopsy revealed that
most of the cells stain for MPO, CD15, CD117 (dim), and CD68,
and are negative for TdT and CD79. CD34 highlights scattered
cells accounting for less 5% of the cellularity in the core
biopsy. Overall, the findings are very similar to those present
on a previous biopsy, including the number of myeloblasts in the
peripheral blood and marrow. Given the high cellularity of the
bone marrow, the marked myeloid dominance with dysplastic
maturation and increased myeloblasts a diagnosis of
MYELOPROLIFERATIVE/MYELODYSPLASTIC SYNDROME WITH INCREASED
BLASTS is favored. Molecular studies on the marrow aspirate
revealed the presence of a NPM1 exon 12 mutation (type A
mutation), which is highly associated with a sizable group of
acute myeloid leukemia with normal karyotype. This same mutation
has been reported in a small subset of myelodysplastic and
myeloproliferative/myelodysplastic disorders in which the blast
count is increased, but does not meet criteria (>20% blasts) for
a diagnosis of acute myeloid leukemia. Such cases have
frequently progressed to acute leukemia, particularly those who
also harbored FLT3 IDT mutations, which were tested and were not
present in this biopsy. Close follow up and rebiopsy is
recommended as clinically indicated.
.
HYPOXEMIA
On hospital day #2 the patient's oxygen saturation dropped to
83% on RA, with ABG showing respiratory alkalosis. CTA was
negative for PE and revealed atelectasis of RLL thought
secondary to possible aspiration event. In addition to the above
treatments, he was given 1 dose of levofloxacin to cover
atypicals and legionella, and a legionella urinary antigen was
ordered. He was also started on doxycycline for empiric
treatment for tick borne illness (and also would cover
tularemia).
.
CHEST PAIN
Patient complained of mid-sternal to left sided discomfort. He
was found to have mildly elevated troponins with no elevation of
CK, MB and Nonspecific EKG changes. This was felt to reflect
either pericarditis or myocarditis. In addition, plaques were
noted in the patient's oral mucosa suggesting the possibility of
candidal esophagitis, for which he was treated w/ fluconazole.
.
Thrombocytopenia:
.unclear etiology, thought to be due to PPI/enbrel in past.
However, with atypical white blood cell differential,
malignancy/mds is on differential
Medications on Admission:
lisinopril 20mg daily
prilosec 20mg daily
align daily
crestor (unknown dose) daily
enbrel - last taken 2 weeks before admission
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
5. doxycycline hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 3 weeks.
Disp:*42 Capsule(s)* Refills:*0*
6. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
7. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*60 Tablet(s)* Refills:*2*
8. chlorpheniramine-hydrocodone 8-10 mg/5 mL Suspension,
Extended Rel 12 hr Sig: Five (5) ML PO Q6H (every 6 hours) as
needed for cough.
Disp:*500 ML(s)* Refills:*2*
9. Crestor Oral
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Myelodysplastic Syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
to the hospital on [**2149-6-17**] with chest tightness, fever,
dairrhea, and shortness of breath. Because of the several organ
systems involved, and because of your recent travel history, and
because of your persistent fevers, a wide array of infectious
disease studies was sent, and were negative. Your cardiac
enzymes were minimally elevated, and then trended back down by
hospital day 3, likely a reflection of a condition called
pericarditis, which is inflammation around the lining of you
heart, usually from a virus. A bone marrow biopsy showed
dysplastic marrow, but no leukemia.
The following changes were made to your medications:
-Discontinued ENBREL.
-Discontinued ALIGN.
-Started DOXYCYCLINE - please continue taking 100mg every 12
hours for 3 weeks.
-Started FOLIC ACID.
-Started BENZONATATE as required for cough.
-Started CHLORPHENIRAMINE-HYDROCODONE as required for cough.
-Started ZOLPIDEM TARTRATE as requiredfor insomnia.
-Started SENNA and SODIUM DOCUSATE as required for constipation.
Please continue taking your other home medications as usual.
Please follow up with your primary care practitioner and with
heme/onc, see below.
Followup Instructions:
Department: INTERNAL MEDICINE
When: FRIDAY [**2149-6-27**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8244**], MD [**Telephone/Fax (1) 4775**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: HEMATOLOGY/BMT
When: TUESDAY [**2149-7-1**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DERMATOLOGY AND LASER
When: MONDAY [**2150-1-26**] at 3:45 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 4961**], MD [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2149-6-30**] Admission Date: [**2149-7-2**] Discharge Date: [**2149-7-30**]
Date of Birth: [**2090-5-1**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Percocet / Tetanus / lisinopril
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
scheduled admission for chemotherapy.
Major Surgical or Invasive Procedure:
temporary central line placement; bone marrow biopsy
History of Present Illness:
Briefly, this is a 59 year old man who was recently admitted to
[**Hospital1 18**] on [**2149-6-17**] who presented with approximately one week of
fever and diarrhea, recent urticaria, and general malaise found
to have abnormal differential by his PCP as well as ongoing
fever and new hypoxia. CBC showed leucocytosis with blasts, and
bone marrow biopsy was consistent with MDS with 10% blasts. He
was discharged home once his symptoms had improved, but
post-discharge, confirmation of the presence of the NPM1
mutation confirmed a diagnosis of AML. He has been admitted for
7+3 induction chemotherapy.
.
During the last admission he underwent an extensive infectious
workup which was all negative. His symptoms improved, and were
thoguh by ID to be most likely to be due to Lyme/Ehrlichia. He
is currently completing a course of doxycycline (2 more weeks).
.
Since his discharge from [**Hospital1 18**] on [**2149-6-26**] he has been feeling
well and feels that he has been getting stronger. He has
experienced a recurrence of hives, which he frequently gets in
the summer, and has been taking zyrtec and zantac for this. He
has had no fevers.
.
Review of Systems: ROS: Denies fever, chills, night sweats,
headache, vision changes, rhinorrhea, congestion, sore throat,
cough, shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
1. Psoriatic arthritis - on Enbrel, but has not taken for ~4
weeks.
2. Thrombocytopenia - unclear etiology, thought to be
medications. Patient underwent bone marrow biopsy in [**2143**], which
did not show leukemia or lymphoma. Baseline platelet count ~
90-115 prior to this admission.
3. Leiomyoma in esophagus: In [**2131**], he presented with
midepigastric pain. Symptoms were suggestive of GERD. An upper
GI series revealed a leiomyoma. The leiomyoma was surgically
removed at the [**Hospital1 112**] by Dr. [**Last Name (STitle) 8635**]. Over the last 10 years, he
has had recurrent leiomyomas removed. He has had 5 leiomyomas
removed: 3 from esophagus, one from right lung; and one from
right elbow. He also has had a RML wedge resection.
4. TIA in [**2139**]
5. Hypertension
6. Hyperlipidemia
Social History:
lives with daughter and wife in [**Name (NI) **],
employed as an attorney, on the board at [**Hospital1 18**]. Has a son in
graduate school, and a second daughter. Rarely drinks EtOH, no
tob/drugs.
Family History:
Father died of a "giant cell" cancer found in his
thyroid, but aggressive and metastatic on presentation. Mother
had ovarian and breast cancer and died age 72. He has a sister
who is healthy. His maternal grandmother with heart disease. No
family history of hematologic malignancy.
Physical Exam:
VS: 97.2, 112/74, 100, 20, 96% RA.
Physical Examination:
GENERAL: Well-appearing man in NAD.
HEENT: PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no carotid bruits, no appreciable anterior or
posterior lymphadenopathy
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no rh/wh, soft crackles left base
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: 2+ pulses throughout, no edema
SKIN: No rashes or lesions.
LYMPH: No cervical, axillary or inguinal LAD.
NEURO: A&Ox3, CNs II-XII grossly intact, muscle strength 5/5
throughout, sensation grossly intact throughout.
Pertinent Results:
[**2149-7-1**] 02:50PM BLOOD WBC-20.8*# RBC-4.59* Hgb-14.5# Hct-39.9*
MCV-87 MCH-31.6 MCHC-36.2* RDW-15.4 Plt Ct-111*
[**2149-7-2**] 12:45PM BLOOD WBC-15.0* RBC-3.93* Hgb-12.3* Hct-34.2*
MCV-87 MCH-31.2 MCHC-35.9* RDW-15.8* Plt Ct-77*
[**2149-7-3**] 12:01AM BLOOD WBC-14.2* RBC-3.62* Hgb-11.5* Hct-32.3*
MCV-89 MCH-31.8 MCHC-35.6* RDW-15.9* Plt Ct-68*
[**2149-7-4**] 12:00AM BLOOD WBC-10.8 RBC-3.75* Hgb-11.7* Hct-33.0*
MCV-88 MCH-31.1 MCHC-35.3* RDW-15.9* Plt Ct-62*
[**2149-7-5**] 12:00AM BLOOD WBC-6.6 RBC-3.41* Hgb-10.5* Hct-30.4*
MCV-89 MCH-30.7 MCHC-34.5 RDW-15.9* Plt Ct-54*
[**2149-7-6**] 12:00AM BLOOD WBC-5.5 RBC-3.49* Hgb-10.8* Hct-30.3*
MCV-87 MCH-30.9 MCHC-35.7* RDW-15.6* Plt Ct-61*
[**2149-7-7**] 12:10AM BLOOD WBC-4.3 RBC-3.25* Hgb-10.2* Hct-28.2*
MCV-87 MCH-31.3 MCHC-36.0* RDW-15.6* Plt Ct-47*
[**2149-7-8**] 12:00AM BLOOD WBC-1.7*# RBC-3.06* Hgb-9.5* Hct-26.9*
MCV-88 MCH-31.1 MCHC-35.4* RDW-15.4 Plt Ct-43*
[**2149-7-8**] 08:20AM BLOOD WBC-1.9* RBC-3.15* Hgb-9.9* Hct-27.7*
MCV-88 MCH-31.4 MCHC-35.7* RDW-15.3 Plt Ct-42*
[**2149-7-8**] 10:18AM BLOOD WBC-2.2* RBC-3.07* Hgb-9.7* Hct-26.7*
MCV-87 MCH-31.6 MCHC-36.4* RDW-15.3 Plt Ct-33*
[**2149-7-9**] 12:01AM BLOOD WBC-1.3* RBC-2.97* Hgb-9.2* Hct-25.8*
MCV-87 MCH-31.0 MCHC-35.7* RDW-15.2 Plt Ct-37*
[**2149-7-10**] 12:00AM BLOOD WBC-0.8* RBC-2.87* Hgb-8.9* Hct-24.8*
MCV-86 MCH-31.1 MCHC-35.9* RDW-14.9 Plt Ct-37*
[**2149-7-11**] 12:00AM BLOOD WBC-1.0* RBC-2.80* Hgb-8.8* Hct-23.8*
MCV-85 MCH-31.4 MCHC-36.9* RDW-14.8 Plt Ct-26*
[**2149-7-12**] 12:00AM BLOOD WBC-1.1* RBC-3.02* Hgb-9.5* Hct-25.6*
MCV-85 MCH-31.3 MCHC-36.9* RDW-14.6 Plt Ct-22*
[**2149-7-13**] 12:00AM BLOOD WBC-1.1* RBC-2.72* Hgb-8.7* Hct-23.1*
MCV-85 MCH-32.1* MCHC-37.8* RDW-14.3 Plt Ct-15*
[**2149-7-14**] 12:00AM BLOOD WBC-0.8* RBC-2.71* Hgb-8.6* Hct-22.8*
MCV-84 MCH-31.7 MCHC-37.7* RDW-14.3 Plt Ct-6*#
[**2149-7-14**] 10:05AM BLOOD WBC-0.5* RBC-2.38* Hgb-7.5* Hct-20.0*
MCV-84 MCH-31.3 MCHC-37.2* RDW-14.0 Plt Ct-16*
[**2149-7-14**] 04:20PM BLOOD WBC-0.5* RBC-2.60* Hgb-8.0* Hct-21.6*
MCV-83 MCH-30.9 MCHC-37.1* RDW-14.2 Plt Ct-15*
[**2149-7-14**] 06:49PM BLOOD Hct-25.8*
[**2149-7-15**] 02:44AM BLOOD WBC-0.3* RBC-3.13* Hgb-9.6* Hct-25.6*
MCV-82 MCH-30.5 MCHC-37.3* RDW-14.8 Plt Ct-10*
[**2149-7-16**] 03:45AM BLOOD WBC-0.2* RBC-2.78* Hgb-9.0* Hct-24.5*
MCV-85 MCH-30.6 MCHC-35.9* RDW-14.9 Plt Ct-17*
[**2149-7-17**] 12:05AM BLOOD WBC-0.2* RBC-3.10* Hgb-9.6* Hct-26.3*
MCV-85 MCH-31.0 MCHC-36.6* RDW-14.7 Plt Ct-9*
[**2149-7-18**] 12:00AM BLOOD WBC-0.1* RBC-2.84* Hgb-8.5* Hct-24.3*
MCV-86 MCH-30.1 MCHC-35.2* RDW-14.7 Plt Ct-10*#
[**2149-7-19**] 12:00AM BLOOD WBC-0.2*# RBC-2.58* Hgb-8.1* Hct-22.1*
MCV-86 MCH-31.5 MCHC-36.8* RDW-14.5 Plt Ct-13*
[**2149-7-20**] 12:20AM BLOOD WBC-0.1* RBC-2.90* Hgb-9.0* Hct-25.2*
MCV-87 MCH-31.1 MCHC-35.9* RDW-14.2 Plt Ct-19*#
[**2149-7-21**] 12:00AM BLOOD WBC-0.1* RBC-2.67* Hgb-8.4* Hct-23.2*
MCV-87 MCH-31.5 MCHC-36.3* RDW-14.0 Plt Ct-15*
[**2149-7-22**] 12:00AM BLOOD WBC-0.3*# RBC-2.96* Hgb-9.1* Hct-25.9*
MCV-87 MCH-30.5 MCHC-34.9 RDW-13.8 Plt Ct-24*
[**2149-7-23**] 12:00AM BLOOD WBC-0.4* RBC-3.06* Hgb-9.2* Hct-26.0*
MCV-85 MCH-30.2 MCHC-35.5* RDW-13.4 Plt Ct-17*
[**2149-7-24**] 12:00AM BLOOD WBC-0.5* RBC-2.84* Hgb-8.8* Hct-24.0*
MCV-85 MCH-31.1 MCHC-36.7* RDW-13.2 Plt Ct-14*
[**2149-7-25**] 12:00AM BLOOD WBC-0.9*# RBC-3.15* Hgb-9.7* Hct-26.5*
MCV-84 MCH-30.8 MCHC-36.6* RDW-13.2 Plt Ct-34*
[**2149-7-26**] 12:00AM BLOOD WBC-0.9* RBC-3.26* Hgb-9.9* Hct-27.4*
MCV-84 MCH-30.3 MCHC-36.1* RDW-12.9 Plt Ct-32*
[**2149-7-27**] 12:00AM BLOOD WBC-1.2* RBC-3.33* Hgb-10.5* Hct-27.7*
MCV-83 MCH-31.4 MCHC-37.9* RDW-13.1 Plt Ct-40*
[**2149-7-28**] 12:00AM BLOOD WBC-1.4* RBC-3.10* Hgb-9.8* Hct-25.9*
MCV-84 MCH-31.7 MCHC-37.9* RDW-13.4 Plt Ct-55*
[**2149-7-29**] 12:00AM BLOOD WBC-2.1* RBC-3.23* Hgb-9.9* Hct-26.8*
MCV-83 MCH-30.8 MCHC-37.0* RDW-13.4 Plt Ct-74*
[**2149-7-30**] 12:00AM BLOOD WBC-1.9* RBC-3.36* Hgb-10.0* Hct-28.6*
MCV-85 MCH-29.8 MCHC-34.9 RDW-13.8 Plt Ct-102*
[**2149-7-1**] 02:50PM BLOOD Neuts-56 Bands-2 Lymphs-6* Monos-11 Eos-0
Baso-0 Atyps-0 Metas-9* Myelos-6* Blasts-10*
[**2149-7-2**] 12:45PM BLOOD Neuts-49* Bands-8* Lymphs-20 Monos-11
Eos-0 Baso-0 Atyps-2* Metas-3* Myelos-0 Blasts-7*
[**2149-7-3**] 12:01AM BLOOD Neuts-64 Bands-1 Lymphs-14* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-4* Myelos-8* Blasts-7*
[**2149-7-4**] 12:00AM BLOOD Neuts-64 Bands-3 Lymphs-14* Monos-9 Eos-0
Baso-0 Atyps-0 Metas-7* Myelos-0 Blasts-3*
[**2149-7-5**] 12:00AM BLOOD Neuts-76* Bands-0 Lymphs-13* Monos-1*
Eos-1 Baso-0 Atyps-0 Metas-3* Myelos-2* Blasts-4*
[**2149-7-6**] 12:00AM BLOOD Neuts-79* Bands-1 Lymphs-11* Monos-3
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-1* Blasts-1*
[**2149-7-7**] 12:10AM BLOOD Neuts-84* Bands-0 Lymphs-10* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 Blasts-2*
[**2149-7-8**] 12:00AM BLOOD Neuts-86* Bands-0 Lymphs-10* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-1*
[**2149-7-8**] 08:20AM BLOOD Neuts-90* Bands-0 Lymphs-7* Monos-1*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2149-7-8**] 10:18AM BLOOD Neuts-95* Bands-0 Lymphs-4* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-9**] 12:01AM BLOOD Neuts-84* Bands-0 Lymphs-16* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-10**] 12:00AM BLOOD Neuts-82* Bands-0 Lymphs-18 Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-11**] 12:00AM BLOOD Neuts-75* Bands-0 Lymphs-20 Monos-4 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-12**] 12:00AM BLOOD Neuts-58 Bands-0 Lymphs-41 Monos-0 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-13**] 12:00AM BLOOD Neuts-71* Bands-1 Lymphs-27 Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2149-7-14**] 12:00AM BLOOD Neuts-76* Bands-0 Lymphs-20 Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-15**] 02:44AM BLOOD Neuts-36* Bands-2 Lymphs-56* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-16**] 03:45AM BLOOD Neuts-28* Bands-0 Lymphs-68* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-17**] 12:05AM BLOOD Neuts-14* Bands-0 Lymphs-76* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-2*
[**2149-7-18**] 12:00AM BLOOD Neuts-3* Bands-0 Lymphs-84* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0
[**2149-7-19**] 12:00AM BLOOD Neuts-8* Bands-0 Lymphs-88* Monos-4 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-20**] 12:20AM BLOOD Neuts-5* Bands-0 Lymphs-90* Monos-0
Eos-5* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-21**] 12:00AM BLOOD Neuts-10* Bands-0 Lymphs-80* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-22**] 12:00AM BLOOD Neuts-7* Bands-0 Lymphs-83* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Other-3*
[**2149-7-23**] 12:00AM BLOOD Neuts-17* Bands-0 Lymphs-71* Monos-12*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-24**] 12:00AM BLOOD Neuts-18* Bands-0 Lymphs-62* Monos-20*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-25**] 12:00AM BLOOD Neuts-38* Bands-2 Lymphs-36 Monos-24*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-26**] 12:00AM BLOOD Neuts-24* Bands-0 Lymphs-45* Monos-31*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-27**] 12:00AM BLOOD Neuts-17* Bands-1 Lymphs-70* Monos-10
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2149-7-28**] 12:00AM BLOOD Neuts-18* Bands-0 Lymphs-37 Monos-44*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2149-7-29**] 12:00AM BLOOD Neuts-46* Bands-0 Lymphs-28 Monos-25*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2149-7-30**] 12:00AM BLOOD Neuts-29* Bands-0 Lymphs-38 Monos-32*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2149-7-30**] 12:00AM BLOOD Plt Smr-LOW Plt Ct-102*
[**2149-7-30**] 12:00AM BLOOD PT-14.5* PTT-29.6 INR(PT)-1.3*
[**2149-7-1**] 02:50PM BLOOD PT-14.5* INR(PT)-1.3*
[**2149-7-1**] 02:50PM BLOOD Plt Smr-LOW Plt Ct-111*
[**2149-7-26**] 12:00AM BLOOD Fibrino-288
[**2149-7-22**] 12:00AM BLOOD Fibrino-459*#
[**2149-7-17**] 12:05AM BLOOD FDP-10-40*
[**2149-7-17**] 12:05AM BLOOD Fibrino-809*
[**2149-7-16**] 03:45AM BLOOD FDP-10-40*
[**2149-7-15**] 02:44AM BLOOD FDP-10-40*
[**2149-7-14**] 06:49PM BLOOD FDP-10-40*
[**2149-7-8**] 04:45PM BLOOD FDP-80-160*
[**2149-7-8**] 08:20AM BLOOD FDP-80-160*
[**2149-7-8**] 12:00AM BLOOD FDP-40-80*
[**2149-7-7**] 04:15PM BLOOD FDP-80-160*
[**2149-7-7**] 11:00AM BLOOD FDP-40-80*
[**2149-7-30**] 12:00AM BLOOD Gran Ct-563*
[**2149-7-29**] 12:00AM BLOOD Gran Ct-987*
[**2149-7-28**] 12:00AM BLOOD Gran Ct-264*
[**2149-7-27**] 12:00AM BLOOD Gran Ct-306*
[**2149-7-26**] 12:00AM BLOOD Gran Ct-209*
[**2149-7-25**] 12:00AM BLOOD Gran Ct-334*
[**2149-7-1**] 02:50PM BLOOD Gran Ct-[**Numeric Identifier 42314**]*
[**2149-7-3**] 12:01AM BLOOD Gran Ct-[**Numeric Identifier 4550**]*
[**2149-7-4**] 12:00AM BLOOD Gran Ct-7992
[**2149-7-6**] 12:00AM BLOOD Gran Ct-4455
[**2149-7-7**] 12:10AM BLOOD Gran Ct-3681
[**2149-7-8**] 12:00AM BLOOD Gran Ct-1436*
[**2149-7-9**] 12:01AM BLOOD Gran Ct-1050*
[**2149-7-10**] 12:00AM BLOOD Gran Ct-615*
[**2149-7-11**] 12:00AM BLOOD Gran Ct-765*
[**2149-7-12**] 12:00AM BLOOD Gran Ct-609*
[**2149-7-15**] 02:44AM BLOOD Gran Ct-114*
[**2149-7-18**] 12:00AM BLOOD Gran Ct-8*
[**2149-7-19**] 12:00AM BLOOD Gran Ct-16*
[**2149-7-20**] 12:20AM BLOOD Gran Ct-30*
[**2149-7-21**] 12:00AM BLOOD Gran Ct-12*
[**2149-7-22**] 12:00AM BLOOD Gran Ct-21*
[**2149-7-23**] 12:00AM BLOOD Gran Ct-66*
[**2149-7-24**] 12:00AM BLOOD Gran Ct-95*
[**2149-7-25**] 12:00AM BLOOD Gran Ct-334*
[**2149-7-26**] 12:00AM BLOOD Gran Ct-209*
[**2149-7-27**] 12:00AM BLOOD Gran Ct-306*
[**2149-7-28**] 12:00AM BLOOD Gran Ct-264*
[**2149-7-29**] 12:00AM BLOOD Gran Ct-987*
[**2149-7-30**] 12:00AM BLOOD Gran Ct-563*
[**2149-7-30**] 12:00AM BLOOD Glucose-82 UreaN-9 Creat-0.7 Na-139 K-3.9
Cl-104 HCO3-26 AnGap-13
[**2149-7-1**] 02:50PM BLOOD UreaN-26* Creat-1.2 Na-138 K-4.8 Cl-102
HCO3-26 AnGap-15
[**2149-7-2**] 12:45PM BLOOD Glucose-117* UreaN-28* Creat-1.1 Na-137
K-4.5 Cl-102 HCO3-24 AnGap-16
[**2149-7-30**] 12:00AM BLOOD ALT-20 AST-16 LD(LDH)-296* AlkPhos-120
TotBili-0.7
[**2149-7-1**] 02:50PM BLOOD ALT-37 AST-33 LD(LDH)-280* AlkPhos-126
TotBili-0.4 DirBili-0.1 IndBili-0.3
[**2149-7-19**] 12:00AM BLOOD proBNP-[**Numeric Identifier 42315**]*
[**2149-7-18**] 12:00AM BLOOD cTropnT-1.00*
[**2149-7-16**] 03:45AM BLOOD CK-MB-3 cTropnT-2.14*
[**2149-7-15**] 10:00PM BLOOD CK-MB-3 cTropnT-2.38*
[**2149-7-15**] 06:45PM BLOOD CK-MB-4 cTropnT-2.76*
[**2149-7-15**] 01:49PM BLOOD CK-MB-6 cTropnT-2.87*
[**2149-7-15**] 02:44AM BLOOD CK-MB-27* MB Indx-4.3 cTropnT-3.26*
[**2149-7-14**] 09:51PM BLOOD CK-MB-54* MB Indx-7.6* cTropnT-3.13*
[**2149-7-14**] 04:20PM BLOOD CK-MB-38* MB Indx-8.7* cTropnT-1.90*
[**2149-7-14**] 10:05AM BLOOD CK-MB-15* MB Indx-7.4* cTropnT-0.74*
[**2149-7-30**] 12:00AM BLOOD Calcium-8.6 Phos-3.1 Mg-1.9
[**2149-7-1**] 02:50PM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2
[**2149-7-18**] 12:00AM BLOOD D-Dimer-1325*
[**2149-7-18**] 12:00AM BLOOD Hapto-337*
[**2149-7-16**] 03:45AM BLOOD D-Dimer-1039*
[**2149-7-15**] 06:45PM BLOOD D-Dimer-1062*
[**2149-7-15**] 02:44AM BLOOD D-Dimer-1068*
[**2149-7-14**] 06:49PM BLOOD D-Dimer-671*
[**2149-7-8**] 08:20AM BLOOD D-Dimer-[**Numeric Identifier 42316**]*
[**2149-7-8**] 12:00AM BLOOD D-Dimer-<150
[**2149-7-7**] 04:15PM BLOOD D-Dimer-> [**Numeric Identifier 3652**]
[**2149-7-7**] 11:00AM BLOOD D-Dimer-GREATER TH
[**2149-7-14**] 12:00AM BLOOD Cortsol-17.2
[**2149-7-23**] 12:00AM BLOOD IgG-949 IgA-154 IgM-66
[**2149-7-18**] 12:00AM BLOOD b2micro-1.8
[**2149-7-15**] 02:16PM BLOOD Type-MIX Comment-GREEN
[**2149-7-15**] 04:52AM BLOOD Type-[**Last Name (un) **] Temp-39.6 pO2-36* pCO2-36
pH-7.44 calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2149-7-14**] 07:10PM BLOOD Type-[**Last Name (un) **] pO2-28* pCO2-33* pH-7.41
calTCO2-22 Base XS--3
[**2149-7-14**] 12:58PM BLOOD Type-MIX pO2-29* pCO2-34* pH-7.42
calTCO2-23 Base XS--2
[**2149-7-15**] 04:52AM BLOOD Lactate-1.2
[**2149-7-14**] 12:58PM BLOOD Lactate-1.0
[**2149-7-15**] 02:16PM BLOOD O2 Sat-88
Echo [**2149-7-3**]
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
elongated. There is mild bileaflet mitral valve prolapse.
Trivial mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined.
Compared with the findings of the prior study (images reviewed)
of [**2149-6-19**], the left ventricular ejection fraction is
increased.
Echo [**2149-7-14**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is moderately depressed (LVEF= 35-40 %) with
hypokinesis of the mid to distal and apical inferior wall,
anterior septum and anterior wall. Right ventricular chamber
size is normal. with focal hypokinesis of the apical free wall.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. 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. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Moderate focal LV hypokinesis. No evidence of
endocarditis - image quality is limited however. Mild mitral
regurgitation. Mild aortic regurgitation. Dilated thoracic
aorta.
Dr. [**Last Name (STitle) 42317**] was notified in person of the results on [**2149-7-14**]
at 11am.
Compared with the prior study (images reviewed) of [**2149-7-3**],
the function of the distal/apical segments is now hypokinetic.
The degree of mitral regurgitation has increased.
Echo [**2149-7-23**]
The left atrium is mildly dilated. The left atrium is elongated.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with hypokinesis of the
apex and mid-distal segments of the anterior, anterior septum,
and infero-lateral walls. The remaining segments contract
normally (LVEF = 40 %). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size is normal. with focal hypokinesis of
the apical free wall. The aortic root is mildly dilated at the
sinus level. The aortic arch is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is a small
circumferential pericardial effusion, more prominent along the
basal infero-lateral wall where it appears small to moderate in
size. The effusion is echo dense, consistent with blood,
inflammation or other cellular elements. There are no
echocardiographic signs of tamponade.
Compared to the prior study dated [**2149-7-14**] (images reviewed),
left ventricular function is similar. The pericardial effusion
is new. The degree of mitral regurgitation has improved
(moderate on the prior study).
Echo [**2149-7-25**]
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). There is a small,
primarily posterior, pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2149-7-23**], the findings are similar.
[**2149-7-11**] CT head without contrast
FINDINGS: There is no evidence of hemorrhage, edema, mass effect
or
infarction. The ventricles and sulci are normal in size and
symmetric in
configuration. There is no shift of normally midline structures.
The
[**Doctor Last Name 352**]-white matter differentiation is well preserved. There is no
acute
fracture. Incidental note is made of a hypoplastic/unpneumatized
right
frontal sinus. The remaining visualized paranasal sinuses and
mastoid air
cells are clear.
IMPRESSION: Normal study.
[**2149-7-14**] EKG
Sinus rhythm. Non-specific septal ST-T wave changes. Compared to
the previous
tracing of [**2149-6-18**] Q waves are not seen in lead III. Anterior T
wave changes
are no longer present.
[**2149-7-14**] CXR
FINDINGS: Single portable frontal view of the chest showed
increase in
pulmonary edema. This is marked by an enlarged cardiac
silhouette and
perihilar congestion. No pleural effusion or pneumothorax. A
right
subclavian line terminates within the right atrium. No focal
consolidation to
suggest pneumonia.
IMPRESSION: Worsening mild pulmonary edema.
[**2149-7-14**] CT chest without contrast
1.Bilateral minimal pleural effusions and dependent lung
atelectasis. There
is no lung consolidation.
2.Mild interstitial pulmonary edema.
3.Recently grown nodule in the superior segment of the right
lower lobe from
5.2 mm to 7.3 mm since [**2149-6-17**] is likely a inflammatory
lymph node. No
new lung nodules of concern. However in view of prior history, a
follow-up CT
is recommended at 6 months to monitor its stability.
4.Stable appearance of dilated esophagus with air-fluid level.
[**2149-7-17**] MRI chest/ mediastinum with contrast
1. Normal left ventricular cavity size with moderate global
hypokinesis. The
LVEF was moderately depressed at 30%. No CMR evidence of prior
myocardial
scarring/infarction.
2. Normal right ventricular cavity size with mild global
hypokinesis. The
RVEF was mildly depressed at 36%. Late gadolinium
contrast-enhanced images
demonstrate areas of hyperenhancement in the distal half of the
right
ventricle. Bright signal on T2 imaging in this region is
suggestive of edema
and the RV wall appears thickened in this region. The
differential diagnosis
includes myocarditis, contusion, or tumor.
3. The indexed diameters of the ascending and descending
thoracic aorta were
normal. The indexed diameter of the main pulmonary artery was
normal.
4. Moderate left and mild right atrial enlargement.
5. Normal coronary artery origins with no evidence of anomalous
coronary
arteries. Further assessment of the coronary artery anatomy was
not possible
due to tachycardia.
6. Small pericardial effusion.
7. No evidence of pericardial constriction found.
8. Increased bilateral moderate pleural effusions, right greater
than left.
Bibasilar atelectasis and/or infection. Thick, enhancing
pericardium.
[**2149-7-19**] CT chest without contrast
1. New scattered ground-glass opacities throughout the upper
lobes
bilaterally, right middle lobe, and lingula are most consistent
with
multifocal (atypical) pneumonia.
2. Increased small bilateral pleural effusions, right greater
than left, with
associated compressive atelectasis.
3. New small pericardial effusion.
4. Patulous esophagus with an air-fluid level, as before.
[**2149-7-19**] CT neck with contrast
1. No evidence of a neck mass or pathologically enlarged lymph
nodes within
the cervical region.
2. Biapical ground-glass opacities within the lungs are most
consistent with
multifocal pneumonia as fully described in the
separately-dictated report of
the concurrent chest.
3. Patulous esophagus with air-fluid level and abundant debris,
not
significantly changed.
4. Small bilateral pleural effusions, right greater than left.
[**2149-7-21**] Bone Marrow Biopsy
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
Hypercellular bone marrow with ~10% CD34 positive blasts,
see note.
Note: By CD34 staining, the number of blasts is increased and
comprises 10% of overall cellularity. While this may be
indicative of residual myeloid disease, the differential
diagnosis is a regenerative marrow. In addition, the marrow is
limited for evaluation due to lack of an aspirate and sampling
(predominantly sub-cortical). Thus a repeat biopsy along with
close clinical follow-up is recommended.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear: Not submitted
Aspirate Smear:
The aspirate material is not submitted due to dry tap.
Clot Section and Biopsy Slides:
The biopsy material is suboptimal for evaluation, and consists
of a small piece of trabecular bone with predominantly
periosteum and cortical bone. The evaluable marrow space is
limited to [**11-24**] intertrabecular spaces. Within this space, the
overall cellularity is approximately 70%. The M:E ratio
estimate is increased. Erythroid precursors are significantly
decreased in number. Myeloid elements are relatively increased
in number and exhibit left-shifted/mildly dyspoietic maturation.
The number of blasts is increased. By CD34+ staining, they
comprise approximately 10%. Megakaryocytes are present in
increased numbers, and are focally loosely clustered, and
exhibit hyper and hypolobated forms. Marrow clot section
contains too few spicules for evaluation.
Clinical: 59 year old male hx AML d+19 from induction 7+3.
Evaluate for ablation/response.
Gross: The specimen is received in one B+ fixative container,
labeled with the patient's name, "[**Known lastname **], [**Known firstname 333**]", the medical
record number, and additionally labeled "M11-530". It consists
of a bone marrow core measuring 0.9 x 0.2 cm in diameter,
entirely submitted in cassette A following decalcification.
Also in the same container are multiple irregular portions of
clot measuring up to 0.8 x 0.3 x 0.2 cm in aggregate, entirely
submitted in cassette B.
Brief Hospital Course:
59 y/o M with new diagnosis of AML, presenting for scheduled
induction chemotherapy with the 7+3 regimen.
.
#AML: NPM+ve, FLT3-ve disease with 8% blasts. Echocardiography
on [**2149-7-3**] showed improved ejection fraction from previous
admission. EF was 55%. Started induction chemo with 7+3
[**2149-7-3**]. Patient had significant nausea during chemotherapy,
and was therefore started on 10 mg IV dexamethasone daily for
the duration of chemotherapy administration. He also received
zofran, compazine and ativan. Following cessation of
chemotherapy, nausea improved, but he then became very nauseous
on [**2149-7-11**]. CT head on [**2149-7-11**] was negative for any acute
intracranial process. On [**7-14**], the patient was transferred to
the ICU for refractory hypotension in the setting of fevers (see
below). His counts nadired and then returned. He was no longer
neutropenic at thetime of discharge. Repeat bone marrow biopsy
was performed on day 19, but showed 10% blast, consistent with
either disease remnants or regenerating marrow. he patient will
need outpatient followup and repeat bone marrow biopsy following
discharge.
.
# Neutropenic fevers: Following chemotherapy, Mr. [**Known lastname **]
developed fevers starting [**2149-7-13**]. He was started on empiric
vancomycin and cefepime, but continued to spike fevers, with
rigors and hypotension to 70/40 on the night of [**2149-7-13**].
Micafungin was then added to broaden his antibiotic coverage.
On the morning of [**2149-7-14**], he became hypotensive once again,
with blood pressure refractory to 3L NS bolus. EKG showed
abnormal, low-voltage R waves in aVL and I. Echocardiogram
showed apical akinesis and reduced EF of 35-40%. He was
transferred to the ICU for management of hypotension. He
continued to be neutropenic and febrile in the ICU. Blood
cultures were sent each time he spiked, all showing no growth.
A sputum culture showed upper respiratory flora and was
nondiagnostic. The patient did not stool, so C diff could not
be sent. Per ID recommendations, he was also sent for
crypto/histo, clymydia, mycoplasma, enterovirus serologies. He
finished his last day of doxycycline for possible lyme disease
while in the ICU, but was started on
vanc/meropenem/voriconazole/flagyl for empiric coverage of an
infectious source. CT chest/neck revealed multilobar atypical
pneumonia and bilateral effusions; cardiac MRI showed
pericarditis. [**Location (un) **] B23 serology was positive.Voriconazole
led to visual hallucinations and was changed to ambisome for
aspergillosus coverage, but ambisome caused hypokalemia and was
eventually altered to posaconazole. B-glucan and aspergillus
galactomannan were negative, but his fevers improved once
ambisome was started. His fevers resolved and he was no longer
neutropenic at the time of discharge.
# Tumour lysis: Patient was started on allopurinol 300 mg daily
prior to starting chemotherapy, but LFTs became elevated.
Allopurinol was therefore discontinued, and Mr. [**Known lastname **] was given
aggressive hydration prior to induction. LFTs trended down and
normalized rapidly. however, uric acid trended up, highest at
9.8. Allopurinol was then reinitiated at 100 mg qday, and
bicarbonate hydration was initiated. Tumor lysis labs
subsequently trended down, and allopurinol was discontinued
following cessation of chemotherapy.
.
# Low fibrinogen: Mr. [**Known lastname 42318**] fibrinogen trended down from
admission until [**2149-7-8**], lowest at 13. D-dimers were also
found to be elevated at >21,000 on [**2149-7-7**] and FDP was 80-160.
However, no clinical evidence of bleeding or clotting, and the
patient was asymptomatic. He was administered 1 unit of
cryoprecipitate on [**2149-7-8**]. Fibrinogen subsequently
stabilised, and began to rise.
# Hypotension: Patient developed refractory hypotension on [**7-14**]
and was transferred to the ICU for closer monitoring.
Hypotension thought to be due to a mixed septic and cardiogenic
process. TTE showed depressed cardiac function supporting
cardiogenic shock, but mixed venous O2 sat was 88, thus was less
concerning for cardiogenic process. After fluid resuscitation,
patient maintained a SBP around 90s-100s. His lactate remained
stable around ~1. He was not started on pressor support and his
home lisinopril was held. Patient's blood pressure improved by
ICU day 2 to be discharged back to the floor.
# Cardiac dysfunction: Upon transfer to the ICU, EKG showed new
non-specific changes (loss of R wave in I and aVL) that were not
suggestive of focal ischemia. Echo shows newly depressed EF of
35-40% since [**7-3**] and moderate focal LV hypokinesis. Troponins
were elevated to 0.74 and then continued to trend up to 3.26 by
ICU day 2. Cardiology was consulted, and differential included
demand ischemia [**12-25**] sepsis (hypotension and tachycardia),
myocarditis/pericarditis secondary to anthracycline therapy (too
early out from 7+3 to get cardiomyopathy) or a viral
myocarditis. Patient was not started on a heparin drip due to
low platelets, as the risk of bleeding was thought to outweight
the risk of demand ischemia. Patient was given oxygen, his
electrolytes were repleted and he was monitored on telemetry.
He was transfused to a goal hct of 28, but his hematocrit only
reached 25 because he became too febrile to transfuse. Cardiac
MRI was performed (since patient was not a candidate for cardiac
catheterization), but showed no evidence of thrombus, instead
showing evidence of peri/myocarditis, likely secondary to viral
infection ([**Location (un) **] B was positive), although Chagas disease
(with previous borderline Chagas IgG) and chemotherapy remain
possible etiologies. On the floor he became tachycardic with
NSVTs, and was rate controlled with metoprolol. He was also
found to be hypokalemic foloowing treatment with ambisome.
Ambisome was discontinued and his electrolytes were repleted.
His tachycardia resolved and he was stable on metoprolol prior
to discharge
# Thrombocytopenia: Mr. [**Known lastname **] has a long history of
thrombocytopenia. Following chemotherapy, he became
appropriately thrombocytopenic, and was administered platelets
when counts fell below 10. He received HLA-matched platelets
from the blood bank.
#Elevated INR: Patient's INR was elevated in the ICU, most
likely because he was getting a lot of abx, he was malnourished.
He did not appear to have liver synthetic dysfunction, was not
being anticoagulated, and did not have evidence of DIC per his
labs. He was given Vitamin K 5mg PO.
# Anemia: Mr. [**Known lastname **] became anemic following chemotherapy, and
was administered blood as required for Hct<24. While in the
ICU, due to his uptrending troponins and suspected demand
ischemia, his transfusion goal was 28. There was also concern
for autoimmune hemolysis given pro-inflammatory state in the
setting of myo-pericarditis. He was given transfusions of PRBCs
as required to a goal Hct of 25.
#Red eye: Patient developed a red eye on [**2149-7-14**]. He was seen
by ophthalmology, who diagnosed conjunctivitis with no
episcleritis/ iritis. He was treated with polytrim eye drops
and his symptoms resolved.
# Urticaria: Mr. [**Known lastname **] had a recurrence of his ongoing urticaria
on admission. He was started on fexofenadine, ranitidine and
diphenhydramine and his symptoms subsided. His hives remained
under control for the remainder of this hospitalization.
#Hyperlipidemia: Rosuvastatin was held during chemotherapy.
Medications on Admission:
levofloxacin 750 mg PO ONCE Duration: 1 Doses Order date: [**6-19**]
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Fever Order date: [**6-19**]
CefePIME 2 g IV Q8H Order date: [**6-19**]
Doxycycline Hyclate 100 mg PO Q12H Order date: [**6-19**] @ 2119
Fluconazole 400 mg PO/NG Q24H treat for one week, day 1=
[**2149-6-18**]
Respiratory:
Ipratropium Bromide Neb 1 NEB IH Q 4 HR PRN sob, hypoxia
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob Order date: [**6-19**]
Other:
Morphine Sulfate 2-4 mg IV Q4H:PRN pain Order date: [**6-19**] @ [**2079**]
Allopurinol 300 mg PO/NG DAILY Order date: [**6-19**] @ [**2079**]
Magnesium Sulfate Replacement (Oncology) IV Sliding Scale
Acetaminophen 650 mg PO/NG Q6H:PRN fever, pain
Omeprazole 40 mg PO BID
Ondansetron 4 mg IV Q8H:PRN nausea Order date: [**6-19**]
Calcium Carbonate 500 mg PO/NG [**Hospital1 **] PRN acid/reflux Order date:
[**6-19**] OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain,
body aches, headache Order date: [**6-19**] @ [**2079**]
Potassium Chloride Replacement (Oncology) PO Sliding Scale
Docusate Sodium 100 mg PO BID
Phytonadione 5 mg PO/NG DAILY Duration: 3 Days
Ranitidine 150 mg PO/NG ONCE Duration: 1 Doses
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Order date: [**6-19**] @ [**2079**]
Lisinopril 20 mg PO/NG DAILY
Lorazepam 1 mg PO/NG QHS PRN insomnia Order date: [**6-19**] @ [**2079**]
traZODONE 25 mg PO/NG HS:PRN insomnia Order date: [**6-19**] @ [**2079**]
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. posaconazole 200 mg/5 mL (40 mg/mL) Suspension Sig: One (1)
200mg PO Q8H (every 8 hours).
Disp:*90 200mg* Refills:*2*
5. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. rosuvastatin Oral
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
8. prochlorperazine maleate 5 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
acute myeloid leukemia
anemia
thrombocytopenia
pneumonia
hypotension
myocarditis
pericarditis
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 1170**] for chemotherapy for acute myeloid leukemia. Your
hospital stay was complicated by hypotension, infection of your
heart, fever, and pneumonia. You have recovered from these
complications. You will need to returned to the hospital for
follow up for acute myeloid leukemia.
Medication changes:
Start taking Acyclovir 400 mg by mouth three times a day;
Start taking Posaconazole Suspension 200 mg by mouth three times
a day;
Start taking lisinopril 5mg by mouth daily;
Start taking Metoprolol 150mg by mouth daily;
Continue taking Crestor as prescribed;
Continue taking Zolpidem 5mg by mouth at night as needed for
insomnia;
Continue taking Omeprazole as prescribed.
Followup Instructions:
At the time that I finalized this discharge, we hadn't formally
arranged your follow up time with Dr. [**Last Name (STitle) **]. You will be
contact[**Name (NI) **] about this [**Name (NI) 2678**].
Department: CARDIAC SERVICES
When: WEDNESDAY [**2149-8-6**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: DERMATOLOGY AND LASER
When: MONDAY [**2150-1-26**] at 3:45 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 4961**], MD [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2149-8-1**]
|
[
"995.92",
"420.90",
"238.75",
"E849.7",
"276.3",
"288.00",
"V02.54",
"511.9",
"215.5",
"696.0",
"423.9",
"112.0",
"277.88",
"V58.11",
"286.9",
"787.01",
"991.6",
"E933.1",
"518.0",
"425.4",
"401.9",
"088.81",
"372.30",
"564.00",
"205.00",
"287.5",
"422.90",
"780.61",
"038.9",
"272.4",
"708.9",
"787.91",
"785.52",
"486",
"780.64",
"790.6",
"276.69",
"518.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.31",
"99.25",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
57776, 57782
|
47858, 55399
|
22536, 22590
|
57920, 57920
|
26024, 47835
|
58833, 59718
|
25100, 25384
|
56889, 57753
|
57803, 57899
|
55425, 56866
|
58071, 58416
|
25399, 25434
|
25456, 26005
|
23792, 24044
|
58436, 58810
|
22459, 22498
|
22618, 23773
|
57935, 58047
|
24066, 24868
|
24884, 25084
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,536
| 195,186
|
31887
|
Discharge summary
|
report
|
Admission Date: [**2111-11-18**] Discharge Date: [**2111-11-29**]
Date of Birth: [**2048-2-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
EEG Monitoring
History of Present Illness:
63 y.o. female with history of seizures and CVA as well as
multiple abdominal surgeries and recent mesenteric ischemia s/p
bowel resection who was admitted to the general medicine floor
lastnight for confusion, hallucinations, increased falls and
worsened abdominal pain. In the ED, she was evaluated by
neurology where an LP was done and was normal and a CT head
showed posterior reversible leukoencephalopathy vs. multiple old
CVAs. She was additionally seen by surgery to evaluate abdomen
and drains were felt to be in place and working well.
.
This morning, patient was found unresponsive by nurse with right
arm twitching, concerning for a seizure. Of note, patient has
history of a seizure disorder since [**2108**] and was on Dilantin
until one month ago when it was stopped because of problems with
line clogging. She was then switched to [**Year (4 digits) 13401**] 500 mg [**Hospital1 **]. She
was also recently taken off of Klonopin. Patient was only
responsive to sternal rub this morning and a trigger was called
for change in mental status. She was given a total of 6 mg of
Ativan with improvement of twitching. She was additionally
loaded with Dilantin after which her blood pressure dropped to
SBP of 80s. She received a 500 cc bolus with improvement of her
BP. The stroke fellow was notified and requested a stat CTA head
perfusion study. Patient was transferred to the ICU for further
management.
Past Medical History:
PVD
L subclavian stenosis s/p bypass
HTN
Hyperlipidemia
COPD
s/p appendectomy
s/p tonsillectomy
Seizure d/o - since [**2108**]
CVA '[**08**]
bilateral CEA
cholecystectomy
SBO s/p bowel resection
Mesenteric ischemia s/p further bowel resection with jejunostomy
Social History:
Married female living with husband. Unknown occupation status.
Smokes cigarettes: unknown amount, denies alcohol/illicit drug
Family History:
n/c
Physical Exam:
General: Cachectic, mute and largely unresponsive, though she
does withdraw from sternal rub
HEENT NC/AT; PERRLA,
CV: S1,S2 nl, no m/r/g appreciated
Lungs: CTAB anteriorly
Abd: Soft with old surgical scars and G and J tubes,
well-appearing
Ext: No c/c/e
Neuro: Limited due to patient's inability to cooperate, but
notable for 2+ bilateral biceps reflexes, but otherwise reflexes
could not be elicited; upgoing toes bilaterally;
Skin: No lesions
Pertinent Results:
CT Head ([**11-18**]): Confluent subcortical white matter hypodensity
in the frontal and parieto-occipital lobes bilaterally, most
likely representing chronic subcortical infarcts. Given the
distribution, another differential consideration would include
PRES, which does not appear concordant with the clinical
presentation.
.
CXR ([**11-18**]): No acute cardiopulmonary process. Evidence of old
granulomatous disease.
.
CSF:
#2
Chemistry: Protein 57 Glucose 61
.
#4
WBC 0 RBC 0
Poly 0 Lymph 70 Mono 30 EOs
.
Ammonia: 25
.
138 99 29
--------------< 117
4.0 32 0.4
Ca: 8.8 Mg: 2.1 P: 4.9
ALT: 73
AP: 276
Tbili: 0.3
Alb: 2.9
AST: 47
[**Doctor First Name **]: 69 Lip: 78
.
WBC: 8.8
HCT: 36
PLT: 337
N:70.0 L:24.8 M:4.3 E:0.7 Bas:0.1
.
PT: 13.3 PTT: 27.0 INR: 1.1
Brief Hospital Course:
63 y.o. female with multiple medical problems, admitted for
confusion and ?gait instability treating in MICU for ? seizure
vs status.
.
Seizure: Patient has a history of seizures and had been on
Dilantin, which was switched to [**Doctor First Name 13401**] because of problems with
a clogged PICC, though [**Name (NI) 13401**] was subtherapeutic. Transferred
to MICU for episode of status vs seizure. She was dilantin
loaded and continued on [**Name (NI) **]. Dilantin levels monitored
closely and doses titrated for goal corrected level 20-25.
Continuous EEG performed without evidence of seizures.
.
Delirium: Likely multifactorial. ID w/u revealing for GNR in
blood (details below) potentially contributing. LP negative.
No evidence of seizures on EEG. Likely significant contribution
of PRESS syndrome(posterior reversible leukoencephalopathy)
causing visual hallucinations from the occipital lobes which was
managed as below. Intermittently responded to Zydis. Her pain
was treated with dilaudid and then morphine elixir after
palliative care consult with question of contribution. She was
eventually started on standing ativan with improved agitation.
.
Reversible posterior leukoencephalopathy syndrome: Seen on MRI.
This could account for hallucinations, altered ms, and seizures.
Pls see neurology notes for details. Thought [**1-30**] hypertension,
which occurs in setting of pain. We maintained goal SBP 140
given proven improvement in sx with good BP control. Were not
more aggressive given hx of bowel ischemia.
.
ID: Grew 2/2 bottles GNR from Hickman cath on presentation to
MICU. Other blood cx negative. Repeat CT abd performed which
showed no evidence of bowel or intraabdominal abscess. Surgery
was consulted and did not recommend surgery or change of line.
Recommended treating through it and she received a 14 day course
of ceftriaxone.
.
Hx of bowel ischemia s/p resection: as above. Surgery followed
pt. Repeat imaging showed no abscess for drainage. Pain
control as below
.
Chronic Pain: In the setting of multiple abdominal surgeries.
Pain medications intially minimized to assess mental status.
These were added back and she was relatively well controlled
with dilaudid IV prn. Fentanyl patch was added back. At the
recommendation of palliative care, dilaudid was changed to
morphine elixir for ease of transition to home.
.
Psych: On multiple medications for depression/anxiety.
- Continued Venlafaxine. Held Restoril given somnolence
.
FEN: She was profoundly malnurished. TPN for nutrition.
.
Access: Right Hickman, left PIV
.
Code: DNR/DNI
.
Dispo: After long discussion with the patient and her family,
patient expressed wishes to go home with hospice. With the help
of the palliative care team, she was transitioned to morphine
and fentanyl for pain, ativan for agitation, and per neuro PR
[**Month/Day (2) **] for seizures. She will not be going home with any IV
medications and the Hickman will not be used any longer. Goals
of care is patient's comfort. She will be receiving home hospice
while at home.
Medications on Admission:
Medications (as an outpatient):
Dilaudid 2mg IV q4H PRN pain
Desenex 2% topical PRN
Tylenol 650mg po q6H PRN pain
Flexeril 10mg po TID PRN spasm
Percocet 1 tab po q4H PRN pain
Compazine 10mg IM q6H PRN nausea
Fentanyl patch 25mcg
KCl elixer 40meq po BID
Calcium carbonate 1250mg po BID
Ativan 2mg po q4H
Zofran 4mg IV q4H PRN
Plavix 75mg po daily
Prevacid 30mg po daily
Vit B12 1000mcg IM qmonth
MSIR 15mg po q4H
Restoril 15mg QHS
Effexor 37.5mg po BID
[**Month/Day (2) 13401**] 500 mg [**Hospital1 **]
.
Allergies/Adverse Reactions: NKDA
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
1. delerium
2. PRESS syndome
3. hypertension
Secondary:
1. mesenteric ischemia
2. epilepsy
3. peripheral vascular disease
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as prescribed
Followup Instructions:
Please follow up with your Primary Care Provider as needed.
Continues with hospice care
Completed by:[**2111-11-29**]
|
[
"496",
"V44.4",
"272.4",
"345.90",
"557.9",
"790.7",
"401.9",
"261",
"579.3",
"999.31",
"338.29",
"V12.54",
"323.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
7186, 7235
|
3536, 6596
|
334, 350
|
7411, 7420
|
2723, 3513
|
7511, 7632
|
2237, 2242
|
7256, 7390
|
6622, 7163
|
7444, 7488
|
2257, 2704
|
278, 296
|
378, 1795
|
1817, 2078
|
2094, 2221
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,588
| 168,548
|
19710
|
Discharge summary
|
report
|
Admission Date: [**2188-12-1**] Discharge Date: [**2188-12-1**]
Date of Birth: Sex: F
Service: GOLD [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: Patient is a 73-year-old female
with a history of hypertension and asthma who presents to [**Hospital3 **] [**Hospital 5503**] Hospital on [**2188-11-29**] with left arm pain
with subcutaneous gas. The patient was admitted to the
intensive care unit, intubated, and resuscitated and treated
with intravenous antibiotics.
Patient was taken to the operating room in the early a.m. on
[**2188-11-30**] for exploration and found to have necrotic muscle
and thrombosed vessels. Patient underwent a proximal upper
extremity amputation and exploration and debridement of
intramammary fold and left abdominal wall. Patient was taken
to intensive care unit for continued resuscitation and
intravenous antibiotics. Patient was transferred to [**Hospital6 1760**] for further management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Asthma.
3. Anxiety.
PAST SURGICAL HISTORY:
1. Hysterectomy.
2. As noted in the History of Present Illness.
MEDICATIONS ON ADMISSION FROM TRANSFER:
1. Vasopressin intravenously.
2. Dopamine intravenously.
3. Levophed intravenously.
4. Bicarbonate intravenously.
5. Vancomycin.
6. Rocephin.
7. Clindamycin.
8. Protonix 40 mg intravenously q. day.
ALLERGIES: Penicillin--Questionable validity.
PHYSICAL EXAMINATION: Patient is afebrile to 101.1, sinus
tachycardiac at 130, pressure is 120/72. Patient is on
assist control at 500 with a gas of 7.27, 28, 96, 13, and -12
with a saturation of 98%. Patient is sedated and intubated.
Left neck is significant for necrotic tissue. Chest has
decreased breath sounds bilaterally at the bases. Heart is
regular rate and rhythm and sinus tachycardiac. Abdomen is
distended with a low midline incision. Extremities exam is
significant for amputated left arm, extensive bullae and
purple colored skin with crepitus of the left neck, back, and
chest. Rectal exam is guaiac negative with normal tone.
LABORATORY DATA ON ADMISSION: Patient had a white count of
22.4, hematocrit of 43.7, platelets of 125, sodium 137,
potassium 5.9, chloride 98, bicarbonate 13, BUN 40, and
creatinine 3.0 with a glucose of 89. Coags were INR of 2.7,
ALT was 2384, ALT of 1338, alkaline phosphatase 162, and
total bilirubin 3.0.
Gram stain from wound culture grew out a gram positive
bacilli.
SUMMARY OF HOSPITAL COURSE: Patient is a 73-year-old female
who is critically ill with multi-organ failure due to severe
left upper extremity necrotizing fasciitis and anaphylactic
shock, renal failure, and acidemia. The patient was
aggressively resuscitated for approximately one hour and
received four units of fresh frozen plasma. Infectious
Disease and Plastic Surgery consulted immediately, and
patient was taken to the Operating Room emergently.
Infectious Disease recommendations included Clindamycin,
Vancomycin, Ceftriaxone, and Flagyl. Patient was taken to
the Operating Room for debridement of left upper extremity
necrotizing fasciitis, disarticulation of the humerus from
the scapula and clavicle, soft tissue debridement coverage
with dressing.
Patient was transferred emergently to the Intensive Care Unit
for further resuscitation. Later on in the day patient had
continued renal failure, respiratory failure, and high
pressures. Dr. [**First Name (STitle) 2819**], Surgical Attending on call, determined
that satisfactory results with any functional recovery was
highly unlikely.
Detailed discussions with the family before and after the
surgery were performed and the patient was removed from
support on [**2188-12-1**] at 10:25 p.m. Patient was declared
with no rhythm, no spontaneous breathing, and no pulse.
Postmortem was approved.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2189-3-7**] 18:16
T: [**2189-3-10**] 15:19
JOB#: [**Job Number 53308**]
|
[
"584.9",
"995.92",
"038.8",
"041.10",
"728.86",
"518.81",
"785.52",
"040.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.08",
"85.47",
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
1057, 1419
|
2477, 4070
|
1442, 2087
|
185, 968
|
2102, 2448
|
990, 1034
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,729
| 151,116
|
19387
|
Discharge summary
|
report
|
Admission Date: [**2179-1-9**] Discharge Date: [**2179-1-21**]
Date of Birth: [**2108-4-4**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Zofran / Seroquel
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Hypoxia, cough
Major Surgical or Invasive Procedure:
Endotrachial intubation
History of Present Illness:
Pt is a 70 yo man w/ h/o COPD, O2 dependant (on 2L NC at home)
presented to ED w/ c/o dyspnea, orthopnea, cough x 1 day.
On presentation to [**Name (NI) **], pt noted to be hypoxic to 80% on home O2
--> 90's on 3-4L, BP initially 99 --> 120's w/ IVF, afebrile.
Noted to be using accessory muscles to breath and was tripoding,
improved somewhat w/ non-rebreather, but c/o tiring, so was
intubated. Peri-intubation, had transient decrease BP to 80's
--> 100 w/ IVF.
In [**Name (NI) **], pt was evaluated w/ CXR demonstrating R > L infiltrates,
so was given cefepime and levoflox. Also got solumedrol 125mg
IV x 1, combivent nebs for probable COPD flare.
Also had EKG demonstrating 1mm STE in V1, V2, V3. CE noted to
be CK 154, MB 13, index 8.4, trop 0.82. Cards consulted and
decided no intervention in cath lab for now. Pt started on
heparin gtt, given ASA, plavix load, no BB given COPD, no nitro
gtt b/c no c/o CP and borderline low BPs.
Past Medical History:
1) COPD on 2L home O2 (FEV1 1.17L (35% pred) in [**2175**]),
steroid-dependent
2) HTN
3) UC
4) BPH
5) Nephrolithiasis
6) Stage III CKD Cr 1.5 thought due to recurrent nephrolithiasis
7) L sided nephrostomy tube [**12-26**] nephrolithiasis
8) ?Paroxysmal AFib
Social History:
Tob: 100pk yr hx; quit 8 yrs ago. Etoh: none. No IVDU. Currently
retired.
Family History:
FH
Physical Exam:
Vitals - T 97.6, HR 100, BP 105/56, RR 26, O2 98% on AC/FiO2
1.0/TV 400/RR 14/PEEP 5
Gen - Intubated, resp distress w/ use of accessory muscles,
awake, following commands
HEENT - dry MM
CVS - RRR, no noted m/r/g
Lungs - Diffuse exp wheezes w/ some exp rhonci/crackles at bases
b/l
Abd - soft, NT/ND
Ext - [**11-25**]+ LE edmea b/l
Pertinent Results:
[**2179-1-9**] 02:45PM WBC-22.6*# RBC-3.62* HGB-10.9* HCT-34.4*
MCV-95 MCH-30.0 MCHC-31.6 RDW-14.6
[**2179-1-9**] 02:45PM NEUTS-93.6* BANDS-0 LYMPHS-4.5* MONOS-1.6*
EOS-0.1 BASOS-0.1
[**2179-1-9**] 02:45PM GLUCOSE-77 UREA N-19 CREAT-1.5* SODIUM-141
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-25 ANION GAP-19
[**2179-1-9**] 02:45PM CALCIUM-9.2 PHOSPHATE-4.6* MAGNESIUM-2.0
[**2179-1-9**] 02:45PM cTropnT-0.82*
[**2179-1-9**] 02:45PM CK-MB-13* MB INDX-8.4*
[**2179-1-9**] 03:20PM URINE BLOOD-LG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2179-1-9**] 03:20PM URINE RBC-21-50* WBC->50 BACTERIA-MANY
YEAST-FEW EPI-[**1-27**]
Brief Hospital Course:
1. Respiratory failure:
Patient has a history of severe COPD, O2 and steroid dependent,
and presents with acute worsening SOB requiring intubation on
presentation. Initial CXR demonstrated bilateral lower lobes
opacities consistent with multifocal pneumonia. He had DFA sent
which was positive for influenza A. He was treated with both a
5 day course of tamiflu as well as Ceftriaxone and azithromycin
for a possible underlying pneumonia.
He was also treated for COPD flare, as his lung exam was quite
wheezy on initial presentation, so was treated with solumedrol,
converted to prednisone taper, as well as combivent MDI.
Patient underwent extubation during MICU course with failure x
2, requiring re-intubation. There was felt to be a volume
overload component, as the patient was quite hypertensive
peri-extubation, leading to volume overload in his lungs. His
BP and volume status were optimized prior to 2nd extubation, but
this also faiiled due to tachypnea --> autopeep, requiring
re-intubation. He then was tried on permissive hypercapnea, by
increasing his sedation, decreasing his respiratory rate, and
allowing his PaCO2 increase (as at baseline patient's HCO3 in
30's, so likely lives at PaCO2 in 60's). His anti-anxiety
regimen was also optimized as it was felt that he had a large
anxiety component peri-extubation causing tachypnea -->
autopeep. 3rd extubation attempt occurred on [**1-19**] and was
successful. The patient was stable on 5l NC. He is on home 2-4L
NC and prednisone 5 mg daily. He was also started on advair
500/50 [**Hospital1 **] and spiriva. He was kept on albuterol MDI prn, and
taken off atrovent because of mucus plugging.
2. STEMI: Pt noted to have 1mm STE in leads V1, V2, V3 in ED.
Also positive cardiac enzymes (elevated index and trop, but CK
peak only 157). Cardiology notified on presentation and opted
not to take patient to cath lab urgently. Patient was initially
started on heparin drip x 48 hrs (now off), started aspirin
325mg PO daily, plavix load given in ED then maintained on
plavix 75mg daily, maintained on beta blocker and started on
lipitor 80mg daily. ECHO during hospital course was of poor
quality, but demonstrated a depressed ejection fraction of
45-50%, septal hypokinesis, could not assess for focal wall
abnormalities. Cardiology followed along during hospital course
but deferred catheterization. He will need cardiology follow
up.
3. Hypotension: Patient with episode of hypotension in ED, very
fluid responsive per report. Felt to be due to dehydration
given infection, less likely sepsis given nromal lactate in ED,
also contribution of intubation/medication given
peri-intubation. BP resolved with IVF on day of admission and
remained stable/hypertensive (as above) during hospital course.
He was continued on his home [**Last Name (un) **] and started on metoprolol and
uptitrated to 75 mg tid.
4. Anemia: Patient with Hematocrit drop from 34 --> 24 on
admission. Baseline Hct appears to be around 30. Felt to be
hemoconcentrated on admission, dilutional with IVF. Hct
returned to baseline and remained at baseline during remainder
of hospital course.
5. Nephrolithiasis/CKD: Patient with baseline Cr 1.5, at
baseline on presentation, remained at baseline throughout
hospital course. Has Left sided nephrostomy tube in place to be
follow up as an outpatient.
6. Urinary tract infection: Patient had positive U/A on
admission. Urine culture grew e coli and enterococcus, now
status post antibiotic therapy.
7. Hypertension: Managed with diovan and metoprolol,
transiently on nitroglycerin drip peri-extubation.
8. Atrial fibrillation: Patient with history of AFib in setting
of intubation in past. Not anti-coagulated. Digoxin was held
on admission, patient remained in normal sinus rhythm. He will
be treated with a beta blocker and continued on full aspirin. He
will need cardiology follow up.
10. Anxiety: Per history, patient with large anxiety component
to shortness of breath, has led to difficulty extubating in
past. Noted during hospital course with failed extubations as
above. Managed with zyprexa PRN, precedex peri-extubation. Had
paradoxical reaction to ativan, so benzos were avoided.
Code status: Full
Communication:
Wife [**Name (NI) 37953**]: (c) ([**Telephone/Fax (1) 52726**], (h) ([**Telephone/Fax (1) 52727**]
Son [**Name (NI) **]: (h) ([**Telephone/Fax (1) 52728**], (c) ([**Telephone/Fax (1) 52729**]
Medications on Admission:
Diovan 80 mg [**Hospital1 **]
Flomax 0.4 mg daily
Spiriva daily
Calcium 1,500 mg [**Hospital1 **]
Multivitamin daily
Albuterol Neb q 6-8 hrs PRN
Proscar 5 mg daily
Simvastatin 80 mg daily
Digoxin 125 mcg daily
Prednisone 5 mg daily
Mucinex 600 mg [**Hospital1 **]
Serevent Diskus 50 mcg [**Hospital1 **]
Pulmicort Flexhaler 180 mcg 2 puff [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inhalation
Inhalation Q4H (every 4 hours) as needed.
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
8. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension Sig: One
(1) tablet PO TID (3 times a day).
9. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Please taper slowly over 2 weeks.
13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inhalation
Inhalation every six (6) hours.
14. Ipratropium
1 nebulizer q6h
Duration: ongoing
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) tablet PO BID
(2 times a day).
17. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
19. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
1. Influenza A
2. Hypoxic Respiratory Failure
3. Community acquired pneumonia
4. Myocardial Infarction
Discharge Condition:
Stable, patient breathing comfortably
Discharge Instructions:
You were admitted with acute respiratory failure and required
intubated. Your were treated for a COPD exacerbation, pneumonia
and the flu. Your respiratory status has since stabilized.
Please take all of your medications as prescribed.
You were noted to have had a small heart attack while you were
here. You were seen by the cardiologist. They discussed
cardiac catheterization extensively, but ultimately recommended
managing you medically with aspirin, plavix, lipitor and a beta
blocker. You should have outpatient follow up with a
Cardiologist to discuss this plan further.
Please follow up with your primary care physician within one
week of discharge.
Followup Instructions:
Please follow up with your primary care physician within one
week of discharge.
Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2179-1-26**] 2:50
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2179-4-15**] 3:10
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2179-4-15**] 3:30
|
[
"487.0",
"410.71",
"599.0",
"276.2",
"995.92",
"600.00",
"276.51",
"038.9",
"V44.6",
"592.0",
"403.90",
"556.9",
"427.31",
"491.21",
"518.81",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"96.04",
"96.72",
"99.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9330, 9409
|
2763, 7207
|
301, 326
|
9564, 9603
|
2062, 2740
|
10317, 10841
|
1691, 1695
|
7614, 9307
|
9430, 9543
|
7233, 7591
|
9627, 10294
|
1710, 2043
|
247, 263
|
354, 1300
|
1322, 1583
|
1599, 1675
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,588
| 187,314
|
34265
|
Discharge summary
|
report
|
Admission Date: [**2138-4-21**] Discharge Date: [**2138-5-3**]
Date of Birth: [**2060-3-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
78 M c hx of bronchiectasis, s/p R sided lobectomy who p/w
dyspnea while at rehab. Underwent L TKR ([**Date range (1) 39099**]) for
osteoarthritis at NEBH. Postoperatively, required
hospitalization ([**Date range (1) 36015**]) at NEBH for dyspnea/hypoxia
attributed to pneumonia and was treated with 10 day course of
ceftriaxone/azithromycin. Over the last 2-3 days, has had
worsening dyspnea with exertion and productive cough c
whitish-clear sputum. At baseline, pt. able to walk upto 1
flight of stairs; recently developing dyspnea with movement.
This afternoon, while at rehab, pt. developed significant
dyspnea while walking to bathroom and ambulance called.
.
In the ED, the pt. hypoxic to mid 80s while on 5L N/C. O2 sats
in mid 90s on NRB. EKG c new RBBB. Underwent CXR c/w L sided
PNA. CTA chest done to exclude PE (no PE noted). Received
levofloxacin and piperacillin-tazobactam in ED and admitted for
HCAP.
Past Medical History:
1. Bronchiectasis - diagnosed in [**2089**] [**1-18**] chronic cough.
Underwent R lower lobectomy with improvement of symptoms.
2. HTN
3. Hypercholesterolemia
4. Gout
5. Mitral Valve Prolapse
6. Osteoarthritis
7. Depression
8. Hemachromatosis - undergoes phlebotomy every other month
9. Subacute bacterial endocarditis - [**2113**] c septic emboli
10. CVA [**2113**]
11. Restless legs syndrome
.
PSH:
1. Tonsillectomy in [**2059**]
2. Right lobectomy for bronchiectasis in [**2096**]
3. Laminectomy in [**2097**]
4. Craniotomy for unruptured cerebral aneurysm [**2127**]
5. Right total hip replacement in [**4-/2136**]
6. L3-L5 laminectomy in [**2135**]
7. Left TKR [**3-/2138**]
Social History:
Smoked 22 years, 1.25 ppd. Quit at age 37. Drinks a cup of
wine each night. No drugs. Lives with his wife. [**Name (NI) **] 2 grown
daughters. Worked as a CPA in the [**2089**]. Served in the
Air-Force in the USA in the early [**2079**]. No recent travel
outside the country.
Family History:
Brother died of complications [**1-18**] COPD in 70s
Physical Exam:
VS- 98.1, 86, 145/79, 95% NRB, RR 20-30
GEN- Elderly man appears fatigued with NRB over face, able to
have conversation
HEENT- no elevation of JVP, anicteric sclerae, dry MM
LUNGS- scattered crackles b/l lung fields
HEART- RRR, S1, S2, + [**3-23**] SM c/w MR
[**Last Name (Titles) **]- soft, ND, NT, BS+
EXTRE- wwp, no edema. 10 cm linear scar over midline L knee,
well healed. No erythema/cords/swelling over L leg
NEURO- A*O*3, moving all extremities
Pertinent Results:
ADMISSION LABS
[**2138-4-21**] 06:30PM BLOOD WBC-9.9 RBC-4.11* Hgb-13.9* Hct-40.0
MCV-97 MCH-33.7* MCHC-34.6 RDW-15.5 Plt Ct-304
[**2138-4-21**] 06:30PM BLOOD Neuts-80.4* Lymphs-12.1* Monos-6.1
Eos-0.9 Baso-0.3
[**2138-4-21**] 06:30PM BLOOD Plt Ct-304
[**2138-4-21**] 06:51PM BLOOD PT-14.1* PTT-30.6 INR(PT)-1.2*
[**2138-4-23**] 06:26PM BLOOD ESR-109*
[**2138-4-21**] 06:30PM BLOOD Glucose-126* UreaN-18 Creat-0.8 Na-135
K-4.7 Cl-97 HCO3-27 AnGap-16
[**2138-4-21**] 06:30PM BLOOD CK(CPK)-36*
[**2138-4-22**] 03:14AM BLOOD ALT-23 AST-23 LD(LDH)-348* AlkPhos-119*
TotBili-1.1
[**2138-4-21**] 06:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2138-4-22**] 03:14AM BLOOD cTropnT-<0.01 proBNP-914*
[**2138-4-22**] 03:14AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.1
[**2138-4-23**] 02:11AM BLOOD Osmolal-271*
[**2138-4-23**] 12:05PM BLOOD ANCA-NEGATIVE B
[**2138-4-23**] 12:44PM BLOOD Type-ART Temp-36.9 pO2-81* pCO2-42
pH-7.46* calTCO2-31* Base XS-5 Intubat-NOT INTUBA
aspergillus-negative
b glucan-negative
anti GMB-negative
.
MICRO
legionella urine antigen-negative
blood, urine cultures-no growth
BAL-no growth
C.diff negative times three
.
IMAGING
CT chest [**4-25**]
1. Mixed changes since prior study, with several areas of
improved ground- glass opacity seen bilaterally, unchanged
donsolidative opacity in the left lower lobe, and increased
consolidation in right lower lobe. Findings are most suggestive
of an acute infection superimposed on a chronic interstitial
fibrotic lung disease. In the absence of infectious symptoms,
acute exacerbation of chronic interstitial pneumonia should also
be considered especially if the patient has experienced
worsening dyspnea in the past month without other contributing
factors.
2. The underlying nature of patient's chronic interstitial
fibrotic lung disease is difficult to assess in the setting of
acute superimposed changes. Given the bronchovascular
involvement and hyperlucent nodules, chronic hypersensitivity
pneumonitis should be considered. Other diagnostic
considerations include usual interstitial pneumonitis (UIP) and
a fibrotic sybtype of nonspecific interstitial pneumonitis
(NSIP).
3. Findings suggestive of pulmonary arterial hypertension
.
4. Saber-sheath configuration of the trachea, finding often seen
in COPD.
5. Increased gallbladder distention compared to prior study. If
clinically indicated, this could be further evaluated with
ultrasound.
.
CT head [**4-25**]
No CT evidence for acute intracranial process.
.
CTA chest [**4-21**]
1. No pulmonary embolism to proximal subsegmental level. More
distal branches obscured by respiratory motion.
2. Multifocal airspace opacities, predominantly basilar and
peripheral, though some appear to follow airways. This could
represent pneumonia, especially with superimposed dense
consolidation and effusion at the left base. The peripheral
interstitial opacity better seen in the right lung could also
represent an interstitial process such as UIP/IPF.
3. Small left pleural effusion.
4. Coronary artery calcifications.
ECHO
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Diastolic function
could not be assessed. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. An eccentric, anteriorly directed jet of mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion..
Brief Hospital Course:
78 man with history of bronchiectasis, recent left knee
replacement and treatment for community acquired pneumonia
presents with hypoxic respiratory failure.
.
# Hypoxic respiratory failure:
Initially concerns included healthcare acquired pneumonia given
his recent bout with pneumonia one week ago (treatedw ith
ceftriaxone and azithro, unclear if his symptoms really
subsided), PE given his recent knee surgery. A chest CTA was
done in the ED that did not show PE but did show some fibrotic
process. He had a CXR in the ED that showed LLL consolidation
and treatment for healthcare acquired pneumonia with vancomycin
and zosyn were started. His increasing oxygen requirement was
concerning and he was intubated. He met ARDS criteria and ARDS
net vent settings were used. Initially there was some concern
for acute on chronic congestive heart failure as a cause of his
respiratory distress, diuresis did not improve his symptoms, BNP
was not elevated and echo was unimpressive. In addition he had
a bronchoscopy and BAL, from which no organsisms were isolated.
Studies looking at Goodpasture, and aspergillus were negative.
A repeat CT chest was done for concern of the fibrotic changes
on his inital CT. The diagnosis of acute IPF was considered
likely as he had not improved on antibiotics. Steroids were
started with minimal improvement in his ventilator requirements.
NAC was also started without effect.
After being intubated for over 7 days, tracheostomy was raised
with his family. As he stated previously that he would not want
to be maintained on a tracheostomy his code status was changed
to CMO after extubation on [**5-3**]. He passed away after
approximately one hour, family present.
.
# Hypotension: His blood pressure decreased to MAP 60 after
intubation, thought to have been [**1-18**] medications given during
intubation v. PEEP impeding venous return. Pt may have also
been septic from pneumonia. Pt was given fluid to maintain CVP
18, and was on pressors for 2 days. He was weaned off pressors
and then became hypertensive, home propanolol and amlodipine
were restarted with good effect.
.
# ARF: Pt had a hypotensive episode on [**4-23**], which likely led to
pre-renal/ATN. Urine lytes revealed a FeNa of <0.1%, UNa <10,
no casts on sed, urine eos neg. With fluids, Cr trended down to
1.0 (baseline).
.
# Hyperglycemia: AAfter initiation of high dose steroids his
blood sugar levels increased, likely [**1-18**] steroids. He was
started on low dose glargine in addition to a sliding scale
which provided adequate glucose control.
.
# Hypernatremia: Two days after initiating tube feeds his serum
sodium became elevated, likely secondary to decreased free water
intake, improved with increased free water boluses.
.
# RBBB: He has an old EKG from [**2135**] with RBBB. This appears to
be intermittent, likely [**1-18**] pulmonary disease. There is no
evidence for PE on CTA. Pt has been ruled out by CEs x3.
.
#Anisocoria-pt was noted to have uneven pupils on HD 3, concern
for ICH given anticoagulation with lovenox but given unstable
clinical status head CT was delayed. On [**4-25**] head CT was normal,
also family stated he has had this for some time.
.
# L TKR-initially anticoagulated on enoxaparin, held for
suspected ICH, then held for ARF. He was anticoagulated with
heparin sc. PT was attempted initally but pt could not
participate [**1-18**] oxygen desaturation.
.
# Gout
held colchicine secondary to ARF
.
# Coronary artery disease: No known hx based on previous notes.
- Continued ASA and atorvastatin
Medications on Admission:
Nitroglycerin 1-inch b.i.d. for hypertension
Azithromycin 500 mgs q twenty-four hours for ten days (started
[**4-7**])
Ceftriaxone one gram IV for ten days daily (started [**4-7**])
Vicodin one tablet p.o. q six hours for pain.
Enoxaparin 40 mgs subcutaneously daily until ambulating
Milk of Magnesia 30 mls q.h.s. p.r.n.
Colace 100 mgs p.o. b.i.d.
Tylenol 650 mgs p.o. q four hours p.r.n. fever or pain.
Mirapex 0.25 mgs p.o. daily,
Zoloft 50 mgs p.o. daily,
Protonix 40 mgs p.o. daily,
Multivitamins one tablet p.o. daily.
Lipitor 5 mgs p.o. daily,
Propranolol 40 mgs p.o. daily,
aspirin 325 mgs p.o. daily,
Losartan 50 mgs p.o. daily,
Colchicine 0.6 mgs p.o. daily,
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
respiratory failure secondary to acute idiopathic pulmonary
fibrosis
Discharge Condition:
expired
Discharge Instructions:
You were admitted with low oxygen and shortness of breath. You
were treated for a pneumonia in the medical ICU. Your low
oxygen required you to be intubated. You had a chest CT scan
that showed likely IPF. You were started on steroids but did
not improve significantly. After a prolonged intubation a
family discussion was initiated and goals of care were
addressed. As per your family you did not wish to be maintained
on a tracheostomy tube and your breathing tube was removed.
Followup Instructions:
none
Completed by:[**2138-5-3**]
|
[
"458.29",
"276.0",
"790.29",
"414.01",
"424.0",
"V66.7",
"E932.0",
"401.9",
"584.9",
"780.6",
"272.0",
"274.9",
"518.81",
"515",
"426.4",
"486",
"379.41",
"275.0",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"38.93",
"96.72",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
10955, 10964
|
6637, 10205
|
334, 349
|
11077, 11087
|
2871, 6614
|
11621, 11656
|
2326, 2380
|
10926, 10932
|
10985, 11056
|
10231, 10903
|
11111, 11598
|
2395, 2852
|
275, 296
|
377, 1304
|
1326, 2008
|
2025, 2310
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,505
| 141,181
|
7038+55804
|
Discharge summary
|
report+addendum
|
Admission Date: [**2111-6-23**] Discharge Date: [**2111-7-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Dyspnea, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Pt is an 84F with emphysema, CAD, cardiomyopathy who
presents with 3-4 days subacute dyspnea, mildly productive
cough, and low grade fever. She felt otherwise well until two
days prior to admission when she developed cough, worsening SOB,
and wheezing over the course of the day. Her cough was
productive of yellow phlegm. She uses 2L 02 at home at night,
but had to increase it to 3L. She also admitted to increased
fatigue, being unable to ambulate as well with her walker.
Additionally, she described low grade fever as well but never
took her temp. She denied sinus congestion, CP,
nausea/vomitting, abd pain, leg pain or swelling, orthopnea,
travel or sick contacts. At baseline, patient lives alone and
is able to carry out ADLs and IALDs. She denies anginal pain or
lightheadedness with exertion. She denies symptoms of chronic
bronchitis but says that she has been admitted to the hospital
with pneumonia 3 times in the last six months.
.
In the ED, T 99.9, HR 96, BP 117/53, RR 26, 92% 3L. BP ranged
from 90-105 systolic, given 2L NS. HR improved to 80s. Pt
given Levofloxacin 750mg IV x1 as well as nebulizers. High
lactate eventually normalized after 2L fluids. EKG unchanged
from prior.
.
On arrival to the floor, pt immediately triggered for BP 82/palp
bilat, HR 80s, RR 26. Pt asymtpomatic, denying dizziness, CP,
worsened SOB or bleeding from anywhere. Brief exam was notable
for dry MM, relatively clear lungs with prolonged exp phase,
cough. With 500ml NS, BP improved to 96/40. Labs/EKG redrawn.
Past Medical History:
1. Emphysema previously followed by Dr. [**First Name (STitle) 9464**] at [**Hospital1 3372**], now seen by Dr. [**Last Name (STitle) 575**]
2. Coronary artery disease status post MI [**22**] years ago. EF
30-35%
3. History of polio.
4. History of falls.
5. Hyperlipidemia.
6. Osteoporosis.
7. Ischemic cardiomyopathy (EF 40% in [**3-10**])
Social History:
The patient does not smoke now, but smoked significantly quit 20
years ago. Today she said she smoked 3 pks/day for 20+ years.
Denies etoh or illicits. Lives in [**Location **], originally from
South [**Country 480**].
Family History:
Noncontributory
Physical Exam:
Physical Exam:
VS: T 99.4, BP 94/54 (94-100/50-58), HR 87, RR 24, 93% 3L
GEN: awake and alert, pleasant, talking in short/mid sentences,
NAD, coughing intermittently throughout exam
HEENT: EOMI, anicteric sclera, MM dry, no pallor
Neck: supple, no LAD, could not find JVP
Heart: RRR, no m/r/g
Lungs: scattered wheeze/rhonci with prolonged exp phase,
symmetric, no focal crackles or rales
Abd: soft NT/ND + BS no rebound or guarding
Ext: warm, no pitting edema or calf swelling/tenderness
Skin: no rashes
Neuro: awake and alert, appropriate, CN II-XII intact
Pertinent Results:
EKG: sinus rhythm, 85bpm, nl axis, Q in III, poor R wave
progression, unchanged from prior
..
CXR [**6-23**]: Normal cardiac size, hyperinflation unchanged. Ill
definied bibasilar opacities unchanged from prior exam, cannot
exclude infectious processes.
Brief Hospital Course:
# HYPOXIA/COPD EXACERBATION AND MRSA ASPIRATION PNA:
Patient was admitted for worsening SOB, fevers, and productive
cough. CXR showed an infiltrate at RLL. She was started on
Levaquin for presumed community aquired pneumonia. There was
also concern that she may have aspirated given her recent speech
and swallow evaluation. Based on physical exam and CXR, she did
not seem significantly fluid overloaded although her EF is ~40%.
She denied any chest pain and cardiac enzymes were negative and
her EKG was unchanged so this was unlikely an acute cardiac
event. Pulmonary embolism was also on the differential but low
on the differential since the patient was ambulatory at home and
had no other risk factors. Although d-dimer was elevated in the
MICU, LE dopplers were negative for DVT.
.
She was started on vancomycin for MRSA in sputum in addition to
the levaquin she was receiving for empiric treatment of CAP.
She received albuterol and ipratropium nebs at standing order
doses, and was also written for acetylcysteine and guaifenesin.
During the hospital course, her oxygen requirements increased
and she was transferred to the MICU briefly for BiPAP. At time
of transfer back to the floors, she was satting in mid 90s on 6L
nasal cannula. She was gradually weaned off of 02 until time of
discharge, at which time her O2 sats were stable on 3L NC O2
with sats of 92-94%. Given her history of emphysema, the goal
for her would be to keep her O2 sat between 90-92%, and not
higher as she would be at risk for CO2 retaining. Her home
baseline NC O2 prior to hospitalization was 2L NC O2 at night.
.
During her time in the MICU, patient was started on IV
solumedrol for treatment of possible COPD exacerbation. It was
also during this time that her abx regimen was broadened to
include vancomycin in addition to levoquin. She finished her 7
day course of vancomycin/levaquin by discharge and was
discharged on a slow prednisone taper of 8 days duration. The
patient should recieve:
40mg x 2 days
30mg x 2 days
20mg x 2 days
10mg x 2 days.
.
# Oral Thrush: The patient reported a slight sore throat and had
some evidence of oral [**Female First Name (un) **], she was started on lidocaine and
nystatin swish and spit. The nystatin can be discontinued in [**4-8**]
days or as symptoms resolve.
.
# BLOOD PRESSURE CONTROL:
On admission, patient was hypotensive with SBP 100s. Her BP
improved with IVF boluses. Baseline BP per OMR records is
120-130s/80. She likely had early sepsis physiology and met SIRS
criteria on admission. She never required pressors during time
in the MICU. At time of transfer back to floors her SBP is
100-120s with hypotension resolved. Her antihypertensives were
held in the ICU but as her BP normalized, she was restarted on
lisinopril which was slowly titrated up to 10mg PO daily at
discharge.
.
# AF WITH RVR:
While in the MICU, patient had brief period of atrial
fibrillation that resolved with electrical cardioversion and
digoxin loading. The likely cause was critical illness, unlikely
to be permanent (PAF) but her ECHO was repeated showing systolic
ventricular function of 40%. The patient was started on digoxin
after a load to improve her cardiac function. She would also
likely benefit from anticoagulation treatment with coumadin,
which the patient is amenable to. The patient was started on
coumadin 5mg PO daily and should be continued on this with INR
monitoring with follow up with an [**Hospital3 **]/PCP for
coumadin adjusting.
.
# CAD:
Continued home ASA.
.
# DEPRESSION:
Continued home Celexa,
.
# HYPERLIPIDEMIA:
Continued simvastatin at home dose.
.
# ACCESS:
Midline was placed in the MICU. PICC was placed when placed for
anticipated IV antibiotics. However, as patient finished her
antibiotic course in the hospital, PICC line was discontinued at
discharge.
.
#. CODE STATUS: The patient was initially admitted with wishes
to be DNR/DNI per discussion on the floor with the patient.
After the patient had her episode of respiratory distress
leading to transfer to the ICU, a family discussion was held
including the patient and her sons, which led to her code status
to be reversed to full code. The patient was never intubated in
the ICU. After transfer back to the floor, code status and goals
of care were readdressed and the patient wishes to continue as
full code at this time. FULL CODE.
Medications on Admission:
ALBUTEROL 1 q 4-6 hours as needed
ALENDRONATE-VITAMIN D3 70 mg-2,800 unit Tablet once a week
CITALOPRAM 20 mg once a day
FLUTICASONE-SALMETEROL 250 mcg-50 mcg/Dose Disk 1 puff twice a
day
IPRATROPIUM-ALBUTEROL Nebulization inhaled four times a day as
needed
SIMVASTATIN 20 mg Tablet once a day in the evening
VALSARTAN 80 mg once a day
ASPIRIN 81 mg once a day
CALCIUM-CHOLECALCIFEROL (D3) [CALCIUM 600 + D] - 600-125 mg-unit
three times a day
ECHINACEA Dosage uncertain
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO q6
hours:PRN as needed for cough.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: Four (4) Tablet PO BID (2 times a
day) as needed.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q6H (every 6 hours) as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed.
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): Dose to be adjusted per lab results. Goal INR
[**1-4**].
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
14. Prednisone 10 mg Tablet Sig: 1-4 Tablets PO once a day for 8
days: Please give 40mg for 2 days then 30 mg for 2 days then
20mg for 2 days then 10mg for 2 days then stop. Total of 8 days
of treatment.
15. Outpatient Lab Work
Please draw PT/PTT/INR on [**7-3**]. Adjust coumadin and repete labs
accordingly.
Please send results to Dr. [**First Name8 (NamePattern2) 712**] [**Name (STitle) 713**] MD
#[**Telephone/Fax (1) 716**]
16. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Community Acuired Pneumonia
COPD Exacerbation
Atrial fibrillation
Systolic Heart Failure
Oral Thrush
Discharge Condition:
The patient was hemodynamically stable, afebrile and without
pain. She was comfortable with O2 sat of 92-94% on 3L NC.
Discharge Instructions:
You were admitted for shortness of breath which was felt to be
due to pneumonia. You were started on antibiotics for your
infection and you have completed a 7 day course of antibiotics
or this infection. Because of your emphysema, you were also
treated with steroids. You will need to continue these steroids
for several more days. You will need follow-up with Dr.
[**Last Name (STitle) 575**] from Pulmonology. You will be contact[**Name (NI) **] regarding an
appointment in the next few weeks.
During your hospitalization you were found to have an irregular
heart rate which required electrical cardioversion and the
addition of new medication, Digoxin. You will need to continue
this medication and to have lab values of the medication
monitored. We have also started a medication called Coumadin.
This medication is used to thins your blood and prevents blood
clots and stroke in case your heart rate becomes irregular
again. The dose of this medication may change overtime and your
blood will need to be closely monitored while you are on this
medication.
Studies of your heart showed that your heart does not pump as
effectively as it should. In order to prevent damage to your
heart and to help control your blood pressure, we have started
you on a medication called Lisinopril. You should take this
medication daily as directed.
You began to experience a sore throat and hoarse voice and this
appears to be due to a yeast infection in your mouth. We have
started you on Nystatin, an antifungal medication which you will
need to use as a mouth rinse several times a day for the next
week. You should also have your dentures cleaned.
You are being discharged into the care of [**Hospital1 100**] Rehabilition
Center. Please alert your doctor if you develop worsening
shortness of breath, chest pain, change in cough or sputum,
fevers, chills, nausea, vomiting or any other symtom of concern.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2111-7-21**]
2:00.
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2111-11-13**] 11:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2111-11-13**] 11:30
Completed by:[**2111-7-2**] Name: [**Known lastname 4539**],[**Known firstname 732**] Unit No: [**Numeric Identifier 4540**]
Admission Date: [**2111-6-23**] Discharge Date: [**2111-7-2**]
Date of Birth: [**2027-1-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4541**]
Addendum:
# Aspiration Risk: The patient's pneumonia raised concern for
risk of aspiration. The patient underwent a video swallow-study
which showed no evidence of aspiration, but did demonstrate
delayed pharyngeal/esophageal transitioning and GERD. The
patient was cleared for a regular diet with thin liquids, but
she was encouraged to take chin-tucked and full effort swallows.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - [**Location (un) 1409**]
[**First Name11 (Name Pattern1) 2868**] [**Last Name (NamePattern4) 2869**] MD [**MD Number(1) 2870**]
Completed by:[**2111-7-2**]
|
[
"414.01",
"428.20",
"311",
"V15.88",
"412",
"530.81",
"112.0",
"518.81",
"V12.02",
"038.9",
"428.0",
"276.50",
"733.00",
"414.8",
"482.41",
"995.91",
"491.21",
"V66.7",
"272.4",
"427.31",
"V09.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"38.93",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
13514, 13760
|
3354, 7711
|
275, 281
|
10210, 10331
|
3074, 3331
|
12294, 13491
|
2464, 2481
|
8234, 9957
|
10086, 10189
|
7737, 8211
|
10355, 12271
|
2511, 3055
|
221, 237
|
309, 1847
|
1869, 2211
|
2227, 2448
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,940
| 139,195
|
39507
|
Discharge summary
|
report
|
Admission Date: [**2199-11-8**] Discharge Date: [**2199-11-12**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p fall onto commode hitting right scapula and hip
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Highly functional [**Age over 90 **]F with mechanical fall onto commode and
struck left scapula, back and hip. Did not strike head, no LOC.
Patient complanies of back pain along medial border of left
scapula. Patient denies light headedness, dizzines, chest pain /
palpitations.
Past Medical History:
Past Medical History: DMII, CHF, Hypercholesterolemia
Past Surgical History: Open appy, TAHBSO
Social History:
Social History: No tob, etoh or illicits. Lives in [**Hospital 4382**] facility. Walks with a cane, performs ADLS and IADLS.
Family History:
N/C
Physical Exam:
Vital signs upon admission: [**2199-11-8**]
Temp:97.7 HR:73 BP:138/58 Resp:16 O(2)Sat:99
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Neck is nontender and has full range of motion without pain
Chest: Right posterior lateral rib tenderness no
significant ecchymosis. Lung sounds were equal
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent nonfocal
ON DISCHARGE: vital signs: bp=106-110/44-50, hr 70-73, O2 sat
93-95%
Heent: alert and oriented to time,person, place
Lungs: Ecchymotic area right post thoracic chest, decreased
breath sounds right side
Heart: ns1, s2, -s3, -s4, no murmur
Abdomen: Soft, non-tender, slightly distenede, hypoactive bowel
sounds
Extremities: warm, pink, + dp bil., no pedal edema bil.
Abdomen: soft, distended, hypoactive bowel sounds
Mentation: alert and oriented
Skin: small abrasion right elbow with dry dressing
Pertinent Results:
[**2199-11-11**] 05:00AM BLOOD WBC-5.9 RBC-3.59* Hgb-9.8* Hct-30.6*
MCV-85 MCH-27.4 MCHC-32.2 RDW-14.6 Plt Ct-238
[**2199-11-10**] 06:55AM BLOOD WBC-6.1 RBC-3.46* Hgb-9.6* Hct-29.3*
MCV-85 MCH-27.9 MCHC-32.9 RDW-14.7 Plt Ct-228
[**2199-11-10**] 06:55AM BLOOD WBC-6.3 RBC-3.42* Hgb-9.6* Hct-29.0*
MCV-85 MCH-28.1 MCHC-33.2 RDW-14.7 Plt Ct-243
[**2199-11-8**] 06:10AM BLOOD Neuts-85.2* Lymphs-9.7* Monos-3.6 Eos-1.2
Baso-0.3
[**2199-11-11**] 05:00AM BLOOD Plt Ct-238
[**2199-11-10**] 06:55AM BLOOD Plt Ct-228
[**2199-11-8**] 06:10AM BLOOD PT-12.8 PTT-22.4 INR(PT)-1.1
[**2199-11-11**] 05:00AM BLOOD Glucose-90 UreaN-32* Creat-0.9 Na-139
K-4.3 Cl-102 HCO3-30 AnGap-11
[**2199-11-10**] 06:55AM BLOOD Glucose-122* UreaN-34* Creat-0.9 Na-139
K-4.2 Cl-101 HCO3-29 AnGap-13
[**2199-11-9**] 02:46AM BLOOD Glucose-171* UreaN-32* Creat-0.8 Na-137
K-4.1 Cl-103 HCO3-26 AnGap-12
[**2199-11-11**] 05:00AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.5
[**2199-11-8**]: EKG:
Sinus rhythm. Late R wave progression. Lateral T wave
abnormalities.
No previous tracing available for comparison
[**2199-11-8**]: Chest x-ray:
Acute fractures of the right upper thorax
[**2199-11-9**]: Chest x-ray
Multiple old right-sided rib fractures. Increased right-sided
pleural
effusion.
Brief Hospital Course:
[**Age over 90 **] year old female who was admitted to the Acute Care Service
[**2199-11-8**] after fallling onto a commode and striking her right
scapula and hip. She did sustain right rib fractures and a right
hemothorax. She did not sustain loss of consciousness. She was
admitted to the Intensive Care Unit where she had a
paravertebral nerve block after a failed epidural catheter for
pain control. She was also receiving tylenol for pain relief and
has resumed her anti-hypertensive agents. She was transferred
to the CC6 on [**2199-11-9**]. Physical therapy has been in to
evaluate her.
She is preparing for discharge to a rehabilitation facility
prior to her return to her retirement community.
Her hospital course is as follows by systems:
NEURO - She is alert and oriented x 3, her speech is clear
CVS - Vital signs are stable, she is afebrile
PULM - Her respiratory rate is 18. She is on room air with
oxygen saturation 93-96%
GI: She is tolerating a regular diet. Denies nausea/vomitting.
She has been placed on a bowel regimen. She was given a ducolax
suppository this today and had a large bowel movement.
GU - A foley catheter was initially placed and discontinued on
hospital day #2, she has had episodes of urinary incontinence
HEME - Her hematocrit is stable
ENDO - Her blood glucose has been 108-216, for this, she has
been on a insulin sliding scale regimen. Patient reports that
she is on no medication for diabetes and is diet controlled.
ID - no active issues
Medications on Admission:
lasix 20', lisinopril 20', dilt 240', klor-con M20', ASA 81
Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
8. milk of magnesium Sig: Thirty (30) cc at bedtime as needed
for constipation.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Right posterior [**5-21**] rib fractures
right hemothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - walks with cane and assistance
Discharge Instructions:
You are being discharged with the following instructions:
*incentive spirometry every 2-4 hours
*may ambulate with assistance
*regular diet
Please follow-up in the emergency room if you experience the
following instructions:
Your injury caused rib fractures 4-6th which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus
Followup Instructions:
Please follow-up with the Acute Care Service in [**3-20**] weeks. You
can schedule this appointment by calling #[**Telephone/Fax (1) 600**]
Completed by:[**2199-11-12**]
|
[
"860.2",
"250.00",
"E885.9",
"272.4",
"807.03",
"428.0",
"737.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"05.31"
] |
icd9pcs
|
[
[
[]
]
] |
5748, 5842
|
3265, 4767
|
314, 321
|
5944, 5944
|
1990, 3241
|
7777, 7950
|
907, 912
|
4878, 5725
|
5863, 5923
|
4793, 4855
|
6113, 7754
|
728, 748
|
927, 941
|
1484, 1971
|
223, 276
|
349, 629
|
955, 1469
|
5959, 6089
|
673, 705
|
780, 891
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,614
| 194,522
|
22206
|
Discharge summary
|
report
|
Admission Date: [**2155-1-8**] Discharge Date: [**2155-1-13**]
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Sulfa (Sulfonamides) /
Buspar / Haldol / Levaquin / Sulfamethoxazole/Trimethoprim /
Trazodone / Percocet
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
trach revision
Major Surgical or Invasive Procedure:
bronchoscopy x2, trach revision
History of Present Illness:
85yoW with h/o metastatic thyroid cancer s/p thyroidectomy and
tracheostomy c/b tracheomalacia, also with h/o asthma and
Guillain-[**Location (un) 57947**] transferred from [**Hospital 8**] hospital for trach
revision.
.
She was initially admitted to [**Hospital 11485**] Med Center [**2154-11-6**] after
reaction to antibiotics and required mechanical ventilation.
She was transferred to [**Hospital1 **] [**2154-12-17**] for trach readjustment.
She was transferred to [**Hospital 8**] Hospital [**2154-12-19**] where she
remained until transfer to [**Hospital1 18**] today. She was brought to
[**Hospital 8**] Hospital [**2154-12-19**] for intermittent hypoxic respiratory
failure and hypotension due to tracheal obstruction by trach
tube with positional changes. At that time she was volume
overloaded and diagnosed with MRSA pneumonia. She is s/p trach
x8yrs complicated by tracheomalacia. While at [**Hospital1 8**] she was
tried on [**Last Name (un) 295**] 6.5 and Shiley 6.0, but these resulted in air
leakage and subjective distress. She also tried 7.0 talk trach,
but she did not tolerate that either. Hospital course was
complicated by MRSA pneumonia, treated with 14days combination
Vancomycin and Linezolid. She was also treated for E.coli UTI
and Staph epi bacteremia. Speech and swallow study at [**Hospital 8**]
Hospital demonstrated aspiration of all consistencies, and she
was fed via dobhoff tube. She and her family decline PEG
placement. She is transferred to [**Hospital1 18**] today for IP trach
revision. Today she underwent bedside bronchoscopy and trach
change. A 11.5cm [**Last Name (un) 295**] was placed. On presentation she c/o
throat pain and persistant dyspnea.
Past Medical History:
Metastatic follicular thyroid cancer s/p thyroidectomy, XRT and
radioactive iodine treatment - mets to lung
Cataracts
h/o DCIS breast ca s/p right mastectomy
Afib
Ulcerative colitis
h/o bilateral DVT s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] filter
Mitral regurg
Critical aortic stenosis
h/o MRSA pneumonia
Asthma
h/o Guillaine-[**Location (un) **]
Hypertension
EF 25-30%
Ocular migraines
Prior stroke
Social History:
Lives in [**Location 22201**], MA. No
history of smoking, no history of drinking
Family History:
History of lung and ovarian cancer
Physical Exam:
T 95.9 HR 110 BP 179/90 RR 19 97%
AC Tv 400 RR 12 FiO2 40% PEEP 5
GEN: anxious, sitting at 45degrees, attempting ot mouth words,
NAD
HEENT: PERRL, anicteric, OP clear, dry MM
Neck: supple, trach, no cervical or supraclavicular LAD, JVP
nondistended
CV: irreg irreg, tachycardic, palpable heave, PMI nondisplaced,
II/VI SEM at LLSB and apex
Resp: mildly coarse and rales bilateral bases heard laterally,
clear anteriorly
Abd: +BS, soft, NT, ND
Ext: right arm iv, BLE with 2+ edema
Back: stage I sacral erythematous skin wound
Pertinent Results:
[**2155-1-8**] 10:47AM GLUCOSE-101 UREA N-26* CREAT-0.5 SODIUM-135
POTASSIUM-3.7 CHLORIDE-89* TOTAL CO2-39* ANION GAP-11
[**2155-1-8**] 10:47AM estGFR-Using this
[**2155-1-8**] 10:47AM proBNP-3427*
[**2155-1-8**] 10:47AM CALCIUM-8.6 PHOSPHATE-4.6*# MAGNESIUM-2.4
[**2155-1-8**] 10:47AM DIGOXIN-1.0
[**2155-1-8**] 10:47AM WBC-8.6# RBC-3.59* HGB-10.5* HCT-31.3* MCV-87
MCH-29.3 MCHC-33.6 RDW-17.2*
[**2155-1-8**] 10:47AM PLT COUNT-322#
[**2155-1-8**] 10:47AM PT-19.0* PTT-49.4* INR(PT)-1.8*
.
CXR [**2155-1-8**]: increased number of lung metastases, small
bilateral pulm effusions
Brief Hospital Course:
85yo woman with h/o metastatic follicular thyroid cancer s/p
tracheostomy c/b tracheomalacia, with recent treatment for
pneumonia and CHF, transferred for trach revision.
.
# Dyspnea: Dyspnea was felt to be due to patient's ill-fitting
trach given her extensive tracheomalacia. She underwent
bronchoscopy by interventional pulmonary on arrival, and the
trach was changed to a 11.0cm [**Last Name (un) 295**]. Her course was also
complicated by volume overload, and she has a history of CHF.
Her last echo showed an EF of 55%, but prior to that it had been
noted to be 25-30%. We attempted to diurese her on the day of
admission; however, that night she became acutely dyspneic and
desaturated. She underwent repeat bronchoscopy, and it was
found that the trach was again abutting the area of
tracheomalacia. It was further advanced, and she had no
additional problems with the trach or desaturation. She
received anesthesia with fentanyl and versed during this
procedure, which caused her blood pressure to drop. She was
given 1.5L of NS bolus. After the sedation was lifted her blood
pressure normalized. It remained normal for the following
36hours prior to transfer to the rehab facility. Her NIF was
checked and was noted to be 6. She had completed treatment for
pneumonia while at [**Hospital 8**] Hospital. Additionally we
attempted ot increase her diltiazem dose from 30mg QID to 60mg
QID to improved rate control for her Afib. This likely
contributed to her relative hypotension, and the dose was
returned to 30mg QID prior ot discharge which she tolerated
well.
.
# CHF: EF 25-35%. Diuresis failed on the first night but was
successful on the second day of admission. She will continue on
standing Lasix for continued diuresis. She is not on a
beta-blocker or ACE inhibitor. CHF management is also
complicated by history of critical aortic stenosis.
.
# Afib: She is rate controlled on diltiazem and digoxin. She
is anticoagulated with warfarin; however, this was held while
procedures were being administered. She had received 5mg
warfarin on [**2155-1-7**] at [**Hospital 8**] Hospital. She was bridged with
Lovenox 60mg [**Hospital1 **] while here. Despite this, her INR continued to
rise, so warfarin was not restarted given concern that she would
become supratherapeutic. Once her INR is decreasing, warfarin
should be restarted at a dose of 2-3mg qHS. Goal INR is [**1-25**].
Once therapeutic, Lovenox can be discontinued. Her digoxin
level was therapeutic at 1.0.
.
# h/o DVT: [**Location (un) 260**] filter is in place. Anticoagulation as
per discussion above
.
# Dispo: She was discharged to [**Hospital **] Rehab for continued
ventilatory management with [**Last Name (un) 295**] 11.0cm in place. She is on
tubefeeds, osmolyte or probalance at 55cc/hr. She is a full
code. Communication is with the patient and her daughter.
Medications on Admission:
Meds on Transfer:
Ativan 0.5mg Q4hr prn
Morphine 1mg Q2hr prn
Calcium carbonate 1250mg [**Hospital1 **]
Vitamin D 400units [**Hospital1 **]
Coumadin dosed daily
Mesalamine 500mg pr TID
Diltiazem 30mg Q6hr
Prevacid 30mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Senna 2tabs QHS
Nystatin powder
Multivitamin daily
Digoxin 0.125mg daily
Synthroid 175mcg daily
Simethicone 80mg [**Hospital1 **]
Acidophilus 1wafer TID
Zelnorm 6mg [**Hospital1 **]
Lovenox 60mg Q12hr
Insulin sliding scale
NPH 9units QAM, 9units QPM
Lasix 80mg daily
Combivent 8puffs Q6hr
Flovent 110mcg 2puffs Q4hr
Olopatadine 0.1% one gtt OU Q12hr
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Eight
(8) Puff Inhalation Q1H (every hour).
2. Calcium Carbonate 500 mg (1,250 mg) Tablet [**Hospital1 **]: One (1)
Tablet PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
4. Mesalamine 1,000 mg Suppository [**Hospital1 **]: One (1) Suppository
Rectal TID (3 times a day).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
6. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
7. Senna 8.6 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO HS (at bedtime).
8. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical QID
(4 times a day) as needed.
9. Hexavitamin Tablet [**Last Name (STitle) **]: One (1) Cap PO DAILY (Daily).
10. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
11. Levothyroxine 175 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO TID (3 times a day) as needed.
13. Tegaserod Hydrogen Maleate 6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet
PO BID (2 times a day).
14. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Last Name (STitle) **]: One (1)
As per instructions below Subcutaneous twice a day: 9 units qam
and 9 units q bedtime.
15. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
16. Naphazoline-Pheniramine 0.025-0.3 % Drops [**Hospital1 **]: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
17. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: [**12-24**] PO Q4-6H (every
4 to 6 hours) as needed for pain.
18. Diltiazem HCl 30 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QID (4
times a day).
19. Lidocaine HCl 1 % Solution [**Month/Day (2) **]: One (1) ML Injection QID (4
times a day) as needed.
20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
21. Ativan 1 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO q2-4 hours PRN.
22. Coumadin 2.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day:
Start once INR trends down. Was 2.4 on day of discharge ([**1-10**]).
23. Morphine Sulfate 1-2 mg IV Q2H:PRN pain
24. Lasix 40 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Dyspnea secondary to tracheostomy
.
Secondary:
Atrial Fibrillation
CHF
HTN
Critical AS
DVTs
Discharge Condition:
Fair
Discharge Instructions:
You were admitted from an outside hospital for revision of your
tracheostomy. You tolerated this procedure well.
.
Take all medications as prescribed.
.
Seek medical attention immediately if you experience new
symptoms including shortness of breath, chest pain, decreased
urine output, wheezing or other concerning symptoms.
.
Follow up at rehab with the doctors [**Name5 (PTitle) **]. You will slowly be
weaned as tolerated from the ventillator.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] N [**Telephone/Fax (1) 57946**] Please call PCP to arrange follow
up.
|
[
"518.81",
"V58.61",
"401.9",
"V10.3",
"398.91",
"519.19",
"396.2",
"458.9",
"519.02",
"197.0",
"V10.87",
"556.9",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"96.72",
"96.6",
"33.21"
] |
icd9pcs
|
[
[
[]
]
] |
10027, 10106
|
3929, 6811
|
367, 400
|
10251, 10258
|
3308, 3906
|
10756, 10876
|
2699, 2735
|
7478, 10004
|
10127, 10230
|
6837, 6837
|
10282, 10733
|
2750, 3289
|
313, 329
|
428, 2136
|
2158, 2584
|
2600, 2683
|
6855, 7455
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,779
| 197,770
|
46716
|
Discharge summary
|
report
|
Admission Date: [**2185-11-12**] Discharge Date: [**2185-12-19**]
Date of Birth: [**2124-7-27**] Sex: F
HISTORY OF PRESENT ILLNESS: Ms [**Known lastname 98802**] is a 61 year old
woman with past medical history significant for
gastroesophageal reflux disease and alcohol abuse. Her
history is also significant for an extended left
gastrointestinal bleed in [**2178**] and consequent ileostomy
takedown. Previously in [**2172**] she required a right colectomy
for a perforated colon and had an ileostomy placed in the
right upper quadrant.
The patient has been in her usual state of health until the night
before admission when she developed sudden diffuse abdominal pain
followed by bilious emesis. The pain did not improve and the
patient presented to the Emergency Room. In the Emergency Room
she was found to be tachycardiac with abdominal pain and bilious
emesis. The patient did not report any fevers or chills or
diarrhea. She reported good ostomy output until at least the
evening before the day of admission. In the Emergency Room a
nasogastric tube was placed and a KUB was obtained which
revealed no free air but did show a focal ileus or possible
early obstruction. An abdominal computerized tomography scan
was recommended for further evaluation of the etiology of her
abdominal pain. The patient was admitted to General Surgery
for further observation and a possible surgical intervention
pending more studies.
PAST MEDICAL HISTORY: 1. Hypertension; 2. Alcohol abuse;
3. Gastroesophageal reflux disease; 4. Small bowel
obstruction.
PAST SURGICAL HISTORY: 1. Extended left hemicolectomy,
appendectomy and a diverting ileostomy for a lower
gastrointestinal bleed in [**2178-8-18**]; 2. Takedown of the
ileostomy in [**2178-10-18**]; 3. Right colectomy for
perforated colon and ileostomy placement in [**2182-5-18**].
SOCIAL HISTORY: History of alcohol abuse and history of
smoking.
MEDICATIONS ON ADMISSION: 1. Lopressor 50 mg p.o. b.i.d.;
2. Prilosec; 3. Remeron; 4. Wellbutrin; 5. Oxycontin.
PHYSICAL EXAMINATION: Afebrile, heartrate 150, blood
pressure 155/81, 18 respiratory rate, 100% on room air. The
patient was alert and oriented but appeared uncomfortable due
to pain. There was no evidence of jaundice. Head, eyes,
ears, nose and throat examination, her sclera were nonicteric
and her mucous membranes were dry. Lungs were clear to
auscultation bilaterally. Cardiac examination, tachycardiac
with regular rhythm and no murmurs, rubs or gallops.
Abdominal examination, a healthy looking pink ileostomy in
the right upper quadrant. Her midline incision was without
hernias. There were no masses felt. There was a diffuse
tenderness in the right upper quadrant and mid epigastrium
with rebound and guarding which was thought to be consistent
with probable peritonitis. Rectal examination, a hard mass
was felt which felt to be likely a foreign body present in
the rectum. Pelvic examination, within normal limits.
Extremities, warm, well perfused, no signs of edema.
LABORATORY DATA: White blood cell count 14, hematocrit 40.6,
platelets 246, neutrophils 87%, sodium 139, potassium 2.7,
BUN 9, creatinine 0.7, glucose 117, INR 3.1. AST 18, ALT 13,
alkaline phosphatase 87, total bilirubin 0.7, albumin 4.4,
lipase 316, amylase 190. Imaging studies: KUB obtained in
the Emergency Room showed focal ileus or possible early
obstruction.
HOSPITAL COURSE: The patient continued to have severe
abdominal pain without much relief. She has been having
normal bowel movements through her ileostomy, however. A
follow up abdominal computerized axial tomography scan was
obtained given nonconclusive findings of the KUB which
revealed fluid and free air in the lesser sac which at that
time was thought to be consistent with a possible perforated
posterior gastric or duodenal ulcer. She also secondarily
appeared to have pancreatitis. Given the above findings, the
patient was taken to the Operating Room for a probable
perforated viscous. On [**2185-11-12**], the patient
underwent exploratory laparotomy with extensive lysis of
adhesions. Of note is that the entire bowel from the
esophagus to the end ileostomy was visualized and there was
no evidence of perforation, only the saponification which was
most consistent with pancreatitis. Please see the full
operative note for details.
The patient was transported to
the Post Anesthesia Care Unit intubated. She was
consequently transferred to the Intensive Care Unit for
further management. She was resuscitated with intravenous
fluids. Her urine output was closely monitored. She was
started on Ampicillin, Gentamicin and Flagyl.
Postoperatively a drain was left in the retroperitoneum as
well as a second drain was placed anterior to the duodenum
and pancreas. However, on postoperative day #1 her anterior
drain was noted to be bile stained. The patient was
consequently brought back to the Operating Room for an
exploration for possible enterotomy at the time of her
exploration or possibly an undiagnosed perforated viscous.
Therefore, on [**2185-11-13**] the patient was taken back to
the Operating Room for an exploratory laparotomy and the
oversew of the duodenal perforation and the placement of a
jejunostomy tube. The findings were consistent with a
duodenal perforation and pancreatitis. Please see the full
operative note for details. The patient remained intubated
and was transported to the Intensive Care Unit. On
postoperative day #2, the patient spiked a fever of 101.3.
Her heartrate remained in the low 100s with her blood
pressure slightly elevated. The abdominal wound swab showed
Escherichia coli and enterococcus taken on [**2185-11-12**].
The Escherichia coli was pansensitive and Enterococcus was
sensitive to Vancomycin but resistant to Ampicillin and
Levofloxacin. Blood cultures showed no growth. The
nasogastric tube remained in place. The respirator support
was gradually weaned. She maintained good urine output and
had stable hematocrit. The tube feeds were started and
advanced to goal rate. The pain was controlled with
Dilaudid. The tachycardia and hypertension were controlled
with Lopressor and Clonidine. The patient was no longer
febrile. She was successfully extubated. She was maintained
on a brief course of Imipenem until sensitivities came back.
The urine culture from [**2185-11-25**] grew yeast. The
patient was encouraged to use the incentive spirometer. A
chest x-ray obtained on [**2185-11-18**] showed new bilateral
small to moderate sized pleural effusions. The total
parenteral nutrition was eventually discontinued and the
patient was just maintained on tube feeds.
Due to a persistent lowgrade fever and elevated white count an
abdominal computerized tomography scan was obtained on
[**2185-11-21**]. The abdominal computerized tomography scan
demonstrated multiple abscesses within the abdomen including
an abscess located between the head of the pancreas and the
duodenum as well as a fluid collection located in the left
upper quadrant near the proximal jejunum. On [**2185-11-24**], the patient underwent another expiratory laparotomy
given the finding of multiple abscesses. The intra-abdominal
drain was repositioned. The patient tolerated the procedure
well. There were no complications. Please see the operative
note for details. The patient was transferred back to the
Intensive Care Unit. She remained intubated. Her acidosis
was corrected. The total parenteral nutrition was continued.
A pigtail catheter was placed by CT scan for further fevers
and a small collection noted near the pancreas. After
placement, it appeared to drain frank bile. It was
repositioned on [**2185-12-1**] as it appeared to be
intraluminal. The antibiotics were changed to Levaquin,
Fluconazole and Vancomycin. The abscess culture obtained on
[**2185-11-25**] grew Corynebacterium species as well as
Pseudomonas species. The Pseudomonas was pansensitive. The
sputum gram stain and culture obtained on [**2185-11-25**] grew
Pseudomonas and Klebsiella with Klebsiella being pansensitive as
well. The antibiotics were adjusted accordingly.
The patient was finally extubated on [**2185-11-29**]. Her
antibiotics at that time were Vancomycin, Ciprofloxacin,
Fluconazole and Flagyl. The [**Location (un) 1661**]-[**Location (un) 1662**] drains were
putting out a moderate amount of discharge. The nasogastric
tube remained in place with a moderate amount of drainage. A
PICC line was placed by Interventional Radiology on [**2185-12-5**] for the need of total parenteral nutrition. The
abdominal incision remained slightly opened with wet to dry
dressings applied. It gradually was granulating. A repeat
abdominal computerized axial tomography scan on [**2185-12-7**] showed stable appearance of the abdomen with free fluid
in the hepatorenal space and onto the liver. There were
several small locules of fluid noted adjacent to the
pancreas, the largest of which was noted to be lying in the
tail of the pancreas. The surgical drains were noted to be
lying adjacent to the loculated collections. The patient was
eventually transferred to the Regular Floor out of the
Intensive Care Unit. Physical therapy was consulted. The
patient was maintained on Ceftaz, Fluconazole, and
Gentamicin. Her blood pressure was controlled with
Lopressor. She was receiving Reglan through the jejunostomy
tube. Her total parenteral nutrition was discontinued and
she was just maintained on tube feeds which were being cycled
to meet her goal needs. The patient continued to do well.
She remained afebrile. Repeat blood cultures were sent on
[**2185-12-13**] which showed no growth. A catheter tip
from central line was sent as well which showed no growth.
The [**Location (un) 1661**]-[**Location (un) 1662**] drain fluid was sent again to microbiology
on [**2185-12-13**] which again grew Pseudomonas resistant
to Ciprofloxacin but sensitive to everything else and
enterococcus resistant to Ampicillin, Levofloxacin and
Penicillin but sensitive to Vancomycin. Nutrition continued
to follow the patient during her hospitalization. The
abdominal wound continued to improve without any evidence of
cellulitis. Granulation process continued. There was no
evidence of pus or any other signs of infection. The repeat
blood cultures on [**12-13**] were obtained in response to a
temperature spike to 103.5. The patient otherwise remained
asymptomatic. The white blood cell count peaked at 12.2 but
stabilized at 10. The central line was changed over a wire
as a possible cause of her fever on [**2185-12-14**]. The
patient continued to do well. She was ambulating. Her oral
intake was moderate but she tolerated food well. The patient
was discharged to the rehabilitation facility in good
condition.
CONDITION ON DISCHARGE: Good.
DISCHARGE DESTINATION: [**Hospital3 4419**] Facility.
DISCHARGE DIAGNOSIS:
1. Pancreatitis, status post exploratory laparotomy with
lysis of adhesions.
2. Duodenal perforation, status post exploratory laparotomy,
oversewing of the duodenal perforation and jejunostomy tube
placement.
3. Intra-abdominal abscesses, status post drainage.
4. Urinary tract infection (yeast).
5. Hypertension.
6. Gastroesophageal reflux disease.
DISCHARGE MEDICATIONS:
1. Gentamicin 60 mg intravenously q. 8 hours
2. Ceftazidime 2 gm intravenously q. 8 hours
3. Fluconazole 400 mg intravenously q. day
4. Metoprolol 50 mg b.i.d. through jejunostomy tube
5. Insulin regular sliding scale
6. Tylenol 325 mg to 650 mg via jejunostomy tube prn
7. Reglan 10 mg q.i.d. via jejunostomy tube
8. Miconazole powder 2% b.i.d.
9. Artificial tears one to two drops prn
10. Albuterol 4 puffs inhaler q. 6 hours prn
11. Lansoprazole oral solution 30 mg via jejunostomy tube
12. Heparin 500 units subcutaneously q. 12 hours
13. Tube feeds, specifically Promote with fiber cycled over
night.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow up with Dr. [**Last Name (STitle) **], her
surgeon within the next week to two weeks after discharge.
2. The patient is to follow up with her primary care
physician within the next two weeks.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13186**], M.D. [**MD Number(1) 13187**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2185-12-18**] 12:23
T: [**2185-12-18**] 08:13
JOB#: [**Job Number 28904**]
|
[
"569.83",
"568.0",
"511.9",
"112.2",
"291.81",
"276.2",
"567.2",
"577.0",
"303.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.99",
"54.59",
"46.79",
"46.39",
"96.07",
"96.72",
"38.93",
"54.11",
"99.15",
"96.6",
"54.91",
"54.19"
] |
icd9pcs
|
[
[
[]
]
] |
11309, 11925
|
10929, 11286
|
1963, 2055
|
3437, 10820
|
11949, 12455
|
1605, 1869
|
2078, 3315
|
153, 1454
|
1477, 1581
|
1886, 1936
|
10845, 10908
|
3333, 3419
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,395
| 127,024
|
34424
|
Discharge summary
|
report
|
Admission Date: [**2128-8-6**] Discharge Date: [**2128-8-24**]
Date of Birth: [**2052-11-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Third time redo sternotomy.
2. Second time aortic valve replacement with a 21-mm onyx
mechanical valve, reference number [**Serial Number 79137**], serial
number [**Serial Number 79138**].
3. Redo CABG times 2 with reverse saphenous vein graft from
the neo ascending aorta to the preexisting saphenous
vein graft to the right coronary artery; reverse
saphenous vein graft from the neo ascending aorta to the
preexisting OM1 vein graft.
4. Endoscopic vein harvesting.
5. Replacement of ascending aorta with a 28 mm tube graft
using deep hypothermic circulatory arrest
6. Sternal re-exploration, removal of packing and
sternal closure
History of Present Illness:
Mr. [**Known lastname **] is a 75 yo man with a h/o CAD, s/p CABG in [**2112**],and DES
[**8-5**] and [**7-6**], s/p AVR in [**2120**], and hyperlipidemia who presents
with 1 month of worsening CP on exertion and DOE. Approximately
1 month ago, Mr. [**Known lastname **] noted worsening chest pain on exertion and
DOE which have been worsening over the last 4 weeks.
Approximately 1 week ago, he also noted resting shoulder pain,
and nocturnal cough. Pain responded to nitro at home. He denies
nausea, lightheadedness, dizziness, leg swelling, palps. Denies
fevers, chills, sick contacts or cold symptoms. Does endorse a
nonproductive cough for the last 3 days. Denies recent increase
in salt intake.
.
In the ED, initial vitals were 98.0; 142/75; 76; 20; 97%RA. Labs
significant for Trop 0.06; BNP [**2075**] with no prior. EKG with new
TWI in I, aVL, V4-V6. CXR showed low lung volumes, patchy focal
infiltrate in LLL which may indicate early pneumonia vs
aspiration, no pulmonary edema. CTA chest showed no PE, b/l
pleural effusions and septal thickening c/w fluid overload,
bibasilar consolidations, atelectasis vs pneumonia. He developed
an episode of CP in the ED that resolved with 1 SL nitro.
Patient was given ASA 325mg, Lasix 20mg IV, Levofloxacin 750mg
IV, Nitro 0.4mg SL x1. Blood cultures were drawn. Vitals on
transfer were 98.0, 62 NSR, 22 RR, 104/53, 92% 4L NC. He
diuresed 800 cc of urine to 20mg IV of lasix.
.
On arrival to the floor, patient is comfortable without CP or
SOB, feels well.
.
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, hemoptysis, or red
stools. He does endorese black stools x several months. 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 orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: CABG X 5 in [**2112**]
-PERCUTANEOUS CORONARY INTERVENTIONS: [**7-/2125**] DES to RCA [**2124**],
DES to LIMA [**2125**]
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
AVR [**2120**] with "cow valve"
Atrial Fibrillation - rhythm controlled occurred s/p valve
replacement
.
Social History:
Divorced. Lives with companion of 25 years, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in
[**Location (un) 47**]. Four adult children live in the area. Retired
maintenance worker for [**Company 14672**].
-Tobacco history: Quit 20 years ago; previously smoked 1 PPD X
35 years
-ETOH: 2 highballs/night
-Illicit drugs: denies
Family History:
Father died suddenly at age 53 of unknown cause. Brother with
CAD, s/p CABG at age 70.
Physical Exam:
VS: T= 98.2 BP= 106-118/55-64 HR= 60-69 RR= 20 O2 sat= 94-97% 3L
NC 89.8kg
GENERAL: WDWN male in distress [**12-31**] chest pain, using accessory
muscles, 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 9 cm, +HJR.
CARDIAC: RR, normal S1, S2 click. III/VI holosystolic murmur
without radiation to carotids. No thrills, lifts. No S3 or S4.
LUNGS: Diminished BS at the bases, insp crackles above that on
L, no wheezes or rhonchi. No chest wall deformities, scoliosis
or kyphosis. Resp was labored.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: Trace pedal edema b/l worse on R>L (SVG was
obtained from RLE). No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2128-8-22**] 06:12AM BLOOD WBC-7.1 RBC-3.39* Hgb-10.6* Hct-30.0*
MCV-89 MCH-31.4 MCHC-35.4* RDW-14.2 Plt Ct-163
[**2128-8-7**] 05:48AM BLOOD Neuts-71.3* Lymphs-19.0 Monos-7.7 Eos-1.4
Baso-0.6
[**2128-8-22**] 06:12AM BLOOD PT-25.6* INR(PT)-2.4*
[**2128-8-22**] 01:23PM BLOOD Na-139 K-3.8 Cl-99
TEE:
-No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
-There is moderate to severe regional left ventricular systolic
dysfunction with EF 30% with moderate inferoseptal wall
hypokinesis.
-The appearance of the ascending aorta is consistent with a
normal tube graft.
-A bileaflet aortic valve prosthesis is present. The aortic
valve prosthesis leaflets appear to move normally. The
transaortic gradient is normal for this prosthesis. There is no
aortic valve stenosis. [The amount of regurgitation present is
normal for this prosthetic aortic valve.] No abnormal
perivalvular leak is appreciated.
-The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
-There is no pericardial effusion.
Brief Hospital Course:
75M with complex cardiac history. He underwent CABG in [**2112**] and
a redo sternotomy, AVR in [**2120**] and then stented in [**2124**] and
[**2125**]. Over the past month he has developed progressive DOE and
chest pain.
He presented to the ED with an NSTEMI and new onset CHF on
[**2128-8-6**]. Echo revealed severe bioprosthetic Aortic Valve
stenosis with a valve area 0.8-1.0cm2. Cath revealed
multi-vessel CAD. Cardiac surgery is consulted for 3rd time
sternotomy, AVR,CABG evaluation.
On [**2128-8-16**] he was taken to the operating room where he underwent
1. Third time redo sternotomy.
2. Second time aortic valve replacement with a 21-mm onyx
mechanical valve, reference number [**Serial Number 79137**], serial
number [**Serial Number 79138**].
3. Redo CABG times 2 with reverse saphenous vein graft from
the neo ascending aorta to the preexisting saphenous
vein graft to the right coronary artery; reverse
saphenous vein graft from the neo ascending aorta to the
preexisting OM1 vein graft.
4. Endoscopic vein harvesting.
5. Replacement of ascending aorta with a 28 mm tube graft
using deep hypothermic circulatory arrest.
His chest was left open at the end of the case despite multiple
blood products, the patient was coagulopathic and Dr. [**Last Name (STitle) 914**]
decided to pack the chest and the the chest and the chest open.
The patient was taken directly from the OR to the ICU for
ongoing post-op care and management. He was on milrinone, epi,
vasopressin, Neo and propofol. He was taken back tothe operating
room on POD#1 and his chest was closed. He was weaned and
extubated on POD#2. He was weaned off his inotropes and was
hypertensive and refractory to po anti-hypertensives and started
on a nicardipine drip. The oral antihypertensives were increased
and the nicardipine was weaned off. He was started on coumadin
for mechcanical AVR. He was started on statin, ace, betablocker
and lasix therapies. despite aggressive diuresis he continued to
have firm taut edema of his lower extremities. He continued to
progress quickly and was transferred to the stepdown unit on
POD#6. He was evaluated by physical therapy for strength and
conditoning and discharge to rehab was recommended. He was noted
to have mild erythema and scant serous drainage of his right SVH
incision site On POD#8 and #9 he was discharged to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3549**]
Rehab [**Location (un) 1110**].
Medications on Admission:
Sotalol 80mg [**Hospital1 **]
Verapamil ER 240mg daily
Imdur 120mg daily
Crestor 20mg daily
ASA 81mg daily
Fish oil 1 cap daily
Vit C 500mg PO daily
Vit D 1000 units daily
Discharge Medications:
1. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
2. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO Q12H (every 12 hours).
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).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): until edema resolves.
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
13. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Indication mech AVR
Goal INR 2.5-3
daily coumadin based on INR.
15. Outpatient Lab Work
follow INR daily until therapeutic then 3 times weekly until
stable
Next draw [**2128-8-25**]
16. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day: while on lasix but
follow bun/creat and potassium levels 2 times weekly.
17. cephalexin 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 7 days: for erythema of leg incision.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**]
Discharge Diagnosis:
1. Prosthetic aortic valve stenosis.
2. Severe 3-vessel coronary disease.
3. Severe disease of vein grafts from previous coronary
artery bypass grafting.
4. Peripheral vascular disease.
5. Open chest status post 3rd time redo
coronary artery bypass grafting, aortic valve replacement and
replacement of ascending aorta yesterday with post procedure
coagulopathy.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait but deconditoned
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing with slight erythema and scant serous
drainage- keflex started x 7days.
Edema: taut firm edema to bilateral lower extremities.
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: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2128-10-5**] 1:45 in the [**Hospital **] medical office building
Please call to schedule appointments with your
Primary Care/Cardiologist: CHAKRABORTY,AUROBINDO [**Telephone/Fax (1) 8058**] in
[**11-30**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication mech AVR
Goal INR 2.5-3
First draw [**2128-8-25**]
Results to phone fax - please arrange coumadin follow up upon
discharge from rehab
Completed by:[**2128-8-24**]
|
[
"V45.82",
"433.30",
"996.72",
"410.71",
"414.01",
"414.2",
"996.71",
"286.9",
"428.0",
"424.1",
"998.11",
"V15.82",
"E929.8",
"V49.62",
"414.02",
"V58.61",
"486",
"785.51",
"440.20",
"285.1",
"518.82",
"401.9",
"440.0",
"433.10",
"V17.49",
"E849.0",
"908.6",
"998.0",
"428.31",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.59",
"35.22",
"88.57",
"96.6",
"37.21",
"38.45",
"96.71",
"39.61",
"34.79",
"88.56",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
10530, 10672
|
6023, 8501
|
319, 998
|
11083, 11396
|
4923, 6000
|
12234, 12998
|
3792, 3880
|
8723, 10507
|
10693, 11062
|
8527, 8700
|
11420, 12211
|
3895, 4904
|
3126, 3271
|
269, 281
|
1026, 3032
|
3302, 3410
|
3054, 3106
|
3426, 3776
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,817
| 148,380
|
49632+59191
|
Discharge summary
|
report+addendum
|
Admission Date: [**2196-12-9**] Discharge Date: [**2196-12-18**]
Date of Birth: [**2120-6-24**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
electric shock like sensation
Major Surgical or Invasive Procedure:
[**2196-12-14**]: Posterior cervical laminectomy C6-C7, T1-T2 for
resection of intradural tumor at C7-T1.
History of Present Illness:
This is a 76 year old white male who reported that he has had
feelings of pins and needles in his right arm for years. He had
a CT in [**2192**] of his neck that he recalls being normal. This was
done at [**University/College **]/[**Location (un) 38**] by his PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Two days
ago he was shaving and he got an electric shock in the right
side of this neck. the next day he was turning his head and he
got an even bigger shock. This one was so sever that it caused
him to lower himself to the ground. He reported this to his pcp
who ordered [**Name Initial (PRE) **] CTA. This was reported as normal. He then
underwent an MRI of the spine. He was told to come to the ED.
Past Medical History:
high cholesterol
broken leg / non surgical
Social History:
He lives with wife of 44 [**Name2 (NI) 1686**] in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. He is a retired
engineer. He quit smoking 33 [**Last Name (NamePattern4) 1686**] ago. He denies etoh use.
Family History:
NC
Physical Exam:
On Admission: Gen: WD/WN, comfortable, NAD.
HEENT: NCAT Pupils: [**3-23**] b/l EOMis
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
B T IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5
Sensation: Intact to light touch,
Reflexes: Pa Ac
Right 2 0
Left 2 0
PHYSICAL EXAM UPON DISCHARGE:
His wound was clean and dry with resorbable sutures. There were
[**3-25**] areas of [**2-25**] mm cysts at the superior pole. They were not
purulent. There was no drainage. He has full strength. He is in
a collar.
Pertinent Results:
[**12-10**] CXR: FINDINGS: The lung volumes are normal. Flattening of
the hemidiaphragms on the lateral film could suggest mild
overinflation. Borderline size of the cardiac silhouette with
tortuosity of the thoracic aorta but without evidence of
pulmonary edema. No pleural effusions. No lung nodules or
masses.
[**12-10**] CT C-Spine: IMPRESSION: Known intradural extramedullary
mass at the level of C7-T1 does not appear to be associated with
any calcifications on this non-contrast study.No expansion of
neural foramina or bony erosion seen. Cranio-cervical bony
abnormality with spinal stenosis at C1.
[**12-10**] MRI Head:
1. No acute intracranial process.
2. No pathologic focus of enhancement; specifically, there is no
finding to suggest meningioma in the intracranial compartment.
3. Mild-moderate global atrophy, particularly bifrontal
cortical, and sequela of chronic small vessel ischemic disease.
4. Relatively mild chronic inflammatory changes in the paranasal
sinuses.
5. Markedly dysmorphic appearance to the atlas and axis; please
see
separately-dictated report of the concurrent MR examination of
the cervical spine.
MRI C-Spine: [**2196-12-15**]
1. Re-demonstration of the extramedullary-intradural but
dural-based lesion, occupying much of the right half of the
spinal canal, centered at the C7-T1 level. This has imaging
characteristics strongly suggestive of "typical" meningioma,
with significant mass effect upon and compression of the
subjacent spinal cord, without signal abnormality.
2. Likely os odontoideum with likely associated fusion anomaly
involving the anterior neural arch of C1; as above; these
dysmorphic vertebrae significantly narrow the ventral spinal
canal and, in combination with the resultant angulation of the
spinal cord, as well as ligamentum flavum thickening, severely
narrow the spinal canal, compressing the cord, which
demonstrates intrinsic signal abnormality, likely representing
myelomalacia.
N.B. Instability with abnormal motion at this level (which
commonly
accompanies such anomalies) cannot be excluded on this static
study.
3. Multilevel degenerative disease, most marked at the C5-6
level, where
there is significant left anterolateral spinal canal and severe
left neural foraminal stenosis with likely impingement upon the
exiting left C6 nerve root.
Brief Hospital Course:
Mr. [**Known lastname 103791**] was admitted to the Neurosurgery service on [**12-9**].
He was placed in a hard collar when OOB. From [**Date range (1) 103792**] the
patient remained neurologically stable. He ambulated frequently
in the hallway without any difficulty. An MRI of his neck and
spine was obtained which revealed a extramedullary-intradural
lesion occupying much of the spinal canal. Findings were
suggestive of a meningioma. His MRI Brain was unremarkable for
tumor. He was prepped for surgery and radiation oncology was
consulted for assistance with plan of care.
On [**12-14**] he was taken to the OR with Dr. [**Last Name (STitle) **] and underwent a
C6-T2 laminectomy and excision of intradural, extramedullary
tumor. He tolerated the procedure well. He was kept flat for 48
hrs to prevent CSF leak. He had a post-op MRI on [**12-15**]. He was
elevated on [**12-16**] without incident and transitioned OOB
minimally. His Foley was removed and he was voiding well. He was
tolerating a regular diet. His wound had running Monocryl
superficial sutures with some small areas of cyst formation but
no sing of infection. He was cleared for discharge to home on
[**2196-12-18**].
Medications on Admission:
pravastatin 40 daily, aspirin 81mg qod
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain fever: max 4g/24 hrs.
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: Two (2) Tablet PO DAILY
(Daily).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
6. methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q8 () for 48
days: start at 4pm [**12-18**] for 48hrs, then 1 tab Q12 for 48hrs,
then [**1-24**] tab Q12 for 48hrs then [**1-24**] tab Q24 for 48hrs, then
stop.
Disp:*13 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Intradural, extramedullary spinal cord tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound clean and dry / No tub baths or pool swimming
for two weeks from your date of surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Wear your cervical collar at all times when out of bed for one
month.
?????? You may shower briefly whikle sitting in your shower chair. We
have given you pads to change for your collar after the shower.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any medications such as Aspirin unless directed by
your doctor.
?????? You should take Advil/Ibuprofen 400mg three times daily. This
is over the counter.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in 10 days (from date of surgery)
for a wound check. This appointment can be made with the Nurse
Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic in 6 weeks.
The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**],
in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call to make this appointment.
Completed by:[**2196-12-18**] Name: [**Known lastname 16807**],[**Known firstname 63**] Unit No: [**Numeric Identifier 16808**]
Admission Date: [**2196-12-9**] Discharge Date: [**2196-12-18**]
Date of Birth: [**2120-6-24**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 599**]
Addendum:
Patient was discharged home with services.
Discharge Disposition:
Home
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2196-12-19**]
|
[
"V15.82",
"272.0",
"336.3",
"723.0",
"225.4",
"724.9",
"V15.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"03.4"
] |
icd9pcs
|
[
[
[]
]
] |
9491, 9635
|
4716, 5908
|
340, 448
|
7001, 7001
|
2372, 4693
|
8414, 9468
|
1572, 1576
|
5997, 6883
|
6933, 6980
|
5934, 5974
|
7152, 8391
|
1591, 1591
|
270, 302
|
2138, 2353
|
476, 1251
|
1605, 1731
|
7016, 7128
|
1273, 1318
|
1334, 1556
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,931
| 199,884
|
8180
|
Discharge summary
|
report
|
Admission Date: [**2176-7-9**] Discharge Date: [**2176-7-16**]
Date of Birth: [**2104-3-14**] Sex: M
Service: INT MED
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old man
with a history of coronary artery disease (ejection fraction
10-15%) on anticoagulation for LV aneurysm, with recurrent GI
bleeds, who presented to the Emergency Room with melena. The
patient was started on coumadin in [**2175-12-21**] and has had
three GI bleeds since that time.
On the day of admission, the patient reports having melena.
On the afternoon of admission, the patient reports symptoms
of lightheadedness, dizziness and unsteady gait. The patient
denies syncope, abdominal pain, nausea, vomiting, chest pain,
palpitations or shortness of breath. The patient has a
history of diarrhea for which he takes Imodium.
In the Emergency Room, the patient was afebrile with blood
pressure 80/42, pulse 74, oxygen saturation 100% on room air.
GI was consulted and patient underwent NG lavage which was
negative. The patient received two liters of normal saline,
in addition to one unit of packed red blood cells. The
patient's hematocrit on admission was 26.0 and dropped to
20.6 with hydration. The patient's INR was 2.6 on admission
and was reversed with vitamin K and FFP. The patient was
taken for EGD which revealed a bleeding angiectasia in the
third part of the duodenum which was subsequently cauterized
with successful hemostasis. The patient was admitted to the
MICU for close monitoring.
PAST MEDICAL HISTORY: 1) Coronary artery disease, status
post anterolateral MI in 12/00. The patient is status post
cath with stent of LAD and D1, complicated by apical thrombus
requiring emergent CABG. 2) CHF with EF of [**9-2**]%. Echo in
[**5-19**] showed marked dilation of the left and right atria. LV
severely dilated. Kinesis involving the whole LV sparing the
base. A large anterior apical aneurysm. No apical thrombus
seen. Severe MR [**First Name (Titles) **] [**Last Name (Titles) **]. 3) History of atrial fibrillation.
4) Status post DDD pacemaker - AICD. 5) Status post CVA
without residual deficits. 6) Hyperlipidemia. 7) Chronic
renal insufficiency with baseline creatinine of 1.4. 8)
History of upper GI bleeds. EGD [**2-18**] showed grade 2
esophagitis without bleeding. Angiectasias in the second
part of the duodenum seen. EGD [**3-19**] - hiatal hernia,
cholesterol plaque in the duodenum and jejunum. EGD [**4-19**] -
normal. Colonoscopy [**3-19**] - diverticulosis, a single polyp
at 12 cm. Colonoscopy [**2-18**] - diverticulosis of the sigmoid.
9) Status post ablation of atrial tachycardia. 10) History
of MRSA pneumonia. 11) Status post appendectomy. 12)
Depression.
MEDICATIONS ON ADMISSION: 1) Aspirin 325 mg po qd, 2)
coumadin 5 mg po q hs, 3) aldactone 25 mg po qd, 4) digoxin
0.125 mg po qd, 5) Lipitor 20 mg po qd, 6) Zoloft 100 mg po
qd, 7) Niferex 100 mg po qd, 8) multivitamin 1 tab po qd, 9)
Protonix 40 mg po qd, 10) Toprol XL 12.5 mg po qd, 11)
amiodarone 200 mg po qd, 12) Zestril 40 mg po qd, 13) lasix
80 mg po bid.
ALLERGIES: Neosporin eye drops.
SOCIAL HISTORY: The patient lives with his wife and adopted
5-year-old son. The patient quit smoking tobacco 11 years
ago with 50-pack year history of smoking. The patient quit
alcohol 40 years ago.
PHYSICAL EXAM ON ADMISSION: Temperature 97.3, heart rate 74,
blood pressure 86/61, respiratory rate 16, oxygen saturation
100% on room air. General - comfortable, in no acute
distress. HEENT - anicteric sclerae. Pupils equal, round,
reactive to light. Extraocular muscles intact. Mucus
membranes moist with no oral lesions. Lungs - crackles at
the left base. Heart - regular rate, normal S1, S2, with
II/VI holosystolic murmur best heard at the apex. Abdomen
soft, nontender, nondistended with normal bowel sounds.
Rectal - melenic stool. Extremities - no edema.
LABS ON ADMISSION: Hematocrit 26, INR 2.6, BUN 68, CPK 36.
HOSPITAL COURSE - 1) GI: The patient presented with GI
bleed. NG lavage in the ED was negative. The patient
underwent EGD which showed bleeding angiectasia in the third
part of the duodenum which was cauterized with successful
hemostasis. The patient was admitted with an INR of 2.6
which was reversed with vitamin K and FFP. Aspirin and
coumadin were both held and discontinued at discharge. The
patient remained hemodynamically stable throughout this
admission. The patient was transferred from the MICU to the
floor on hospital day #3.
The patient continued to slowly drop his hematocrit during
this admission and received a total of 17 units of packed red
blood cells. The patient's slow GI bleeding is thought to be
due to other AVMs. Angiography was considered, but as
patient remained hemodynamically stable and asymptomatic, it
was decided to pursue conservative management and follow
patient's hematocrit [**Hospital1 **]. At the time of discharge, the
patient's hematocrit remained stable at around 30 and stools
were guaiac negative.
2) CARDIOVASCULAR: The patient remained hemodynamically
stable. The patient received lasix in between units of
packed red blood cells. The patient did not have any chest
pain or shortness of breath during this hospital course.
Given the patient's history of recurrent GI bleeds on
coumadin, it was decided to discontinue both aspirin and
coumadin at the time of discharge.
3) ELECTROLYTES: With diuresis, the patient became
hypernatremic with sodium of 152 which reversed itself with
gentle hydration. The patient had a sodium of 144 at the
time of discharge.
4) PSYCH: The patient presents with a history of depression.
The patient's mood became very depressed during this hospital
stay. The patient was seen by his PCP who recommended
increasing Zoloft to 200 mg qd at the time of discharge.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient discharged to home.
DIAGNOSES: 1) Gastrointestinal bleed. 2) Coronary artery
disease. 3) Congestive heart failure.
MEDICATIONS AT THE TIME OF DISCHARGE: 1) lasix 80 mg po bid,
2) aldactone 25 mg po qd, 3) digoxin 0.125 mg po qd, 4)
Lipitor 20 mg po qd, 5) Zoloft 200 mg po qd--increase in
dose, 6) multivitamin, 7) Protonix 40 mg po qd, 8) Toprol-XL
12.5 mg po qd, 8) amiodarone 200 mg po qd, 9) Zestril 40 mg
po qd.
MEDICATIONS DISCONTINUED AT THE TIME OF DISCHARGE: 1)
aspirin 325 qd, 2) coumadin 5 mg po q hs.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Last Name (NamePattern1) 1297**]
MEDQUIST36
D: [**2176-7-16**] 13:14
T: [**2176-7-16**] 12:23
JOB#: [**Job Number 29098**]
|
[
"276.8",
"414.11",
"593.9",
"402.91",
"537.83",
"311",
"E934.2",
"285.9",
"286.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"96.34"
] |
icd9pcs
|
[
[
[]
]
] |
2761, 3134
|
5858, 6731
|
168, 1516
|
3931, 5843
|
1539, 2734
|
3151, 3351
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,099
| 191,738
|
51710
|
Discharge summary
|
report
|
Admission Date: [**2198-3-16**] Discharge Date: [**2198-3-20**]
Date of Birth: [**2134-1-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2198-3-16**]
1.Coronary artery bypass graft x4, left internal mammary
artery to left anterior descending artery, and saphenous
vein grafts to diagonal obtuse ramus artery and the
right coronary artery.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
64 yo M with complaints of chest burning while shoveling with
+ETT today, sent directly for cardiac catheterization. Admitted
for CABG
Past Medical History:
Hyperlipidemia
Asthma
GERD
Gout
testicular CA
Past Surgical History:
s/p testicular surgery
Social History:
-Born and lives in [**Location 3146**], MA
-Occupation: Telecommunications technician
-Tobacco history: Quit cigars >10 years ago
-ETOH: Infrequent
-Illicit drugs: None
Family History:
- Father CAD age 62.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse: Resp: O2 sat:
B/P Right:167/99 Left:165/101
Height:180 lbs Weight:5'5"
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur II/VI SEM @ LUSB
Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds +[]
Extremities:Warm[x], well-perfused[x] Edema: none
Varicosities:None
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2198-3-16**] 07:34AM HGB-13.1* calcHCT-39
[**2198-3-16**] 07:34AM GLUCOSE-107* LACTATE-1.2 NA+-141 K+-4.0
CL--104
[**2198-3-16**] 12:20PM FIBRINOGE-112*
[**2198-3-16**] 12:20PM PT-15.3* PTT-28.1 INR(PT)-1.3*
[**2198-3-16**] 12:20PM PLT COUNT-175
[**2198-3-16**] 12:20PM WBC-18.1*# RBC-3.52* HGB-9.8* HCT-28.2*
MCV-80* MCH-27.7 MCHC-34.6 RDW-13.7
[**2198-3-16**] 01:14PM UREA N-15 CREAT-0.8 CHLORIDE-110* TOTAL
CO2-23
[**2198-3-20**] 05:50AM BLOOD WBC-11.5* RBC-3.47* Hgb-9.6* Hct-28.1*
MCV-81* MCH-27.8 MCHC-34.2 RDW-14.0 Plt Ct-221
[**2198-3-20**] 05:50AM BLOOD Plt Ct-221
[**2198-3-16**] 01:14PM BLOOD PT-13.8* PTT-28.9 INR(PT)-1.2*
[**2198-3-20**] 05:50AM BLOOD Glucose-124* UreaN-26* Creat-1.0 Na-136
K-4.6 Cl-94* HCO3-29 AnGap-18
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 107122**]
FINDINGS: In comparison with the study of [**3-18**], there is no
convincing
evidence of pneumothorax at this time. Right central catheter
remains in
place. Persistent opacification at the left base is again
consistent with
atelectasis and effusion.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 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: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Sinus Level: 3.5 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler. Prominent
Eustachian valve (normal variant).
LEFT VENTRICLE: Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV
systolic function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The patient appears to be in sinus rhythm. See
Conclusions for post-bypass data
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-bypass:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium or left
atrial appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is mildly
depressed (LVEF= 45-50 %). Right ventricular chamber size is
normal. with borderline normal free wall function. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. There is no prolapse or flail leaflets. Even with T
[**Doctor Last Name **], MR remains mild. Mild (1+) mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
Post-bypass:
Intact thoracic aorta.
Mild MR.
LVEF 45-50%
Preserved Right ventricular systolic function. LV similar
toprebypass.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2198-3-16**] 12:10
Brief Hospital Course:
Mr [**Known lastname 107121**] was a same day admit to the operating room for
coronary bypass grafting. Please see operative report for
details in summary he had coronary bypass graftinf x4 with:1.
left internal mammary artery to left anterior descending artery,
and saphenous vein grafts to diagonal obtuse ramus artery and
the right coronary artery.
2. Endoscopic harvesting of the long saphenous vein. His bypass
time was 155 minutes with a crossclamp time of 95 minutes. He
tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition.
In the immediate post operative period he remained
hemodynamically stable, woke neurologically intact and was
extubated. On POD1 he was transferred from the ICU to the
stepdown floor for continued care and physical recovery. All
tubes lines and drains were removed according to cardiac surgery
protocol. The remainder of his hospital course was uneventful,
his activity level advanced and on POD4 he was discharged home
with visiting nurses. Followup with Dr [**Last Name (STitle) 7772**] in 4 weeks.
Medications on Admission:
1. Albuterol Sulfate 1-2 Puffs Q6H/PRN for wheezing.
2. Allopurinol 100 mg DAILY
3. Doxazosin 1 mg QHS
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk [**Hospital1 **]
5. Metoprolol Tartrate 12.5 mg [**Hospital1 **]
6. Nitroglycerin 0.3 mg (1)PRN for chest pain:
7. Simvastatin 10 mg DAILY
8. Aspirin 325 mg DAILY
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Puff/Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation prn as needed for shortness of breath
or wheezing.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
s/p CABG X4 (LIMA to LAD, SVG to Diag-Ramus-RCA
PMH:
Hyperlipidemia, Asthma, GERD, Gout, testicular CA, s/p
testicular surgery
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Sternal wound healing well, no erythema or drainage.
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Dr [**Last Name (STitle) 7772**] on [**4-16**] @1:45PM
Please call to schedule appointments with:
PCP: [**Name10 (NameIs) 1576**],[**Name11 (NameIs) 1575**] [**Telephone/Fax (1) 1579**] in [**3-7**] weeks
Cardiologist: Dr [**First Name (STitle) **] [**Name (STitle) 1911**] in [**3-7**] weeks
[**Hospital 409**] clinic in 2 weeks-nurses to schedule appointment before
discharge
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2198-3-20**]
|
[
"530.81",
"274.9",
"272.4",
"V10.47",
"V45.89",
"493.90",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
9109, 9180
|
6319, 7421
|
288, 560
|
9351, 9351
|
1841, 4981
|
10150, 10650
|
1044, 1180
|
7786, 9086
|
9201, 9330
|
7447, 7763
|
9549, 10127
|
816, 841
|
5025, 6296
|
1195, 1822
|
237, 250
|
588, 724
|
9365, 9525
|
746, 793
|
857, 1028
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,874
| 122,293
|
19829
|
Discharge summary
|
report
|
Admission Date: [**2183-10-18**] Discharge Date: [**2183-10-25**]
Date of Birth: [**2110-5-31**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
gentleman with a past medical history significant for chronic
obstructive pulmonary disease (with recent exacerbation),
chronic atrial fibrillation, and the onset of lower extremity
weakness over the past several weeks. The patient was
transferred from [**Hospital 1562**] Hospital with methicillin-resistant
Staphylococcus aureus bacteremia, methicillin-resistant
Staphylococcus aureus and Pseudomonas in his sputum, and
questionable new cerebrovascular accident.
Per the patient's daughter, the patient has a long history of
chronic obstructive pulmonary disease and is on home
nebulizers but not oxygen. On [**2183-8-15**], the patient
became acutely short of breath and was admitted to [**Hospital 1562**]
Hospital with a chronic obstructive pulmonary disease
exacerbation. His sputum grew methicillin-resistant
Staphylococcus aureus, and the patient was treated with
antibiotics. The patient subsequently improved and was
discharged to a rehabilitation facility. Per the patient's
daughter, he was doing well. He was mentally alert and was
ambulating without difficulty at the facility.
On [**2183-10-11**], the patient developed severe worsening
of back pain he had been having since [**2183-5-18**] in
addition to lower extremity weakness with the right being
greater than the left. The patient's daughter reports he was
unable to stand without pushing himself up from a chair.
In the early morning of [**2183-10-12**], the patient was
readmitted to [**Hospital 1562**] Hospital with a fever. Significantly,
he had previously had methicillin-resistant Staphylococcus
aureus cultured from a wound in his sacral area and
peripherally inserted central catheter line. The
peripherally inserted central catheter line was subsequently
removed on [**Month (only) 359**] ? 16, [**2182**].
In the Emergency Department at [**Hospital 1562**] Hospital, the
patient's blood pressure was 80/50, his temperature was 99
degrees Fahrenheit, and his heart rate was 106. His white
blood cell count was 17.7. The patient received fluids,
ciprofloxacin, gentamicin, and hydrocortisone. He was then
admitted to the Medical Intensive Care Unit at the outside
hospital for further care. The patient was stabilized
hemodynamically. He received vancomycin, ciprofloxacin, and
Azactam. Per the patient's daughter, his speech became very
garbled on hospital day one, and he was suddenly unable to
swallow. The patient continued to have worsening weakness
(right greater than left) and developed right upper extremity
weakness.
On [**2183-10-13**], the patient had a computed tomography of
the head showing subacute versus chronic lacunar infarction
and right parietal arachnoideus. On [**2183-10-14**], a
magnetic resonance imaging showed an acute left brain stem
and lower cerebellar infarction. A magnetic resonance
imaging of the spine showed increased activity in the lumbar
spine with L1 and L2 compression fractures and L4 compression
fracture versus metastases. Throughout this time, the
patient continued to have positive blood cultures and sputum
cultures. On [**2183-10-15**], the patient became unable to
handle his secretions, requiring intubation. He underwent a
bronchoscopy at that time and was found to have copious
yellow-brown sputum, mainly from his right bronchus
intermedius and right middle lobe. Bronchial washings showed
rare epithelial cells, and many neutrophils, and many
gram-positive cocci, moderate gram-negative rods, and
frequency gram-positive rods. No fungi were seen on smear.
Per family wishes, the patient was transferred to [**Hospital1 346**] for further neurologic and oncologic
workup.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. Atrial fibrillation.
3. Past methicillin-resistant Staphylococcus aureus in
sputum.
4. Anemia.
5. Chronic back pain.
6. Coronary artery disease; status post coronary artery
bypass graft.
7. Inguinal hernia repair.
8. Status post left total hip replacement.
9. Spinal stenosis.
ALLERGIES: PENICILLIN.
MEDICATIONS ON ADMISSION:
1. Vancomycin 750 mg by mouth q.12h.
2. Lasix 20 mg intravenously twice per day.
3. Dexamethasone 4 mg intravenously once per day.
4. Morphine drip 2 mg intravenously per hour.
5. Solu-Medrol 30 mg intravenously once per day.
6. Lacri-Lube.
7. Azactam 1 gram intravenously q.6h.
8. Albuterol nebulizers.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient's temperature was 102.5
degrees Fahrenheit, his blood pressure was 147/37, his heart
rate was 100, synchronized intermittent mandatory ventilation
650/37/0.4/5. In general, the patient was not sedated but he
was lethargic. The patient blinked appropriately and
responded to questions. The patient followed simple
commands. Head, eyes, ears, nose, and throat examination
revealed the patient was intubated. No cervical
lymphadenopathy. Cardiovascular examination revealed
hyperdynamic. Normal first heart sounds and second heart
sounds. No murmurs, rubs, or gallops. A regular rate and
rhythm. Pulmonary examination revealed coarse breath sounds
anterolaterally with diffuse rhonchi. There was diminished
air movement bilaterally. The abdomen was soft, nontender,
and nondistended. Positive bowel sounds. Extremity
examination revealed no clubbing, cyanosis, or edema. No
peripheral signs of endocarditis. Rectal examination
revealed complete lack of rectal tone. The prostate was
enlarged and boggy. No nodules palpated. Neurologic
examination revealed the patient followed simple commands.
The patient squeezed left hand but was unable to do so on the
right. The patient wiggled his toes bilaterally. Deep
tendon reflexes were 1+ and symmetric.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission revealed the patient's white blood cell count
was 25.5, his hematocrit was 29.5, and his platelets were
317. Differential revealed 76 neutrophils, 0 bands, 15
lymphocytes, 5 monocytes, 0 eosinophils, 0 basophils, and 1
atypical cell, and 2 metamyelocytes, and 0 myelocytes. The
patient's prothrombin time was 13.4, his partial
thromboplastin time was 37.8, and his INR was 1.2.
Chemistries revealed his sodium was 137, potassium was 4.3,
bicarbonate was 34, blood urea nitrogen was 50, creatinine
was 0.8, and blood glucose was 124. His
alanine-aminotransferase was 149, his aspartate
aminotransferase was 107, his lactate dehydrogenase was 396,
his alkaline phosphatase was 162, his amylase was 164, his
total bilirubin was 0.8, and his lipase was 18. His albumin
was 2.7. His calcium was 9, his magnesium was 2.1, and his
phosphorous was 3.3. His lactate was 1.3. Free calcium was
1.18.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray on admission
revealed bilateral patchy infiltrates with loss of right
costophrenic angle and loss of left heart border.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. INFECTIOUS DISEASE ISSUES: Following admission, the
patient had methicillin-resistant Staphylococcus aureus
bacteremia with multiple sources of infection.
(a) Bacteremia: The patient was continued on vancomycin
throughout his admission. He also completed five days of
gentamicin for Synergy. The patient consistently had
positive blood cultures on admission; however, on [**2183-10-24**], he had pending negative cultures from [**2183-10-22**].
However, on [**2183-10-24**], his white blood cell count was
increasing. Surveillance cultures were continued.
(b) Aortic valve endocarditis: The patient had a small
vegetation on his aortic valve. He was evaluated by
Cardiothoracic Surgery on [**2183-10-23**]. The patient was
not a surgical candidate at that time since he had no
abscess. The patient did have mitral regurgitation which was
considered most likely due to coronary artery disease and/or
left ventricular dysfunction.
Given the patient's multiple surgical risk factors,
Cardiothoracic Surgery did not feel he was a candidate for
valve replacement surgery at this time. They agreed with the
team and Infectious Disease plan of six weeks of vancomycin
for treatment of his endocarditis.
(c) Methicillin-resistant Staphylococcus aureus/Pseudomonas
Pneumonia: Throughout the patient's admission, he was double
covered for Pseudomonas with gentamicin and levofloxacin. He
was extubated on [**2183-10-23**]. He was doing well on
[**2183-10-24**] with apparent improvement of his pneumonia
clinically and on x-ray. However, he did continue to have a
significant amount of secretions which were frequently
suctioned.
2. L4-L5 OSTEOMYELITIS/L4 EPIDURAL ABSCESS ISSUES: The
patient was evaluated by Neurosurgery for this finding on
[**2183-10-23**]. He was considered not to be a surgical
candidate at this time as he had no evidence of cord
compression and only a very small epidural abscess.
Per Neurosurgery and Infectious Disease recommendations, the
patient was continued on the antibiotics.
3. RESPIRATORY FAILURE ISSUES: The patient was supported on
a ventilator from admission until [**2183-10-23**]. On
[**2183-10-23**], the patient was extubated and was doing
well on cool nebulizers. The patient did have significant
secretions which he suctioned with help from nursing. The
patient maintained good oxygen saturations throughout the
evening of [**2183-10-23**] and [**2183-10-24**].
4. ATRIAL FIBRILLATION ISSUES: The patient was not
anticoagulated for his atrial fibrillation throughout this
admission as there were multiple discussions with
Cardiothoracic Surgery and Neurosurgery regarding the
possibility of a future surgery for the patient's
endocarditis and/or osteomyelitis or epidural abscess.
On the evening of [**2183-10-24**], the patient was restarted
on Coumadin; receiving 5 mg by mouth times one. The patient
was not currently on any rate control medications with a
heart rate that had been well controlled throughout his
admission. This was monitored closely.
5. NONSUSTAINED VENTRICULAR TACHYCARDIA ISSUES: The patient
had an episode of nonsustained ventricular tachycardia on the
evening of [**2183-10-24**]. He was started on a beta
blocker for rate control, and the patient continued to be
monitored on telemetry. The Electrophysiology Service was
not consulted as the patient was thought not to be a surgical
candidate at this time.
6. CHRONIC OBSTRUCTIVE PULMONARY DISEASE ISSUES: The
patient's chronic obstructive pulmonary disease was stable.
The patient was continued on meter-dosed inhalers and
nebulizers. His steroids were tapered once cord compression
was ruled out. On [**2183-10-24**], the patient was on
prednisone. There was a plan to taper him to 30 mg by mouth
every day on [**2183-10-25**].
7. ANEMIA ISSUES: The patient received one unit of packed
red blood cells on [**2183-10-23**]. He did have
guaiac-positive stool; although, there was no gross bleeding
or melena. The patient's hematocrit was followed closely
throughout his admission.
8. PROPHYLAXIS ISSUES: Subcutaneous heparin, and pneumatic
compression boots, and proton pump inhibitor, and a bowel
regimen.
9. CODE STATUS: The patient's code status is full.
On [**2183-10-24**] at 11:33 p.m. a code blue was called
regarding this patient. He was found to be pulseless with no
electrical activity and in asystolic arrest. Cardiopulmonary
resuscitation was begun immediately. The patient was
reintubated by Anesthesia. He received epinephrine and
atropine. In addition, one ampule of bicarbonate was given.
The patient was given 10 units of insulin with 1 ampule of
D-50. Normal saline was administered wide open for
hydration. Dopamine was also given. After approximately 30
minutes, the patient continued to have no palpable pulse, and
all efforts were stopped at 12:01 in the morning.
It was believed that the patient's death was most likely due
to either mucous plugging with subsequent cardiac arrest or
primary cardiac arrest. The family was contact[**Name (NI) **] and
notified of the patient's death. They declined an autopsy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D. [**MD Number(2) 8038**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2183-11-10**] 10:36
T: [**2183-11-10**] 12:23
JOB#: [**Job Number 53592**]
|
[
"518.81",
"482.41",
"038.8",
"324.1",
"730.08",
"482.1",
"434.91",
"421.0",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"99.15",
"77.49",
"96.6",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
4235, 7064
|
7098, 12495
|
164, 3830
|
3852, 4209
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,944
| 129,888
|
6340
|
Discharge summary
|
report
|
Admission Date: [**2108-4-17**] Discharge Date: [**2108-5-3**]
Date of Birth: [**2039-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
interventional radiology procedures: angiocath thrombectomies.
PICC line placement.
History of Present Illness:
68 yo M with h/o MDS, thrombocythemia, HTN, COPD and recent GIB
was admitted from NH for decreased HCT (HCT was at baseline 22)
and leukocytosis. He was recently admitted to [**Hospital1 18**] on the [**Hospital Ward Name **] between [**3-22**] - [**4-13**] for a massive GIB, DVT, and
cholecystitis. That hospitalization was summarized by the
following:
1. GIB: He underwent colonscopy which showed blood in the colon,
sigomid diverticulosis, but no clear source of the bleeding. A
SMA angiogram was significant for extravasation of contrast at
the distal ileocolic branches, which was successfully embolized.
He received a total of 10 U pRBC and 10 U FFP while in the MICU.
He was discharged with a HCT of 22, stable.
2. DVT: Pt has a h/o of DVT and spelic thrombosis. Had been on
coumadin, but this was reversed with Vit K when had GIB. Lenis
during last admission showed appearing L superficial vein DVT.
An IVC filter was placed. He was restarted on coumadin before
discharge.
3. Cholecystitis: He was noted to have worsening abd pain and
elevated LFTs. RUQ US showed concern for cholecystitis. He
underwent cipro, flagyl, and unasyn and then underwent an ERCP
in which a stone was removed from the biliary tree, a
sphincterotomy was performed, and the CBD was noted to be
dilated to 12 mm. He is scheduled for a CCY in the future,
although several providers have disagreed as to whether or not
he really needs this.
4. PNA: he was treated for PNA with ceftriaxone and azirhtomycin
via PICC on discharge to finish the course on [**4-19**].
.
He was discharged to a NH on [**4-13**] with a PICC in place for abx.
He was readmitted tot he 11R floor for anemia (though HCT was
stable). He was transfused 1 unit of PRBC on [**4-18**] to which his
HCT did not respond (know to be very difficult crossmatch). Attg
and Dr. [**Last Name (STitle) **], his hematologist, felt that he has some degree of
slow GIB still. IVC gram done to assess clot burden and showed
that there was clot above the filter and could extend into the
hepatic vein entry. IR was consulted who rec thrombolytics. This
was performed on [**4-19**] in the afternoon. The patient was
transferred to the [**Hospital Unit Name 153**] for further monitoring after this
procedure. He was continued with an infusion of TPA overnight
that was infused through a catheter extending the length of the
clot and then was taken back to the IR suite on [**4-20**] and imaging
showed that the clot had broken up a little. He was placed in a
supine position and plan was to try to do a thrombectomy, but
the patient began developing chest pain. This resolved as soon
as he was placed on his back again.
.
On arrival to the MICU he states he is feeling well and that the
chest pain was very fleeting - it was only present when he was
lying on his stomach and is now completely gone. Denies any SOB,
abd pain, or palpitations.
Past Medical History:
1. DVT RLE ([**2105**]) hospitalized
2. Aortic Regurg ([**7-/2101**]) LVEF 60-65%
3. Influenza A--> "coma" for 21 days ([**2100**]) Pt admitted to [**Hospital1 **]
for respiratory distress. Dignosed w/ influenza or PNA. pt was
intubated. cultured MRSA. RUQ ultrasound showed a hypoechoic
pancreas and sludge in the gallbladder. He was subsequently
extubated and did better. He received antibiotics. Incidentally
was diagnosed with Anemia and manocytosis so got Bone Marrow
Biopsy.
4. Anemia/ Manocytosis (myelodysplastic syndrome), very
difficult blood type match. on epogen
5. hemochromocytosis or sideroblastic anemia? [**2100**]
6. Pancreatitis: [**2100-1-15**] during ICU admission.
7. HTN: well controlled with Tiazadone
8. Gout: controlled with Allopurinal 300 daily
9. COPD "breathing much improved since stopped smoking 9 months
ago".
10 Scarlet fever as child.
11. Essential thrombocythemia: normally on antiplatlet agents,
held in anticipation of surgery
Social History:
1-2 packs per day for > 50 years (began whe he was 9 and just
stopped 9 months ago). Pt has positive alcohol history: claims
to have stopped or greatly reduced drinking, but did report in
[**2100**] drinking [**2-18**] six- packs per day on the weekends, 2-3 beers
a day during the week.
Family History:
Mother died in 80s not sure what from. His father has
hypertension- died in his 60s from heart attack?. 2 siblings are
alive and in good health. Son has asthma.
Physical Exam:
98.1, 155/69, 107, 93% on 2L NC
Gen - Alert, no acute distress but then transiently becomes very
sleepy and is hard to keep awake, but then will wake up and be
conversant.
HEENT - extraocular motions intact, anicteric, mucous membranes
dry
Neck - no JVD, no cervical lymphadenopathy
Chest - slight end exp wheeze
CV - Normal S1/S2, RRR, III/IV SEM rad to carotids biaterally
Abd - Soft, nontender, mild distended, with normoactive bowel
sounds
Extr - 4+ bilat perph edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3
Skin - No rash
Pertinent Results:
Micro:
[**2-19**] bcx positive for coag neg staph
cdiff neg x1
.
Rads:
[**4-19**] IVC gram: clot above the filter
[**4-18**] CT abd: PNA vs. small PE's; There is a large clot burden
extending from the IVC just proximal to the insertion of the
hepatic veins down the IVC through the known IVC filter into the
common iliac veins and through the superficial and deep femoral
veins bilaterally. Stable RP LN. no abscess
[**4-17**] RUQ US: No definite evidence of acute cholecystitis. No
intrahepatic biliary ductal dilatation. CBD not seen.
[**4-17**] CXR: No pneumonia noted. Left basilar atelectasis.
[**4-22**] CXR: The cardiac silhouette is mildly enlarged with
pulmonary vascular redistribution and small bilateral pleural
effusion suggesting an element of fluid overload. The right
subclavian line with tip in the SVC is unchanged. There is
subsegmental atelectasis in the left lower lobe.
Brief Hospital Course:
A/P: 68 yo m with a h/o MDS, anemia, ETT, recent large GIB, now
with large clot burden of DVT extending into the IVC:
.
#) DVT s/p thrombolysis: Required thrombolysis since his clot
burden was rising above the filter in the IVC. IR tried three
times to do thrombectomies but they reported that flow was still
sluggish in the veins (likely [**2-17**] distal clot they were not able
to reach?). TPA was infused overnight on several occasions but
repeat venogram still showed substantial clot. IR felt there
were no further interventions available. The patient was taken
off of coumadin and started on lovenox with the thought that
this might be slightly better at preventing further extension of
clot. The patient was informed that it may take months for this
clot to dissolve and the risk of further progression as well as
embolization is very real. For now he will continue on lovenox,
aspirin, anagrelide and hydrea. Lovenox levels should be checked
periodically by measuring Factor Xa levels (therapeutic is
between 0.6 and 1.0). Level checked before discharge was 0.9.
.
#) SOB/hypoxia: Has some wheezing, crackles and decreased BS at
the bases. O2 sats to high 80s when sleeping on 2 L NC and
increased to 4 L NC in the setting of SOB and satting in high
90s. Also, likely PEs contributing, but did not confirm with CTA
given would not change management. During previous admssion he
required small amounts of nasal cannula oxygen intermittently
which was attributed likely secondary to volume overload and
atelectasis. He also has a history of COPD. On last discharge
his pulse ox on room air was 88% and on 2L was 97%. CXR with
small b/l pleural effusions and overload and LL atelectasis. He
was intubated for IR procedure on [**4-25**] and TEE, and after
extubation required facemask ventilation. His breathing seemed
to improve with diuresis (was given 20IV lasix daily for approx
a week) and he required less oxygen. At discharge bicarb was
rising to 35 and Cl was decreasing and thus it was felt that
contraction alkalosis was developing. Lasix was held but volume
status needs to be repeatedly evaluated with further diuresing
as needed. There was also some concern for aspiration given that
at times pt was seen to have profuse coughing when drinking thin
liquids. He did not aspirate on a formal speech and swallow
eval, but given these episodes were intermittent he was placed
on a thickened liquid diet (soft solid) diet with aspiration
precautions.
.
#) UTI: UA [**4-27**] w/ mod bacteria, pt has dysuria, started Cipro
for 7 day course (last dose 4/19) and pyridium for dysuria,
considered FC change but deferred given possibility of not being
able to replace because of edema.
.
#) Tachycardia: likely from possible PE's. Has been stably in
90's to 110's.
.
#) Scrotal swelling: likely from poor venous and lymphatic
drainage in legs from extensive DVT's. The patient seemed to
have substantial pain with this which was treated with judicious
use of lidocaine jelly, miconazole powder, and elevation as
possible. Oxycontin and breakthrough oxycodone were also used.
The scrotal swelling did gradually improve but will still
require aggressive management of pain.
.
#) chest pain: occurred transiently in the setting of pt lying
on his stomach during an interventional radiology procedure.
This never occured again and was felt likely [**2-17**] lying on his
stomach given that pt states it had never occurred before and
was gone immediately after being turned back onto his back. No
ECG changes. No further episodes.
.
#) Bacteremia: with coag neg strep - 2/4 bottles were positive
from [**4-17**]. Likely skin contaminant, but d/c'ed PICC from R arm
anyway since it was present when the positive blood cultures
were drawn. TTE and TEE were negative for vegetations. ID was
consulted and recommended Vanco for 2 weeks s/p removal of R
PICC (last dose will be [**5-7**]).
.
#) PNA: Pt had this diagnosis during last admission: completed
azithro and cetriaxone to complete 10 days per ID recs (finished
on [**4-22**]). However, his sputum production increased near the end
of the hospitalization and CXR on [**5-3**] demonstrated new LLL
pneumonia. He was started on zosyn and should complete a 7 day
course (finish [**5-9**]).
.
#) Cholethiasis: RUQ ultrasound showed no definite evidence of
acute cholecystitis. No intrahepatic biliary ductal dilatation.
Per heme/onc fellow [**Last Name (un) 24535**] [**Last Name (un) **] (has followed pt for over a
year), gallbladder issues are secondary and would be too high
risk to stop anticoagulation again. No plans for cholecystectomy
unless acute gallbladder pathology again. Pt did continue to
complain of intermittent RUQ pain but stated this was not
worsening.
.
#) Anemia/MDS: The patient has myelodysplastic syndrome - from
which
anemia is the primary manifestation. He requires intermittent
transfusions. Recently had severe GIB which required an SMA
angiogram which showed bleeding at the distal ileocolic
branches, which underwent successful embolization. He was
transfused several units while in house but was not felt to be
actively bleeding as Hct was relatively stable and would drop
very slowly after a few days. Baseline Hct is 21-22. Dr. [**Last Name (STitle) 24535**]
[**Name (STitle) **], heme/onc fellow follows the pt closely and states pt has
antibodies to E and F Antigens so his blood transfusions should
be arranged with this in mind. He can be a difficult crossmatch.
Dr. [**Last Name (STitle) **] d/c'd epopoetin for now but restarted hydrea and
anagrelide. The patient needs to follow up with him on Tuesday
[**5-8**].
.
#) Essential thrombocythemia - Patient has history of multiple
thromboses due to this disorder. Were holding aspirin and
anagrelide while awaiting cholecystectomy, but now seems like
this is not going to happen. Pt should follow up with Dr.
[**Last Name (STitle) 468**] to discuss any possible further treatment. On admission
plt count was initially normal and even on the low side so
hydrea and anagrelide were stopped. Hydrea restarted [**4-27**] when
plt count began to rise again and subsequently anagrelide was
started as well. Aspirin was to reduce clotting of plts that are
present, and this was restarted after his last IR procedure.
.
#) HTN: - continued metoprolol and diltiazem.
.
#) COPD: Continued nebs prn.
.
#) Gout: allopurinol 100 mg daily
.
#) Chronic back pain: oxycodone.
.
#) FEN: When pt was intubated for one of the interventional
radiology procedures he had some trauma to his teeth. Afterwards
he had some pain and requested a soft diet. A dental consult
should be obtained when able.
.
#) Access: PICC placed on [**4-27**].
.
#) DNR/DNI per discussion with patient [**4-27**].
.
#)Contact: [**Name (NI) 4489**] [**Name (NI) 24532**] - home phone- [**Telephone/Fax (1) 24533**], cp 617
[**Telephone/Fax (1) **].
.
Medications on Admission:
Meds on transfer from floor to unit:
mag sulfate 2 x1
atenolol 12.5
azithro 250
ceftriaxone 1gm IV q24
hydrea 500mg qday
pantoprozole 40 q24
dilt ER 120 daily
epo [**Numeric Identifier 389**] Unit qMWF
allopurinol 100
coumadin 10
lovenox 150 [**Hospital1 **]
vancomycin 1000 iv q12 Day 1 = [**4-19**]
oxycodone 5 prn
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
7. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
8. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. Enoxaparin 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y
(120) mg Subcutaneous Q12H (every 12 hours).
14. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
15. Anagrelide 0.5 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
16. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
17. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
18. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
19. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
20. Vancomycin 1000 mg IV Q 12H
LAST DOSE 4/23 PER ID CONSULT TEAM
21. Morphine Sulfate 2-4 mg IV Q3H:PRN Start: [**2108-4-28**]
for breakthrough pain after po oxycodone
22. Zosyn 4.5 g Recon Soln Sig: One (1) Intravenous every six
(6) hours for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagsoses:
1)Extensive intra-abdominal and lower extremity venous clot
burden with thrombus extending superior to the IVC filter ending
just proximal to the drainage of the hepatic veins into the IVC.
2)Extensive lower extremity and scrotal swelling.
3)LLL pneumonia
4)Hypoxia likely [**2-17**] combo of COPD, pneumonia, pulm edema, and
PE's.
Secondary:
-MDS with anemia, transfusion depedent
-Essential Thrombocythemia
-HTN
-Gout
-COPD
Discharge Condition:
Stable.
Discharge Instructions:
During this hospitalization you were diagnosed with extensive
deep venous thromboses in your legs. It is important that you
remain on the Lovenox for now until you follow up with your
hematologist, Dr. [**Last Name (STitle) **].
Followup Instructions:
- PCP f/u for f/u imaging:
Stable retroperitoneal lymphadenopathy, may be reactive or
related to
thrombus within IVC. Recommend continued evaluation to exclude
process such as lymphoma.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 8848**], MD Phone: [**Telephone/Fax (1) 24536**] Date/Time:
[**2108-5-8**] 11:00 a.m.
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2108-5-21**]
9:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2108-6-4**]
2:00
Provider: [**Name10 (NameIs) 3833**] Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2108-7-2**] 11:30
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"996.79",
"453.40",
"285.29",
"E879.8",
"287.5",
"041.09",
"444.0",
"574.20",
"238.75",
"276.3",
"453.2",
"584.5",
"511.9",
"428.0",
"790.7",
"996.62",
"401.9",
"415.19",
"E849.7",
"799.02",
"608.86",
"562.10",
"599.0",
"274.9",
"496",
"303.93",
"785.0",
"486",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.51",
"99.10",
"96.04",
"99.04",
"96.71",
"97.49",
"38.93",
"88.72",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
15582, 15653
|
6283, 13134
|
320, 405
|
16143, 16153
|
5365, 6260
|
16430, 17235
|
4623, 4785
|
13502, 15559
|
15674, 16122
|
13160, 13479
|
16177, 16407
|
4800, 5346
|
274, 282
|
433, 3312
|
3334, 4301
|
4317, 4607
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,896
| 141,038
|
52068
|
Discharge summary
|
report
|
Admission Date: [**2182-8-30**] Discharge Date: [**2182-9-16**]
Date of Birth: [**2107-1-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac catheterization on [**9-22**]
History of Present Illness:
75 y/o M w/ h/o CABG [**2167**], NSTEMI [**2180**], HTN, CRI, DM p/w chest
pain. He had chest pain at rest yesterday evening, took maalox
and went to bed. On awakening in the morning, he had breakfast
and began to have CP again. Took NTG X 2 at home and did not get
relief so called 911. Still not relieved w/ another NTG en-route
to ED. CP is sub-sternal, central chest, sharp in quality
without radiation. He has baseline SOB but this was not made
worse by pain. No N/V/diaphoresis. He states that he has not had
pain like this since his last hospitalization one year ago. He
takes one NTG every morning for good measure but has not used
them for CP since prior discharge. No orthopena or PND. He has
chronic LE swelling which is not worse than usual. No f/c. No
cough/diarrhea. His only exercise is walking to the mailbox.
.
In the ED, initial vitals: T 97, 194/71, 82, 18, 97% on RA. NTG
ggt started for hypertensive urgency. Also, given ASA, metop,
maalox, demerol, morphine, heparin ggt. BP symmetric in both
arms.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
NSTEMI [**2180**] (cath, no intervention)
CHF (systolic and [**Last Name (LF) 107778**], [**First Name3 (LF) **] 40-50%)
peripheral [**First Name3 (LF) 1106**] disease
diabetes ([**4-15**] A1c 6.3)
hypertension
hypercholesterolemia
grade II internal hemrohrroids
olonic diverticulosis
GERD
hypoxic respiratory failure secondary to pneumonia and CHF.
Chronic renal insufficiency baseline 1.5 - 2.0
PVD with B fem to distal bypass
Cardiac:
CABG x 3 in [**2167**] (LIMA-LAD, SVG-OM, SVG-PDA) with only LIMA-LAD
patent multiple PCI's:
[**11/2176**]: ostial LIMA_LAD stent with re-stenosis and
brachytherapy [**5-/2177**]
[**2180-4-6**]: Taxus in the RPDA.
[**2180-5-2**]: rotational atherectomy of the RCA - r stents in RCA
plus stnent rPDA.
[**2179**]- rothational atherectomy LMCA into LCX s/p Cypher stent,
and stent to LCX. Also + Cypher stet to RCA
Last Cath [**2181-6-8**] baloon coronary PLB + stent to subclavian
artery.
[**2180**]: Cath w/ 3VD w/o intervenable stenosis in setting of NSTEMI
-CHF 2.[**2179**] EF 40-50% inf wall hypokinesis mild to moderate AR
MR
[**Name13 (STitle) **] w/ RVR, not anticoagulated due to GI bleed
Social History:
Social history is significant for the absence of current tobacco
use. He quit smoking 2 years ago after 60+ pack years. He was a
heavy drinker in the past but quit EtOH 2 yrs ago. He lives
alone but his son lives upstairs.
Family History:
Noncontributory.
Physical Exam:
VS - 125/67, 50, 15, 100% on 2L
Gen: 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 flat neck veins.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. III/VI systolic murmur heard best at RUSB. No
thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, w/ occ exp
wheezes.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: trace bilateral LE edema w/ changes of chronic venous
stasis dry skin, scaling, lack of hair)
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+ PT
Pertinent Results:
Admission Labs:
[**2182-8-30**] 11:32PM GLUCOSE-156* UREA N-44* CREAT-2.0* SODIUM-139
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
[**2182-8-30**] 11:32PM CK(CPK)-252*
[**2182-8-30**] 11:32PM CK-MB-17* MB INDX-6.7 cTropnT-0.67*
[**2182-8-30**] 11:32PM WBC-4.9 RBC-3.77* HGB-11.6* HCT-33.2* MCV-88
MCH-30.8 MCHC-34.9 RDW-15.1
[**2182-8-30**] 11:32PM PLT COUNT-113*
[**2182-8-30**] 08:06AM GLUCOSE-247* K+-4.0
[**2182-8-30**] 07:57AM GLUCOSE-282* UREA N-48* CREAT-2.1* SODIUM-140
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17
[**2182-8-30**] 07:57AM estGFR-Using this
[**2182-8-30**] 07:57AM ALT(SGPT)-18 AST(SGOT)-16 CK(CPK)-170 ALK
PHOS-61 AMYLASE-171* TOT BILI-0.5
[**2182-8-30**] 07:57AM LIPASE-156*
[**2182-8-30**] 07:57AM cTropnT-0.02*
[**2182-8-30**] 07:57AM CK-MB-5
[**2182-8-30**] 07:57AM CALCIUM-9.8 PHOSPHATE-3.4 MAGNESIUM-2.8*
[**2182-8-30**] 07:57AM WBC-5.4 RBC-4.77 HGB-14.2 HCT-42.8 MCV-90
MCH-29.7 MCHC-33.1 RDW-15.2
[**2182-8-30**] 07:57AM NEUTS-59.1 LYMPHS-31.2 MONOS-3.8 EOS-5.1*
BASOS-0.7
[**2182-8-30**] 07:57AM PLT COUNT-148*
[**2182-8-30**] 07:57AM PT-12.4 PTT-27.6 INR(PT)-1.1
.
STUDIES:
[**2182-8-30**] PTCA COMMENTS: The initial angiography revealed a
distal 70-80% RCA stenosis between two previously placed stents
and a 90% in stent PDA
stenosis (within a previously placed Taxus stent). Heparin was
administered for anticoagulation. The inital strategy was to
perform
angioplasty with angioscore balloon of the in stent restenosis
in the
PDA and balloon angioplasty with provisional stenting of the
distal RCA.
The JR4 Guide providede poor support and was exchanged for an
AR-1 guide
which provided poor support. The lesion was wired with some
difficulty
due to proximal stent struts with both Prowater and Choice PT XS
wires
but we were unable to deliver the 2.0 X 15 angioscore or Voyager
balloon
past the mid vessel. We recrossed with Wizdom wire and with much
difficulty were able to deliver a 2.0 X 15 balloon to the PDA
and dilate
it at 12 atms with rsidual 30% stenosis. The distal RCA lesion
was also
dilated with the same balloon at 12 atms with 30-50% residual
stenosis.
We attempted to deliver a 3.0 X 8 mm Vision stent but were
unable to do
so. Given good angioplasty result and high contrast load in a
patient
with renal insufficiency we aborten further attempts at stent
delivery.
There was no evidence of dissection or embolization and the TIMI
flow
was III. The patient left the cath lab in stable condition
.
CT Abd [**2182-8-31**]:
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Multiple low-attenuation lesion seen within the kidneys
bilaterally, some of which are consistent with cysts, others are
too small to characterize by CT.
3. 3-mm low-attenuation lesion again seen at the liver dome,
unchanged from [**2180-10-10**].
.
[**2182-9-9**] ECHO
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with focal
hypokinesis of the inferior and mid inferolateral wall and
distal septum. There is mild hypokinesis of the remaining
segments (LVEF = 30%). The right ventricle is not wall seen -
mild free wall hypokinesis is suggested. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (area 1.0cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-11**]+) 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 [**2182-9-3**],
global left ventricular systolic function is more depressed
(mild global hypokinesis with similar regional dysfunction).
Right ventricular hypokinesis may now be present.
.
Brief Hospital Course:
Patient is a 75 M w/ pmh of CAD s/p CABG and NSTEMI in [**2180**],
HTN, DM2, PVD p/w chest pain. His hospital course is as
follows:
.
Chest pain: Known CAD s/p CABG (LIMA - LAD, SVG-OM and SVG-PRDA;
NSTEMI [**2180**] (cath, no intervention). The patient ruled in for
MI and was taken to the cath lab. He was found to have severe
native/graft disease. He underwent POBA to the RPDA, RCA. Post
cath he experienced a vagal episode with hypotension/bradycardia
responsive to atropine. CT was negative for RP bleed. The
patient was stable on ASA, Plavix, BB, ACE-I, statin until [**8-31**]
when he experienced acute 10/10 chest pain. EKG demonstrated ST
depressions in V1-V6 with ST elevation in AVR. He was
re-started on heparin gtt, nitro gtt, and his BP was controlled
with metoprolol PO/IV, ACE-I, nitro gtt, Nifedipine,
hydralazine. His enzymes did trend upwards. Given his
difficulty for cath with renal failure CT surgery was consulted
for possible redo CABG. However, the decision was made to take
him back to the cath lab. He underwent repeat cath on [**2182-9-2**]
with DES to the ostial LIMA with a DES. Transferred to CCU
after 2 episodes of chest pain, tachycardia to 140s with EKG
changes, predominantly ST depressions in V2-V4. Chest pain
resolved with nitro gtt. Sinus tachycardia improved with
lopressor 5 IV. Started on heparin gtt at this time. Also found
to be febrile to 101.5. He was on a nitro drip c/o left finger
numbness, and this was eventually weaned off. Patient had
several repeat episodes of chest pain for which he got morphine
with no effect, and then dilauded, which worked. The finger
numbness continued on and off, and dilauded sometimes relieved
it, non cardiac causes are considered for the finger numbness.
On discharge patient was intructed to return to the hospital for
chest pain not relieved by SL nitro, lasting for over 1 hour.
.
CHF: systolic and [**Last Name (LF) 107778**], [**First Name3 (LF) **] 40-50%: Relatively stable on
admission, but in decompensated heart failure upon transfer to
CCU. He was volume overloaded and desaturating on RA requiring
70% facemask. Patient treated with PRN lasix until euvolemic,
and eventually weaned off O2. Patient also recieved nebulizer
treatments as needed.
.
Bacteremia: Patient with fever on admission the CCU. blood
cultures grew coag positive staph aureus for which he was
treated for with 10 days of vanc/zosyn. Subsequent blood
cultures negative.
.
Phase 4 Block: In the ICU, the patient was found to have AV
prolongation, which was Phase 4 block. Because of the
bacteremia, he was unable to get a placemaker while in the
hospital. He was d/ced with f/u with Dr. [**Last Name (STitle) 2357**] to plan for
pacemaker placement. Beta [**Last Name (STitle) 7005**] was dc/ed.
.
Hypertension: SBP in 200s on admission. Stablized in house with
aggressive regimen of ACE-I, nifedipine, hydralazine. He was
restarted on a nitro gtt after his repeat chest pain and
transferred to the ICU. He was finally stabilied on isosorbide,
diltiazem, ACEI, and amlodipine. BBlocker was not used because
of the phase 4 block
.
Elevated pancreatic enzymes: No elevated WBC count, no N/V or
abdominal pain so presentation was not consistent w/
pancreatitis as this is a clinical diagnosis. His enzymes
subsequently trended down.
.
CKD: Cr remained at 2.1-2.3 even in the setting of cath. He was
given aggressive pre-cath hydration each time with mucomyst.
.
Diabetes, Type 2 ([**4-15**] A1c 6.3): Maintained sliding scale
insulin while in house.
.
COPD: Continued combivent
.
Code: FULL
Medications on Admission:
Adalact 60 mg daily
ASA 325
Clopidogrel 75 mg daily
Combivent 2 puffs tid
Furosemide 80 mg
glipizide 5
ISDN 30 tid
Lisinopril 20 mg
Metop 75 mb [**Hospital1 **]
NTG
Prilosec 20 mg daily
Roxicet qid
Simvastatin 80 mg
Discharge Medications:
1. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2*
3. Blood cultures Sig: One (1) sets once for 1 days: Please
perform 2 sets of screening blood cultures on [**9-23**]. Please
send results to Dr. [**Last Name (STitle) **] (office phone: ([**Telephone/Fax (1) 5862**]). .
Disp:*1 qs* Refills:*0*
4. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Isosorbide Dinitrate 20 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**12-11**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
8. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Nasal twice a day.
Disp:*1 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Acute coronary syndrome
Hypertensive emergency
Systolic congestive heart failure, chronic
Hyperlipidemia
Diabetes mellitus, Type II
Discharge Condition:
Hemodynamically stable. Ambulatory.
Followup Instructions:
Please f/u with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] this week. his number is
[**Telephone/Fax (1) 1247**].
.
Please get a blood culture drawn in 1 week [**9-23**]. Have results
faxed to: Dr. [**Last Name (STitle) **] (office phone: ([**Telephone/Fax (1) 5862**]). Also
make an appt to followup with him on [**9-27**]. His office number is
included.
.
Please make a follow-up appointment with Dr. [**First Name (STitle) **] within the
next 4 weeks. Tel. ([**Telephone/Fax (1) 7236**].
.
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2182-10-1**]
8:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2182-10-1**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2182-10-1**] 9:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2182-9-22**]
|
[
"041.11",
"440.20",
"396.3",
"459.81",
"428.43",
"530.81",
"496",
"790.7",
"584.9",
"585.6",
"518.81",
"410.71",
"599.7",
"E849.8",
"455.0",
"486",
"403.91",
"428.0",
"996.72",
"280.0",
"414.01",
"414.02",
"427.31",
"E879.0",
"562.10",
"250.70"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.49",
"37.22",
"99.04",
"93.90",
"00.40",
"36.07",
"00.45",
"38.93",
"88.56",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
13383, 13440
|
8075, 11649
|
326, 365
|
13619, 13657
|
4192, 4192
|
13680, 14716
|
3284, 3302
|
11916, 13360
|
13461, 13598
|
11675, 11893
|
3317, 4173
|
276, 288
|
393, 1869
|
4208, 8052
|
1891, 3028
|
3044, 3268
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,721
| 107,493
|
6461
|
Discharge summary
|
report
|
Admission Date: [**2182-5-11**] Discharge Date: [**2182-5-14**]
Date of Birth: [**2155-12-25**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 24828**] is a gentleman with
end stage renal failure who underwent a cadaveric renal
transplant approximately three months ago. This transplant
was complicated by primary nonfunction. The donor was
hemodynamically unstable at the time of the procurement and
the patient was given the option of taking a chance on
transplantation, given the fact that the premorbid renal
function of the donor was normal. The patient was told of
the risk of delayed function and/or nonfunction and wished to
take the risk to try to get off of dialysis.
HOSPITAL COURSE: The patient underwent transplant and
unfortunately nonfunction did occur. Multiple biopsies
throughout the course revealed no evidence of rejection;
however, there was progressive scarring of the kidney and
worsening acute tubular necrosis. At this point a decision
was made to stop the immunosuppression as the patient was at
risk for infection, and so the immunosuppression was tapered
to off. Unfortunately with the tapering of the
immunosuppression, the patient developed a severe acute
rejection with swollen painful graft.
The patient was admitted and was taken to the Operating Room
for a transplant nephrectomy. This occurred on [**2182-5-12**].
The patient did well postoperatively and had immediate
resolution of symptoms.
DISPOSITION: The patient was stable for discharge on
postoperative day three and will follow-up in my clinic for
relisting for cadaver retransplant.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Dictator Info **]
D: [**2182-6-25**] 19:25
T: [**2182-6-25**] 22:01
JOB#: [**Job Number 24829**]
cc:[**Hospital 24830**]
|
[
"285.21",
"996.81",
"585",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"55.53"
] |
icd9pcs
|
[
[
[]
]
] |
736, 1895
|
157, 718
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,511
| 195,951
|
33382
|
Discharge summary
|
report
|
Admission Date: [**2148-3-18**] Discharge Date: [**2148-4-5**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
86 year old male with pmh significant for DM, HL, HTN, CAD s/p
distant IMI (no prior cath), and systolic congestive heart
failure with EF of 40-45%, who presented to [**Hospital3 **] Hospital on
[**3-16**] with chest pain x 2 weeks. EKG showed ST depressions and pt
ruled in for NSTEMI via biomarkers. Patient was managed
medically, but on [**3-18**], the patient experienced had sudden onset
lightheadedness, hr 30. Thought to be a vagal episode, but had
new T wave inversions in V3-V6, so was transferred to [**Hospital1 18**] for
cath. Of note, the patient did have an episode of agitation
while at [**Hospital3 **]. Head CT at the time was negative.
.
Patient arrived at [**Hospital1 18**], Vitals 58, 118/62, 15, 100%2L. He
underwent catheterization where he was found to have diffuse
disease including 90% proximal RCA stenosis. He received a BMS
to the RCA as well as stents to both common and external iliac
arteries. After the procedure the patient became agitated,
pulling at lines, pulling out his right femoral sheath, and
tried to get up from the table. Vitals were HR 68, SBP 140,
O2sat 99% RA. He was sedated with haldol 2.5mg IV X1 and
transferred to the CCU for closer monitoring.
.
In the CCU he remained agitated. His left femoral sheath was
pulled two hours after arrival. The patient was sedated with
zydis, haldol 5mg IV, morphine 2mg IV X1, and physical
restraints. A geriatrics c/s was called. Workup for infectious,
organic etiology negative. Pt's mental status improved slowly.
Creatinine bumped to max of 2.8 from baseline 2.0, attributed to
CIN, given gentle IVF.
.
Upon transfer to the floor, he is in good spirits and surrounded
by family. He has no complaints.
Past Medical History:
prostate CA
diabetes
COPD
htn
prior IMI
hyperlipidemia
cataract surgery
Social History:
Lives with daughter in [**Name (NI) 5110**]. Used to work in the telephone
company. Widower, wife died 3 [**Name2 (NI) 1686**] ago. Patient is not a smoker
but does have h/o tobacco use >10 years ago. EtOH maybe 1x/week.
No illicits. Previously independent in all ADL/IADLs.
Family History:
No family history of SCD or early CAD.
Physical Exam:
exam on transfer to the floor [**3-22**]
VS - 97.5, 161/84, 66, 18 100% RA
Gen: WDWN elderly male, oriented to name, date, and "hospital."
Pleasant, mood and affect appropriate, not agitated or fidgiting
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 6 cm.
CV: RR, S1, S2. 2/6 systolic murmur at apex. No thrills, lifts.
No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. fine crackles at bases.
Abd: Soft, NT/ND. No HSM or tenderness. No abdominial bruits.
Ext: WWP, no c/c/e
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 1+
Left: Carotid 2+ DP 1+
Pertinent Results:
CBC:
[**2148-3-18**]
WBC-9.1 RBC-3.74* Hgb-11.8* Hct-34.4* MCV-92 MCH-31.6 MCHC-34.4
RDW-14.0 Plt Ct-295
[**2148-3-22**]
WBC-11.6* RBC-3.91* Hgb-12.0* Hct-35.7* MCV-91 MCH-30.7
MCHC-33.6 RDW-13.9 Plt Ct-305
.
COAGS:
[**2148-3-18**]
PT-28.5* PTT-80.9* INR(PT)-2.9*
[**2148-3-20**]
PT-12.6 PTT-28.4 INR(PT)-1.1
.
CHEM:
[**2148-3-18**]
Glucose-151* UreaN-48* Creat-2.0* Na-133 K-4.4 Cl-99 HCO3-23
AnGap-15
[**2148-3-22**]
Glucose-133* UreaN-56* Creat-2.7* Na-140 K-4.3 Cl-106 HCO3-20*
AnGap-18
.
CE's:
[**2148-3-19**] 05:31AM BLOOD CK(CPK)-153* BLOOD CK-MB-9
[**2148-3-20**] 06:00AM BLOOD CK(CPK)-233* CK-MB-7
[**2148-3-21**] 05:25AM BLOOD CK(CPK)-617* CK-MB-14* MB Indx-2.3
.
proBNP
[**2148-3-27**]
[**Numeric Identifier 77482**]
.
Anemia Studies:
[**2148-3-21**]
Iron-37* calTIBC-274 VitB12-1566* Folate-15.4 Ferritn-191
TRF-211
.
TFTs:
[**2148-3-21**]
TSH-1.2
.
Hgb A1c: 7.3%
.
[**2148-3-20**] 5:30 pm URINE Source: Catheter.
**FINAL REPORT [**2148-3-21**]**
URINE CULTURE (Final [**2148-3-21**]): NO GROWTH.
.
[**3-20**] BCx: NGTD x 2
[**3-21**] RPR negative
[**3-23**] urine Cx: negative
[**3-26**] urine Cx: negative
[**3-29**] Bcx: NGTD
[**3-30**] BCx: NGTD
.
[**2148-3-18**] EKG
Sinus bradycardia. A-V conduction delay. Left ventricular
hypertrophy.
Left anterior fascicular block. T wave inversions in leads I,
aVL and V3-V6 with ST segment depressions. These findings are
consistent with active
anterolateral ischemic process. Rule out myocardial infarction.
Followup and clinical correlation are suggested. No previous
tracing available for
comparison.
.
[**3-18**] CARDIAC CATH
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Anomalous origin of LCX from right coronary cusp.
3. Diastolic LV dysfunction.
4. Bilateral common iliac artery disease.
5. Successful PCI/stent to proximal RCA with bare metal stent.
6. Successful PTA/stent to right common iliac.
7. Successful PTA/stent to left common iliac.
.
[**2148-3-18**] EKG #2
Sinus rhythm. The previously mentioned multiple abnormalities
persist.
The T wave inversions previously recorded on [**2148-3-18**] have
improved.
Otherwise, no diagnostic interim change. Clinical correlation is
suggested
.
[**3-19**] R GROIN U/S
IMPRESSION: No evidence of right groin pseudoaneurysm, AV
fistula or dissection
.
[**3-19**] CXR
FINDINGS: No previous images. There is enlargement of the
cardiac silhouette with tortuosity of the aorta. Some plethora
of ill-defined pulmonary markings is consistent with elevated
pulmonary venous pressure. Blunting of the left costophrenic
angle could reflect pleural effusion or thickening. No evidence
of acute pneumonia.
.
[**2148-3-21**] EKG
Sinus rhythm. First degree A-V delay. Consider left atrial
abnormality
Right bundle branch block. Left anterior fascicular block. Q-Tc
interval appears prolonged but is difficult to measure. ST-T
wave abnormalities - are in part primary and are nonspecific.
Since previous tracing of [**2148-3-20**], no significant change.
.
[**2148-3-23**] EKG
Sinus rhythm. P-R interval prolongation. Left atrial
abnormality. Left
anterior fascicular block of right bundle-branch block type. Q-T
interval
prolongation. ST-T wave abnormalities. Since the previous
tracing of [**2148-3-22**] probably no significant change.
.
[**2148-3-26**] CT HEAD W/O CONTRAST
FINDINGS: No edema, masses, mass effect, hemorrhage, or
infarction is detected. The ventricles and the sulci are mildly
prominent consistent with involutional changes. The left
maxillary sinus contains a small amount of fluid. The remainder
of the visualized paranasal sinuses and mastoid air cells are
clear. Note is made of calcification of the cavernous portion of
both carotid arteries.
IMPRESSION: No acute intracranial pathology including no
hemorrhage.
.
[**3-26**] CXR (PA+lat)
IMPRESSION:
1. Mild pulmonary vascular congestion.
2. Left lower lobe atelectasis and a small effusion that could
be followed up in future chest radiographs
.
[**3-26**] RENAL U.S.
IMPRESSION: Small renal size bilaterally with no hydronephrosis
identified
.
[**3-28**] CXR
As compared to the previous radiograph, there is slight
enlargement of the cardiac silhouette. In a generalized manner,
moderate-to-severe reticular opacities are seen, mainly in the
periphery of the lung, these are suggestive for fluid overload.
This suggestion is supported by the bilateral perihilar haziness
and the slight increase in diameter of the apical pulmonary
vessels. There is no evidence of larger pleural effusions, no
focal parenchymal opacity suggestive of pneumonia are seen.
.
[**3-29**] EEG
IMPRESSION: This is an abnormal routine EEG in the waking and
drowsy
states due to intermittent bursts of moderate amplitude theta
frequency
slowing in the left temporal region, suggestive of an underlying
area of
subcortical dysfunction. The tracing cannot specify the
etiology, but
vascular disease would be a common cause. In addition, at times,
the
background was disorganized, had excessive admixed theta
activity
posteriorly and was interrupted by bursts of generalized mixed
frequency
slowing. This latter constellation of findings is consistent
with an
early or mild encephalopathy and suggests dysfunction of
bilateral
subcortical or deep midline structures. Medications, metabolic
disturbances and infection are among the common causes of
encephalopathy. There were no epileptiform features and no
electrographic seizure activity was noted.
.
[**3-29**] ECHO
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate to severe global left ventricular
hypokinesis (LVEF = 30 %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal. with borderline normal free
wall function. There are focal calcifications in the aortic
arch. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is mild aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is no pericardial effusion.
.
[**3-29**] EKG
Sinus bradycardia. P-R interval prolongation. Left anterior
fascicular block. Intraventricular conduction delay. Consider
left ventricular hypertrophy. Since the previous tracing of
[**2148-3-25**] the rate has decreased.
Brief Hospital Course:
86 y.o. male w/CAD and recent NSTEMI, now s/p BMS to RCA and b/l
stents to common iliacs, hospital course complicated by
persistent delirium and acute on chronic renal failure presumed
to be CIN.
.
#. CAD s/p NSTEMI: Patient presented with NSTEMI, and is now s/p
BMS to RCA. Continued aspirin, plavix, metoprolol, simvastatin.
Pt was delirious after cath and pulled out femoral sheath
necessitating CCU admission for monitoring. A femoral bruit was
heard but an U/S of cath site was without e/o hematoma or
pseudoaneurysm. On the floor his MB index remained low and CE's
eventually normalized. He did have occasional further episodes
of nonspecific chest/abdominal pain. Serial EKGs was unchanged.
He was restarted on Metoprolol 12.5 mg PO bid and Atorvastatin
40 mg qhs prior to discharge, and should have LFTs followed up
as an outpatient.
.
# Acute on Chronic RF Stage 3: Suffered a new creatinine
increase from baseline 2.1-->2.7--> max of 3.0, thought likely
to be contrast induced nephropathy (CIN). Received contrast on
[**3-18**]. Renally dosed meds. Creatinine trended down and settled
circa 2.0. Creatinine was at was 2.0 at discharge.
.
# Delirium: According to patient's family, he has a history of
delirium while hospitalized (was febrile at that time). Mental
status and attention waxed and waned, requiring 1:1 sitter.
Geriatrics was consulted in the CCU. There was no evidence of
infection on CXR or U/A, and a CT head at OSH was normal. This
was repeated here and was without obvious etiology. He was not
impacted, having regular bowel movements with an aggressive
regimen, and also with a normal KUB. He was not retaining urine
by PVR checks (although did begin to do so when given Zyprexa,
thought to be secondary to anticholinergic side effects). An EEG
was expectedly abnormal but was without seizure activity. TSH,
B12, and RPR were all WNL. Various antipsychotic regimens were
recommended by the geriatrics service, and final regimen was low
dose morphine and ativan as needed for extreme agitation.
Throughout, we encouraged OOB with ambulation, reorientation,
avoided disturbance of sleep/wake cycle, controlled pain, and
avoided unnecessary sedatives. Please avoid all antipsychotics.
.
#. chronic systolic CHF - prior LVEF 40-45%, but after MI a
repeat echo showed new LVEF of 30%. This could be due to
myocardial stunning. He also went into volume overload more
easily, which was to be expected. Diuresed with good effect. We
are currently holding metoprolol because of hypotension, it can
be restarted at a low dose as an outpatient. Holding ACE-I in
setting of CIN. Followed daily weights and maintained strict
I/O's
.
#. Rhythm - NSR w/ 1st degree block, RBBB, LAFB. Monitored on
tele without incident.
.
#. DM: held home hypoglycemics while in hospital, checked FSG
qid, gave HISS. Can consider restarte Glyburide as outpatient
when tolerating more POs
.
# Anemia - checked B12, folate, and iron studies, which did not
reveal deficiency. Trended HCT daily.
.
#. HTN: was suboptimally controlled. He was stable without use
of antihypertensives on discharge.
.
#. FEN: had poor po intake with a restricted diet. Nutrition was
consulted and provided supplements. Minimized restrictions on
diet to regular cardiac HH diet.
.
#. PPx: sub q heparin, aggressive bowel regimen as above
.
#. Code: presumed full
.
#. Dispo: seen by PT/OT, to rehab
Medications on Admission:
MEDS ON TRANSFER:
toprol 100mg PO daily
plavix 75mg started on [**3-17**] with no apparent loading dose
Imdur 60mg PO daily
aspirin 325mg
colace 100mg
glipizide 10mg PO daily
timoptic eye gtts .5%
alphagan .15%
Zocor 80mg PO daily
Diovan
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
5. Bimatoprost 0.03 % Drops Sig: One (1) drop to OU Ophthalmic
qhs ().
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-6**]
Drops Ophthalmic PRN (as needed).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
14. Morphine 15 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for extreme agitation.
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for extreme agitation.
16. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
18. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
19. Outpatient Lab Work
Liver function tests, next available
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Primary:
Non ST elevation myocardial infarction
contrast induced nephropathy
delirium
.
Secondary:
prostate CA
diabetes
COPD
htn
CAD s/p prior IMI
hyperlipidemia
cataract surgery
Discharge Condition:
stable, improved, baseline mental status
Discharge Instructions:
You were admitted to the hospital after suffering a heart
attack. You had a cardiac catheterization with a stent placed in
a coronary artery to relieve a blockage. After the procedure you
stayed in the hospital while recovering from delirium and
temporary kidney damage.
.
You will be going to rehab to work on your strength before going
home. You will be taking several new medications.
.
Please take all medications as prescribed, and please keep all
of your outpatient appointments. If you experience any further
chest pain, weakness, nausea, or other symptoms which concern
you, please call your doctor or go to the ED.
Followup Instructions:
CARDIOLOGY:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 20141**], M.D. Phone:[**Telephone/Fax (1) 4022**]
Date/Time:[**2148-4-11**] 9:00
.
PRIMARY CARE:
Please make an appointment to see your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
[**Telephone/Fax (1) 40144**] in the next 2 weeks.
|
[
"285.21",
"410.71",
"414.01",
"428.0",
"440.21",
"585.3",
"584.9",
"428.22",
"272.4",
"496",
"250.00",
"788.20",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.48",
"39.50",
"36.06",
"00.42",
"00.66",
"00.47",
"39.90",
"88.42",
"88.56",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
15259, 15326
|
9868, 13240
|
277, 302
|
15549, 15592
|
3265, 4893
|
16264, 16594
|
2427, 2467
|
13528, 15236
|
15347, 15528
|
13266, 13266
|
4910, 9845
|
15616, 16241
|
2482, 3246
|
222, 239
|
330, 2023
|
2045, 2119
|
2135, 2411
|
13284, 13505
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,617
| 140,121
|
45949
|
Discharge summary
|
report
|
Admission Date: [**2102-10-20**] Discharge Date: [**2102-10-24**]
Date of Birth: [**2036-11-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Hypotension and positive troponin
Major Surgical or Invasive Procedure:
Cardiac Cath [**10-23**]
Pleurx catheter drainage daily
History of Present Illness:
65 yo M with history of CAD sp MI, CABG and recent MI([**2102-5-23**])
while at HD. He is s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] 3 and VT arrest on the cath table.
Patient has recurrent transudative effusions status post
multiple thoracentesis and trapped lung physiology. Patient had
a right-sided pleurx catheter placed on [**2102-10-6**] and a left-sided
pleurx catheter placed [**2102-10-13**]. Patient has been home with VNA
and has been alternating drainage every day. Was in USOH until
[**2102-10-19**], when he developed severe LUQ abdominal pain during
drainage of the catheters. Was admitted to [**Hospital1 18**] [**10-20**], and the
pain continued until he had a large BM, after which it was much
improved. Had a CT of the abdomen which was unrevealing of any
pathology to explain his abdominal symptoms.
After dialysis on [**10-20**] and again today he was found to be
hypotensive to the 70s systolic. A 500 cc fluid bolus was
given, and BP increased to 80s systolic. Patient says he felt a
little lightheaded, but no chest pain, nausea, vomiting,
abdominal pain, or palpitations. Has had chronic breathing
issues, no worse. Team checked an ECG that showed slightly more
pronounced ST depressions across anterior leads and Troponin of
1.24 with flat CK and MB. He denied any further feelings of
dizziness/lightheadedness. Notes that when he had the MI, he
experienced severe chest pain, and had not had similar episode
since. Bedside echo revealed a dilated LA, mild LVH, mild LV
hypokinesis (LVEF = 45-50 %), RV moderately dilated with severe
global free wall hypokinesis and abnormal septal motion
consistent with volume overload, and moderate PA systolic
hypertension.
.
On review of systems, he has baseline SOB from chronic pleural
effusions. He denies recent fevers, chills or rigors. He does
report continued mild diffuse pain in his abdomen [**4-25**]
intensity, worst RLQ. Reports tremors of hands that have gotten
worse since in past
week.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, orthopnea, PND and syncope and ankle edema.
.
Upon arrival to the ICU, initial vitals were: Afebrile, BP
72/48, HR 71, Sa02 94% on 3L NC. He was asymptomatic, mentating
well.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: No Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: 7-vessel CABG in [**2079**]
-PERCUTANEOUS CORONARY INTERVENTIONS: STEMI s/p Vision stent x
3 on [**2102-5-19**] complicated by vfib arrest requiring 2 shocks
-PACING/ICD: None
-Atrial fib/flutter s/p ablation [**2099**], recurrence in [**2100**] on
Coumadin
-Diastolic Congestive Heart Failure: EF 60%
3. OTHER PAST MEDICAL HISTORY:
Upper GI bleed [**2101**], pill esophagitis and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **] tear
Lower GIB [**6-24**] with AVM seen on [**Last Name (un) **] (d/c'd warfarin at this
time).
Recurrent candidal esophagitis.
ESRD on HD, failed renal transplant in [**2069**].
Recurrent squamous cell skin cancer, ? related to
immunosuppression Basal cell carcinoma
Diverticulitis.
Home O2 2L NC
Chronic Bilateral Pleural Effusions
.
PAST SURGICAL HISTORY:
Renal biopsy
Appendectomy
Left AV fistula placement 30 years ago.
Skin resections for CA
Social History:
Social history is notable for his being married.
He has 2 grownchildren. He lives with his wife. [**Name (NI) **] is a retired
automation engineer. He does not drink alcohol. He smoked cigars
for about a year [**13**] years prior. He had tried marijuana 45 years
ago. No other illicit drug use. He was exposed to second hand
smoke as a child. Although he states that he is still working in
a pharmaceutical plant. He does have a dog at home. He lives in
[**Location 86**].
-Tobacco history: prior cigar smoking 20 years ago
-ETOH: Denies
-Illicit drugs: Denies
Family History:
Family history is notable for a brother with a deep venous
thrombosis (DVT) at age of 67.
Physical Exam:
VS: T=96.6 BP=81/48, HR=74 RR=21 O2 sat= 93% on 3 L NC
GENERAL: appears older than stated age, NAD. Oriented x2 (date
[**2103**]).
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP to jaw, no carotid bruits
CARDIAC: Irregularly irregular, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, crackles audible midway up
bilaterally, decreased breath sounds throughout. b/l pleurx
drain dressings c/d/i, slightly tender to palpation
ABDOMEN: Soft, diffusely tender to deep palpation, no rebound or
guarding. No HSM. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: multiple basal cell carcinomas visible over legs
PULSES: Radial 2+ b/l, DP 2+ b/l
Neuro: CN grossly intact, appropriate affect and mood, bilateral
UE tremor
Left AV fistula
Pertinent Results:
[**2102-10-20**] 03:35PM BLOOD WBC-10.2 RBC-4.73# Hgb-12.1*# Hct-43.0#
MCV-91 MCH-25.7* MCHC-28.2* RDW-19.5* Plt Ct-227
[**2102-10-20**] 09:10PM BLOOD WBC-8.4 RBC-4.56* Hgb-11.9* Hct-42.3
MCV-93 MCH-26.1* MCHC-28.1* RDW-18.0* Plt Ct-233
[**2102-10-21**] 01:05PM BLOOD WBC-8.8 RBC-4.85 Hgb-12.8* Hct-45.6
MCV-94 MCH-26.4* MCHC-28.0* RDW-18.0* Plt Ct-239
[**2102-10-22**] 05:23AM BLOOD WBC-8.5 RBC-4.80 Hgb-12.4* Hct-44.1
MCV-92 MCH-25.9* MCHC-28.1* RDW-19.2* Plt Ct-242
[**2102-10-23**] 05:18AM BLOOD WBC-11.4* RBC-4.87 Hgb-12.5* Hct-44.6
MCV-92 MCH-25.7* MCHC-28.1* RDW-19.3* Plt Ct-269
[**2102-10-23**] 12:19PM BLOOD WBC-10.3 RBC-4.33* Hgb-11.1* Hct-38.6*
MCV-89 MCH-25.7* MCHC-28.9* RDW-18.4* Plt Ct-219
[**2102-10-23**] 08:47PM BLOOD WBC-9.2 RBC-4.06* Hgb-10.6* Hct-35.6*
MCV-88 MCH-26.2* MCHC-29.8* RDW-18.7* Plt Ct-198
[**2102-10-24**] 05:00AM BLOOD WBC-8.5 RBC-3.88* Hgb-10.3* Hct-34.4*
MCV-89 MCH-26.5* MCHC-29.8* RDW-18.5* Plt Ct-184
[**2102-10-21**] 01:05PM BLOOD Neuts-87.3* Lymphs-6.0* Monos-5.1 Eos-1.1
Baso-0.5
[**2102-10-22**] 05:23AM BLOOD Neuts-84.5* Lymphs-6.8* Monos-7.5 Eos-1.0
Baso-0.2
[**2102-10-22**] 05:23AM BLOOD PT-14.7* PTT-54.3* INR(PT)-1.3*
[**2102-10-23**] 05:18AM BLOOD PT-13.7* PTT-28.9 INR(PT)-1.2*
[**2102-10-23**] 12:19PM BLOOD PT-14.5* PTT-37.4* INR(PT)-1.3*
[**2102-10-23**] 08:47PM BLOOD PT-14.4* PTT-40.5* INR(PT)-1.3*
[**2102-10-24**] 05:00AM BLOOD PT-14.6* PTT-30.7 INR(PT)-1.3*
[**2102-10-20**] 03:35PM BLOOD Glucose-79 UreaN-17 Creat-4.5*# Na-142
K-4.0 Cl-96 HCO3-35* AnGap-15
[**2102-10-21**] 01:05PM BLOOD Glucose-97 UreaN-31* Creat-6.1*# Na-139
K-4.8 Cl-93* HCO3-32 AnGap-19
[**2102-10-22**] 05:23AM BLOOD Glucose-111* UreaN-37* Creat-6.9* Na-137
K-4.6 Cl-94* HCO3-30 AnGap-18
[**2102-10-23**] 05:18AM BLOOD Glucose-85 UreaN-49* Creat-8.4*# Na-136
K-5.3* Cl-93* HCO3-25 AnGap-23*
[**2102-10-23**] 12:19PM BLOOD Glucose-120* UreaN-20 Creat-4.0*# Na-139
K-3.4 Cl-94* HCO3-31 AnGap-17
[**2102-10-23**] 08:47PM BLOOD Glucose-88 UreaN-31* Creat-5.8*# Na-136
K-4.0 Cl-95* HCO3-21* AnGap-24*
[**2102-10-24**] 05:00AM BLOOD Glucose-77 UreaN-36* Creat-6.2* Na-137
K-4.1 Cl-95* HCO3-24 AnGap-22*
[**2102-10-20**] 09:10PM BLOOD ALT-8 AST-9 AlkPhos-87 Amylase-35
TotBili-0.3
[**2102-10-21**] 01:05PM BLOOD CK(CPK)-81
[**2102-10-21**] 09:36PM BLOOD CK(CPK)-155
[**2102-10-22**] 05:23AM BLOOD CK(CPK)-141
[**2102-10-23**] 12:19PM BLOOD CK(CPK)-119
[**2102-10-23**] 08:47PM BLOOD CK(CPK)-150
[**2102-10-24**] 05:00AM BLOOD CK(CPK)-1003*
[**2102-10-21**] 01:05PM BLOOD CK-MB-NotDone cTropnT-1.24*
[**2102-10-21**] 09:36PM BLOOD CK-MB-20* MB Indx-12.9* cTropnT-1.18*
[**2102-10-22**] 05:23AM BLOOD CK-MB-17* MB Indx-12.1* cTropnT-1.09*
proBNP-[**Numeric Identifier **]*
[**2102-10-23**] 05:18AM BLOOD CK-MB-15* cTropnT-1.53*
[**2102-10-23**] 12:19PM BLOOD CK-MB-13* MB Indx-10.9* cTropnT-1.46*
[**2102-10-23**] 08:47PM BLOOD CK-MB-23* MB Indx-15.3* cTropnT-1.61*
[**2102-10-24**] 05:00AM BLOOD CK-MB-251* MB Indx-25.0* cTropnT-3.53*
[**2102-10-20**] 03:35PM BLOOD Calcium-9.0 Phos-3.2 Mg-1.8
[**2102-10-21**] 01:05PM BLOOD Calcium-9.0 Phos-6.0*# Mg-1.9
[**2102-10-22**] 05:23AM BLOOD Calcium-9.1 Phos-7.3* Mg-1.9
[**2102-10-23**] 05:18AM BLOOD Calcium-9.2 Phos-7.5* Mg-2.2
[**2102-10-23**] 12:19PM BLOOD Calcium-8.0* Phos-3.2# Mg-1.8
[**2102-10-23**] 08:47PM BLOOD Calcium-8.1* Phos-4.6* Mg-1.9
[**2102-10-24**] 05:00AM BLOOD Calcium-8.5 Phos-5.8* Mg-2.0
[**2102-10-22**] 05:23AM BLOOD Cortsol-12.3
[**2102-10-23**] 08:57PM BLOOD Type-ART Rates-34/28 Tidal V-400 FiO2-50
pO2-138* pCO2-26* pH-7.54* calTCO2-23 Base XS-1
Intubat-INTUBATED Vent-CONTROLLED
[**2102-10-24**] 02:31AM BLOOD Type-ART pO2-155* pCO2-29* pH-7.50*
calTCO2-23 Base XS-0
[**2102-10-24**] 05:16AM BLOOD Type-CENTRAL VE pO2-49* pCO2-34* pH-7.44
calTCO2-24 Base XS-0
[**2102-10-24**] 12:24PM BLOOD Type-ART pO2-112* pCO2-54* pH-7.39
calTCO2-34* Base XS-6 Intubat-INTUBATED
.
BCx [**10-22**] NGTD
.
Imaging:
.
[**10-20**] CXR PA/Lat: New large bilateral pleural effusions with
stable bilateral lower lobe hydropneumothoraces and Pleurex
catheters.
.
TTE [**2102-10-21**]: The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild global left ventricular hypokinesis (LVEF = 45-50
%). The right ventricular cavity is moderately dilated with
severe global free wall hypokinesis. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. The pulmonic
valve leaflets are thickened. There is a trivial/physiologic
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2102-5-31**], the right ventricle is now dilated,
hypokinetic with evidence of pressure volume overload.
.
CT ABD and CTA Chest [**10-20**]:
1. No pulmonary embolism. Slightly enlarged main pulmonary
artery could be from pulmonary arterial hypertension.
Cardiomegaly as before. CABG with
patent proximal grafts not well assessed on this non-gated
study,
2. Large bilateral loculated pleural effusions containing a
significant amount of air. Bilateral drainage catheters are
noted within these pleural effusions. Bibasilar atelectasis.
3. No findings within the left upper quadrant of the abdomen to
explain patient's symptoms.
4. Small 5-mm hypodensity in the tail of the pancreas, likely
unchanged from [**2102-5-8**]. Differential includes IPMN an MRCP is
recommended in 6 months to chracterize further if CT scan with
contrast is not performed in the interim for other reasons.
.
Cardiac Cath [**2102-10-23**]:
1. Coronary angiography in this right dominant system
demonstrated three
vessel disease. The LMCA had no angiographically apparent
disease. The
LAD was occluded at its origin. The LCx had a proximal tubular
90%
lesion and occluded OM branches. The RCA was proximally
occluded.
2. Arterial conduit angiography revealed an SVG-LCA that was
occluded at
its origin. The SVG-acute RV marginal-PDA had a 90% instent
restenosis
after the anastamosis of the graft with the acute marginal
branch. The
remainder of the stents in the graft were widely patent. The
LIMA was
not engaged.
3. Limited resting hemodynamics revealed moderate systemic
arterial
hypertension with a SBP of 143 mmHg and a DBP of 80 mmHg.
4. The procedure was complicated by patient disorientation
during the
PCI, ultimately requiring intubation.
5. Unsuccessful PCI of the SVG-AM-RPDA was performed. Final
angiography
showed no flow past the takeoff of the acute marginal from the
SVG.
(See PTCA comments.)
6. The right common femoral arteriotomy was successfully closed
using a
6 Fr Angioseal STS device.
.
FINAL DIAGNOSIS:
1. Occluded LAD and RCA.
2. Proximal 90% LCx stenosis with occluded OM branches.
3. 90% instent restenosis of RCA SVG after anastamosis with
acute
marginal branch.
4. Unsuccessful PCI attempt.
.
CXR [**2102-10-23**]:
IMPRESSION: AP chest compared to [**10-20**]:
Pleural drainage catheters are present at the base of each
hemithorax.
Moderate bilateral pleural effusion remains, probably loculated,
and residual
volume of air in the pleural space is small, bilaterally.
Cardiac silhouette
partially obscured is mildly enlarged but unchanged. There is no
pulmonary
edema. Lower lungs are largely obscured by pleural
abnormalities, but the
suprahilar hilar portions of both lungs are clear. ET tube in
standard
placement, nasogastric tube passes below the diaphragm and out
of view.
.
TTE [**2102-10-24**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is 10-20mmHg. Transmitral Doppler and tissue velocity
imaging are consistent with Grade III/IV (severe) LV diastolic
dysfunction. The right ventricular cavity is mildly dilated with
borderline normal free wall function. 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. Moderate (2+) mitral regurgitation is seen.
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. The pulmonic valve leaflets are
thickened. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2102-10-21**],
left ventricular systolic function is now significantly worse
and mitral regurgitation is now more prominent.
.
CXR [**2102-10-24**]:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The tip of the endotracheal tube projects approximately
1 cm more
proximal than before. A major displacement is not noticeable.
Currently, the tip of the tube is projecting 6 cm above the
carina. All other changes are constant.
Brief Hospital Course:
65M PMH CAD with CABG [**2079**], s/p STEMI c/b VF arrest in [**5-25**],
diastolic dysfunction with recurrent pulmonary effusions, s/p
bilateral pleurex catheter placement, ESRD on HD, initially
admitted for abdominal pain that resolved with bowel movement;
abdominal CT was unrevealing of any pathology. He was
transferred to the CCU for hypotension thought to be secondary
to new right ventricular failure of unclear etiology.
Hypotension was responsive to IV fluid boluses, with SBP
increasing from 70s to 80s/90s. Additionally, the patient had
slightly increased cardiac enzymes and mildly increased ST
depressions in anterior leads on ECG, concerning for recent or
evolving MI. On [**10-23**] during hemodialysis the patient had an
episode of chest pain, somewhat relieved with nitroglycerin, and
an ECG concerning for anterior wall ischemia. He underwent
emergent PCI, which was technically difficult; an unsuccessful
attempt at PCI of the SVG-AM-RPDA was performed. Final
angiography
showed no flow past the takeoff of the acute marginal from the
SVG. Additionally, the patient became extremely agitated in the
cath lab, requiring endotracheal intubation. He was managed on
the ventilator overnight. A right IJ central catheter was
placed, but attempts to place a radial arterial line were
unsuccessful. He continued to be hypotensive overnight with SBP
in 70s-80s, again responsive to IV fluid boluses.
.
In the AM on [**10-24**], the patient was being weaned off of his
sedation with a plan to extubate mid-morning. Around 12pm, the
patient had a PEA arrest, a code was called and CPR intiated.
Patient then went into periods of Vtach and PEA arrest, and
received one 200J shock for Vtach during the code. Bedside echo
did not show any evidence of tamponade. He received wide open
fluids and bicarbonate, calcium, atropine, epinephrine,
vasopressin, dopamine gtt and Norepinephrine ggt. After
discussion with the family, the code was called off and patient
was pronounced dead at 12:42 PM. Immediate cause of death is
cardiopulmonary arrest most likely secondary to evolving MI.
Other chief causes include heart failure and ESRD.
.
Medications on Admission:
Carvedilol 12.5 mg twice daily, Plavix 75 mg
daily,aspirin 325 mg daily, Celexa 30 mg daily, Epogen
13,000-17,000 units per dose once weekly, Imdur 60 mg daily,
Ativan as needed,omeprazole 20 mg twice daily, oxygen as needed,
pravastatin 80 mg daily, prednisone 5 mg daily, promethazine as
needed for nausea,renal tabs daily, Renvela 800 mg two to three
times a day after meals, temazepam at bedtime for insomnia,
Colace as needed,fluconazole for [**Female First Name (un) 564**] esophagitis, and
allopurinol 100 mg every other day for gout prophylaxis.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary Arrest
Discharge Condition:
Expired
|
[
"428.43",
"173.7",
"458.21",
"311",
"V45.82",
"585.6",
"427.41",
"414.02",
"274.9",
"427.31",
"276.4",
"428.0",
"V45.11",
"427.5",
"511.89",
"414.01",
"V58.61",
"410.71",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"96.04",
"39.95",
"37.22",
"96.71",
"88.57",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
17167, 17176
|
14379, 16531
|
351, 408
|
17242, 17252
|
5296, 12169
|
4379, 4471
|
17139, 17144
|
17197, 17221
|
16557, 17116
|
12186, 14356
|
3688, 3779
|
4486, 5277
|
2852, 3163
|
278, 313
|
436, 2722
|
3194, 3665
|
2766, 2832
|
3795, 4363
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,555
| 100,791
|
52323
|
Discharge summary
|
report
|
Admission Date: [**2189-2-28**] Discharge Date: [**2189-3-11**]
Date of Birth: [**2144-11-9**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Zomig
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
fevers, nausea, vomiting
Major Surgical or Invasive Procedure:
Central Line Placement
History of Present Illness:
44yF with autoimmune hepatitis s/p transplant in [**2176**] with
multiple complications (including recurrent AIH, chronic
rejection, chronic portal vein thrombosis, and chronic LLE)
presenting one day after discharge for IR dilatation of IVC
stricture with nausea, vomiting, syncope, and fever. Was
admitted [**Date range (1) 60486**] for planned IR balloon dilatation of IVC for
treatment of chronic lower extremity edema. On the drive home
from the hospital yesterday she felt nauseated and vomited six
times (non-bloody, non-bilious). Each time she pulled over and
passed out briefly after vomiting. Awoke at 3am with continued
nausea and fever to 101.7, diffuse myalgias, but no syncopal
episodes. She presented to [**Hospital3 15402**], where she was hypotensive
to 80s and labs revealed a WBC of 22 and 26% bandemia. She was
given a 500cc NS bolus, vancomycin (1gm) and zosyn (3.375mg) at
1:30/12:30pm.
On transfer to the [**Hospital1 **] ED, vitals were T 98.9, HR 105, BP 113/54,
RR 18, 98% on RA. WBC 23, 26% bands, and lactate of 6.6. Sepsis
line was placed. Given 4L NS and CVP was 10, ScvO2 79, and
making 50cc/hr urine. Was hypoglycemic to 60s and given 2 amps.
Ultrasound of groin showed no evidence of aneurysm. RUQ
ultrasound showed patent IVC. Liver consulted with nothing to
add.
On transfer to floor, vitals were T 97.5, HR 105, BP 121/58, RR
19, 96% on RA. Patient appeared well but complained of diffuse
body pain, worse on right leg.
Review of Systems:
+ worsening lower extremity pain and edema
+ myalgias
+ lower back pain/soreness x1 days
+ HA, relieved with morphine
Otherwise, denies rash, chest pain, cough, shortness of breath,
diarrhea, constipation, dysuria, hematuria, frequency, urgency,
oliguria.
Past Medical History:
1. Autoimmune hepatitis, s/p orthotopic liver transplant in UAB
in 2/98, known recurrent AIH treated with prednisone and
azathioprine. not cirrhotic. Most recent bilirubin is down to
4.2 from a peak of 30.7 in [**Month (only) 359**] c/b encephalopathy
2. Chronic portal vein thrombosis
3. Chronic lymphedema, s/p liver transplant
4. Psorasis
5. Allergic rhinitis
6. Dysfunctional uterine bleeding s/p partial hysterectomy
7. s/p CCY
8. Depression
9. ? extrahepatic bile duct obstruction.
Social History:
Pt moved to [**Location (un) 86**] in [**10-19**]. Pt lives with her daughter and
grandson. Pt is disabled. No tobacco use. Has alcohol only on
special occasions (birthdays, holidays). Last drink in [**10-20**]. No recreational drugs.
Family History:
Notable for heart disease and diabetes in multiple members. No
history of auto-immune hepatitis or liver failure.
Physical Exam:
Vitals:BP 99/59, HR 95 SpO2 100% on RA
General: In no distress, still some generalized pain
Neuro: Alert, Oriented x3, no asterixis
CV: RRR
Lungs: Clear x 2
Abdomen: S, NT, Distended but not tense, no perceivable
organomegaly, Chevron scar
Extemities: Massive dependednt edema, hard to compression
Pertinent Results:
LABS ON ADMISSION:
[**2189-2-27**] 06:15AM BLOOD WBC-7.2 RBC-3.76* Hgb-12.1 Hct-37.4
MCV-100* MCH-32.2* MCHC-32.3 RDW-16.4* Plt Ct-113*
[**2189-2-28**] 02:55PM BLOOD Neuts-70 Bands-18* Lymphs-6* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2189-2-28**] 02:55PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
[**2189-2-27**] 06:15AM BLOOD PT-17.8* PTT-42.3* INR(PT)-1.6*
[**2189-2-27**] 06:15AM BLOOD Glucose-112* UreaN-17 Creat-1.2* Na-134
K-3.2* Cl-102 HCO3-25 AnGap-10
[**2189-2-27**] 06:15AM BLOOD ALT-98* AST-157* LD(LDH)-212 CK(CPK)-59
AlkPhos-137* TotBili-3.1*
[**2189-2-28**] 02:55PM BLOOD Lipase-12
[**2189-2-27**] 06:15AM BLOOD CK-MB-1 cTropnT-<0.01
[**2189-2-27**] 06:15AM BLOOD Calcium-7.5* Phos-4.1 Mg-1.5*
[**2189-2-28**] 02:55PM BLOOD Ammonia-49
[**2189-2-28**] 02:55PM BLOOD Cortsol-13.9
[**2189-2-28**] 02:55PM BLOOD CRP-50.4*
[**2189-3-1**] 04:13AM BLOOD Vanco-6.5*
[**2189-2-28**] 09:47PM BLOOD Type-MIX pO2-42* pCO2-38 pH-7.37
calTCO2-23
[**2189-2-28**] 03:03PM BLOOD Lactate-6.6*
.
Micro:
Coag neg staph at the OSH blood culture. Sensitive to Vanc.
.
[**2189-2-28**] Urine Culture
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
.
[**2189-3-2**]
URINE CULTURE (Final [**2189-3-3**]):
YEAST. 10,000-100,000 ORGANISMS/ML.
.
Imaging:
[**2189-2-27**]
IMPRESSION: No right lower extremity DVT.
.
[**2189-2-28**] CXR
IMPRESSION: No acute intrathoracic process. Right IJ CV line in
appropriate position.
.
[**2189-2-28**] Left groin ultrasound
FINDINGS: Direct ultrasound examination was performed on the
left groin area at the site of prior catheterization. The left
common femoral artery and vein are patent with normal waveform
without evidence of aneurysm. There is no DVT or hematoma.
.
[**2189-2-28**] RUQ Ultrasound
IMPRESSION: Limited Doppler exam detailed above with patency of
IVC
demonstrated.
.
[**2189-3-4**]
Pelvic Ultrasound
IMPRESSION: Near resolution of previously seen ovarian cysts,
with one simple residual cyst on the right, measuring 2.3 cm.
Focal calcifications within both ovaries, of uncertain
significance. No evidence of malignancy.
.
[**2189-3-4**] Abdominal Ultrasound
IMPRESSION: Portal veins were not able to be seen. However, this
is
unchanged since multiple prior ultrasounds and the CT of the
abdomen and pelvis of [**2188-10-12**]. No large volume ascites.
.
[**2189-3-5**] KUB
IMPRESSION: No evidence of bowel obstruction or free
intraperitoneal air.
.
[**2189-3-6**] Abdomen and Pelvis CT
IMPRESSION:
1. Diffuse anasarca.
2. Bilateral pleural effusion, right greater than left with
adjacent
compressive atelectasis in the right lung base.
3. Nonobstructive left kidney stones, the largest measures
5mm,however no hydronephrosis.
4. Splenorenal shunt and venous collaterals. Unable to assess
presence of portal vein thrombus in this non-contrast study.
.
[**2189-3-8**] CXR
IMPRESSION:
1. Patchy right infrahilar opacity, which may be due to
atelectasis or pneumonia.
2. Interstitial edema and small pleural effusions, left greater
than right.
3. Enlarged main pulmonary artery suggestive of pulmonary
arterial
hypertension.
.
WBC [**3-7**]: 7.5
WBC [**3-9**]: 13.6
WBC [**3-11**]: 10.9
.
Labs on discharge:
WBC 10.9
Hct 26.9
Plt 141
INR 1.7
Cr 1.0
TBili 2.9
Brief Hospital Course:
Ms. [**Known lastname 108169**] is a 43 year old woman with a history of auto-immune
hepatitis, s/p liver transplant with recurrent AIH. She recently
underwent balloon dilation of the IVC. Two days following the
procedure she presented with hypotension, syncope, emesis, and
bandemia. She has positive blood cultures from an outside
hospital.
.
#) Sepsis: She presented with hypotension and fevers. A central
line was placed and she was given Zosyn and Vancomycin in
addition to approximately 5 L of IV fluids. The blood cultures
from the outside hospital eventually grew. coag neg staph. Her
antibiotics were narrowed to vancomycin. She completed a seven
day course. She remained afebrile and hemodynamically stable on
the floor. The infection was thought to have occurred as a
result of instrumentation following the IVC dilation.
.
#) Elevated WBC: Her WBC began to increase one day after
stopping antibiotics. Obtained urine, blood, and CXR. Afebrile,
cultures did not show evidence for infection, and patient was
feeling well. As such, antibiotics were held and another course
was not re-started. WBC then downtrended.
.
#) UTI: She had a urinary infection with enterococcus suscepible
to vancomycin. She received a total of seven days treatment.
.
#) HRS: Following fluid resucitation she developed HRS. This was
treated with midodrine, albumin, and octreotide. Her creatinine
began to improve after several days. She maintained a good urine
output. With improved creatinine, she was transitioned back to
her home diuretic regimen and she put out multiple liters to
this over the first 2 days, then diuresis volumes tapered down.
.
#) Volume Status: Ms. [**Known lastname 108169**] [**Last Name (Titles) 108171**] has 4+ LE edema. She
underwent an IVC dilation to see if it would improve her edema.
She also had a pelvic ultrasound while admitted to see if a
cystic structure noted on previous imaging could be contributing
to her edema. However, this structure had resolved. Her
diuretics were held given hypotension and HRS. They were
restarted on [**3-7**]. She had 4-5 L negative daily over the first
two days. The increased edema caused much discomfort in her
abdomen and legs. With diuresis, discomfort improved and
ambulation became easier.
.
# Autoimmune hepatitis s/p liver transplant with
recurrence--stable.
Continued immunosuppression with Azathioprine, Cellcept,
Tacrolimus and Prednisone. Levels of tacrolimus were within the
therapeutic range. She met with social work during the admission
because she was having difficulty paying for medications. They
were able to provide her with a temporary supply while applying
for alternate health care coverage.
.
#) Depression: Continued home meds. She met with social work
while an inpatient. Cheerful on discharge. Discharged with SW
f/u and services at home (nursing, home safety eval, PT, social
work).
Medications on Admission:
Azothiaprine 50mg [**Hospital1 **]
Mycophenolate Mofetil 1000mg [**Hospital1 **]
Prednisone 15mg PO QD
Tacrolimus 1mg [**Hospital1 **]
Spironolactone 150mg PO QD
Torsemide 40mg PO QD
Omeprazole 20mg PO QD
Ursodiol 600mg PO QD
Kristalose 10ml QD
Singulair 10mg PO QD
Nasonex 50mcg 2 sprays QD
Cholecalciferol 400U PO QD
Calcium Carbonate 500mg PO QID
Magnesium Oxide 2000mg PO QD
Clobetasol 0.05% one application topically [**Hospital1 **]
Lactobacillus acidophilus one capsule TID
Potassium chloride 1 capsule QD
Vitamin K (not taking due to expense)
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO Q 24H (Every
24 Hours).
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
10. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
11. Magnesium Oxide 400 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
12. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
16. Spironolactone 100 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
17. Kristalose 10 gram Packet Sig: One (1) PO once a day.
18. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2)
sprays Nasal once a day.
19. Lactobacillus Acidophilus Capsule Sig: One (1) Capsule
PO three times a day.
20. Potassium Chloride Oral
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Primary Diagnosis:
Bacteremia
Chronic Lower Extremity Edema
Hepatorenal Syndrome
Sepsis
Urinary Tract Infection
.
Secondary Diagnosis:
Autoimmune Hepatitis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Thank you for allowing us to take part in your care. You were
admitted to the hospital after having fevers and passing out.
Tests showed you had bacteria in your blood stream. You were
treated with antibiotics for this infection. In the course of
being treated your kidneys were not working as well as they
should be. You were given medical treatment and your kidneys
returned back to normal.
Followup Instructions:
Previously-scheduled appointments:
.
Provider: [**Name10 (NameIs) 278**] [**Name8 (MD) **], RN Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2189-4-10**] 10:15
.
Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD (Hepatology)Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2189-4-10**] 11:40
Completed by:[**2189-3-11**]
|
[
"995.91",
"518.0",
"311",
"511.9",
"038.19",
"E878.0",
"452",
"782.3",
"996.82",
"572.4",
"571.42",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11786, 11842
|
6739, 9610
|
311, 336
|
12042, 12042
|
3328, 3333
|
12607, 12948
|
2879, 2994
|
10212, 11763
|
11863, 11863
|
9636, 10189
|
12190, 12584
|
3009, 3309
|
1842, 2099
|
247, 273
|
6663, 6716
|
364, 1823
|
11998, 12021
|
11882, 11977
|
3347, 6644
|
12057, 12166
|
2121, 2610
|
2626, 2863
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,074
| 198,559
|
23946
|
Discharge summary
|
report
|
Admission Date: [**2200-4-19**] Discharge Date: [**2200-5-11**]
Date of Birth: [**2151-12-2**] Sex: F
Service: [**Last Name (un) **]
Briefly this is a 49 year old female who presented with
nausea, vomiting and abdominal pain. She was found to have
acute pancreatitis. She had been seen previously in [**Month (only) 958**] of
this year with the same symptomatology. She was started on IV
fluids and analgesics and kept NPO. Workup here revealed that
it was likely due to gallstones.
Her past medical history is significant for status post
cesarean section, status post breast implants and
pancreatitis. No known drug allergies. Her medications at
home included insulin sliding scale. Past medical history is
also significant for diabetes.
On her physical examination, she was afebrile, tachycardic at
122, pressure was 144/69, respiratory rate 20, with 98%
oxygen saturation. She was in mild distress. Her lungs were
clear. Heart was tachycardic but regular. Her abdomen was
tender in the right upper quadrant with no rebound or
guarding. Her extremities were warm and well perfused.
Her labs were significant for a white count of 19. Her ALT
and AST were normal at 33 and 34. Her alkaline phosphatase
was 128, total bilirubin was 0.4. Her amylase and lipase were
123 and 131, respectively.
She was admitted to the surgical service under the purple
service of Dr. [**Last Name (STitle) **] and was managed expectantly with NPO
and IV fluids. She was evaluated by the ERCP service. At that
time, they felt no ERCP was indicated. A PICC line was
placed. The patient was started on TPN. The patient
defervesced slowly on NPO and TPN and further evaluation
showed she had multiple pseudocysts. It was felt that the
patient needed time for the pseudocysts resolution prior to
the operating room. She was kept on imipenem empirically for
the severe pancreatitis. The patient was transfused 2 units
of packed red blood cells on [**2200-4-30**], preoperatively for
a low hematocrit in order to prepare for the operation. The
patient was taken to the operating room on [**2200-5-1**], for
an exploratory laparotomy cystoduodenostomy and make multiple
pancreatic drainages as well as G-J tube placement. Please
see the operative report for further details.
Postoperatively, she was transferred to the intensive care
unit and slowly did well. She was weaned off the ventilator.
Boots were placed intraoperatively and being used when the
patient went back to bed. Postoperatively she continued to
slowly improve and was able to transfer out to the floor.
Physical therapy was consulted and she did well with physical
therapy. It was felt that she could likely go home after
completion of her medical issues. She was started on tube
feeds through her J-tube and her G-tube was kept to gravity.
She continued to do well and tolerated her tube feeds to
goal. Her TPN was slowly weaned off during this time period.
The patient then started on a p.o. diet after tolerating her
tube feeds. She slowly did well from this with intermittent
bouts of nausea requiring her G-tube to be vented. CT scan
was performed which showed complete resolution of her
pancreatic cysts with good drainage with J-P drains and no
other fluid collections that were undrained. The patient
continued to do well and her tube feeds were slowly weaned
off as she increased her p.o. intake. Ultimately her J-tube
and G-tube were clamped and she was able to tolerate this.
Her PICC line was left in until the day of discharge at which
time it was removed. Her J-P drains continued to put out
adequate amounts. The right drain which was near the
cystoduodenostomy site slowly decreased in output. After
tolerating a regular diet, a J-P amylase was sent on the
right drain and it came back at 280. Therefore, her right J-P
drain was removed. It was only putting out approximately 5 cc
per day. She slowly continued to improve and was cleared by
physical therapy. It was decided the patient could be sent
home on regular diet with no tube feeds and with her J-P
drains in place. The patient was discharged on [**2200-5-11**],
tolerating regular diet. PT had cleared her. She was on p.o.
pain medication and doing well. Her J-P drains were putting
out approximately 100 cc per day both superior and inferior
and consisted of pancreatic fluid. The patient was discharged
in stable condition.
Her discharging medications included Lopressor 25 mg p.o.
b.i.d., Protonix 40 mg p.o. daily, Vicodin 1-2 tabs p.o.
q.4hours p.r.n. for pain as well as Colace 100 mg p.o. b.i.d.
She was also instructed to continue on her home medications.
Her staples were left in place and she was instructed to
follow-up with Dr. [**Last Name (STitle) 468**] in [**12-15**] weeks for staple removal
and wound evaluation. The patient was also instructed to keep
her J-P drain outputs so that possible removal could be done
at a future date. The patient was discharged in stable
condition.
DISCHARGE DIAGNOSES: Pancreatitis.
Pancreatic pseudocysts.
Status post exploratory laparotomy, cystoduodenostomy,
drainage of multiple other pancreatic pseudocysts, G-tube and
J-tube placement.
Past history of diabetes.
Status post breast augmentation.
Status post cesarean section.
During this hospitalization, she has had hypokalemia,
hypovolemia, anemia and pneumonia.
The patient was discharged in stable condition.
[**Name6 (MD) **] [**Last Name (NamePattern4) 7542**], [**MD Number(1) 7543**]
Dictated By:[**Doctor Last Name 11225**]
MEDQUIST36
D: [**2200-5-11**] 10:50:45
T: [**2200-5-11**] 12:00:05
Job#: [**Job Number 61011**]
|
[
"276.8",
"560.89",
"276.5",
"577.0",
"486",
"V58.67",
"285.9",
"038.9",
"577.2",
"574.70",
"250.00",
"567.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"44.32",
"52.4",
"96.6",
"99.04",
"52.22",
"87.53",
"88.74",
"51.22",
"54.4",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
4962, 5615
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,449
| 169,230
|
9518
|
Discharge summary
|
report
|
Admission Date: [**2193-1-8**] Discharge Date: [**2193-1-21**]
Date of Birth: [**2168-10-28**] Sex: M
Service: MEDICINE
Allergies:
Cozaar / Spironolactone / Lisinopril
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
failure to extubate
Major Surgical or Invasive Procedure:
Internal Cardiac Defibrillator Implantation
History of Present Illness:
Mr. [**Known lastname 32362**] is a 24 yo M with non-ischemic cardiomyopathy (EF 25%
in [**9-28**]) who was admitted for right heart cardiac catherization
and AICD placement today. He is being transferred to the CCU
after difficulty with extubation s/p cath. Patient was recently
admitted to the CCU from [**2192-12-23**] - [**2192-12-26**] with acute congestive
heart failure in the setting of dietary non-compliance. He was
scheduled to have his AICD placed today under general anesthesia
per recommendation by Dr. [**Last Name (STitle) **]. Per anesthesia, patient was a
difficult intubation due to his body habitus, and was maintained
on a phenylephrine gtt in order to maintain his blood pressures
during the procedure (SBPs in 100s-120s). He underwent RHC which
showed elevated wedge, PA, RV, and RA pressures (see
hemodynamics below). He had a [**Company 2267**] single chamber
ICD placed through cutdown of left cephalic vein without
complication. Received 1.2 L of LR in the OR. He was continued
on a neo gtt which was weaned at 5 pm, and remained off pressors
for 4 hours prior to CCU transfer. Patient was transitioned to
PS [**9-29**] in an attempt at extubation in the PACU, but these
attempts were unsuccessful due to tachypnea and secretions
requring continuous secretions. Patient was also noted to be
difficult to sedate during ventilation and was maintained on
propofol 70 mcg/kg/min. A-lines attempts in both radial arteries
by anesthesia were unsuccessful. It was thought that the failure
to extubate was due to body habitus and pulmonary edema. Prior
to transfer to CCU, VS were 98.6 112/48 110 20 100% on CPAP with
PEEP of 10 and FiO2 of 50%. He received 20 mg of IV lasix in the
PACU and was transferred to the CCU for further management.
.
ROS unable to be obtained due to patient being intubated and
sedated.
.
Past Medical History:
1. Presumed Idiopathic dilated cardiomyopathy, EF 15-20% (echo
[**9-28**])
- diagnosed [**11-27**] when he presented to [**Hospital1 18**] with cough, fever,
and increasing SOB. Chest CT showed bilateral lung infiltrates
and enlarged mediastinal lymph nodes consistent with multifocal
pneumonia, and echocardiography showed moderate to severe
global left ventricular hypokinesis (LVEF = 25-30 %), with
normal valve function, and no pericardial effusion. Lab work
for RSV was positive, while HIV, influenza, EBV, CMV, Lyme and
multiple blood cultures were unremarkable. Repeated echo 10
months later confirms severely depressed and dilated LV with
LVEF of [**10-4**]%, and LVEDD of 7.8 cm
- last hospitalized [**5-29**] and [**12-30**] for CHF exacerbation, treated
with IV lasix
2. Childhood asthma
3. Morbid obesity
4. Sleep apnea - on CPAP but has not been using it
5. Moderate, Worsening pulmonary hypertension (46 mmHg [**9-28**])
(20-28 in [**4-28**])
6. Fatty Liver by CT. Obese and hx of EtOH. INR 1.4-1.7 since
[**5-29**]; Bili 1.7; HCV neg; HBV immune.
Social History:
He is unmarried and lives at home with his parents. He works as
a high school wrestling coach and in security. He never smoked.
He drank "a lot" in college, previously quoting 6 beer/weekend
but not elaborting this time; started drinking in [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32363**]
high school. He has a history of cocaine use, "a great deal" in
sophmore year. Drinks an occasional glass of wine.
Family History:
Father is 65 year-old and mother is 55 year-old.
Both have diabetes. He has 4 healthy older sisters. There is no
family history of SCD or cardiomyopathy.
Physical Exam:
VS: T= 101.2 BP= 98/48 (A-line 75/46) HR= 98 RR= 20 O2 sat= 92%
on CPAP PEEP 12, FiO2 50%.
GENERAL: obese M intubated, sedated
HEENT: NCAT. PERRL, EOMI.
NECK: unable to assess JVP due to body habitus.
CARDIAC: PMI laterally displaced. RR, normal S1, S2. No m/r/g.
No thrills, lifts. No S3 or S4.
LUNGS: ventilated breath sounds
ABDOMEN: obese, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: [**12-22**]+ pitting edema bilaterally. +venous stasis
changes and dirt noted over bilateral extremities.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Discharge exam: vitals stable
pulmonary exam: clear to auscultation bilaterally.
Otherwise unchanged.
Pertinent Results:
CXR [**1-8**]: In comparison with the study of [**12-23**], there is again
huge
enlargement of the cardiac silhouette with evidence of pulmonary
vascular
congestion. It is difficult to determine whether there are
layering
effusions, because of extensive scattered radiation related to
the body
habitus of the patient. The ICD line is poorly seen, though it
appears to
extend to the region of the apex of the right ventricle.
CXR [**1-9**]: In comparison with the study of [**1-8**], there are very
low lung
volumes. Huge enlargement of the cardiac silhouette persists.
Pulmonary
vessels are difficult to evaluate, though they do not appear to
be especially engorged. The AICD line extends to the region of
the apex of the right ventricle. The area behind the hugely
enlarged heart cannot be evaluated for the possible presence of
pneumonia or effusion.
ECHO [**1-9**]:
[**2193-1-8**] 10:50PM BLOOD WBC-11.8* RBC-4.95 Hgb-11.7* Hct-36.9*
MCV-75* MCH-23.5* MCHC-31.6 RDW-20.4* Plt Ct-229
[**2193-1-9**] 04:16AM BLOOD WBC-12.4* RBC-5.10 Hgb-12.1* Hct-37.9*
MCV-74* MCH-23.6* MCHC-31.8 RDW-20.6* Plt Ct-275
[**2193-1-9**] 04:16AM BLOOD Neuts-77.9* Lymphs-15.9* Monos-5.3
Eos-0.6 Baso-0.3
[**2193-1-8**] 10:50PM BLOOD PT-16.4* PTT-26.4 INR(PT)-1.5*
[**2193-1-8**] 10:50PM BLOOD Glucose-84 UreaN-20 Creat-1.7* Na-141
K-4.2 Cl-104 HCO3-24 AnGap-17
[**2193-1-9**] 04:16AM BLOOD Glucose-89 UreaN-24* Creat-2.1* Na-140
K-4.4 Cl-104 HCO3-25 AnGap-15
[**2193-1-9**] 04:16AM BLOOD ALT-19 AST-51* AlkPhos-97 TotBili-2.7*
DirBili-2.0* IndBili-0.7
[**2193-1-9**] 04:16AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.3
[**2193-1-8**] 10:32PM BLOOD Type-ART pO2-111* pCO2-49* pH-7.36
calTCO2-29 Base XS-1
[**2193-1-9**] 09:26AM BLOOD Type-ART pO2-88 pCO2-45 pH-7.35
calTCO2-26 Base XS-0
[**2193-1-9**] 07:43AM BLOOD Lactate-1.4
[**2193-1-21**] 07:08AM BLOOD WBC-12.5* RBC-5.60 Hgb-13.5* Hct-41.4
MCV-74* MCH-24.0* MCHC-32.5 RDW-20.8* Plt Ct-295
[**2193-1-18**] 04:56AM BLOOD Neuts-85.8* Lymphs-8.0* Monos-3.8 Eos-2.2
Baso-0.2
[**2193-1-21**] 07:08AM BLOOD Glucose-103* UreaN-18 Creat-0.7 Na-140
K-4.1 Cl-103 HCO3-29 AnGap-12
AP CHEST, 8:24 A.M. [**1-19**]
HISTORY: Intubated. Multilobar collapse or infection, assess
change.
IMPRESSION: AP chest compared to [**1-15**] and 28.
Severe cardiomegaly has improved since [**1-15**], subsequently
stable.
Previous mild pulmonary edema has also improved, though
pulmonary vascular
engorgement remains. Left lower lobe is consolidated, but has
probably
improved since [**1-15**] and since there was previously ipsilateral
mediastinal
shift much of that is probably atelectasis. The course of the
transvenous
right ventricular pacemaker lead is obscured in the heart by
cardiac motion.
[**2193-1-18**] CT chest/[**Last Name (un) 103**]/pelvis
Final Report
INDICATION: 24-year-old man with persistent fever after ICD
placement. Study
is to evaluate for source of infection.
TECHNIQUE: MDCT images were acquired from the thoracic inlet
through the
pubic symphysis without administration of IV contrast.
Multiplanar
reformatted images were provided, essential in delineating
anatomy and
pathology.
CT CHEST WITHOUT CONTRAST: There is complete collapse of the
left lower lobe
and partial collapse of right lower lobe, with an endotracheal
tube in place.
This probably represent atelectasis, although underlying
infection cannot be
excluded particularly in the setting of fever and leukocytosis.
Examination
of fine parenchymal detail or small nodules is severely limited
by motion
artifact as well as image quality. There is no pericardial or
pleural
effusion.
Visualization of the thyroid gland is limited by motion,
however, a small
hypodensity with central hyperattenuation is seen in the
posterior left lobe
of the thyroid (2, 3), measuring approximately 8 mm. There is
moderate-to-
severe cardiomegaly. Patient is status post a left-sided ICD
placement with
metallic leads terminating in the right atrium and right
ventricle. Small
mediastinal and axillary lymph nodes do not meet CT criteria for
pathologic
enlargement.
CT ABDOMEN WITHOUT CONTRAST: A nasogastric tube is in place with
its tip
terminating in mid stomach. Small amorphous echogenic material
layering along
the posterior fundal stomach probably represents ingested
material. Within
limitation of non-contrast technique, the liver, spleen, adrenal
glands, and
kidneys appear unremarkable. The gallbladder is not visualized.
A 2cm
hypodense area in the head of pancreas (2,73; 103b,41) may
represent a cyst.
There is no nephrolithiasis or hydronephrosis. There is no free
air or free
fluid. A few small focal areas of soft tissue thickening in the
right
abdominal adipose tissue are of uncertain etiology, for example,
series 2,
image 87.
CT PELVIS WITHOUT CONTRAST: The bladder is decompressed with a
Foley catheter
which is in place. The rectum and sigmoid colon are collapsed.
Uterus is not
well seen. A 12mm right iliac lymph node is noted (2, 118),
non-specific.
Additional small scattered inguinal and pelvic sidewall lymph
nodes do not
meet CT criteria for pathologic enlargement. There is no free
fluid in the
pelvis.
OSSEOUS FINDINGS: No suspicious lytic or blastic lesions.
IMPRESSION:
1. Endotracheal tube in place with complete and partial collapse
of left and
right lower lobes probably represent atelectasis. However,
underlying
infection cannot be excluded given clinical presentation.
2. No fluid collection or abscess identified in the abdomen or
pelvis.
3. 8-mm left thyroid cyst or nodule can be further evaluated by
ultrasound.
4. 2-cm hypoattenuating area in pancreatic head may represent a
cyst.
Further evaluation as clinically indicated.
5. Cardiomegaly with ICD in place.
6. Isolated 12mm right iliac lymph node is non-specific.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
24 yo M with non-ischemic cardiomyopathy admitted to CCU after
failure to extubate s/p elective AICD placement and right heart
cath. This failure was related to pulmonary edema, pneumonia
(serratia) and atelectasis. Over 10 days of ventillation, the
patient's I/O's were 8 L negative. In this time he had a
swan-ganz catheter placed and a myocardial biopsy. His course
was complicated by fevers which may have been related to
atelecatisis or a drug reaction (he had a bilateral blanching
erythematous rash) and/or serratia in his sputum. He was
extubated and swiftly transferred to the floor. He was
discharged to rehab______
#. Failure to extubate: Patient was unable to be extubated in
the PACU s/p ICD placement. Likely in setting of extrapulmonary
restriction (morbid obesity/large body habitus) and poor lung
compliance due to volume overload from patient's systolic and
diastolic heart failure, leading to elevated elastic pressures.
Mr. [**Known lastname 32362**] required 8 litres of measured diuresis and an
antibiotic course over 10 days to become suitable for extubation
(he was, until that point, hypercarbic on pressure support).
Pulmonary was consulted. A Chest CT on the day before extubation
highlighted atelecatasis. After extubation, he saturated at
91-94% on room air.
.
#. Non-ischemic dilated cardiomyopathy: His EF is 10% or less.
This is the indication for his ICD placement. Etiology thought
to be related to obesity, post-viral or related to distant
history drug use. A myocardial biopsy was unrevealing. His has
chronic systolic and diastolic heart failure. He required
invasive monitoring (SGC) and lasix, metolazone, diamox diuresis
to 8 measured litres negative. He will need a transplant work
up. He was discharged on metoprolol, [**Last Name (un) **], digoxin, lasix and
eplerinone.
.
#. Fever: Pt with T to 101.2 in the PACU and rising
leukocytosis. Likely febrile in setting of recent procedure. He
also had a bilateral, blanching, confluent erythematous rash
from his toes to umbillicus that gradually fades. His urine was
positive for Eosinophils. Blood cultures with coag negative
staph. C Diff negative. His Fever waxed and waned, peaking at
104.0 on ventillator day 8. He was placed under a cooling
blanket and given round-the-clock tylenol. A CT chest
underscored atelectasis but could not rule out pna. He slowly
defervesced while on antibiotics, so he continued on a full
course for VAP.
.
#. Acute renal failure: Mr. [**Known lastname 32362**] had two episodes of ARF. On
admission his Cr was up to 1.7 (baseline 1.1), which was likely
related to hypotension intraoperatively. This resolved. Later,
as his diuresis reached goal, his creatinine bumped to 2.4.
Renal was consulted and felt this was related to diuresis and
[**Last Name (un) **] therapy. This too resolved. During the workup, he was found
to have urine eos.
.
#. Hyperbilirubinemia: Patient had hyperbilirubinemia to 2.7
with direct fraction of 2.0. When previously admitted for CHF
exacerbation, he had bilirubin elevations to 2.0. This is likely
related to congestive hepatopathy. As he diureses, these numbers
improve. He received an unremarkable RUQ US which commented on
the non-visualization of his gallbladder, which cannot be seen
on his CT's. This has not been confirmed by any direct
visualization. His CT abdomen this admission described a normal
appearing liver, while a prior exam described fatty infiltration
with nodularity.
.
#. Anemia, Microcytic: Mr. [**Known lastname 32362**] has Known iron deficiency
anemia s/p normal CT colonography. He has hemorrhoids and HbAC
(benign but gives microcytosis). He was maintained on iron with
vitamin C.
# Asthma: It is the reason he wasn't started on carvedilol.
Patient states he had childhood asthma, and hasn't had asthma
symptoms since high school. Albuterol inhaler prn was given.
#. OSA: Patient would benefit from CPAP, but he refused CPAP
here in the hospital after extubation.
Medications on Admission:
1. Valsartan 40 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Digoxin 250 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO TID
5. Ascorbic Acid 250 mg Tablet PO TID
6. Furosemide 40 mg PO BID
7. Toprol XL 100 mg Tablet Sustained Release PO BID
8. Colace 100 mg PO BID
9. Senna 8.6 mg PO daily:PRN constipation
Discharge Medications:
1. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
3. Ascorbic Acid 250 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Valsartan 40 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Eplerenone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Ascorbic Acid 500 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
14. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO BID (2 times a
day).
16. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Non-Ischemic Dilated Cardiomyopathy
Morbid Obesity
Obstructive Sleep Apnea
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
VS: Within normal limits
Lungs: clear
Wound: clean
CV: regular
Ext: no edema
Discharge Instructions:
It was a pleasure to be involved in your care, Mr. [**Known lastname 32362**]. You
were admitted to [**Hospital1 69**] Cardiac
Care Unit after an defibrillator was placed. You had an
internal defibrillator implanted for primary prevention of
sudden cardiac death in the setting of a non-ischemic dilated
cardiomyopathy. After the defibrillator was placed, you were
intubated for 10 days because of difficulties to extubate you.
You were aggressively diuresed with IV lasix, and you were also
treated with antibiotics for pneumonia. You were extubated on
[**1-18**], and since then you recovered rapidly.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.in 2 days or 5 pounds in 5 days.
Your medications have been changed:
You have been started on 20mg torsemide daily
Your valsartan has been increased to 120mg daily
You have been started on eplernone 50mg daily
You have been started on an antibiotic ciprofloxacin 500mg twice
daily for 3 days.
You have beens started on pantoprazole 40mg daily for 1 month
Followup Instructions:
You have the following follow-up appointments
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2193-1-29**] 11:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2193-2-11**]
10:00
Completed by:[**2193-1-22**]
|
[
"493.90",
"276.4",
"571.8",
"425.4",
"041.85",
"428.0",
"682.6",
"278.01",
"584.9",
"458.29",
"416.8",
"997.31",
"428.43",
"518.81",
"E930.5",
"782.4",
"693.0",
"327.23",
"280.9",
"455.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94",
"89.49",
"38.91",
"89.64",
"96.6",
"96.72",
"88.72",
"37.21",
"38.93",
"37.25"
] |
icd9pcs
|
[
[
[]
]
] |
16516, 16573
|
10573, 14533
|
325, 371
|
16692, 16692
|
4730, 10550
|
17999, 18375
|
3785, 3940
|
14883, 16493
|
16594, 16671
|
14559, 14860
|
16915, 17976
|
3955, 4608
|
4624, 4711
|
266, 287
|
399, 2237
|
16706, 16891
|
2259, 3325
|
3341, 3769
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,833
| 181,806
|
46735
|
Discharge summary
|
report
|
Admission Date: [**2121-12-7**] Discharge Date: [**2122-1-23**]
Date of Birth: [**2061-9-20**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Heparin Agents
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Anuria, hyponatremia
Major Surgical or Invasive Procedure:
Paracentesis
Liver transplant [**2122-1-11**]
History of Present Illness:
60F with PMH of primary biliary cirrhosis/end stage liver
disease c/b HCC and diuretic resistant ascites inability to
unriante over past 2 days. Pt feels urge but nothing comes out
when she tries to go. Patient reports increasing ascites, but no
fever, abdominal pain, n/v, SOB, CP or latered mental status,
disorientation.
.
The patient was recently discharged after admission from [**11-30**]
to [**12-4**] for weakness, found to be [**3-12**] hyponatremia (Na 116) and
placed on 1L fluid restriction. Had foley but dc'ed prior to
discharge. Denies fevers, abdominal pain or back pain but
endorses long-term loose stools. Some suprapubic discomfort.
Patient has had additional previous admissions for hyponatremia.
.
In the ED, initial VS were 97.2 79 104/44 16 100% RA. She was
fluid restricted. Rectal exam revelaed normal tone; normal LE
strength; no neuro deficits on exam. Per renal c/s: admit to
ICU; give hypertonic saline 20/hr 3% w/Q2 hr Na checks max 30/hr
of saline goal Na 121, delta/hour <1meq if overshoots give D5W
and DDAVP. If albumin check Na Q2H b/c may shut down ADH and
dilute urine w/acute change in Na. 150 cc of turbid urine came
out the foley.Per hepatology, repeat Na, vs this admit to ICU vs
floor (Dr [**Name (NI) **]).
.
In the ED, LFTs: AST 46*, ALT 48*, Alk Phos 184*, T. Bili 4.6*.
Albumin was 2.2, lipase was 56. Chem 7 was Na 113, K 4.3 Cl 88*
HCO3 20* Anion gap 9 BUN 15 Cr 0.8. Her serum osmolality was
253. Hb/Hct 9.5*/28.4*. Pt, PTT, INR of 21.1*/64.1*1/1.9*. UA
was unremarkable, Urine cultures were sent.
.
Bedside abdominal US revealed a ?distended bladder which was
difficult to differentiate from surrounding ascites; moderate
hydronephrosis on R, L kidney poorly visualized. ED CT Abdomen
and Pelvis w/o contrast: Bladder collapsed around Foley catheter
and not optimally evaluated. Bladder nondistended. No evidence
of hydronephrosis bilaterally. Large amount of ascites. Hepatic
cirrhosis and evidence of portal hypertension with varices.
hepatic dome lesion better evaluated on contrastenhanced
studies.
cholelithiasis. extensive soft tissue edema/anasarca.
.
On arrival to the MICU, vital signs were stable. She was well
oriented and in no discomfort.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss .
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Seronegative autoimmune hepatitis/primary biliary cirrhosis
overlap syndrome.
Cirrhosis.
Hyponatremia.
Peripheral edema/? ascites.
Hepatic encephalopathy.
Pruritus.
Non-insulin-dependent diabetes mellitus.
Diabetic gastroparesis.
Small intestinal bacterial overgrowth.
Abdominal hysterectomy.
Social History:
Worked as a property manager. She has two nonbiologic children.
She was a smoker and quit over ten years ago, was never a
drinker or IV drug abuser.
Family History:
Father died of colon cancer early 70s. Sister died of breast
cancer in her 40s, mother died of ovarian cancer in her 50s.
Physical Exam:
Admission Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera icteric,
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: distended belly, no pain, fluid thrill +, no
tenderness/guarding.
GU: foley in place
Ext: warm, well perfused, +++ pedal 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
[**2121-12-7**] 02:00PM BLOOD WBC-5.5 RBC-2.85* Hgb-9.5* Hct-28.4*
MCV-100* MCH-33.4* MCHC-33.5 RDW-18.6* Plt Ct-71*
[**2121-12-7**] 02:00PM BLOOD Neuts-75.8* Lymphs-12.7* Monos-9.8
Eos-1.3 Baso-0.4
[**2121-12-7**] 02:00PM BLOOD PT-21.1* PTT-64.1* INR(PT)-1.9*
[**2121-12-7**] 02:00PM BLOOD Glucose-181* UreaN-15 Creat-0.8 Na-113*
K-4.3 Cl-88* HCO3-20* AnGap-9
[**2121-12-7**] 02:00PM BLOOD ALT-46* AST-48* AlkPhos-184* TotBili-4.6*
[**2121-12-7**] 08:38PM BLOOD Calcium-7.8* Phos-3.0 Mg-1.9
[**2121-12-7**] 02:12PM BLOOD Lactate-2.2*
[**2121-12-7**] 08:57PM BLOOD Lactate-1.9
[**12-7**] CT abd: IMPRESSION:
1. Hepatic cirrhosis and secondary findings of portal
hypertension including
patent umbilical vein, extensive varices, and large amount of
ascites, as
above.
2. Bladder collapsed around a Foley catheter, thus not optimally
assessed.
No free air seen. No evidence of hydronephrosis bilaterally.
3. Extensive soft tissue edema consistent with anasarca.
4. Cholelithiasis.
5. Punctate non-obstructing right renal calculus.
6. Small umbilical hernia containing fluid.
.
[**12-13**] CXR: IMPRESSION:
Left PICC catheter with its tip in the superior vena cava.
Interval
improvement in aeration with some linear opacity at the left
base, which
likely reflects subsegmental atelectasis. No evidence of
pulmonary edema or pleural effusions. No pneumothorax. Cardiac
and mediastinal contours are within normal limits and unchanged.
.
MRI head [**2121-12-17**]: 1. Subtle high T1 signal in bilateral basal
ganglia, likely related to hepatic insufficiency.
2. Abnormal signal intensity adjacent to the third ventricle
just to the left of midline, might be related to a dilated
tortuous basilar artery indenting the third ventricle. An MRI of
the sella and MRA of the brain are recommended for further
evaluation.
.
MRA brain/MRI sella: 1. Although the prior outside studies are
not available for comparison, the cystic lesion described on the
previous study in the region of hypothalamus appears to be due
to a prominent perivascular space, due to indentation in the
region of hypothalamus by basilar artery tip. Indentation is
produced by tortuous basilar artery. No mass lesion is seen in
the hypothalamus nor is there evidence of pituitary micro- or
macroadenoma.
2. MRA of the head demonstrates no evidence of aneurysm or
vascular
malformation. A tortuous basilar artery indenting the
hypothalamus is
visualized.
.
RUQ ultrasound [**2121-12-22**]: 1. Cirrhosis with sequelae of portal
hypertension including multiple varices, ascitis and
splenomegaly. Hepatic vasculature is patent.
2. Cholelithiasis. Nondistended gallbladder with gallbladder
wall thickening which is a nonspecific finding and can be seen
in cirrhosis. There is no intra- or extra-hepatic biliary
dilatation
.
CT abd/pelvis without contrast [**2121-12-31**]: 1. No evidence of
hemorrhage.
2. Sequelae of cirrhosis including moderate ascites and
extensive varices.
Brief Hospital Course:
60F w h/o cirrhosis, [**3-12**] PBC and autoimmune hepatitis, c/b HCC
and diuretic resistant ascites, on transplant list, admitted
with weakness and increasing ascites and found to have
hyponatremia. Admission complicated by anemia, acute injury,
and worsening volume overload. She was admitted to the ICU with
sodium of 113. Hypertonic saline was given with improved sodium.
IV Lasix was started to augment tolvaptan.
On [**12-9**], Na improved to 122. She was transferred to the medical
floor. PO Torsemide and fluid restriction continued. Tolvaptan
was stopped and salt tabs were given with sodium stable
Hematocrit had dropped from 25 to 20, requiring [**2-9**] units of
PRBCs. EGD and colonoscopy showed no evidence of active bleed.
Capsule endoscopy was positive for active bleed in the duodenal
bulb. However, repeat EGD was without evidence of bleed. The
patient underwent attempted TIPS without success and IR was not
able to identify a bleeding vessel to embolize. An active type
and cross was maintained throughout admission and hematocrit was
monitored closely.
Urine was positive for vancomycin-sensitive enterococcus [**12-23**].
Seven days of vancomycin was given and UTI resolved. Subsequent
urine cultures grew yeast ([**Female First Name (un) **] albicans). Foley was
exchanged.
During her admission, TIPS procedure was attempted, but was
unsuccessful due to small size of liver and technical
difficulty. She received a large contrast load, and underwent a
6L paracentesis. Albumin was given post procedure, but
creatinine began to rise from her baseline of 1.0. The patient
was started on albumin, midodrine, and octreotide for presumed
hepatorenal syndrome vs. contrast induced nephropathy. Doses of
midodrine and octreotide were titrated up without effect. She
became oliguric and was transferred to the ICU for possible
initiation of dialysis (CVVHD). This was started on [**1-5**].
Paracentesis was required every 5 days. MELD score increased.
On [**1-11**], a liver donor offer was available and was accepted. She
underwent liver transplant. Abdomen was left open due to massive
edema. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative
note for details. Postop, she was sent to the SICU for
management. On [**1-13**], she went back to the OR for takedown of
temporary abdominal closure by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Closure was
successful. LFTs improved. Liver duplex was wnl. JP drains were
non-bilious. She continued to require CVVHD. She was extubated.
She was initially confused, but mental status gradually
improved. Diet was slowly initiated, but was insufficient for
daily needs. A post pyloric feeding tube was placed and tube
feeds were started.
Urine output increased slowly to 1000cc/day. Creatinine
improved. Dialysis was stopped. Creatinine decreased to 1.3.
Potassium increased to 5.6. Feeding formula was switched to
Nepro (lower potassium content). On [**1-22**], the feeding tube was
clogged. Fluoro was unsuccessful in getting postop pyloric. This
was successfully accomplished on [**1-23**]. Tube feedings were
resumed.
Immunosuppression consisted of Cellcept(mycophenolate
mofetil)which was well tolerated. Solumedrol was tapered to
prednisone per transplant protocol. Prograf was started on [**1-12**].
Doses were adjusted daily per trough levels (goal of 10). Of
note, LFTs were significant for slowly rising alk phos which was
52 po postop day 1. This increased daily to 310 on [**1-18**] when
all LFTs were increased (alt 164, ast 164, alk phos 234 and
t.bili 2.8 from 97, 26, 87 and 1.6 respectively). Liver duplex
was done noting patient vasculature with normal waveforms. No
biliary ductal dilatation was seen. LFTs decreased the next day
and continued to trend down with the exception of the alk phos
which was slower to trend down (254 from 309).
Physical therapy assessed her and recommended rehab due to
debilitation. She was unable to stand due to extreme
weakness/debilitation from illness. [**Hospital3 **] screened her
and accepted her. She is transferring there today [**1-23**].
She remained afebrile. SBPs in 120 range. Glucoses 150-200
range. Weight on [**1-23**] was 81.5kg. Abdominal incision was dry
and intact with staples(to be removed in f/u at [**Hospital1 18**]).
Of note, she had history of small hypothalamic cyst, followed by
[**Hospital3 328**] neuro-oncology, first discovered in [**6-18**]. Cyst was
discussed at tumor board with clear documentation that it should
not preclude the patient from receiving a liver transplant.
While the patient was in-house, she underwent repeat imaging of
her brain for 6-month follow-up (MRI brain/MRI sella/MRA brain).
Imaging showed resolution of the cyst.
Medications on Admission:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. tolvaptan 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
8. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
9. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed for mouth irritation.
12. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
13. sitagliptin 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Medications:
1. prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily):
follow transplant taper protocol.
2. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for SOB.
4. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
5. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection [**Hospital1 **] (2 times a day).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
10. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
12. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
13. NPH insulin human recomb 100 unit/mL Suspension Sig: Six (6)
units Subcutaneous twice a day: am and supper time.
14. insulin regular human 100 unit/mL Solution Sig: follow
printed sliding scale Injection four times a day.
15. Outpatient Lab Work
Every Monday and Thursday, stat processing
cbc, chem 10, ast, alt, alk phos, t.bili, albumin, trough
prograf
fax results to [**Telephone/Fax (1) 697**] attn: Transplant RN coordinator
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Primary Biliary cirrhosis with hyponatremia, UGI Bleed,
hepatorenal syndrome
Liver transplant
HRS/Contrast induced nephropathy
UTI, VRE [**2121-12-7**]
UTI, Vanco sensitive enterococcus [**2121-12-23**]
UTI, Yeast
Malnutrition
DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
-You will be transferring to [**Hospital3 **] in [**Hospital1 8**]
-Please call the Transplant Center [**Telephone/Fax (1) 673**] if you have any
of the warning signs.
-You will have blood drawn for lab monitoring every Monday and
Thursday
-You may shower with assistance
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2122-1-29**] 1:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2122-2-5**] 1:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2122-2-5**] 3:00
Completed by:[**2122-1-23**]
|
[
"V58.67",
"455.0",
"571.5",
"583.9",
"572.3",
"572.2",
"250.60",
"789.59",
"599.0",
"E878.0",
"537.89",
"455.3",
"456.8",
"286.9",
"287.5",
"584.9",
"E947.8",
"E849.7",
"458.0",
"571.42",
"998.11",
"578.9",
"276.1",
"263.9",
"285.9",
"571.6",
"599.71",
"155.0",
"V49.83",
"536.3",
"041.04",
"572.4",
"276.69",
"272.4",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"45.23",
"00.93",
"54.62",
"50.59",
"38.95",
"38.91",
"96.6",
"39.95",
"45.19",
"45.13",
"38.97",
"88.64",
"50.4"
] |
icd9pcs
|
[
[
[]
]
] |
14690, 14761
|
7212, 12010
|
340, 388
|
15035, 15035
|
4235, 7189
|
15467, 15972
|
3529, 3652
|
13115, 14667
|
14782, 15014
|
12036, 13092
|
15170, 15444
|
3667, 4216
|
2641, 3029
|
279, 302
|
416, 2622
|
15050, 15146
|
3051, 3346
|
3362, 3513
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,010
| 122,034
|
40120
|
Discharge summary
|
report
|
Admission Date: [**2144-1-29**] Discharge Date: [**2144-2-6**]
Date of Birth: [**2081-6-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Expired
History of Present Illness:
The patient is a 62 yo man with h/o DM2, HTN, hyperlipidemia,
and recent back surgery, who presented to [**Hospital6 302**] on
[**2144-1-22**] with altered mental status. He reportedly underwent back
surgery in [**Month (only) 1096**] and was taking a substantial amount of pain
medication for the past month. On [**1-21**], he had dinner, drank
three alcoholic beverages, and took his Valium and pain
medications. Per the OSH records, his voice was slurred at this
time, and his wife thought it was secondary to EtOH. The next
morning, his wife let him sleep until noon; however, at that
point, she was unable to wake him up. EMS was called, and his
FSBG at the time of arrival was 18. Of note, he was taking
Glimepiride for DM2. He was thus taken to [**Hospital3 **] for further
evaluation.
.
In the ED at [**Hospital3 **], he was given Dextrose, Niacin, and
Thiamine. Per report, he was decorticate at that time and was
intubated in the Emergency Room. He was admitted to the MICU,
where his mental status did not improve. He troponin was found
to be increased, so cardiology was consulted and serial EKGs and
TTE were within normal limits. Neurology was also consulted
given his persistent unresponsiveness despite weaning of
sedation, and he had an EEG which was suggestive of severe
cerebral dysfunction. During his course, his also developed a
LLL opacity and grew serratia marcescens from his sputum, and he
was placed on Vancomycin and Cefepime. Given his family's desire
for a second opinion, he was transferred to [**Hospital1 18**].
.
On arrival to the floor, the patient is non-reponsive and was
unable to provide further history. His family was not present
for further information.
.
.
Review of systems: Unable to obtain due to patient's altered
mental status
Past Medical History:
Type 2 Diabetes Mellitus
Hyperlipidemia
Hypertension
Recent back surgery
GERD
Retinopathy
Chronic renal insufficiency
Social History:
The patient lives with his wife in [**Name (NI) 6981**], MA. He smokes
cigarettes and drinks EtOH.
Family History:
Non-contributory
Physical Exam:
On Admission:
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: right pupil minimally reactive, fake left
eye
Head, Ears, Nose, Throat: Poor dentition, Endotracheal tube,
Macroglossia
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Diminished), (Left
DP pulse: Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Rhonchorous: Diffusely, but worse
at the bases)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+
Skin: Warm
Neurologic: Responds to: Unresponsive, Movement: Non
-purposeful, Tone: Not assessed
Pertinent Results:
Admission Labs:
[**2144-1-30**] 12:03AM BLOOD WBC-12.2* RBC-3.02* Hgb-8.9* Hct-26.0*
MCV-86 MCH-29.3 MCHC-34.1 RDW-13.4 Plt Ct-314
[**2144-1-30**] 12:03AM BLOOD Neuts-76.9* Lymphs-14.2* Monos-6.0
Eos-2.5 Baso-0.4
[**2144-1-30**] 12:03AM BLOOD PT-13.4 PTT-25.8 INR(PT)-1.1
[**2144-1-30**] 12:03AM BLOOD Glucose-147* UreaN-45* Creat-1.8* Na-137
K-4.2 Cl-109* HCO3-21* AnGap-11
[**2144-1-30**] 12:03AM BLOOD ALT-56* AST-41* LD(LDH)-178 AlkPhos-99
TotBili-0.2
[**2144-1-30**] 12:03AM BLOOD Albumin-2.5* Calcium-9.4 Phos-3.5 Mg-2.3
[**2144-1-30**] 12:03AM BLOOD Triglyc-101
[**2144-1-31**] 03:13PM BLOOD Ammonia-7*
[**2144-1-31**] 04:31AM BLOOD TSH-4.1
[**2144-1-31**] 04:31AM BLOOD T4-6.4 T3-108
[**2144-2-4**] 02:58AM BLOOD Cortsol-15.6
Studies:
[**2144-1-29**] CXR: The endotracheal tube terminates approximately 3 cm
above the
carina. Left-sided PICC line is at the junction of the right
subclavian and upper SVC. Orogastric tube terminates inferior to
the lower margin of the film. Bilateral layering effusions are
present. No pneumothorax is present. Lower thoracic and lumbar
spinal hardware is present without complications.
[**2144-1-29**] EEG: Abnormal portable EEG due to the slow and low
voltage
background with occasional bursts of generalized slowing. These
findings indicate a widespread encephalopathy affecting both
cortical
and subcortical structures. There were no areas of prominent
focal
slowing, but encephalopathies may obscure focal findings. There
were no
epileptiform features.
[**2144-1-29**] CT Head:
1. No acute intracranial abnormality.
2. Opacification and aerosolized secretions in the right
sphenoid sinus.
Findings may be related to intubation but sinusitis cannot be
excluded.
[**2144-2-1**] CONTINUOUS EEG: Showed a very low voltage slow
background from the
beginning, at 6:54 on the morning of [**2-1**]. There were
some runs
of 2 Hz generalized slowing. Most of the background was in the
theta
frequency range and of low voltage. It appeared fairly
symmetric,
without prominent focal abnormalities or emphasis. Over the
morning,
the background voltages appeared to decrease moderately
[sometimes the
effect of medications]. They were a bit higher in the afternoon,
but
the pattern remained the same, low voltage [**5-27**] Hz activity with
a
widespread distribution, less superimposed intermittent 2 Hz
delta
slowing with a bifrontal emphasis. This remained the same
through the
end of the recording at 21:05 that evening when the leads were
disconnected for an MRI study.
SPIKE DETECTION PROGRAMS: Showed no clear epileptiform
discharges.
SEIZURE DETECTION PROGRAMS: There were no entries in these
files.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: No normal waking or sleeping patterns were evident.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry showed an encephalopathic background
throughout. There was no significant discontinuity, and there
were no
epileptiform features. The pattern remained fairly invariant
from
beginning to end. There were no prominent focal abnormalities.
[**2144-2-1**] MRI Brain: Subcortical white matter hyperintensities on
FLAIR, likely reflect chronic small vessel ischemia. Opacified
right sphenoid sinus, likely inspissated mucus. Otherwise,
normal study.
[**2144-2-4**] RUE NI: 1. Non-occlusive thrombus in the right
subclavian vein, new compared to the prior study. 2. Thrombosis
of the right basilic, cephalic vein and axillary vein.
Brief Hospital Course:
62 yo man with h/o DM2 on glimiperide at home and recent back
surgery who presented to the OSH on [**2144-1-22**] with hypoglycemic
coma and is now transferred to [**Hospital1 18**] for further evaluation of
persistent unresponsiveness.
.
#. Coma: The patient has been unresponsive since he was found by
his wife on [**2144-1-22**], and his neuro exam is consistent with
minimal brainstem reflexes. EEG at the OSH was suggestive of
severe cerebral dysfunction. He was found to be hypoglycemic on
presentation. The differential for his coma included anoxic
brain injury vs. hypoglycemic coma. He underwent work up
including a negative CT scan and an inconclusive MRI and EEG
under the recommendations of neurology. No definitive
explanation for his coma was determined, but it was felt that
given the lack of cortical activity and the length of time of
his unresponsiveness his overall prognosis was poor and chance
for recovery virtually zero. A family meeting was held with the
ICU and neurology teams to discuss these findings and the family
decided to make the patient comfort measures only, extubate, and
put [**Last Name (un) **] on a morphine drip. He was transferred to the floor for
continued comfort focused care and expired shortly after
transfer.
.
#. Respiratory failure: The patient was intubated on arrival to
the ED on [**2144-1-22**] for AMS and failure to protect his airway. He
had no gag and a poor cough on physical exam throughout his
hospitalization. He remained intubated on CPAP despite passing
several SBTs as it was felt that he would be unable to protect
his airway. As goals of care transitioned to comfort measures
only he was extubated on [**2-5**] and placed on a morphine drip.
.
#. Ventilator Associated PNA: Mr. [**Known lastname 88148**] was found to have
bilateral opacities on CXR at OSH and his sputum grew Serratia.
He was started on Cefepime and Vancomycin at the OSH, but it is
uncertain as to when exactly this was started. He was continued
on these antibiotics until goals of care were transitioned to
CMO.
.
#. DM2: The patient has a history of DM2, for which he was
taking glimiperide at home. His FSBG were monitored and remained
within normal limits.
.
#. CKI: Mr. [**Known lastname 88148**] had a history of CKI with unknown baseline
creatinine. His creatinine on admission is 1.8. This remained
stable throughout his hospitalization.
Medications on Admission:
Buproprion XL 300 mg PO daily
Diazepam 5 mg PO q6h
Diclofenac sodium 1% one gtt OS 6x/day
Diltiazem 240 mg PO daily
Doxycycline 100 mg PO daily
Lasix 40 mg PO daily
Glimepiride 2 mg PO daily
Hydralazine 25 mg PO daily
Lorazepam 0.5 mg PO daily
Pravastatin 40 mg PO qhs
Prednisolone acetate 1 gtt OD qid
Timolol maleate 0.5% one gtt OU TID
Valsartan 320 mg PO daily
MEDICATIONS ON TRANSFER:
Pantoprazole 40 mg IV daily
Lorazepam 0.5 mg IV q6h prn for EtOH withdrawal
Cefepime q8h
Vancomycin 1000 mg
HISS
ASA 81 mg daily
Colace 100 mg PO daily
Heparin SC
Metoprolol Tartrate 50 mg PO q6h
Banana bag daily IV
NTG 10 mg patch daily
Chlorhexidine gluconate
Albuterol HFA 60 HFA q6h prn
Prednisolone 1% gtts 4x/day to right eye
Timolol 0.5% one gtt TID to both eyes
Diclofenac 0.1% gtt q4h to left eye
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypoglycemia
Severe Cerebral Dysfunction
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"291.81",
"585.9",
"V49.86",
"305.40",
"996.74",
"518.81",
"250.00",
"530.81",
"041.85",
"453.81",
"272.4",
"362.10",
"349.82",
"997.31",
"780.01",
"V66.7",
"251.2",
"V45.4",
"305.1",
"403.90",
"305.50",
"303.90",
"V43.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"89.19",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9932, 9941
|
6671, 9055
|
300, 310
|
10026, 10036
|
3199, 3199
|
10092, 10239
|
2388, 2406
|
9902, 9909
|
9962, 10005
|
9081, 9446
|
10060, 10069
|
2421, 2421
|
2057, 2114
|
239, 262
|
338, 2038
|
4726, 6648
|
3215, 4717
|
2435, 3180
|
9471, 9879
|
2136, 2256
|
2272, 2372
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,663
| 177,236
|
13130
|
Discharge summary
|
report
|
Admission Date: [**2131-7-6**] Discharge Date: [**2131-7-14**]
Date of Birth: [**2058-7-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
coronary aretery bypass grafts x 4
(LIMA-LAD,SVG-dg,SVG-OM,SVG-PDA) [**2131-7-6**]
History of Present Illness:
This 72 year old white male with known coronary artery disease
has had recurrent palplitations and dyspnea. A stress test was
positive and a cardiac csatheterization reveled triple vessel
disease. He was referred for revascularization for which he is
now admitted.
Past Medical History:
hypertension
fatty liver
noninsulin dependent diabetes mellitus
paroxysmal atrial fibrillation
s/p appendectomy
Social History:
dental exam within 6 months
lives with his wife. 50-100 pk year history prior to 16 years
ago
rare ETOH use
parttime truck driver,retired fireman
Family History:
father and brother with coronary disease in 50s
Physical Exam:
Pulse: 73 sr Resp: 16 O2 sat: 98% RA
B/P Right: 195/94 Left: 184/97
Height: 66" Weight: 155
General: WDWN in NAD
Skin: Warm, dry and intact
HEENT: NCAT, PERRL, EOMI, sclera anicteric, OP benign. Teeth in
good repair.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, I/VI Systolic ejection murmurbest heard at
right sternal border.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit Right: + Bruit Left: None
Pertinent Results:
[**2131-7-10**] 01:00AM BLOOD WBC-5.4 RBC-3.05* Hgb-9.2* Hct-26.5*
MCV-87 MCH-30.0 MCHC-34.6 RDW-14.5 Plt Ct-209
[**2131-7-10**] 01:00AM BLOOD Glucose-146* UreaN-13 Creat-0.7 Na-135
K-3.8 Cl-101 HCO3-27 AnGap-11
[**2131-7-6**] 12:27PM BLOOD UreaN-13 Creat-0.7 Cl-109* HCO3-23
[**2131-7-11**] 05:05AM BLOOD WBC-5.6 RBC-3.58* Hgb-10.4* Hct-30.9*
MCV-87 MCH-29.2 MCHC-33.7 RDW-14.8 Plt Ct-300
[**2131-7-12**] 09:10AM BLOOD PT-17.1* PTT-51.4* INR(PT)-1.5*
[**2131-7-11**] 05:05AM BLOOD Glucose-157* UreaN-12 Creat-0.7 Na-135
K-3.8 Cl-100 HCO3-24 AnGap-15
[**2131-7-13**] 04:50AM BLOOD PT-24.5* PTT-54.3* INR(PT)-2.3*
[**2131-7-12**] 06:00PM BLOOD PTT-65.7*
[**2131-7-12**] 09:10AM BLOOD PT-17.1* PTT-51.4* INR(PT)-1.5*
[**2131-7-13**] 04:50AM BLOOD UreaN-14 Creat-0.9 Na-137 K-3.9 Cl-103
[**2131-7-8**]
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W&W/O
CONTRAST Clip # [**Clip Number (Radiology) 40079**]
Reason: evaluate for R MCA stroke
1. Multiple punctate acute infarcts bihemispherically in
watershed
distribution, many more on the right than on the left.
2. High-grade proximal right internal carotid artery stenosis.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the aortic arch.
There are complex (>4mm) atheroma in the descending thoracic
aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
pericardial effusion.
POST_BYPASS:
Biventricular normal systolic function. LVEF 55%. Trivial MR.
Mild AI.
Intact thoracic aorta.
Brief Hospital Course:
On [**2131-7-6**] Mr.[**Known lastname 40080**] was taken to the Operating Room and
underwent coronary artery revascularization x 4 (left internal
mammary artery grafted to the left anterior descending
artery/Saphenous vein grafted to the Diag/Obtuse
Marginal/Posterior descending artery). Please refer to
Dr[**Last Name (STitle) **] operative report for further details. The patient
tolerated the procedure well and was weaned from bypass on Neo
Synephrine and Propofol in sinus rhythm. He was transferred to
the CVICU for further invasive monitoring. He awoke
neurologically intact, weaned from his drips and was extubated
without incident postoperative night. CTs were removed per
protocol and subsequently temporary pacing wires. Beta
blockers/Statin/aspirin and diuresis were initiated. POD 3 he
was transferred to the floor for further monitoring. Physical
Therapy was consulted to evaluate his strength and mobility.
On POD 2 he was noted to have mild weakness on the left hand and
arm and left neglect with visual field cut. A neurology consult
was obtained and a head CT suggested a right lucunar infarct of
indeterminate age. A MRA demonstrated multiple watershed
punctate infarcts, more so on the right than left.
Mr.[**Known lastname 40080**] was transferred back to the CVICU for closer
monitoring and CVA evolution. Physical therapy continued to work
with him and by POD6 he had only minor residual weakness of the
left arm.
Vascular surgery saw him and anticoagulation was begun with ASA,
Plavix and a Heparin infusion, followed by Coumadin. He will be
followed after discharge and the 90% right carotid stenosis
addressed after recovery from his cardiac surgery.
He went into rapid atrial fibrillation on post operative day 6
and converted to sinus rhythm with 20 mg IV Lopressor.
Lopressor was titrated up and he remained in sinus rhythm for
the remainder of his hospital course.
Arrangements were made for Coumadin follow up with Dr. [**First Name (STitle) 3646**].
His target INR is 2-2.5. First draw to be done by VNA [**7-15**] with
results called to [**Telephone/Fax (1) 40081**]. POD# 8 he was cleared by Dr.
[**Last Name (STitle) 914**] (Dr.[**Name (NI) 5572**] colleague) for discharge to home with
VNA/OT. All follow up appointments and precautions were advised.
Medications on Admission:
Atnelolo 50mg daily
ASA25mg daily
vitamin
Glyburide 5mg AM/2.5 mg in PM
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day: one
tablet in AM(5mg), [**2-3**] tablet in PM(2.5mg).
Disp:*60 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
8. Amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): two tablets twice a day for two weeks, then one
tablet twice daily for two weeks, then one tablet daily.
Disp:*100 Tablet(s)* Refills:*2*
9. Outpatient [**Name (NI) **] Work
PT/INR on 6/***, then prn. Call results to ****
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: INR goal of [**3-6**].5 for atrial fibrillation. Coumadin
will be dosed by Dr. [**First Name (STitle) 3646**] .
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts x4
paroxysmal atrial fibrillation
cerebrovascular disease
s/p right hemispheric stroke
hypertension
s/p appendectomy
fatty liver
noninsulin dependent diabetes mellitus
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/Left - healing well, no erythema or drainage. Edema:none
Discharge Instructions:
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.
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**]).
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on Thurs., [**8-9**] at 1:30pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12816**] ([**Telephone/Fax (1) 12817**]) in [**2-3**]
weeks
Cardiologist: Dr. [**First Name (STitle) 3646**] in [**2-3**] weeks [**Telephone/Fax (1) 21903**]
Vascular :[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], call in [**4-5**] weeks
Neurology: Dr.[**Last Name (STitle) **], call in [**4-5**] weeks
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Labs: PT/INR for Coumadin ?????? indication: s/p Multiple punctate
acute infarcts bihemispherically in watershed distribution, many
more on the right than on the left. 90% right carotid stenosis.
Goal INR: 2-2.5
First draw: [**2131-7-15**]
Results to: Dr. [**First Name (STitle) 3646**]
phone: [**Telephone/Fax (1) 40081**]
Completed by:[**2131-7-14**]
|
[
"997.02",
"401.9",
"427.31",
"E878.2",
"413.9",
"250.00",
"433.11",
"414.01",
"729.89",
"571.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7692, 7767
|
3777, 6077
|
311, 396
|
8037, 8270
|
1842, 3754
|
9023, 10180
|
1006, 1055
|
6199, 7669
|
7788, 8016
|
6103, 6176
|
8294, 9000
|
1070, 1823
|
251, 273
|
424, 692
|
714, 827
|
843, 990
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,118
| 146,001
|
54488+54489
|
Discharge summary
|
report+report
|
Admission Date: Discharge Date:
Date of Birth: Sex: F
Service: Gold Surgery
HISTORY OF PRESENT ILLNESS:
Patient is a 40-year-old female with a history of Crohn's
disease and status post ileostomy and status post colectomy
two years ago. Patient had intrauterine implantation
following five days of Lupron and Follistim admitted for
nausea, vomiting, abdominal pain on [**2194-10-7**].
The patient was on follicle stim and two cycles OCPs Lupron
and Follistim, Repronex since [**2194-7-9**] and patient
presented with nausea, vomiting, and abdominal pain.
PAST MEDICAL HISTORY:
Crohn's disease status post colectomy two years ago, status
post fissurectomy in [**2180**] and [**2184**], and her disease has been
inactive since nine years ago and she has been off
medications.
HOME MEDICATIONS:
Progesterone, suppository, and Lupron.
HOSPITAL COURSE:
The patient had a somewhat complicated hospital course on
[**10-9**]. The patient had CT scan which showed a small
bowel obstruction and her stomal hernia from the ileostomy
site on [**10-10**], patient underwent exploratory
laparotomy and lysis of adhesion and takedown of peristomal
hernia.
Postoperatively the patient was transferred to the Intensive
Care Unit and while in the Intensive Care Unit, patient
developed a pulmonary embolus at the site of embolus that was
treated by Interventional Radiology and IVC filter was placed
by Interventional Radiology at the time.
On [**10-20**], patient remained in the Intensive Care Unit
and was close monitoring status on [**10-20**]. The
patient was taken back to the operating room and underwent
closure of the incision and for parastomal hernia. Meanwhile
the patient was started on TPN, and was on triple antibiotics
for a low-grade fever. ID was consulted. Patient was
intubated for a long period of time.
The patient was eventually trached due to her status
requiring long-time ventilatory support.
On [**2194-11-4**] the patient developed onset of upper
gastrointestinal bleeding. GI was consulted and EGD was done
which showed a non-bleeding ulcer in the gastroesophageal
junction and blood in the stomach, ulcer in the fundus,
stomach body, and antrum, and erosion of the antrum, and
friable erythema in conjunction of the antrum stomach body
compatible with gastritis.
Postoperatively the patient developed an enterocutaneous
fistula that was protruding out from the portion of the
abdominal incision. The fistulogram was performed on
[**2194-11-13**] and showed high fistula and fistula was
considered a high-output fistula because it put out more than
500 cc/day. The patient remained in the Intensive Care Unit.
However, patient's condition improved over the next several
days on [**2194-11-13**]. The patient's condition was
improved efficient enough that the patient was extubated and
ventilatory support was withdrawn. CPAP was drawn from the
trache and the trache was capped. The patient tolerated it
well and the trache was decannulated.
Subsequently the patient was transferred onto the floor and
her status was stable, and the patient has remained afebrile
for a long time. Her antibiotics were discharged except for
fluconazole per ID recommendation. Patient still remained
NPO and continued on TPN.
So on [**11-17**] the patient was deemed to be stable
enough to be transferred to the floor. While on the floor
the patient was afebrile and vital signs stable. Patient was
deemed ready for rehab.
Prior to discharge, patient was afebrile. Vital signs
stable. Chest was clear to auscultation and abdomen was
soft, nontender, and nondistended. Ileostomy site was clean.
Mucosa was pink and viable, and it is putting out. Patient
has a midline incision that was packed with wet-to-dry
dressing. A sump drain was placed in the enterocutaneous
fistula that continued putting out and connected to a
suction, and patient has an ostomy bag over the incision
catching the drainage that was putting out.
DISCHARGE MEDICATIONS:
Continue TPN, NPO, Protonix 40 mg IV q 12 hour, sliding scale
regular insulin, and Epogen 40,000 units subQ q week,
fluconazole 200 mg IV q day, and albuterol two puffs q four
hours prn, and Morphine 2-4 mg IV q 4-6 hours prn.
DISCHARGE INSTRUCTIONS:
Patient is told to followup with Dr. [**Last Name (STitle) **] in two weeks and
patient is to get some drain care and have daily recording of
the total fistula output at midline, and the patient is to
get wet-to-dry dressing change to the abdominal wound midline
[**Hospital1 **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2194-11-19**] 11:07
T: [**2194-11-19**] 11:15
JOB#: [**Job Number **]
Admission Date: Discharge Date: [**2194-11-27**]
Date of Birth: Sex: F
Service: GOLD SURGERY
ADDENDUM: The patient's history of present illness, hospital
course and discharge instructions per previous dictation.
The [**Hospital 228**] hospital course remained unchanged since last
dictation on [**11-19**]. The patient was stable, afebrile and
vital signs stable on TPN. Since the last dictation her
condition has been unchanged and was undergoing abdominal
dressing changes to her abdominal wound b.i.d. and recording
her sump drain output daily. The Fluconazole has been
discontinued since last dictation, because the culture has
been negative for any fungal. Additionally we would like the
nursing home to record the sump drain output from her fistula
track daily and while she is following up with Dr. [**Last Name (STitle) **]
in two weeks to please bring the summary of her sump drain
output.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2194-11-27**] 11:59
T: [**2194-11-27**] 12:30
JOB#: [**Job Number 111500**]
|
[
"459.0",
"041.86",
"552.29",
"415.11",
"569.81",
"996.62",
"569.69",
"256.1",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.43",
"46.42",
"42.23",
"88.72",
"31.1",
"96.72",
"38.7",
"38.15",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
4011, 4239
|
895, 3988
|
4263, 6021
|
838, 878
|
146, 600
|
622, 820
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,671
| 101,208
|
1202
|
Discharge summary
|
report
|
Admission Date: [**2141-7-19**] Discharge Date: [**2141-7-31**]
Date of Birth: [**2082-3-4**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / Fentanyl / Nickel
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
Diarrhea, tenesmus, abdominal bloating.
Major Surgical or Invasive Procedure:
Exploratory laparotomy, supracervical hysterectomy with
bilateral salpingo-oophorectomy, omentectomy, sigmoid resection
with rectal anastamosis, repair of cystotomy and tumor
debulking.
History of Present Illness:
The patient is a 59-year-old G2, P2 who presented with a
several-week history of diarrhea, tenesmus, and abdominal
bloating. She had a CT of the abdomen and pelvis on [**2141-7-4**]
at [**Hospital1 18**], which revealed a small amount of ascites. There was
para-aortic lymphadenopathy measuring up to 12 mm. The left
adnexum had a 5.6-cm mass. There was an additional 9-mm
enhancing peritoneal implant in left pericolic gutter. Other
peritoneal implants could not be excluded. A CA-125 was noted
to be elevated at 1587. The patient otherwise feels well. She
is
tolerating a regular diet. She denied any urinary complaints.
She has had no vaginal bleeding. Her weight has been stable.
She had a colonoscopy several years ago which was normal per her
report. She denied any rectal bleeding.
Past Medical History:
Significant for adenoid cystic carcinoma of the right jaw,
status post maxillectomy and radiation therapy in [**2137**]. She has
been disease free since then. She is followed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 7610**] at [**Hospital6 1708**]. She reports that she
had a chest CT several months ago which revealed a question of
an enlarged lymph nodes and was to have followup for this.
Also, history of NSAID nephropathy, postoperative atrial
fibrillation following maxillectomy, squamous cell carcinoma of
the face status nose surgery.
PAST SURGICAL HISTORY: As above.
ALLERGIES TO MEDICATIONS: Penicillin and fentanyl.
CURRENT MEDICATIONS: Evoxac, Tylenol, oral rinse, and vitamins.
OB HISTORY: Vaginal delivery x2.
[**Hospital6 **] HISTORY: Last Pap smear was recently normal. Last
mammogram
was recently abnormal but followup was recommended.
SOCIAL HISTORY: The patient neither smokes nor drinks.
FAMILY HISTORY: Significant for a maternal aunt who had breast
cancer in her 70s, another maternal aunt with esophageal cancer,
and paternal relatives with lung cancer.
Physical Exam:
GENERAL: Well developed and thin.
HEENT: Sclerae were anicteric. There were postoperative and
post-radiation changes on the right side of the face.
LYMPHATICS: Lymph node survey was negative.
LUNGS: Clear to auscultation.
HEART: Regular without murmurs.
BREASTS: Without masses.
ABDOMEN: Soft and moderately distended and without palpable
masses.
EXTREMITIES: Without edema.
PELVIC: The vulva and vagina were normal. The cervix was
normal to palpation. Bimanual and rectovaginal examination
revealed a large firm mass in the cul-de-sac which was somewhat
immobile. There was a question of cul-de-sac nodularity. The
rectal was intrinsically normal.
Pertinent Results:
[**2141-7-19**] 08:35PM BLOOD WBC-11.5* RBC-3.28* Hgb-10.1* Hct-30.7*
MCV-94 MCH-31.0 MCHC-33.0 RDW-13.2 Plt Ct-498*
[**2141-7-19**] 08:35PM BLOOD Glucose-150* UreaN-12 Creat-0.6 Na-139
K-4.1 Cl-105 HCO3-25 AnGap-13
[**2141-7-19**] 08:35PM BLOOD Calcium-8.2* Phos-3.9 Mg-1.5*
.
[**2141-7-19**] Surgical pathology:
1. Uterus, right fallopian tube and ovary, hysterectomy and
salpingo-oophorectomy (A-H):
A. Carcinoma in myometrium and para-metrial soft tissue,
present at inked parametrial soft tissue margin.
B. Carcinoma in paratubal soft tissue.
C. Unremarkable endometrium.
D. Unremarkable ovary and fallopian tube.
2. Ovary and fallopian tube, left, salpingo-oophorectomy (I-N):
A. Papillary serous carcinoma, ovary.
B. Unremarkable fallopian tube.
3. Cul de sac tumor, biopsy (O):
Carcinoma in fibrous tissue.
4. Lymph nodes, peri-aortic, biopsy (P-S):
Metastatic carcinoma in three lymph nodes ([**2-18**]).
5. Omentum, excision (T):
Carcinoma in adipose tissue.
6. Cecum, tumor, biopsy (U):
Carcinoma in fibrous tissue.
7. Rectosigmoid colon, resection (V-AA):
A. Carcinoma in bowel mesentery.
B. Blood vessels with lymphoplasmacytic and granulomatous
"vasculitis". SEE NOTE.
8. Lymph node, peri-aortic, biopsy (AB-AG):
Metastatic carcinoma in seven lymph nodes ([**6-24**]).
Extra-nodal extension of tumor is present.
9. Rectum, proximal donut, excision (AH):
A. Blood vessels with lymphoplasmacytic and granulomatous
"vasculitis". SEE NOTE.
B. No malignancy identified.
10. Rectum, distal donut, excision (AI):
A. Blood vessels with lymphoplasmacytic and granulomatous
"vasculitis" and vascular thrombus. SEE NOTE.
B. No malignancy identified.
11. Lymph node, left gutter, biopsy(AJ):
Metastatic carcinoma in one lymph node ([**12-19**]).
.
[**2141-7-21**] Echo: The left ventricular cavity is small. Left
ventricular systolic function is hyperdynamic (EF 70-80%). There
is severe focal
hypokinesis/dyskinesis of the apical half free wall of the right
ventricle. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
trivial mitral regurgitation. mild pulmonary artery systolic
hypertension.
.
[**2141-7-25**] Echo: Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%) The
right ventricular cavity is dilated. There is focal hypokinesis
of the apical free wall of the right ventricle. Right
ventricular systolic function appears depressed. The aortic
valve leaflets (3) are mildly thickened. mild pulmonary artery
systolic hypertension. Compared with the findings of the prior
study (images reviewed) of [**2141-7-21**], overall rtight
ventricular contractile function appears somewhat improved.
Brief Hospital Course:
Ms. [**Known lastname 7611**] was admitted after undergoing an exploratory
laparotomy, supracervical hysterectomy with bilateral
salpingo-oophorectomy, omentectomy, sigmoid resection with
rectal anastomosis, repair of cystotomy and tumor debulking for
a pelvic mass previously visualized on CT. Prior to her surgery,
an epidural was placed by anesthesia for post-operative pain
management. Her post-operative course was complicated by
hypotension, right ventricular hypokinesis, NSTEMI, a-fib,
anemia and oxygen desaturation. She was admitted to the ICU on
post-op day four for management of post-operative a-fib.
# Hypotension: On post op day one and two, the patient was
hypotensive to the 80s/40s. There was no evidence of acute
blood loss as her HCT remained stable post-operatively. Her
urine output was adequate. An epidural was in place for pain
control. Her SBP was maintained > 90 with aggressive fluid
management. The ddx for her hypotension included epidural
induced sympathectomy versus myocardial ischemia. Her EKG was
unchanged. When the hypotension did not resolve after capping
the epidural an Echocardiogram performed which showed focal
right ventricular hypokinesis. She had a positive troponin
which peaked at 0.2 on post-op day two.
# Elevated cardiac enzymes: No known h/o CAD prior to this
hospitalization. Troponin bumped to max of 0.20, then trended
down slightly to 0.06. MBI negative x3. CEs sent initially in
the setting of hypotension and finding on TTE of RV free wall
hypokinesis. Reportedly this was prior to a. fib w/ RVR so
troponin leak appears to predate the rapid a. fib. Picture is
suggestive of perioperative NSTEMI per cardiology.
Differential, however, includes ischemia vs. less likely
myocarditis as cause of elevated troponin. EKG when in NSR in
the setting of hypotension did not reveal evidence of ischemia,
but w/ atrial fibrillation now has new TWI in I, aVL which may
represent demand ischemia in LCx distribution. A statin, BB, and
ASA were started for risk factor modification per cardiology.
# Right ventricular hypokinesis: Severe free wall motion
hypokinesis on echocardiogram likely represents small RV NSTEMI.
CEs elevated, but plateaued prior to a. fib w/ RVR. The patient
was initially hypotensive requiring IVF boluses and 2u RBC, but
remained hemodynamically stable for the remainder of her ICU
course. Repeat TTE [**2141-7-25**] showed somewhat improved RV
contractile function.
# Atrial fibrillation: Pt. reportedly has h/o post op a. fib
after her surgery in [**2137**] which responded well to Lopressor and
was self limited. She denies any further episodes since. Rate
responded poorly to IV and PO metoprolol on the floor, but
improved control after second dose of diltiazem (15mg IV on the
floor, 20mg IV in the ICU), approximately 100 down from 140s on
transfer with rate ~110s-120s on diltiazem 5mg/hr gtt. She was
loaded with amiodarone on [**7-23**] and cardioverted to NSR on [**7-24**] at
noon. At this point the diltiazem drip was discontinued and she
was started on PO lopressor. Remains in NSR with HR 70s - 80s.
She was started on Lovenox for thromboembolic prophylaxis. An
attempt to transition her to Coumadin was abandoned after her
INR was noted to be 4.7 after three days of Coumadin at 5mg qd.
She was given vitamin K, her HCT was monitored serially, and
there was no evidence of acute bleeding as her INR returned to
baseline. Bridging to Coumadin may be re-attempted as an
outpatient once her nutritional status improves.
# Hypoxia: Mid 90s on 2L NC. CXR does show evidence of b/l
pleural effusions and possible LLL opacity vs. atelectasis, o/w
without significant pulmonary edema. No evidence of left
ventricular wall motion abnormalities nor depressed EF to
suggest significant risk for pulmonary edema, but has been
receiving fluids for BP maintenance given RV wall motion
abnormalities and mild bibasilar crackles were heard on exam .
Likely hypoxia is secondary to fluid overload and dependent
atelectasis. Responded well to 20mg IV Lasix during ICU course
with good response (neg. 1700cc) which resulted in improved
pulmonary function and oxygenation at 99% on 2L. Pt ruled out
for PE on CTA.
# Leukocytosis: WBC was max 17.0 without left shift with pt
afebrile. She denies cough, UA did show occ. bacteria, neg.
nitrites, small amount of leuk. esterase, lg. blood. Treated
with 3 days of Cipro for presumed UTI, however urine cx showed
no growth. No diarrhea. At the time of discharge she was
afebrile and her WBC had trended downward to 10.7.
# Anemia: Previously normal baseline, but most recently 30-33
in early [**Month (only) 205**]. Postoperatively hct has been 24-27, without
evidence of bleeding. up 34.0 [**2141-7-24**] s/p 2u PRBCs then dropped
to 27.3 [**7-25**]. Stabilized around 30.4.
# Proph: Lovenox
Pt was transferred out of the ICU on POD8 and did well on the
floor, maintaining her O2 sats well on room air, ambulating, and
tolerating a regular diet. She was discharge on post-op day
twelve in stable condition. She has follow up with her PCP, [**Name10 (NameIs) **]
Oncology and Cardiology.
Medications on Admission:
Evoxac
Tylenol
Oral rinse
Vitamins
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day).
Disp:*30 syringe* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
Pelvic mass
Discharge Condition:
Stable
Discharge Instructions:
You may resume your regular diet. Please resume your regular
home medications. Please do not lift anything heavier than 10
pounds for 6 weeks. No intercourse for 4 weeks.
You may shower, but not tub baths or swimming for 6 weeks.
Please call Dr. [**First Name (STitle) 1022**] if you have increasing pain, fever, chills,
nausea, vomiting, shortness of breath or chest pain.
Followup Instructions:
Provider: [**Name10 (NameIs) **], [**Name11 (NameIs) **]. Phone: [**Telephone/Fax (1) 7612**]. Date/Time:
[**2141-8-4**] 11:30 (Cardiology [**Hospital **] Clinic)
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) 3947**]. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2141-8-7**] 10:00 (Cardiology)
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 7614**] Date/Time:[**2141-8-31**]
1:30
Completed by:[**2141-8-3**]
|
[
"196.2",
"V10.81",
"998.2",
"518.0",
"198.82",
"458.8",
"428.0",
"997.1",
"410.71",
"E878.6",
"427.31",
"197.6",
"183.0",
"511.9",
"197.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.4",
"48.63",
"68.39",
"57.81",
"38.93",
"65.61",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
11660, 11727
|
6047, 7322
|
344, 532
|
11783, 11792
|
3206, 6024
|
12216, 12765
|
2353, 2508
|
11274, 11637
|
11748, 11762
|
11215, 11251
|
11816, 12193
|
1982, 2046
|
2523, 3187
|
7340, 11189
|
265, 306
|
2068, 2279
|
560, 1361
|
1383, 1958
|
2296, 2336
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,021
| 157,169
|
5287
|
Discharge summary
|
report
|
Admission Date: [**2135-10-23**] Discharge Date: [**2135-11-4**]
Date of Birth: [**2084-5-12**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
IVIG infusion for five days, PICC placement
History of Present Illness:
Mr. [**Known lastname **] is a 51M with stiff person syndrome, DVT in [**10-3**]
on coumadin, recent PEG tube placement, who presented from a
rehabilitation facility with fever. The patient was discharged
to the rehab facility on [**2135-10-7**] and was doing well until he
developed fevers, chills, nausea and vomiting acutely. He had
two episodes of emesis prior to arrival at the [**Hospital1 **] ED and had a
fever to 105F.
.
In the ED, he was febrile to 102.8 (rectal temp), BP ranged from
79-97/40-60, HR 69-95 with an oxygen saturation of 99% on 2L NC.
He recieved 5L normal saline, vancomycin 1gm IV, Zosyn 4.5 gm,
Azithromycin 500mg, Valium 20mg, Morphine 2mg IV. Ultrasound of
the lower extremity in the ED showed resolving DVT.
.
In the MICU, urine, blood, sputum cultures were obtained, as
well as a chest x-ray (CXR). CXR revealed RML/RLL PNA. The
patient had a RML PNA during his last hospital admission in
[**9-2**], and was treated with a 10-day course of levofloxacin.
Patient was started on Vanc/Zosyn to cover for hospital acquired
PNA. The UA was negative for infection.
Past Medical History:
-Stiffperson syndrome history, per OMR notes: He has had this
diagnosis for ~15 years and symptoms for ~25 years. His workup
has included MRI (last in [**2125**]), EEG ([**2125**]), EMG ([**2125**]), nerve
biopsy, muscle biopsy, sleep study, metabolic studies,
mitochondrial evaluation and anti Gad antibodies (done
elsewhere), all of which apparently were unrevealing. He has
tried multiple medications including Diamox, Imuran, gabapentin,
lidocaine, baclofen pump, dopamine, Sinemet, prednisone,
Mirapex,
mexiletine, Demerol, hydromorphone, Fentanyl, and morphine pump.
He has also been treated with multiple rounds of plasmapheresis.
He has also undergone IVIg multiple times. He received 6 cycles
of Rituxan from [**Date range (1) 21561**], which unfortunately were not
effective. Had IVIG with admissions in [**2134-3-25**] and
[**2135-2-25**]. He developed leukopenia with the treatment of
IVIg in [**2134-3-25**]. In [**2135-2-25**], he was here for eight
days
receiving a course of IVIG; the condition responded to treatment
and he was subsequently near his baseline on a [**Month (only) 958**] visit with
Dr. [**Last Name (STitle) **].
-Deep vein thrombosis (~20 yrs ago) s/p IVC filter placement
-Urinary tract infections
-History of indwelling line infections
-Cerebral palsy with spastic hemiparesis of left face, arm, leg
-Intermittent lower extremity edema
-Prior GI bleed with EGD demonstrating esophagitis.
Social History:
He lives alone at home, and uses an electric wheelchair to get
around. He
has not walked for 9 years. He has a housekeeper who comes
1x/week, and a nurse who comes 1x/month. He cooks his own food,
showers and dresses himself, and transfers himself. He is on
disability. He denies alcohol, tobacco, or drug use.
Family History:
No neurologic disease
Physical Exam:
Vitals: T: 98.1, BP 110/60, HR 70, RR 18 96% on RA
Gen: appears stated age, unable to move neck
HEENT: PERRL, EOMI, Clear OP, MMM
NECK: Supple, No LAD, No JVD, unable to move
CV: RRR. nl S1, S2. No murmurs, rubs or gallops
LUNGS: CTAL
ABD: normoactive bowel sounds, NT/ND. No HSM
EXT: No edema
NEURO: diminished ROM in neck, symmetric ROM in UE, with
diminished strength, strength and sensation symmetric b/l
Pertinent Results:
ADMISSION LABS
[**2135-10-23**] 08:00AM BLOOD WBC-12.5*# RBC-3.13* Hgb-10.1* Hct-29.1*
MCV-93 MCH-32.2* MCHC-34.5 RDW-14.2 Plt Ct-212
[**2135-10-23**] 08:00AM BLOOD Neuts-93.5* Lymphs-3.9* Monos-2.1 Eos-0.3
Baso-0.1
[**2135-10-23**] 08:00AM BLOOD Plt Ct-212
[**2135-10-23**] 04:45PM BLOOD PT-24.3* PTT-48.3* INR(PT)-2.4*
[**2135-10-23**] 08:00AM BLOOD Glucose-110* UreaN-25* Creat-0.7 Na-137
K-4.2 Cl-97 HCO3-33* AnGap-11
[**2135-10-23**] 04:45PM BLOOD ALT-19 AST-16 AlkPhos-68
[**2135-10-23**] 04:45PM BLOOD TotProt-5.9* Albumin-3.1* Globuln-2.8
Calcium-8.3* Phos-4.0 Mg-1.8
[**2135-10-23**] 04:45PM BLOOD Cortsol-11.3
[**2135-10-23**] 08:09AM BLOOD Lactate-1.4
[**2135-10-23**] 02:07PM BLOOD Lactate-1.5
[**2135-10-23**] 10:30PM BLOOD O2 Sat-80
[**2135-10-23**] 08:15AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2135-10-23**] 08:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2135-10-23**] 8:00 am BLOOD CULTURE
**FINAL REPORT [**2135-10-29**]**
Blood Culture, Routine (Final [**2135-10-29**]): NO GROWTH.
[**2135-10-23**] 8:15 am Urine
**FINAL REPORT [**2135-10-24**]**
URINE CULTURE (Final [**2135-10-24**]): NO GROWTH.
[**2135-11-1**] 2:55 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2135-11-3**]**
FECAL CULTURE (Final [**2135-11-3**]):
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final [**2135-11-3**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2135-11-2**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
.
DISCHARGE LABS
[**2135-11-4**] 06:12AM BLOOD WBC-2.9* RBC-3.02* Hgb-9.8* Hct-26.9*
MCV-89 MCH-32.5* MCHC-36.5* RDW-14.4 Plt Ct-221
[**2135-11-2**] 06:06AM BLOOD Neuts-35* Bands-5 Lymphs-41 Monos-9
Eos-10* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2135-10-31**] 04:55AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2135-11-4**] 06:12AM BLOOD Plt Ct-221
[**2135-11-4**] 06:12AM BLOOD Glucose-77 UreaN-28* Creat-0.7 Na-137
K-4.5 Cl-98 HCO3-34* AnGap-10
[**2135-11-3**] 05:41AM BLOOD LD(LDH)-121 TotBili-0.2
[**2135-11-4**] 06:12AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.8
.
.
CHEST (PORTABLE AP) Study Date of [**2135-10-23**] 8:50 AM
FINDINGS: The cardiomediastinal silhouette is stable. Left
subclavian venous catheter ends at the low superior vena cava,
as before. An IVC filter is in place.
There is a subtle area of lung consolidation with air
bronchograms projecting over the cardiophrenic angle, consistent
with early pneumonia. There is no pulmonary edema, pleural
effusion or pneumothorax.
IMPRESSION: Findings consistent with early right basal
pneumonia.
.
.
[**Numeric Identifier **] PICC W/O PORT Study Date of [**2135-10-28**] 1:57 PM
TECHNIQUE: Using sterile technique and local anesthesia, the
right cephalic
vein was punctured under direct ultrasound guidance using a
micropuncture set. Hard copies of the ultrasound images were
obtained before and immediately after establishing intravenous
access. A peel-away sheath was then placed over the guidewire
and a double-lumen PICC line measuring 27 cm in length was then
placed through the peel-away sheath with its tip positioned in
the SVC under fluoroscopic guidance. The position of the
catheter was confirmed by a fluoroscopic spot film of the chest.
The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile
dressing applied. The patient tolerated the procedure well.
There were no immediate complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
double-lumen PICC line placement via the right cephalic venous
approach. Final internal length is 27 cm with the tip positioned
in the SVC. The line is ready to use.
.
.
CHEST (PORTABLE AP) Study Date of [**2135-10-30**] 4:54 PM
FINDINGS: As compared to the previous radiograph, the jugular
left-sided
central venous access has been removed, unchanged is the
left-sided subclavian venous access. Newly inserted is a PICC
line over the right subclavian vein, the tip of the line
projects over the mid SVC. There is no evidence of pneumothorax
or other complications. The retrocardiac atelectasis has
resolved in the interval. The transparency of the right lung
base has increased. No evidence of newly occurred focal
parenchymal opacity suggestive of pneumonia.
Brief Hospital Course:
Mr. [**Known lastname **] is a 51 year old man with stiff person syndrome
and on anticoagulation for DVT who presented on [**2135-10-24**] with
fevers while at a rehabilitation facility. In the MICU, the
patient was found to have a right-sided PNA by CXR. He was then
transfered to the floor, where he developed an exacerbation of
his Stiff Person Syndrome.
.
# Pneumonia:
On admission chest x-ray the patient was found to have a right
middle lobe pneumonia. Given that the patient was transfered to
[**Hospital1 18**] from a rehabilitation facility, he was treated with
Vancomycin and Zosyn for 8 days for a health-care acquired
pneumonia. that is health care facility acquired because he was
previously at rehab. During this hospitalization the patient
did not experience shortness of breath, or cough and all blood
cultures were negative for any growth. On discharge the patient
was breathing comfortably on room air.
.
# Hypotension:
During the hospitalization the patient had multiple episodes of
hypotension with systolic blood pressure in the 80's. The was
likely due to the vasodilatory effects of the Dilaudid PCA the
patient was on, as well as autonomic dysfunction that is
associated with Stiff Person Syndrome. The patient responded
well to 500 cc normal saline fluid boluses, and did not
experience any additional episodes of hypotension after the
Dilaudid PCA was discontinued and the patient's pain was managed
solely with liquid oxycodone.
.
# Stiff Person Syndrome.
Following transfer from the MICU to the floor the patient
developed neck stiffness that he recognized as a prodrome of his
prior Stiff Person Syndrome exacerbations. The patient then
developed an exacerbation with painful rigidity of his upper and
lower extremities as well as his neck, and was treated with 5
days of intravenous immune globulin per the neurology consult
team recommendations. On [**11-2**] following IVIg administration, the
patient regained baseline function of his upper extremities and
his neck became more mobile. On discharge the patient's legs
continue to be rigid with limited range of motion, but, per
patient report, he usually requires 2 weeks to regain lower
extremity function. His pain is a [**7-5**], which is baseline for
him. The patient's home Valium regimen was continued during this
admission.
.
# Chronic pain.
The patient suffers from chronic pain due to Stiff Person
Syndrome and cerebral palsy. During this admission the patient
was transitioned from Dilaudid PCA that was added on to
patient's pain regimen in the MICU to liquid oxycodone. The
patient normally takes PO oxycontin, but during this
exacerbation of Stiff Person Syndrome the patient was unable to
tolerate PO formulations. As the patient's swallowing ability
improves the patient should transition back to his home
Oxycontin regimen.
.
# Deep Vein Thrombosis:
Patient was diagnosed with DVT of left common femoral and
superficial femoral veins in [**9-/2135**] and is currently
anticoagulated on coumadin. Repeat ultrasound in the emergency
room showed resolving DVT. Goal INR is [**2-27**]. On discharge patient
was continued on Coumadin with daily INR checks.
.
# Neutropenia/Anemia.
Following IVIG administration Patient's ANC was trending down.
Neutropenia is a known side effect of IVIG therapy, but is not
associated with an increased risk of infection. Hematocrit has
also been trending down. Hemolysis is a known side effect of
IVIG, as there are often alloantibodies against RBC
glycoproteins. The patient's hemolysis labs were negative. On
discharge the patient was instructed to obtain CBC with
differential to evaluate his improving leukopenia.
.
# FEN:
The patient was continued on tube feeds during this admission.
.
# CODE:
The patient was DNR/DNI during this admission. Health care proxy
is sister [**Name (NI) 5036**]:[**Telephone/Fax (1) 21567**].
Medications on Admission:
Acetaminophen 325mg q6h as needed
Senna twice daily
colace liquid twice daily
phenol-phenolate sodium, 1 spray as needed
oxycontin 160mg qam, 200mg qpm
polyethylene gylcol po daily (why?)
Diazepam 20mg every 4 hours
Protonix 40mg twice daily
Aspirin 81mg daily
Coumadin 7.5mg daily
dilauded 2mg q4h as needed
Magnesium hydoxide (Milk of Magnesia) 400mg/5ml. 30mL as needed
dulcolax
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Diazepam 10 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
6. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO
once a day.
7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
8. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours).
9. Ondansetron 4 mg IV Q8H:PRN
10. Oxycodone 5 mg/5 mL Solution Sig: Fifty (50) mg PO Q4H
(every 4 hours).
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary: Pneumonia, Stiff Person Syndrome
.
Secondary: Deep vein thrombosis
Discharge Condition:
Good.
Discharge Instructions:
You were admitted with fever and found to have a pneumonia. You
were treated with antibiotics and your fever improved. During
the admission you then developed neck stiffness, which you
thought was a prelude to your Stiff Person Syndrome
exacerbations. You then developed an exacerbation and you were
treated with five days of IV Ig. After the IV Ig treatment your
symptoms improved.
.
Due to your difficulty swallowing during this admission because
of the exacerbation of you Stiff Person Syndrome, your home
oxycontin dose was converted to a liquid oxycodone that is
administered via your G-tube. Your new pain regimen is:
Oxycodone 50mg liquid per g-tube every 4 hours.
At the rehabilitation facility they may change your oxycodone
back to your home dose of PO oxycontin when your swalling
ability has improved more.
.
We have also added the following medications to your regimen:
Sarna lotion (for opioid associated pruritis)
Miconazole powder for candidal groin rash.
.
If you have any sudden chest pain, shortness of breath, fevers
and chills or nausea and vomiting please contact your primary
care physician or go to the emergency room.
Followup Instructions:
You are being discharged to the [**Hospital 38**] Rehab facility. After
your stay at the rehab facility you will need to follow up with
your primary care doctor, Dr. [**Last Name (STitle) **]. Please call his office
at [**Telephone/Fax (1) 21566**] to make an appointment after your discharge from
[**Hospital 38**] Rehab.
|
[
"V44.1",
"V12.51",
"334.1",
"507.0",
"E934.6",
"287.4",
"V58.61",
"288.50",
"458.9",
"338.29",
"453.41",
"333.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.14",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13484, 13581
|
8257, 12115
|
292, 338
|
13701, 13709
|
3726, 8234
|
14900, 15226
|
3257, 3281
|
12549, 13461
|
13602, 13680
|
12141, 12526
|
13733, 14877
|
3296, 3707
|
247, 254
|
366, 1459
|
1481, 2912
|
2928, 3241
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,467
| 176,950
|
9632
|
Discharge summary
|
report
|
Admission Date: [**2143-2-4**] Discharge Date: [**2143-2-11**]
Date of Birth: [**2078-10-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Anterior ST Elevation Myocardial Infarction
Major Surgical or Invasive Procedure:
Intubation
Cypher Stent to proximal LAD
Intra-aortic balloon pump insertion, and removal
History of Present Illness:
The patient is a 64 y.o. male w/ pmh CAD, s/p inferior STEMI in
[**2134**] treated with BMS to left CX with known occluded RCA, who
awoke from sleep at 1am with with crushing substernal chest
pain. The patient called EMS, was transported to [**Hospital1 **], where he was found to have an anterior STEMI. He V-Fib
arrested in the ED, was defibrillated, given amiodarone 300mg,
placed on lidocaine gtt, and intubated. Total code time was
20-30 minutes. He was transferred to [**Hospital1 18**] on lidocaine gtt.
On arrival to [**Hospital1 18**], he received aspirin and plavix, and was
started on heparin and integrellin. He was hypotensive and so
was started on a dopamine drip. Left heart cath at [**Hospital1 18**]
revealed occlusion of prox LAD, LAD w/ 40-50% occlusion, RCA
with total occlusion and with left to right collateralls. He
received a cypher stent to the LAD. The patient had a swan
placed which revealed elevated wedge pressures to 26. He was
given lasix 80mg IV. Patient also became acidotic 7.01 w/
elevated CO2 73. Given his proximal LAD lesion, along with
marginal blood pressures on dopamine, a balloon pump 40cc was
inserted 1:1.
.
patient is intubated and unable to provide ROS.
Cardiac review of systems is notable for chest pain
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS:: Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**2132**]-stent to LCx, rotablator and angioplasty of diagonal
[**2134**]-stent to mid LCx Bx Velocity
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Right toe open fracture.
.
Social History:
unable to obtain, per previous notes denies tobacco, occansional
ETOH
Family History:
unable to obtain
Physical Exam:
VS: T=98.0 BP=89/72 HR=98 RR=...O2 sat=96% FiO2
GENERAL: WDWN male intubated.
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. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. crackles b/l.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 1+ PT 1+
Pertinent Results:
Admission labs:
[**2143-2-4**] 03:45AM WBC-26.9*# RBC-5.25 HGB-16.5 HCT-48.2 MCV-92
MCH-31.5 MCHC-34.3 RDW-13.4
[**2143-2-4**] 03:45AM GLUCOSE-375* UREA N-24* CREAT-1.8*
SODIUM-132* POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-19* ANION GAP-18
[**2143-2-4**] 04:11AM TYPE-ART TIDAL VOL-600 PEEP-10 O2-100
PO2-119* PCO2-60* PH-7.11* TOTAL CO2-20* BASE XS--11 AADO2-550
REQ O2-89 INTUBATED-INTUBATED
Discharge Labs: [**2142-2-10**]
wbc 11.2, Hct 40.6, plts 243
Na 139, K 3.6, Cl 107, HCO3 27, BUN 27, Cr 1.3, glu 109
Cardiac Enzyme trend:
[**2143-2-4**] 03:45AM CK(CPK)-223*
[**2143-2-4**] 03:45AM CK-MB-15* MB INDX-6.7*
[**2143-2-4**] 06:16AM CK-MB-239* MB INDX-11.1* cTropnT-5.15*
[**2143-2-4**] 06:16AM BLOOD CK(CPK)-2153*
[**2143-2-5**] 03:01AM BLOOD CK(CPK)-2742*
[**2143-2-8**] 05:01AM BLOOD CK(CPK)-332*
EKG [**2143-2-4**]:
Sinus rhythm. Left atrial enlargement. Low limb lead voltage.
Prior
anteroseptal myocardial infarction. Compared to the previous
tracing
of [**2134-10-6**] the rate has increased. There is variation in
precordial
lead placement. The previously recorded early precordial R wave
transition is
no longer in evidence. There are now Q waves in leads V1-V2
consistent with
interim anteroseptal infarction. The limb lead voltage has
diminished.
The rate has increased and there are ST-T wave changes. Followup
and clinical
correlation are suggested.
Cardiac Catheterization [**2143-2-4**]:
1. Selective coronary angiography of this right dominant system
revealed
3 vessel disease with an acute proximal LAD lesion. The LMCA
had no
angiographically apparent flow limiting disease. The LAD had an
acute
lesion of 99% stenosis in the proximal segment. The first
diagonal had
80% stenosis. The LCX had 40% hazy stenosis at the mid segment.
The
RCA was chronically totally occluded at the proximal segment and
was
filled by left to right collaterals.
2. Resting hemodynamics demonstrated markedly elevated right
sided
filling pressures (RVEDP 26 mm Hg) and markedly elevated left
sided
filling pressures (PCWP 25 mm Hg). There was mild PA
hypertension (PA
40/27 mm Hg).
3.
4. Stenting of very proximal LAD with Cypher 3x18mm stent
posted to
3.25mm in setting of STEMI.
5. IABP inserted for cardiogenic shock.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Mild diastolic ventricular dysfunction.
3. Acute anterior myocardial infarction, managed by acute ptca.
PTCA of vessel.
Transthoracic Echo [**2143-2-4**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
moderate to severe hypokinesis of the septum. The anterior wall
may be hypokinetic also. The inferolateral wall may be slightly
hypokinetic but suboptimal image quality limits certainty. The
right ventricular cavity is dilated. The aortic root is mildly
dilated at the sinus level. 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. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Symmetric LVH with moderate to severe septal
hypokinesis. The anterior wall is probably hypokinetic but is
not well seen. The RV is dilated and probably hypokinetic but
image quality limits interpretation. No significant valvular
abnormality seen. Large anterior fat pad.
Brief Hospital Course:
64M w/ pmh CAD p/w chest pain, found to have anterior STEMI,
complicated by V-fib arrest s/p defibrillation, now s/p cypher
stent to prox LAD.
.
# ST Elevation Myocardial Infarction: Cardiac catheterization
revealed a totally occluded RCA with Left to right collaterals,
99% stenosis of proximal LAD, and 40% stenosis of LCx. He
receiving a cypher stent to his proximal LAD and was admitted to
the CCU. During catheterization he was hypotensive, requiring a
dopamine drip and an intraaortic balloon pump. He was intubated
prior to arrival at [**Hospital1 18**]. During the catheterization he was
vomiting and concern was raised for aspiration. he was initially
acidotic, with a pH of 7.01 and elevated lactate to 2.9. He was
started on aspirin and plavix and atorvastatin, and his IV
heparin was continued while he was still on the IABP. He
underwent the arctic sun cooling protocol as well. he was also
started on an insulin drip to keep his blood glucose under 180.
Echo on [**2-5**] showed an LVEF of 30% with septal and anterior
hypokinesis. His RV was also dilated. After several days his
blood pressure stabilized and his dopamine was discontinued on
[**2-6**]. His balloon pump was removed [**2-6**]. He was extubated on
[**2142-2-6**]. He was started on carvedilol and lisinopril, which were
initially held given his hypotension. His carvedilol was
switched to metoprolol and he was found to have better rate
control with metoprolol. His enzymes were trended and found to
peak at CK 2742, troponin 5.15. Given his septal and anterior
wall hypokinesis, the patient was bridged with enoxaparin and
started on coumadin. He was started on 5mg coumadin daily from
[**2-5**] to [**2-9**], his INR increased from 1.3 to 2.5. He was then
given 3mg of coumadin on [**2-10**] when his INR was 3.6. His coumadin
was held on [**2-11**]. The plan was to continue anticoagulation with
goal INR [**3-12**] for 3-6 months and to re-evaluate in 1 month with
repeat TTE and cardiac MR. [**Name13 (STitle) **] will be discharged home on the
[**Doctor Last Name **] of Hearts monitor for two weeks, with results followed up
by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at [**Hospital1 18**].
By discharge, his systolic blood pressure was ranging between
100-140, and primarily in the 120s, and heart rate ranging from
60-85.
The patient was instructed to visit his PCP [**Last Name (NamePattern4) **] [**2-12**], and [**2-13**] to
have labs drawn to monitor his INR while on coumadin.
He was also instructed to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] from
the department of Cardiology and Electrophysiology after his
Cardiac MRI is performed.
The patient was also completed a 7 day course of levofloxacin
and flagyl for empiric coverage of aspiration pneumonia.
Medications on Admission:
aspirin
metoprolol
atorvastatin
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Outpatient [**Name (NI) **] Work
PT, PTT, INR drawn three times per week.
Results should be sent to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Fax# [**Telephone/Fax (1) 32617**]
Tel# [**Telephone/Fax (1) 4475**]
7. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once daily .
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
primary: ST-elevation myocardial infarction
secondary: hyperlipidemia, hypertension
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital because you had a heart
attack. A stent was placed in one of the arteries to your
heart. Medications were started to decrease your risk for
having heart problems in the future.
The following medications were changed in the hospital:
Lisinopril was started
Coumadin was started
Clopidogrel was started
Metoprolol was increased
Atorvastatin was increased
Please continue to take your medications as prescribed.
Please do not take coumadin today, [**2142-2-10**].
.
You should visit Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at his office [**2142-2-11**] and
[**2142-2-12**] to have blood tests drawn, in order to manage the dosing
of your coumadin. Do not restart taking coumadin until [**2-12**],
unless instructed otherwise by Dr. [**Last Name (STitle) **].
.
Because you are taking Coumadin, a medication that thins your
blood, you will need to have your blood tested regularly to make
sure the level is correct. The INR is the name of test for the
coumadin level.
You will also be sent home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor.
Please wear this for two weeks.
Please return to the emergency room or call 911 if you
experience recurrent chest pain or shortness of breath.
Additionally, seek medical attention for high fevers and chills,
vomiting, or other symptoms that are concerning to you.
Followup Instructions:
The cardiac MRI [**Last Name (NamePattern4) **] will call you to schedule an appointment.
This should be in approximately 1 month. Please be sure this
study is performed before you meet with Dr. [**Last Name (STitle) **].
.
You have an appointment for an ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2143-3-11**] 3:00
.
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Telephone/Fax (1) 62**]
Friday [**2142-3-21**], at 1pm. This appointment is located
on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] building.
Please keep your regularly scheduled appointment on [**2-13**] to
have your blood drawn at Dr.[**Name (NI) 32618**] office. At that time you
should have your INR checked. The level should be [**3-12**] with
adjustment of your comadin as directed by your doctor. You were
given 5mg PO daily from [**2-5**] to [**2-9**], then 3mg on [**2-10**], INR was
3.9 on discharge. Discharged on 2mg to start on [**2-12**] (held for
[**2-11**]).
|
[
"428.0",
"276.4",
"428.20",
"507.0",
"518.81",
"785.51",
"272.4",
"482.42",
"584.9",
"272.0",
"410.11",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"37.61",
"00.42",
"00.46",
"00.66",
"37.23",
"38.91",
"96.71",
"36.07",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10471, 10529
|
6596, 9413
|
360, 452
|
10659, 10668
|
3016, 3016
|
12120, 13148
|
2193, 2211
|
9495, 10448
|
10550, 10638
|
9439, 9472
|
5278, 6573
|
10692, 12097
|
3429, 5261
|
2226, 2997
|
1864, 2030
|
277, 322
|
480, 1735
|
3033, 3413
|
2061, 2089
|
1779, 1844
|
2105, 2177
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,393
| 111,268
|
4765
|
Discharge summary
|
report
|
Admission Date: [**2164-11-21**] Discharge Date: [**2164-11-23**]
Date of Birth: [**2096-9-8**] Sex: F
Service: MEDICINE
Allergies:
Cephalexin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Central venous line placement
History of Present Illness:
68 year old female with metastatic renal cell carcinoma (lung,
lymph nodes, liver) presents with hypotension. The patent's son
reports that the patient has not been eating or drinking much
for the last few days. She has been having copious diarrhea and
vomiting for the last few weeks as well. The son had not noticed
any change in mental status or any other new issues other than
continued weakness.
In the ED, the patient's presenting vitals were T97 P113 BP63/39
R10 O293%RA. At the time of evaluation by the MICU team, her
vitals were T97.4 P106 BP76/54 R19. She received 5L of NS and 2
units PRBC and IV levofloxacin, as well as potassium and
magnesium repletion. A right IJ central line was placed.
Of note, the patient was reported to be enrolled [**Hospital 1121**]
Hospice. Discussions with the son suggested that the family was
not aware of the general goals of hospice care. After explaining
the various options of care, the patient and her son elected for
full medical care (including intubation and resuscitation as
needed) pending further discussion with oncology.
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**]
Past Medical History:
1) Metastatic renal cell carcinoma
- s/p left nephrectomy with concurrent resection of an isolated
pulmonary nodule in 12/[**2160**].
- Adjuvant high-dose interleukin-2 therapy in [**1-/2161**]
- CCI/IFN trial terminated in [**11/2162**] because of cumulative side
effects and the lack of definitive measurable disease.
- Thalidomide d/c [**8-/2163**] due to side effects and disease
progression.
- Avastin off study terminated because of disease progression.
- Photodynamic therapy terminated because of hemoptysis and MI
during bronchoscopy.
- Mediastinal radiation therapy.
- Gemcitabine terminated because of disease progression.
- Currently enrolled in open-access sorafenib trial (started
[**2164-9-12**]
- [**2164-10-29**] Torso CT: unchanged thoracic inlet LAD, large
pretracheal LN, subcarinal LN, LLL mass (3.7 X 3.4 cm), multiple
hypodense liver masses.
2. Status post TAH, uterine prolapse repair
3. Hyperlipidemia
Social History:
SHx: Married. Lives with family. Denies tobacco or other alcohol
use
at home with hospice.
Family History:
FHx: noncontributory
Physical Exam:
On admission to MICU:
PE:
Temp 97.4 P113 BP 76/54 (pre-levophed) RR 19 O2 sat 96 NC
Gen - Alert, no acute distress, Russian-speaking elderly female,
cachectic
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - RIJ in place; nodules at base of left neck (tumors, per
patient)
Chest - Coarse breath sounds on right.
CV - Normal S1/S2, tachycardic, regular
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes
Extr - Warm, with clubbing but no cyanosis. 2+ pitting edema
bilaterally. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**3-10**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Pertinent Results:
Studies:
CXR: 1. Multifocal airspace opacities, unchanged since the prior
study, concerning for post-obstructive atelectasis or pneumonia.
2. Small bilateral pleural effusions, left greater than right.
.
CT ([**2164-10-29**]):
CT OF THE CHEST WITHOUT CONTRAST: Examination for comparative
purposes is somewhat limited by the absence of IV contrast. In
the soft tissue windows, there is no axillary lymphadenopathy.
In the left thyroid lobe, there is a 4- mm calcification that is
unchanged. The lymphadenopathy in the thoracic inlet is
unchanged. There are multiple masses within the mediastinum that
are relatively unchanged. Lesion #3 is a pretracheal lymph node
measuring 23 x 18 mm and is unchanged. Target lesion #4 is a
subcarinal lymph node measuring 23 x 17 mm and is also
unchanged. There is also hilar lymphadenopathy that is
unchanged. In the lung windows, there is a mass in the left
lower lobe as target lesion #1 measuring 37 x 34 mm and is also
relatively unchanged. There are multiple areas of focal patchy
infiltrates bilaterally including geographic paramediastinal
consolidations (presumably patient had prior radiation therapy)
that are unchanged. Tiny noduleas are present at both lung bases
, unchanged. No new large pulmonary nodules are identified.
There are small bilateral pleural effusions that smaller than on
prior study. There is a pericardial effusion that is unchanged.
CT OF THE ABDOMEN WITHOUT CONTRAST: There are multiple hypodense
lesions in the liver that are unchanged. Specifically, these
include one 19-mm in the segment VII and another unchanged
lesion in segment VI. No new liver lesions are identified. There
is interval increase in a massive left nephrectomy bed lesion
that now measures 107 x 104 mm that is, allowing for absence of
IV contrast, increased from approximately 95 x 92 mm. This is
target lesion #2. A large left adrenal mass measuring 5.7 cm is
unchanged. The spleen and right kidney are normal. The large and
small bowel loops are of normal caliber. There is no free fluid
in the abdomen.
IMPRESSION: Widely metastatic disease with interval enlargement
of target lesion #2 in the left nephrectomy bed. Stable
mediastinal ,lung, liver and left adrenal disease.
.
Head CT: ([**8-31**]) no mets
.
CXR ([**11-22**]):
Comparison to a prior chest x-ray shows certainly no improvement
and possibly the increasing densities at both lung bases
consistent with increasing pleural effusions. Bilateral upper
lobe airspace disease is present. The heart is enlarged.
IMPRESSION: Increasing effusion since [**2164-11-20**].
Brief Hospital Course:
A/P: 68 year old female with metastatic renal cell carcinoma
admitted to MICU with hypotension.
1) Hypotension: Concern for infection and sepsis/SIRS
physiology. Potential sources of infection include
post-obstructive pneumonia, UTI (given positive U/A). Patient
also has known large left adrenal mass. Blood, sputum and urine
cultures were sent and had no growth, and a repeat urine was
negative for infection. The patient was started on antibiotics
in the emergency department. Steroids were also given, although
the results of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]-stim test did not support the idea of
adrenal suppression. The patient was maintained on levophed and
fluids.
.
2) Respiratory distress: On HD 2 the patient developed
significant respiratory distress with bilateral wheezes/rales.
She had only a minimal response in UO to lasix with a BP drop,
and couldn't tolerate aggressive diuressis. Given end-of-life
discussions (see below), the patient was not intubated and was
only supported with non-invasive means. On HD3 she was tachypnic
all morning and was supported with O2 by face mask (which she
refused) and nasal canulla. In the early afternoon her nurse
found her not breathing; given her DNI/DNR status (see below)
she was not intubated and passed away. Her family was present at
the time, and her oncologist and PCP were notified.
.
3) Code status: the patient had metastatic renal cancer and, per
her oncologist, had always been resistant to discussions about
advanced directives. Although enrolled in hospice care at home,
per her family this was only for the home services and not
because she was declining further treatment. However, from her
arrival in the ED the patient refused most treatment, including
foley catheters and ECGs. There were multiple discussions with
her, her family, the MICU staff and her oncologist, with the
resultant conclusion that she was DNR/DNI. The Palliative Care
service (which already knew the patient) was also consulted.
.
3) F/E/N: House diet, but patient had poor appetite and refused
most food. She did somewhat better with Russian food her husband
brought. .
4) Anemia: HCT 26.5. Baseline HCT 27-31. Most likely ACD
secondary to malignancy.
Transfused 2u PRBC in ED, no active bleeding, Hct stable in
MICU.
.
5) Coagulopathy: INR>2, up from baseline; no active bleeding but
given PO vitamin K with resulting INR=1.5.
.
6) Prophylaxis: PPI, bowel regimen, heparin SC
.
7) Communication: [**Name (NI) 19989**] [**Name (NI) 19990**] (son) [**Telephone/Fax (1) 19991**] (cell)
Medications on Admission:
Sorafenib 400 mg daily
lorazepam 0.5 mg p.r.n.
Paxil
Robitussin Methadose
Ambien
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypotension
Respiratory arrest
Metastatic renal cell carcinoma
Discharge Condition:
Expired
|
[
"197.0",
"038.9",
"584.9",
"197.7",
"995.92",
"585.9",
"599.0",
"276.51",
"196.0",
"285.9",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8692, 8701
|
5964, 8532
|
284, 315
|
8807, 8817
|
3365, 5591
|
2570, 2592
|
8663, 8669
|
8722, 8786
|
8558, 8640
|
2607, 3346
|
233, 246
|
343, 1494
|
5600, 5941
|
1516, 2445
|
2461, 2554
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,614
| 189,675
|
54965
|
Discharge summary
|
report
|
Admission Date: [**2138-5-8**] Discharge Date: [**2138-5-10**]
Date of Birth: [**2082-10-28**] Sex: M
Service: MEDICINE
Allergies:
chloroquine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Chief Complaint: new liver mass, weakness
Reason for MICU transfer: hyperkalemia w/ peaked T's
Reason for Medicine transfer: comfort measures only
Major Surgical or Invasive Procedure:
Hemodialysis
Central line
History of Present Illness:
Mr.[**Name13 (STitle) 112241**] is a 55yoM with h/o HepB - treated, DM, malaria who
was transferred from [**Hospital **] Hospital with MRI showing
metastatic liver cancer and labs showing [**Last Name (un) **] and hyperkalemia w/
peaked T's. He and his wife report that he has been having
abdominal pain x weeks, and upon coming back from liberia a
month ago, he was seen in [**State **], for increased swelling
in his legs and jaundice. An ultrasound was done which showed
echogenic masses concerning for liver cancer. He was seen in
[**Hospital **] clinic on [**2138-4-25**] for abdominal pain. ALT was found to be
319, SGPT 135, ALP 497, albumin of 2.2, alfa fetoprotein was >
30,000. INR was 1.6, CXR was suggestive of mets. He has been
complaining of significant weight loss and poor appetite. MRI
yesterday showed extensive metastatic liver disease (IVC
extension, renal vasculature extension, lung mets, and near
replacement of the liver). He was seen again in clinic today,
when he was referred to ER because of these findings and
abdominal pain. His creatinine on [**2138-4-25**] was 0.75. He initially
went to [**Hospital **] hospital where he was hypothermic; his labs
showed a INR of 2.5, K of 6.1, creat of 4.3, BUN 87, calcium
9.2, bicarb 11,sodium 135, K 7.0bil 18.2, direct 16.3, hb 10.4.
He was given kayexelate 30 gm PO and bicarb 1 amp with D50 and
insulin. He was then transferred to [**Hospital1 18**] ED.
.
In the ED, initial VS were: 97.5 90 130/70 16 100% on RA.
Labs revealed K 7.2, BUN/Cr 87/4.5, anion gap of 26. INR was
2.5, lactate 10.4. VBG showed 7.29/32/47. CXR showed R effusion
with elevation of R hemidiaphragm and nodules. CT Head was
performed - showed no intracranial mets, but did show blastic
and lytic lesions in the skull. EKG showed NSR with peaked T's.
He had no urine output in the ER. Renal was consulted who plans
to place HD catheter for urgent dialysis. Transplant surgery was
consulted re: ? anticaogulation for extension of tumor into IVC
who recommended heparin. Vancomycin and Zosyn were given for
leukocytosis. He was given 4L IVF and also started on bicarb gtt
per renal fellow. Access was 4 PIVs. VS prior to transfer 97.4
109 120/94 24 98% on RA.
.
On arrival to the MICU, the patient is oriented, alert, somewhat
slow to answer questions. He and his wife understand that he has
cancer but it is not clear they understand the extent of
disease. He adds that he hasn't been eating or drinking much
lately. Denies fevers, + vomiting, no diarrhea, has been
urinating at home, + abd pain. + SOB recent 30 lbs weight loss.
VS 97.5 101 130/80 17 97% on RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies Denies chest pain,
chest pressure, palpitations, or weakness. Denies diarrhea,
constipation. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Hepatitis B - treated in [**2130**] with lamivudine
DMII
Malaria - [**2130**]
Social History:
Originally from Liberia - works for the Liberian government.
Lives in-between [**Location (un) 86**] and there. Wife lives in [**Location 86**].
- Tobacco: never
- Alcohol: none
- Illicits: none
Family History:
no h/o liver cancer
Physical Exam:
On transfer to MICU:
Vitals: 97.5 101 130/80 17 97% on RA
General: Alert, oriented, slow to respond to questions, appears
cachectic
HEENT: icteric sclera, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP flat, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation anteriorlly
Abdomen: distended, no fluid wave, TTP diffusely, rare bs
GU: foley with 10 cc's of very dark urine
Ext: warm, well perfused, 2+ pulses, 2+ pitting edema up to
bilateral thighs
Neuro: CNII-XII intact, 5/5 strength in UE, able to lift both
legs off bed, grossly normal sensation, ? fine asterixis
Pertinent Results:
On admission:
.
[**2138-5-8**] 04:30PM BLOOD WBC-20.2* RBC-5.38 Hgb-11.1* Hct-38.7*
MCV-72* MCH-20.6* MCHC-28.7* RDW-22.7* Plt Ct-489*
[**2138-5-8**] 04:30PM BLOOD Neuts-80.9* Lymphs-13.1* Monos-5.5
Eos-0.1 Baso-0.4
[**2138-5-8**] 04:30PM BLOOD PT-26.5* PTT-35.7 INR(PT)-2.5*
[**2138-5-8**] 04:30PM BLOOD Glucose-102* UreaN-87* Creat-4.5* Na-137
K-7.2* Cl-97 HCO3-14* AnGap-33*
[**2138-5-8**] 04:30PM BLOOD ALT-537* AST-2173* AlkPhos-417*
TotBili-18.6*
[**2138-5-8**] 04:30PM BLOOD Albumin-2.6* Calcium-9.0 Phos-10.5*
Mg-3.2*
[**2138-5-8**] 11:02PM BLOOD HBsAg-POSITIVE* HBsAb-NEGATIVE
HBcAb-POSITIVE
[**2138-5-8**] 11:02PM BLOOD HCV Ab-NEGATIVE
[**2138-5-8**] 04:40PM BLOOD Type-[**Last Name (un) **] pO2-47* pCO2-32* pH-7.29*
calTCO2-16* Base XS--9 Comment-GREEN TOP
[**2138-5-8**] 04:40PM BLOOD Lactate-10.4* K-7.3*
.
blood and urine cultures: pending
.
MRI OSH: most of the liver replaced by large masses, invasion of
the portal and portal veins. multiple enhancing lung nodules. R
periaortic mass, likely represents metastatic disease. tumor
extends into IVC. large RP mass diplaces IVC anteriorly and
encases R renal vasculature and possibly upper pole of the right
kidney
'largest lesion in R lobe is 16.4 x 12.2 x 16.6 cm', tumor
extension into the R portal vein with enhancing tumor thrombus
within the portal vein; main portal vein is patent; tumor
protrudes into the IVC, No definite tumor thrombus in the R
atrium, multiple nodules at both lung bases and along the
undersurface of the diaphragm; large periaortic mass measures
10.5 x 7.3 x 13.2 cm. R renal vasculature is involved.
.
EKG: NSR, Nl axis and intervals, peaked T's
.
Renal U/S:
IMPRESSION:
No evidence of hydronephrosis.
Solid mass lesion in the right upper abdomen in close relation
to the right
kidney and the inferior liver. The exact organ of origin is
indeterminate.
This could represent an exophytic hepatic mass or
retroperitoneal mass.
Please correlate with the patient's previous outside imaging.
Limited Doppler study. Normal systolic acceleration noted in the
intrarenal
arteries bilaterally. Renal arterial stenosis would be unlikely
in this
setting.
.
CT Head:
IMPRESSION:
1. No CT evidence of intracranial metastasis; however, MR is
more sensitive
for detection of metastatic disease.
2. Multiple osseous lytic and blastic lesions may potentially
represent
metastatic disease.
.
CXR:
IMPRESSION:
1. Elevation of the right hemidiaphragm vs possible subpulmonic
effusion.
Associated right base atelectasis vs possible consolidation.
2. Bilateral nodules suspicious for metastatic disease given
history.
Correlate with prior imaging.
Brief Hospital Course:
Assessment and Plan:
Mr.[**Name13 (STitle) 112241**] is a 55yoM with h/o treated HepB, DMII who was
transferred from [**Hospital **] Hospital with MRI showing extensive
metastatic liver cancer and labs showing [**Last Name (un) **] and hyperkalemia w/
peaked T's
.
Active Issues:
A family meeting was held on [**2138-5-9**], and at that time it was
decided to make the patient comfort measures only. Mr. [**Known lastname **] [**Last Name (Titles) 69415**]d shortly after on [**2138-5-10**] at 0600.
.
Inactive Issues:
.
# Hyperkalemia: K was elevated to 7.2 on arrival to [**Hospital1 18**] ER. He
had received bicarb, insulin, kayexelate, calcium at OSH and
received a 2nd round in ER. He was not urinating and EKG changes
w/ peaked T's were evident. Emergent HD catheter was placed and
HD was started. K improved to 5 after dialysis though renal
failure remained persistent.
.
# [**Last Name (un) **]: Cr acutely elevated to 4.2 from 0.75 on [**4-25**] w/ BUN of 87.
Likely ATN given multiple casts on sediment vs. obstructive
component from metastatic lesion. He remained oliguric despite
IVF and aggressive resuscitation was stopped as his respiratory
status began to worsen. Renal U/S showed no obvious obstruction
though did show an RP mass adjacent to the kidney.
.
# Presumed metastatic HCC: Large burden of disease on MRI the
day prior to admission as an outpatient. New diagnosis for
patient. AFP > [**Numeric Identifier **] at recent clinic appt. Given the extensive
burden of disease (lungs, IVF extension, portal vein extension,
large periaortic LN), it was explained to the wife and patient
that there were no options available to treat or palliatite the
cancer. The patient and family understood and elected to
transition to comfort care. SW, [**Hospital1 **] chaplain, and palliative care
were all involved.
.
# Tumor thrombus: [**Last Name (un) **] on MRI in R portal vein. Will hold off on
heparin gtt tonight given concern for coagulopathy and bleeding
into hepatic mets.
.
# Coagulopathy: INR 2.5 w/ nl PTT. Likely poor synthetic
function in setting of extensive liver disease.
.
# Metabolic acidosis/lactic acidosis: Initial anion gap of 26
with lactate of 10.4 and new renal failure. Likely related to
poor clearance of lactate in hepatic/renal failure and extensive
tumor burden.
.
# Leukocytosis: WBC 20.2 w/ 80.9% PMNs. Afebrile per patient
(though was hypothermic at OSH). Received Vanc/Zosyn in ER (now
being dialyzed off). Highest concern would be for biliary
sepsis. Antibiotics were held on admission.
.
# DMII: On Glipizide 2.5 mg ER at home. Was placed on
conservative HISS given renal failure.
.
# LFTs: Obstructive and hepatotoxic pattern likely both related
to extensive tumor burden. T.bili 18.6.
.
DVT prophylaxis was with subcutaneous heparin. Communication
with Mymah [**Telephone/Fax (1) 112242**]. Code status transitioned to comfort
measures.
.
Transitional Issues:
N/A (Patient expired.)
Medications on Admission:
Codeine 30 mg q6-8h prn (just added [**4-25**])
Lasix 40 mg qday (added [**4-25**])
Glipizide 2.5 mg ER qday
Discharge Medications:
N/A (Patient expired.)
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A (Patient expired.)
Discharge Condition:
N/A (Patient expired.)
Discharge Instructions:
N/A (Patient expired.)
Followup Instructions:
N/A (Patient expired.)
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2138-5-10**]
|
[
"584.5",
"V66.7",
"276.2",
"197.0",
"300.00",
"250.00",
"276.7",
"799.4",
"V49.86",
"155.0",
"198.89",
"196.2",
"070.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10242, 10251
|
7101, 7366
|
427, 454
|
10317, 10341
|
4447, 4447
|
10412, 10601
|
3769, 3791
|
10195, 10219
|
10272, 10296
|
10061, 10172
|
10365, 10389
|
3806, 4428
|
10011, 10035
|
3121, 3438
|
257, 389
|
7381, 7604
|
482, 3102
|
6601, 7078
|
7621, 9990
|
4461, 6592
|
3460, 3540
|
3556, 3753
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,351
| 192,792
|
7600
|
Discharge summary
|
report
|
Admission Date: [**2144-2-27**] Discharge Date: [**2144-3-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 84 chinese only speaking female w/HTN, NIDDM who was
admitted last week to OSH for hypertensive urgency and LE edema
at which time her metformin was DCed, actos started, and
lisinopril started. Her edema resolved with diuresis and her son
believes that she had a [**Name (NI) **] wnl. Today, she was asymptomatic
with a FS of 40 found by VNA. EMTs gave D50 and glucagon.
Patient reports fatigue since yesterday, but denies all other
symptoms. Denies fevers, chills, cough, dyspnea, abdominal pain,
dysuria, hematochezia, brbpr, change in bowel habits, nausea,
vomiting, change in appetite. Patient reports that her son helps
her with her medications but that she doesn't take them
everyday. In the ED, the patient was given levofloxacin,
hydralizine, D50 and D5. Her FS was initially 148, but then fell
to 31; came up to 168 w/1A of D50.
.
Of note, she also had a recent fall at home which she reports
was w/o vertigo or presyncope. She reports it to be
accidental/mechanical.
Past Medical History:
HTN
NIDDM
Hypercholesterolemia
Social History:
SH: Lives along, son visits regularly. Cantonese speaking. VNA
also visits. No EtoH, no IVDA, no smoking
Family History:
NC
Physical Exam:
PE:
96.2 142/62 54 18 97RA 113
Gen: pleasant female, NAD
HEENT: Pupils equal, non-reactive to light, 1 mm bilaterally.
MMM & oropharynx clear. ecchymosis over R eye. Vision grossly
intact bilaterally.
Neck: Supple, no LAD, no thyromegaly.
Lungs: Crackles bilaterally in lower lung bases, no wheezes,
rhonchi, crackles.
Card: Bradycardic, regular rhythm. 3/6 systolic murmur that
radiates to the right neck. No rubs, gallops.
Abd: Soft, nt, nd, +BS. No hepatosplenomegaly.
Extremities: WWP X 4 w/o c/c/e
Neuro: Alert, moving all 4 extremitis. No focal deficits noted.
Exam limited by language barrier.
Pertinent Results:
[**2144-2-27**] 06:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2144-2-27**] 05:00PM GLUCOSE-165* UREA N-39* CREAT-2.0* SODIUM-138
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
[**2144-2-27**] 05:00PM CK(CPK)-105
[**2144-2-27**] 05:00PM CK-MB-2 cTropnT-0.01
[**2144-2-27**] 05:00PM CALCIUM-8.7 PHOSPHATE-3.4 MAGNESIUM-1.9
IRON-18*
[**2144-2-27**] 05:00PM calTIBC-218* FERRITIN-122 TRF-168*
[**2144-2-27**] 05:00PM TSH-0.93
[**2144-2-27**] 05:00PM WBC-8.2 RBC-3.43* HGB-8.6* HCT-26.2* MCV-76*
MCH-25.2* MCHC-33.0 RDW-14.7
[**2144-2-27**] 05:00PM NEUTS-84* BANDS-3 LYMPHS-6* MONOS-5 EOS-1
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2144-2-27**] 05:00PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+
SCHISTOCY-1+ FRAGMENT-1+
[**2144-2-27**] 05:00PM PLT SMR-NORMAL PLT COUNT-143*
[**2144-2-27**] 05:00PM PT-11.3 PTT-33.4 INR(PT)-1.0
PTH: 115
Retic: 2.1
U Protein:Creat: 1.8
Uosm: 437
Echo: The left atrium is elongated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The 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. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
EKG: Sinus bradycardia. Probable old anteroseptal myocardial
infarction.
Non-specific ST-T wave abnormalities. No previous tracing
available for
comparison.
CT head: No evidence of acute intracranial hemorrhage. No
fracture.\
CXR: Either scarring or chronic effusion in the left lung base.
Otherwise, no acute pulmonary process.
Microbiology:
Blood cx negative to date
Brief Hospital Course:
Hypoglycemia/DM- Likely due to glyburide secondary to renal
insufficiency and lisinopril. While in the hospital, the
patient was placed on an insulin sliding scale where her finger
sticks required insulin boluses. [**Last Name (un) **] was consulted and they
recommended to stop current glycemic treatment and start amaryl
on discharge. Diabetes in general appears in good control at
this point (HbA1C 6.9 compared to 6.9 in [**Month (only) 216**]). Appointment
recommended with [**Last Name (un) **] for follow up diabetes care.
.
Renal insufficiency- Creatinine values ranged from 1.9 to 2.5
during admission. Several factors likely contributed including
overall worsening secondary to uncontrolled hypertension and
diabetes. Creatinine clearance was found to be 25, stage IV
nephropathy. PTH was elevated to 115, however her phosphate
remained within normal limits. A trial of lisinopril failed due
to hyperkalemia. She was discharged on diovan. Follow up with
nephrology was arranged to improve management of her nephropathy
given its severity. Outpatient appointment with Dr. [**Last Name (STitle) 4090**].
.
HTN- Continued to have high systolic pressures to 180s. Various
regimens were tried including lisinopril to 40 mg qd,
hydralazine and increasing metoprolol and amlodipine. Final
regimen included Toprol XL, Lisinopril, Amlodipine.
Bradyarrhythmia: Likely secondary to treatment with metoprolol.
However, although patient will have heart rates in the 50s, she
remains asymptomatic throughout these episodes. After several
days of admission, these events resolved.
.
Recent falls- PT was consulted. They found her to be unsteady
secondary to deconditioning. They recommended rehab to rebuild
strength upon discharge. CT of her head was negative. Patient
should have appointment regarding osteoporosis care at the
endocrine unit (phone ([**Telephone/Fax (1) 9072**]).
.
Microcytic anemia- Has had low hct in the past to the 30s,
however hct throughout her admission was lower than at baseline
and progressively decreased to 20.2. Her anemia was believed to
be multifactorial. On HD3, patient began complaining of left
groin pain and clinical exam was suspicious for hip fracture.
Plain films of the hip were negative, however MRI demonstrated
an acetabular fracture with hematoma. As hct had dropped to
20.2, she was transfused with 2 U PRBCs with an appropriate bump
in hct. However, her hematocrit continued to drop, she was
transferred to the unit for closer monitoring where she received
additional units (PTT 139.8, ?heparin reaction). MICU course
below. Other causes of anemia include chronic renal failure
(reticulocyte count indicated a hypoplastic process). Patient
also revealed h/o thalassemia which would explain iron studies
and h/o microcytic anemia with normal iron stores. Epoetin and
iron was started.
Hypercholestermia: Atorvastatin increased to 40 mg, however
LFTs increased, therefore it was decreased to 20 mg.
Hip pain: On hospital day 4, she developed severe left hip pain
without any acute stressors. Her hip was tender to palpation
and she had decreased passive range of motion. Plain films of
the hip demonstrated no fracture, however an MRI showed
acetabular fracture with psoas hematoma. Orthopedics was
consulted. They recommended no further management, as she is
able to bear weight. Increasing LLQ tenderness in the setting
of decreasing hematocrit warranted further imaging (CT torso)
demonstrating a large, expanding hematoma. PTT was found to be
139.8. Heparin was stopped. For prophylaxis she was given
boots. An IVC filter was placed one day prior to admission to
be removed two weeks from placement date.
IVC will removed by [**Hospital1 18**] IR on [**2144-3-16**].
MICU course [**2058-3-5**]: She received 2U PRBC on [**3-5**] and 1U PRBC on
[**3-6**] with appropriate bump in Hct. Her Hct remained stable at
~30 for 24 hours. Vascular and ortho signed off. Her ASA
continued to be held due to the RP bleed but was restarted after
48 hrs of stable Hct. LENIs were negative, but she remains a
high DVT risk given her hip Fx. IVC filter placed after
discharged from the ICU as above.
Medications on Admission:
Toprol 200 QD
Lisinopril 40/20
Glipizide 5 qd
Actos 30 qd
ASA 81 qd
Amlodipine 10 qd
Lipitor 20mg QD
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Glimepiride 1 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*60 Tablet(s)* Refills:*0*
8. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) Injection
every two weeks.
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Health & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
1. Hypoglycemia
2. Myocardial Infarction
3. Hip fracture with hematoma
Secondary
1. Chronic Kidney Disease Stage III/IV.
2. Proteinuria.
3. Anemia of CKD.
4. Diabetes Mellitus Type II.
5. Hypertension.
6. Hypercholesterolemia.
7. ? thalassemia (per patient)
Discharge Condition:
stable, euglycemic, hypertension controlled
Discharge Instructions:
You were admitted with low blood sugars. During your admission,
you experienced a mild heart attack due to low blood. Your
blood was low because you were bleeding into your abdomen as a
result of a hip fracture likely suffered during your fall prior
to admission.
For your low blood sugars, we stopped your old diabetes
medications and started amaryl 1mg to take daily in the morning.
You should follow up with the [**Hospital **] clinic (call
[**Telephone/Fax (1) 27737**]).
For your heart, we increased atorvastatin to 20 mg daily. You
shoudl continue to take ASA 81 mg every day. You should make an
appointment with Dr. [**Last Name (STitle) **] for further follow up.
For your high blood pressure we changed your amlodipine to 20 mg
daily. We also changed your metoprolol to ??
For your hip fracture, orthopedics stated that surgery was not
indicated. You may bear weight as tolerated. Hip fractures
commonly lead to blood clots. To prevent blood clots, an IVC
filter was placed. You are to have your IVC filter removed as
scheduled below.
For your renal failure, you should follow up with Dr. [**Last Name (STitle) 4090**] on
[**3-19**] as scheduled below. In addition you should continue
taking iron and epopoietin to improve your anemia which is being
worsened by your renal failure. Your renal failure also
contributes to thin bones, please follow up with endocrinology
as noted below.
Please follow up with doctors as described below.
Please call yor primary care doctor if you have increased
weakness, pain, dizziness, chest pain, shortness of breath,
palpitations or any other concerning symptoms.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 8236**] for close follow up.
.
Please follow up with the [**Hospital **] clinic (phone:
[**Telephone/Fax (1) 27738**]regarding blood sugar control.
.
Kidney follow up: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2144-3-19**] 3:00
.
Please follow up with Division of endocrinology (phone ([**Telephone/Fax (1) 27739**]regarding management of your osteoporosis as scheduled
below.
Provider: [**Name10 (NameIs) **] DENSITY TESTING Phone:[**Telephone/Fax (1) 4586**]
Date/Time:[**2144-4-14**] 4:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2144-4-17**] 2:30
.
Please call [**Telephone/Fax (1) 8243**] to schedule for removal of your IVC
filter on [**2144-3-16**].
Completed by:[**2144-3-10**]
|
[
"272.0",
"E888.9",
"573.3",
"E942.9",
"410.71",
"250.82",
"868.04",
"403.90",
"808.2",
"285.1",
"276.7",
"585.4",
"808.0",
"285.21",
"250.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
9438, 9539
|
4212, 8384
|
273, 279
|
9851, 9897
|
2128, 3973
|
11570, 11817
|
1487, 1491
|
8536, 9415
|
9560, 9830
|
8410, 8513
|
9921, 11547
|
1506, 2109
|
11828, 12536
|
221, 235
|
307, 1291
|
3982, 4189
|
1313, 1346
|
1363, 1471
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,739
| 175,908
|
48559
|
Discharge summary
|
report
|
Admission Date: [**2133-12-17**] Discharge Date: [**2133-12-23**]
Date of Birth: [**2058-12-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
cholangitis
Major Surgical or Invasive Procedure:
ERCP, sphincterotomy
History of Present Illness:
Mr. [**Known lastname **] is a 75 yo M with history of HTN, HL, Hodgkin's
lymphoma (dx [**2121**]) and follicular lymphoma grade II (dx [**2127**]),
s/p chemo and xrt, on IVIG therapy for hypogammaglobulinemia
(last dose [**2133-12-9**]), and paroxysmal afib w/ RVR who presented
yesterday with 36 hours of midepigastric abdominal pain, without
radiation, [**2-6**] in pain scale, worse with deep inspiration.
Denied nausea, vomiting, fever, chills, diarrhea, constipation,
BRBPR, SOB, cough, chest pain, unexplained weight loss,
fatigue/malaise/lethargy, pruritis or jaundice. Does note
decreased appetite, pain not associated with food. Last BM 2
days ago. Patient took percocet x1 and later oxycodone x1, which
helped pain. Notified Dr. [**First Name (STitle) **] who recommended he go to the ED.
.
In ED, VS 99.2 64 203/88 20 98%. Labs showed WBC 6.5, elevated
LFTs (ALT 470, AST 278, AP 189, LDH 278, Tbili 9.8, Dbili7.5).
RUQ US showed gallstones, sludge and a distended gallbladder but
no pericholecystic fluid, CBD dilitation, GB wall thickening,
and was negative Murphies. No history of biliary colic,
cholecystitis, or liver disease. CT chest negative for PE.
Patient was admitted to ACS for monitoring, overnight patient
was hypertensive with SBP in the 180s, got hydralazine 10mg IV
however developed Afib with RVR with HR into the 140s this
morning, BP stable. EKG reportedly with ST depressions, CE
negative (CKMB 3, Trop<0.01). Previous episodes of afib with RVR
attributed to chemotherapy, fevers, volume overload. Patient's
HR was stabilized with diltiazem 10mg x2 and 15mg x1, and
metoprolol 10mg x3. Patient was transferred to the [**Hospital Unit Name 153**] with
plans for ERCP for possible cholangitis, based on LFTs and
elevated bilirubin, however patient is afebrile with a normal
WBC and no CBD dilitation on RUQ US. Afib with RVR attributed to
hepatobiliary process.
.
On arrival to the [**Hospital Unit Name 153**], VS: T 98.2, BP 123/71, HR 53, RR 18, 95%
on RA. Patient without abdominal pain, resting comfortable in
sinus rhythm. Patient has not received any pain medicine either
in the ED or on the floor.
Past Medical History:
1. Hodgkin's Lymphoma (diagnosed [**2121**], relapsed [**2126**] treated
with AVBD c/b Afib w/RVR, bleomycin lung toxicity, PCP
[**Name Initial (PRE) 1064**]) and Non-Hodgkin's (follicular) lymphoma (diagnosed
[**2127**], treated w/rituxan in [**2128**]).
2. Bleomycin toxicity
3. h/o PCP [**Name Initial (PRE) 1064**]
4. Paroxysmal A-Fib: Noted in clinic on day of his first dose of
neupogen, [**2127-3-11**], has been recurrant in setting of pulmonary
edema, chemotherapy, fever.
5. Hypertension
6. Hypercholesterolemia
7. Nephrolithiasis
8. Retinal detachment [**6-/2129**]
9. Peripheral neuropathy
10. psoriasis
11. Hypogammaglobulinemia
.
Onc history:
- Left-sided neck adenopathy biopsied in [**5-/2122**]: Hodgkin
disease with flow cytometry noted for monoclonal B cells which
were CD5 positive,raising the possibility of CLL. This was felt
likely due to
persistence of germinal centers and he was treated for stage IA
lymphocyte [**Doctor First Name **] Hodgkin disease with radiation therapy with a
total dose of 3060 centigrade of modified mantle field with
three
fractions of left neck cone down completed in 09/[**2121**].
- CT on [**2127-1-20**] revealed a left pleural mass with biopsy
consistent with relapsed classical Hodgkin lymphoma status post
ABVD X 6 cycles with complications of neutropenia, necessitating
the use of Neupogen, rapid atrial fibrillation, and bleomycin
toxicity along with PCP [**Name Initial (PRE) 1064**]. Bleomycin was held after
cycle two day one. Cycle six completed on [**2127-7-25**].
- Recurrent adenopathy noted in [**6-/2128**] with waxing and [**Doctor Last Name 688**]
size that was followed over time with a slowly increasing
adenopathy. Excisional biopsy of right neck adenopathy done by
Dr. [**Last Name (STitle) 1837**] on [**2129-3-28**] revealed a follicular lymphoma
grade 2.
- Status post four weeks of Rituxan from [**2129-4-19**] to [**2129-5-10**]
and one dose on [**2129-6-7**] followed by six cycles with Rituxan,
Doxil, and Cytoxan on [**2129-7-8**], [**2129-7-29**], [**2129-8-19**],
[**2129-9-8**], [**2129-10-14**] and [**2129-11-4**]. PET after 2 cycles with
marked improvement. PET scan after 4 cycles with no FDG avidity.
Doxil dose reduced to 25mg/m2 for 5th and 6th cycle due to
hand/foot rash.
- PET scan on [**2130-1-27**] revealed no FDG-avid disease. Treated
with 2 doses of maintenance Rituxan on [**2130-3-31**] and [**2130-4-7**].
- Follow up PET scan on [**2130-5-16**] showed new FDG avid
lymphadenopathy in the left infrarenal paraaortic and iliac
regions, with the largest paraaortic node measuring 30 x 16 mm
and SUVmax of 20.4, felt representing recurrent lymphoma but not
amenable to biopsy. No other new focal FDG uptake in the chest,
abdomen or pelvis.
- Received 1 cycle of ICE on [**2130-5-31**] complicated by fluid
overload and atrial fibrillation and flutter.
- Received 1 cycle of ESHAP on [**2130-6-22**] complicated by
bradycardia and repeat admission for atrial fibrillation.
- Repeat FDG imaging on [**2130-7-20**] continued to show FDG
avidity within the left paraaortic lymph node with SUV max of
11.2. Given prior history of Hodgkin's lymphoma and
non-Hodgkin's lymphoma, he underwent a biopsy by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 3748**] from Urology with laparoscopic surgery on [**2130-9-4**]
which did not show any evidence for non-Hodgkin's lymphoma or
Hodgkin's lymphoma.
- Repeat PET scan in [**9-/2130**] revealed resolution of his
lymphadenopathy and FDG avidity with no new areas. Follow up FDG
tumor imaging on [**2130-12-11**] reveals no evidence for
lymphadenopathy or recurrent lymphoma.
- Further treatment with Rituxan held due to recurrent sinus
infections which have been treated extensively with antibiotics
under the guidance of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] from ID. Follow up sinus
CTs finally showed resolution of his infection.
- Last treatment with Rituxan in [**3-/2131**] for 2 doses. Receiving
periodic IVIG for hypogammaglobulinemia, last given [**2132-12-30**].
- Follow up PET scanning in [**4-/2131**] and [**9-/2131**] notable for
enlarging FDG avid subcutaneous lesion in the right posterior
neck and new FDG-avidity in a tiny (3 mm) right level 5 lymph
node. These were followed with examinations and scans and the
right occipital node was increasing in size and proceeded with
FNA on [**2132-7-8**] which was nondiagnostic.
- Biopsy of right occipital mass on [**2132-7-31**] showed follicular
lymphoma, Grade 3A and follicular lymphoma, Grade [**11-30**],
diffuse(Extranodal extension) with concurrent lymphocyte-[**Doctor First Name **]
classical Hodgkin's lymphoma.
- Underwent XRT to right occipital area for total 3600cGy
completing on [**2132-10-1**] as only area of disease.
- PET CT on [**2133-2-4**] shows resolution of numerous previously
seen sites of FDG-avid cervical lymphadenopathy and right
suboccipital tissue nodal tissue with persistence of a 10 x 6 mm
left level IIB node with significant FDG avidity (SUV max 5.4).
Social History:
He lives at home with his wife. They have 2 children and 7
grandchildren. He is a retired telecommunications engineer. No
tobacco or alcohol use.
Family History:
Denies FH of DM, heart disease/MI, stroke, cancer. Thinks father
may have had a thyroid problem.
Physical Exam:
Exam (On admission to [**Hospital Unit Name 153**]):
Vitals: T 98.2, BP 123/71, HR 53, RR 18, 95% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear
Skin: jaundiced, psoriatic lesions over shins
Neck: supple, JVP not elevated, no LAD
Lungs: minimal bibasilar rales otherwise clear, no wheezes or
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 2/6 systolic
murmur, no rubs, gallops
Abdomen: soft with some firmness in midepigastrium, minimally
tender in mid epigastrium and RUQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. neg
murphys sign.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CN II-XII grossly intact, moving all extremities
Pertinent Results:
Imaging:
EKG: bradycardic at 57, prolonged QTc 460, otherwise normal
intervals, nonspecific T wave inversion unchanged from 8/[**2132**].
.
[**2133-12-16**] CXR: No signs of pneumonia or CHF.
.
[**2133-12-16**] RUQ US: Distended gallbladder containing stones and
probable tumefactive sludge. Findings are equivocal for acute
cholecystitis given lack of son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. Please
correlate clinically for lab abnormalities or other signs of
acute cholecystitis, and if the concern persists, a HIDA scan
can be obtained for further evaluation.
.
[**2133-12-16**] CTA: 1. No acute pulmonary embolism or thoracic aortic
pathology. 2. Small airways disease. 3. Diffusely dilated upper
thoracic esophagus, likely relates to esophageal dysmotility or
stricture. An esophagram can be performed on a non-emergent
basis for further assessment.
.
[**2133-12-17**] ERCP:
Normal major papilla
Cannulation of the biliary duct was successful and deep after a
guidewire was placed
A small filling defect, compatible with a stone was noted at the
distal bile duct. Otherwise, normal biliary tree
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
A small stone and large amount of pus were extracted
successfully using a balloon.
Otherwise normal ercp to third part of the duodenum
.
[**2133-12-21**]:
Atrial fibrillation with rapid ventricular response. Compared to
the
previous tracing of [**2133-12-21**] sinus rhythm is absent.
TRACING #2
.
Microbiology:
[**2133-12-18**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2133-12-17**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2133-12-17**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
.
[**2133-12-23**] 01:40PM BLOOD Hct-31.5*
[**2133-12-23**] 06:30AM BLOOD WBC-4.3 RBC-3.15* Hgb-10.3* Hct-29.9*
MCV-95 MCH-32.6* MCHC-34.3 RDW-13.7 Plt Ct-207
[**2133-12-22**] 04:05PM BLOOD Hct-32.7*
[**2133-12-22**] 06:30AM BLOOD WBC-4.1 RBC-3.13* Hgb-10.1* Hct-29.4*
MCV-94 MCH-32.4* MCHC-34.5 RDW-13.8 Plt Ct-177
[**2133-12-21**] 07:05AM BLOOD WBC-4.7 RBC-3.35* Hgb-11.0* Hct-31.2*
MCV-93 MCH-32.9* MCHC-35.3* RDW-13.5 Plt Ct-160
[**2133-12-20**] 07:30PM BLOOD Hct-30.5*
[**2133-12-20**] 07:50AM BLOOD WBC-3.5* RBC-3.31* Hgb-10.8* Hct-31.2*
MCV-94 MCH-32.6* MCHC-34.5 RDW-13.6 Plt Ct-149*
[**2133-12-19**] 09:00AM BLOOD WBC-3.1* RBC-3.21* Hgb-10.6* Hct-30.2*
MCV-94 MCH-33.0* MCHC-35.0 RDW-13.4 Plt Ct-149*
[**2133-12-18**] 04:54AM BLOOD WBC-3.8* RBC-3.31* Hgb-11.0* Hct-31.2*
MCV-94 MCH-33.3* MCHC-35.3* RDW-13.3 Plt Ct-154
[**2133-12-17**] 08:02PM BLOOD WBC-6.1 RBC-3.69* Hgb-12.1* Hct-34.1*
MCV-93 MCH-32.8* MCHC-35.5* RDW-13.1 Plt Ct-154
[**2133-12-16**] 07:50PM BLOOD WBC-6.5 RBC-4.18* Hgb-13.5* Hct-38.6*
MCV-92 MCH-32.3* MCHC-35.0 RDW-12.7 Plt Ct-189
[**2133-12-16**] 07:50PM BLOOD Neuts-82.2* Lymphs-8.0* Monos-6.3 Eos-3.1
Baso-0.4
[**2133-12-18**] 04:54AM BLOOD PT-12.6* PTT-32.9 INR(PT)-1.2*
[**2133-12-17**] 08:02PM BLOOD PT-13.1* PTT-29.7 INR(PT)-1.2*
[**2133-12-23**] 06:30AM BLOOD Glucose-90 UreaN-22* Creat-1.3* Na-140
K-4.0 Cl-103 HCO3-29 AnGap-12
[**2133-12-22**] 06:30AM BLOOD Glucose-97 UreaN-33* Creat-1.3* Na-143
K-3.9 Cl-107 HCO3-29 AnGap-11
[**2133-12-21**] 09:30PM BLOOD UreaN-33* Creat-1.3* Na-140 K-3.6 Cl-103
[**2133-12-21**] 07:05AM BLOOD Glucose-97 UreaN-26* Creat-1.3* Na-141
K-3.8 Cl-104 HCO3-29 AnGap-12
[**2133-12-20**] 07:50AM BLOOD Glucose-100 UreaN-20 Creat-1.3* Na-142
K-3.7 Cl-107 HCO3-28 AnGap-11
[**2133-12-19**] 09:00AM BLOOD Glucose-121* UreaN-19 Creat-1.2 Na-142
K-3.2* Cl-106 HCO3-28 AnGap-11
[**2133-12-18**] 04:54AM BLOOD Glucose-76 UreaN-22* Creat-1.3* Na-141
K-3.5 Cl-105 HCO3-24 AnGap-16
[**2133-12-17**] 08:02PM BLOOD Glucose-88 UreaN-21* Creat-1.2 Na-142
K-3.7 Cl-106 HCO3-23 AnGap-17
[**2133-12-16**] 07:50PM BLOOD Glucose-113* UreaN-28* Creat-1.3* Na-139
K-4.5 Cl-100 HCO3-25 AnGap-19
[**2133-12-23**] 06:30AM BLOOD ALT-239* AST-137* AlkPhos-110
TotBili-3.4*
[**2133-12-22**] 06:30AM BLOOD ALT-216* AST-122* AlkPhos-109
TotBili-3.4*
[**2133-12-21**] 07:05AM BLOOD ALT-212* AST-125* AlkPhos-124
TotBili-5.3*
[**2133-12-20**] 07:50AM BLOOD ALT-172* AST-82* AlkPhos-123 TotBili-5.8*
[**2133-12-19**] 09:00AM BLOOD ALT-183* AST-74* AlkPhos-128 TotBili-6.9*
[**2133-12-18**] 04:54AM BLOOD ALT-235* AST-103* LD(LDH)-155
AlkPhos-140* TotBili-8.6*
[**2133-12-17**] 08:02PM BLOOD ALT-273* AST-125* LD(LDH)-196
AlkPhos-146* TotBili-8.6*
[**2133-12-17**] 09:00AM BLOOD CK(CPK)-58
[**2133-12-16**] 07:50PM BLOOD ALT-470* AST-278* LD(LDH)-278*
AlkPhos-189* TotBili-9.8* DirBili-7.5* IndBili-2.3
[**2133-12-16**] 07:50PM BLOOD Lipase-29
[**2133-12-17**] 08:02PM BLOOD CK-MB-3 cTropnT-<0.01
[**2133-12-17**] 09:00AM BLOOD CK-MB-3 cTropnT-<0.01
[**2133-12-21**] 07:05AM BLOOD IgG-537* IgA-95 IgM-19*
Brief Hospital Course:
75 yo M with PMH of HTN, HL, Hodgkin's lymphoma (dx [**2121**]) and
follicular lymphoma grade II (dx [**2127**]), s/p chemo and xrt, on
IVIG therapy for hypogammaglobulinemia, and paroxysmal afib w/
RVR who presented with RUQ/epigastric pain and elevated [**Hospital 13550**]
transferred to [**Hospital Unit Name 153**] for afib with RVR (resolved), found on ERCP
to have cholangitis.
.
# Cholangitis/bile duct obstruction/choledocholithiasis: Patient
presented with new onset epigastric and RUQ abominal pain in the
setting of elevated LFT's and direct hyperbilirubinemia. RUQ US
was non definitive for acute cholecystitis or biliary
obstruction. Patient has been afebrile with a normal WBC, and no
evidence of CBD dilitation. He was started on Unasyn on [**2133-12-17**]
and transferred to the [**Hospital Unit Name 153**] for ERCP during which a
sphincterotomy was performed and 1 small stone and significant
amount of pus were extracted. Per ERCP recommendation, patient
was switched from unasyn to ciprofloxacin 500mg PO x5days. LFTs,
Dbili, WBC trended down steadily. Blood cultures sent and were
negative. Patient remained stable in the ICU without abdominal
pain, diet was advanced as tolerated and patient was transferred
to the floor for further monitoring. ACS did not plan to perform
cholecystectomy in this acute setting and recommended outpatient
clinic follow up in [**1-1**] weeks (appointment scheduled). The
surgical service recommended [**Date Range **] comment on optimization
prior to surgery. The [**Date Range 3242**] service did not feel as though pt
needed any further interventions from the [**Date Range **] perspective
prior to surgery.
.
# Afib w/ RVR: Previous episodes of Afib with RVR attributed to
chemotherapy, fevers, and volume overload. Patient went into
afib with RVR, rate in the 140s, on the night of admission,
thought to be due to infection/cholangitis. He was given
multiple IV doses of diltiazem and metoprolol and converted back
into sinus rhythm prior to arrival to [**Hospital Unit Name 153**]. HR remained in the
50s (normally 50s-60s). BP remained stable throughout episode.
EKG showed some ST depressions (troponin and CKMB negative).
Repeat EKG was unchanged from EKG prior to Afib w/ RVR episode,
no ST depressions. He is managed with metoprolol and ASA 325 at
home, which were continued through the admission. Abdominal pain
was controlled and patient was monitored on telemetry. Pt did
well on the medical floor but had one evening of RVR that
responded to IV metoprolol. Generally, pt's HR is 50's-60's and
sinus. He was discharged on his home regimen of 25mg Toprol XL.
His aspirin was held on the medical floor due to guaiac+ dark
stool, but HCT remained stable. Pt was instructed to have a
repeat CBC at his PCP's office [**2133-12-29**]. If stable, would resume
aspirin at that time.
.
#anemia-normocytic, Likely acute blood loss and consistent with
chronic inflammation. Baseline appeared to be 34-38. Pt was
constipated for several days after ERCP. However, pt then began
to develop very dark brown guaiac positive stool. Pt's heparin
SC and aspirin were discontinued in this setting. ERCP team was
notified and recommended HCT monitoring. Pt's HCT was monitored
closely and remained stable for 5 days (~HCT 30) prior to
discharge. However, pt continued with dark guaiac + stool (no
blood), without any evidence of hemodynamic compromise during
admission. Upon discharge, pt was instructed to continue holding
his ASA and have a repeat HCT drawn on [**12-29**] at his PCP's office.
HCT 31.5 on day of DC.
.
#CKD-baseline appears to be 1.1-1.3. Remained at baseline during
admission.
.
# h/o PCP [**Name Initial (PRE) 11091**]: Continued on Bactrim DS MWF, no symptoms during
admission.
.
# Gout: Continued allopurinol 100 Q daily.
.
# HTN: Continued home lisinopril and metoprolol
.
# Hyperlipidemia: Held home simvastatin given elevated LFTs.
Consider resuming when LFTs normalize/stabilize.
.
# Hypogammaglobulinemia: Stable, managed on IVIG, seen regularly
by Dr. [**First Name (STitle) **]. Last dose on [**2133-12-9**]. Pt to follow up with Dr.
[**First Name (STitle) **] for further care.
.
# Lymphoma: Patient is not currently on a chemo regimen.
Followed by Dr. [**First Name (STitle) **]. Follow up appointment scheduled prior to
DC.
.
# Psoriasis: Patient has mild psoriasis over shins managed at
home with hydrocortisone. Continued hydrocortisone cream.
.
Transitional Issues:
-repeat CBC and LFTs at PCP's office. Restart asa/simvastatin
when able. Pt has f/u scheduled in surgery clinic as well as
PCP, [**Name10 (NameIs) **], and cardiology.
Medications on Admission:
Albuterol prn
Allopurinol 100'
Bactrim DS 3xWeek (MWF)
Lisinopril 5'
Simvastatin 40'
Metoprolol 25'
Omeprazole DR 20'
Cialis 5'
Asa 325
Vitamin B
MV
Glucosamine 750'
Fish oil ''
Folic acid 400'
hydrocortisone cream for psoriasis
Occasional percocet or oxycodone for pain (rare)
IVIG
Discharge Medications:
1. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. B-complex with vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
10. folic acid 400 mcg Tablet Sig: One (1) Tablet PO once a day.
11. cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day).
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
13. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
14. stop
Please stop your simvastatin and aspirin until instructed to
restart by your PCP
15. Outpatient Lab Work
LFTs, bilirubin and CBC on [**2133-12-29**] at Dr.[**Hospital1 6460**] office.
Discharge Disposition:
Home
Discharge Diagnosis:
choledocholithiasis
cholangitis
transaminitis
afib with RVR
anemia
HTN
history of lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for evaluation of abdominal pain and were
found to have an infection (cholangitis) and stones in your bile
ducts. For this, you underwent and ERCP that found pus and
stones. You also had a sphincterotomy (area of narrowing was
opened).
.
You also had fast atrial fibrillation while in the ICU. You were
continued on your metoprolol.
.
You also had dark stools and a slight drop in your blood count.
However, your blood count has been stable for 5 days. The GI
doctors did not feel that there were any further interventions
that needed to occur.
.
Medication changes:
1.stop your aspirin until instructed to restart by your PCP
after your blood counts are rechecked.
2.please continue to take cipro and flagyl for 5 more days
3.stop your simvastatin until instructed to restart by your PCP
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Address: [**Location (un) **], [**Apartment Address(1) 8308**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 7318**]
Appt: [**12-29**] at 9am
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2134-1-12**] at 2:00 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/[**Hospital Ward Name 3242**]
When: FRIDAY [**2134-1-8**] at 9:00 AM
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: [**Hospital Ward Name 3242**] CHAIRS & ROOMS
When: FRIDAY [**2134-1-8**] at 9:00 AM
Department: CARDIAC SERVICES
When: TUESDAY [**2134-1-19**] at 9:20 AM
With: [**Doctor First Name 900**] [**Name8 (MD) 901**], 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
|
[
"427.31",
"201.98",
"585.9",
"792.1",
"272.0",
"403.90",
"272.4",
"576.1",
"284.19",
"790.4",
"285.1",
"202.00",
"279.00",
"274.9",
"696.1",
"574.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
19848, 19854
|
13472, 17902
|
317, 339
|
19989, 19989
|
8676, 13449
|
21066, 22354
|
7776, 7874
|
18425, 19825
|
19875, 19968
|
18118, 18402
|
20140, 20705
|
7889, 8657
|
17923, 18092
|
20725, 21043
|
266, 279
|
367, 2506
|
20004, 20116
|
2528, 7597
|
7613, 7760
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,122
| 100,779
|
52848
|
Discharge summary
|
report
|
Admission Date: [**2203-8-3**] Discharge Date: [**2203-8-29**]
Date of Birth: [**2140-12-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Anacin
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
[**2203-8-3**]
Right thoracotomy and tracheoplasty with mesh,
right mainstem bronchus and bronchus intermedius
bronchoplasty with mesh, left mainstem bronchus bronchoplasty
with mesh, bronchoscopy with bronchoalveolar lavage.
[**2203-8-15**] -
tracheostomy
[**2203-8-25**]
Flexible bronchoscopy with bronchoalveolar lavage.
History of Present Illness:
The patient is a 62-year-old
gentleman who has severe COPD was found have severe diffuse
tracheobronchomalacia. He had marked improvement in dyspnea
with a silicone Y-stent, and presents for
tracheobronchoplasty. He is using inhalers as prescribed
with some sx improvement and using oxygen at night. Without O2
he
is satting about 88-90%.
He had a mild URI several months ago and fully recovered from
it.
He is able to walk several blocks w/o stopping; he is OK going
up
one flight of stairs but usually needs a break at the end.
He presents now for surgery.
Past Medical History:
# Diabetes mellitus type 2
-- followed at [**Last Name (un) **], on Insulin and Victoza
-- last HgbA1c 9.2% on [**2202-12-14**]
# COPD -- former heavy smoker
-- good functional capacity
# Tracheobronchomalacia
-- severe on CT and bronchoscopy ([**8-/2202**])
-- excellent results with stent trial
-- considering tracheobronchoplasty
# Diastolic CHF
-- seen by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Cardiology
-- last echo ([**2200-9-19**]) with LVEF > 60%
-- stable on Furosemide 60 mg PO daily
-- mild lower extremity edema
# Osteoarthritis -- stable symptoms
# Narcotics Contract -- stable Percocet regimen
-- last renewed on [**2202-3-3**]
# Hypertension -- recently added Hydralazine
# GERD -- no symptoms recently
# Chronic kidney disease stage III
-- seen by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
-- stable creatinine around 1.5
-- Calcitriol for elevated PTH
Social History:
# Diet: He has had difficulty improving his diet. His weight
has remained fairly stable.
# Exercise: Walks approximately one mile each day and is fairly
physically active given his medical issues.
# Smoking: Quit approximately six years ago and previously
smoked 0.5-1 pack per day since the age of 12.
# Alcohol: No alcohol in 15 years, stopped after getting sick
from drinking too much wine at a party.
# Drugs: None
Family History:
# Mother -- died at age 58 from DM complications
# Father -- died at age 73 from "[**Last Name **] problem" but not MI
Physical Exam:
BP: 171/70. Heart Rate: 63. Weight: 251.8. BMI: 35.4.
Temperature: 95.7. O2 Saturation%: 90.
Alwake alert oriented
lungs clear w/o wheezing
heart regular
abd soft, not distended
Pertinent Results:
[**2203-8-3**] 11:20AM HGB-15.1 calcHCT-45
[**2203-8-3**] 01:17PM HGB-14.6 calcHCT-44 O2 SAT-97 MET HGB-0
[**2203-8-3**] 01:17PM GLUCOSE-119* LACTATE-1.4 NA+-140 K+-3.7
CL--104 TCO2-27
[**2203-8-3**] 05:27PM WBC-16.1*# RBC-5.43 HGB-14.5 HCT-45.6 MCV-84
MCH-26.6* MCHC-31.7 RDW-16.3*
[**2203-8-3**] 05:27PM CALCIUM-7.9* PHOSPHATE-4.9*# MAGNESIUM-1.5*
[**2203-8-3**] 05:27PM CK-MB-14* MB INDX-0.8
[**2203-8-3**] 05:27PM CK(CPK)-1719*
[**2203-8-3**] 05:27PM GLUCOSE-136* UREA N-18 CREAT-1.6* SODIUM-141
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-27 ANION GAP-11
[**2203-8-14**] Chest CT :
1. Status post tracheobronchoplasty. ET tube in place with fluid
within the distal trachea. Persistent narrowing of the central
airways.
2. Since [**2203-8-1**], new large right, and moderate left
loculated pleural effusions.
3. New diffuse bilateral ground glass opacities with prominent
pulmonary
vasculature, likely edema.
4. Bilateral lower lobe opacities, likely atelectasis, cannot
exclude
infection.
5. Emphysema.
6. Prior granulomatous disease.
[**2203-8-18**] Bilat lower ext duplex :
No evidence of deep vein thrombosis in either leg.
[**2203-8-23**] Chest CT :
1. Extensive bilateral diffuse ground-glass opacities with
associated
bibasilar severe atelectasis and small pleural effusions along
with the severe tracheobronchial stenosis suggest that a
combination of upper airway obstruction, pulmonary edema,
atelectasis, and likely a concurrent infectious process might be
contributing to the patient's difficulty to wean off the vent.
2. Enlarged mediastinal lymph nodes, not significantly changed
compared with prior studies.
[**2203-8-29**] CXR :
In comparison with the study of [**8-27**], the monitoring and support
devices remain in place. Continued enlargement of the cardiac
silhouette with indistinct pulmonary vessels and bilateral areas
of pulmonary opacification, consistent with pulmonary edema and
multifocal pneumonia.
[**2203-8-12**] 4:20 pm SPUTUM SPUTUM.
**FINAL REPORT [**2203-8-15**]**
GRAM STAIN (Final [**2203-8-12**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2203-8-15**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SERRATIA MARCESCENS. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| SERRATIA MARCESCENS
| |
CEFEPIME-------------- 2 S <=1 S
CEFTAZIDIME----------- 4 S <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S 4 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2203-8-18**] 11:42 am BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2203-8-22**]**
GRAM STAIN (Final [**2203-8-18**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2203-8-22**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA.
>100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SERRATIA MARCESCENS. 10,000-100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| SERRATIA MARCESCENS
| |
CEFEPIME-------------- 4 S <=1 S
CEFTAZIDIME----------- 4 S <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 I <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM------------- 1 S <=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S 8 I
TRIMETHOPRIM/SULFA---- <=1 S
[**2203-8-25**] 12:37 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2203-8-25**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2203-8-27**]):
Commensal Respiratory Flora Absent.
YEAST. 10,000-100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD(S). ~[**2191**]/ML. FURTHER WORKUP ON
REQUEST ONLY.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
FUNGAL CULTURE (Preliminary):
YEAST.
Brief Hospital Course:
Mr. [**Known lastname 108993**] is a 62 year old admitted for tracheobronchomalacia
on whom we performed tracheobronchoplasty with posterior
splinting on [**2203-8-3**]. The procedure went without
complications. Post-operatively in the PACU he failed to
extubate and was transferred to the trauma ICU. A chest xray at
the time showed that the endotracheal tube ended 3.9cm above
carina. The right chest tube was in place. There was only mild
pulmonary edema, no pneumothorax, and bibasilar atelectasis. At
the time he developed low urine output and received a 500 mL
bolus. He was found to have persistent metabolic acidosis.
On POD1, his chest tube was set to waterseal. A second attempt
was made to extubate. He became hypoxic with oxygen saturations
at 88%, so he was placed to CPAP. Due to respiratory distress,
however, he required reintubation. At the time, a chest xray
revealed subcutaneous emphysema tracking along the anterior
chest wall and a pneumothorax. The chest tube was placed back
onto -20 cm H2O suction.
On POD2, his creatinine was elevated to 2.6. A FeNa was 0.2%
and FeUrea was 31.8%. The patient was on furosemide at the
time, so intrinsic renal failure was suspected given the FeUrea
as FeNa is unreliable in patients on furosemide. He was put on
D5 normal saline, and tube feeds were started via an orogastric
tube. A chest xray at the time reveals a stable pneumothorax.
A PICC line was placed for additional access.
On POD3, the pleurovac was found to have a systems leak and was
replaced. Tube feeds were advanced every 6 hours. FeUrea was
43.3, a non-diagnostic value. Creatinine was stable at 2. A
sputum culture from POD1 grew our rare gram negative rods.
On POD4, to optimize respiratory status, furosemide was
continued and a 60mg IV dose administered. Mr. [**Known lastname 108993**] was
started on levofloxacin and piperacillin/tazobactam at this time
too because of the cultures. He was also having hypertension,
and his metoprolol was increased from twice daily to thrice
daily. We felt at this time the chest tube was working against
the patient's ability to exhale efficiently, so we removed the
chest tube. He developed a fever or 102.7 and so cultures were
drawn.
On POD5, the sputum cultures grew out pansensitive pseudomonas
aeruginosa. Because of persistent hypertension with systolic
blood pressures reaching the 190s, a labetalol drip was started
and hydralazine started, which achieved better control. His
FiO2 was increased from 40% to 60% due to low saturations of
80%.
On POD6, he pass a spontaneous breathing trial on 0 and 5
inspiratory pressure support settings; however, after an
extubation trial he became hypoxic at 5 minutes, desatting to
70%. He also became tachypnic and so he was reintubated. To
optimize his ventilatory status, a fluid deficit was desired.
To achieve it, his drips were concentrated. His cumulative
balance that day was -500 mL.
On POD7, a new left subclavian line was placed to begin a
furosemide drip. Inhaled steroids were also added in an effort
to optimize respiratory status.
On POD8, sensitivities came back on the pseudomonas cultures,
and vancomycin was discontinued. Ciprofloxacin was changed to
PO. Fluid balance was -1.6L.
On POD9, copious secretions were noted and repeat sputum
cultures obtained. Fluid balance was -2.4L.
On POD10, he developed a WBC of 18 and low grade temperatures,
so he was pan-cultured. To double cover pseudomonas,
piperacillin/tazobactam was started. The U/A was not conclusive
for infection.
On POD 11, WBC continued to rise to 21. A CT of the chest was
performed to search a source that was potentially drainable. A
large right pleural effusion was found as well as a smaller,
left-sided loculated effusion. His PICC was draining purulent
materal, and a PICC culture was sent but ultimately grew out
nothing (final). His bronchoalveolar lavage culture was 2+PMNs,
and grew out pseudomonas again.
On POD12/0, a tracheostomy was performed in the OR. The
operation went without complications, and post-operatively the
patient was transferred directly to the trauma ICU. A Dobhoff
tube was placed, and a thoracentesis of the pleural effusion was
performed with cultures sent. No organisms were isolated.
On POD13/1, loose stools prompted a C. diff toxin assay, which
was negative. He had increased hypertension, so labetalol IV
was given. His sedation medication, lorazepam, was switched to
propofol in an effort to reduce his hypertension. A blood gas
revealed respiratory alkalosis.
On POD14/2, patient was foudn to have increased abdominal
distention, and a KUB showed ileus. NGT was placed to low
continuous suction, tube feeds held. Methylnaltrexone, a
mu-opioid antagonist, was trialed with no effect. He was found
also on CXR to have a R>L pleural effusion, for which
interventional pulmonology was consulted for pigtail placement.
He continued to be diuresed, receiving 40 mg furosemide IV. He
was also febrile to 101.3 and so he was pan-cultured. Although
the urine, pleural fluid, and blood cultures were negative, the
sputum culture grew out serratia marcesens and pseudomonal
aeruginosa.
On POD15/3, bronchoscopy was performed for respiratory
secretions. He was hypertensive and started on a labetalol
drip. Based on ID recommendations, he was switched to cefepime.
At this time, the source of leukocytosis was unclear but it was
suggested the mesh may be colonized with pseudomonas aeruginosa.
The pulmonology team, who had been consulted for failure to
extubate, felt a wise course would be to permit lung rest on the
ventilator and allow the pneumonia to pass prior to subsequent
extubation attempts. So, he remained on the ventilator on
POD16/4, and that day was otherwise unremarkable.
On POD17/5, the pigtail catheter was removed; however, due to
high PEEP requirements, the trauma ICU was unable to attempt
trach mask. In an effort for further diuresis, on POD18/6 the
tube feeds were concentrated. Also he was switched to D5 1/2NS
for hypernatremia. Despite having been found to have persistent
copious secretions, Mr. [**Known lastname 108993**] was able to be weaned to CPAP
[**1-16**]. He self-discontinued his arterial line, which was
replaced.
On POD19/7, his mental status continued to improve, and bowel
sounds were noted. Tube feeds were continued at goal.
On POD20/8, his mental status continued to improve and he was
able to answer questions. Despite SaO2>95%, he was having
episodes of agitation, which improved with lorazepam. He was
started on inhaled tobramycin for double-coverage of
pseudomonas. A repeat CT chest did not show an appreciable
drainable effusion. He was switched back to assist control for
increased tachypnea despite normal oxygen saturations.
On POD21/9 he had a J tube placed and tube feedings were
continued which were well tolerated. His insulin requirements
were graduaklly decreasing as his infection was controlled and
his insulin was adjusted appropriately.
Over the last few days his WBC had decreased nicely to the 14
range and he remains afebrile on Cefepine ( started [**2203-8-19**]) and
inhaled Tobra (started [**2203-8-23**]). His antibiotics should continue
thru [**2203-9-14**]. His secretions have decreased since his last
bronchoscopy on [**2203-8-25**]. There was no exposed mesh or purulence
noted. He has been weaning better with good CPAP trials and
remains on O2 at 50% with IPS and PEEP both at 8 cm.
He also has been evaluated by the Physical Therapy service
closely and he needs continued encouragement and maximum
assistance to increase his mobility and evantually be more
independent. After a long, complicated course, he was
discharged to rehab of [**2203-8-29**] and will follow up with Dr.
[**Last Name (STitle) **] in 2 weeks.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 40 mg PO DAILY
2. Allopurinol 100 mg PO BID
3. Atenolol 50 mg PO BID
4. Amlodipine 10 mg PO DAILY
5. HydrALAzine 50 mg PO BID
6. Atorvastatin 80 mg PO DAILY
7. Humalog 75/25 80 Units Breakfast
Humalog 75/25 40 Units Lunch
Humalog 75/25 70 Units Dinner
8. Furosemide 60 mg PO DAILY
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
11. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
12. Aspirin 81 mg PO DAILY
13. Tamsulosin 0.4 mg PO HS
14. Ipratropium Bromide MDI 2 PUFF IH QID
15. Calcitriol 0.25 mcg PO EVERY OTHER DAY
16. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. NPH 35 Units Breakfast
NPH 25 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
3. HydrALAzine 50 mg PO BID
4. Albuterol Inhaler 6 PUFF IH Q2H:PRN Wheeze
5. Albuterol-Ipratropium 6 PUFFS IH Q6H
6. Bisacodyl 10 mg PO/PR [**Hospital1 **]
7. CefePIME 2 g IV Q8H
thru [**2203-9-14**]
8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation.
9. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWED
10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
11. Docusate Sodium 100 mg PO BID
12. Famotidine 20 mg PO BID
13. Fluconazole 100 mg PO Q24H Duration: 7 Days
thru [**2203-9-5**]
14. Heparin 5000 UNIT SC TID
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q3H:PRN pain
17. Labetalol 300 mg PO TID HTN
Hold for SBP<120, HR<50.
18. Lorazepam 1-2 mg IV Q4H:PRN agitation
19. Maalox/Diphenhydramine/Lidocaine 15-30 mL PO TID:PRN mouth
sores
20. Metoclopramide 5 mg PO QIDACHS
21. Ondansetron 4 mg IV Q8H:PRN nausea
22. Senna 1 TAB PO BID
23. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
24. Tobramycin Inhalation Soln 300 mg NEB [**Hospital1 **]
thru [**2203-9-14**]
25. Atorvastatin 80 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Tracheobronchomalacia
Pseudomonas and serratia pneumonia
Respiratory insufficiency
Thrush
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
* You were admitted to the hospital for surgery to improve your
airway. Unfortunately you had difficulty breathing on your own
and you required a tracheostomy along with help from a
respirator.
* You are slowly improving and will need time to get stronger
and totally wean from the respirator.
* You are4 being fed through a feeding tube in your stomach but
in time you should be able to swallow and eat regular food.
* You will need to participate in Physical Therapy to get strong
and begin to walk again.
* Dr. [**Last Name (STitle) **] will continue to follow you in the Clinic.
Followup Instructions:
You will need to be seen by Dr. [**Last Name (STitle) **] in the Thoracic
Surgery Clinic on [**2203-9-13**]. His secretary will call the
rehab to arrange a time. ([**Telephone/Fax (1) 16996**])
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) 470**] of the [**Location (un) 40900**] for a chest xray.
Completed by:[**2203-8-29**]
|
[
"512.1",
"518.51",
"428.32",
"585.3",
"041.85",
"496",
"428.0",
"584.9",
"530.81",
"403.90",
"519.19",
"250.00",
"997.31",
"V58.67",
"041.7",
"E879.8",
"112.0",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.48",
"31.79",
"33.24",
"34.91",
"96.6",
"38.97",
"31.1",
"96.72",
"44.32"
] |
icd9pcs
|
[
[
[]
]
] |
19049, 19115
|
8947, 16764
|
281, 609
|
19249, 19249
|
2949, 8875
|
20034, 20421
|
2613, 2734
|
17597, 19026
|
19136, 19228
|
16790, 17574
|
19425, 20011
|
2749, 2930
|
8911, 8924
|
234, 243
|
637, 1201
|
19264, 19401
|
1223, 2159
|
2175, 2597
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,153
| 163,981
|
3662
|
Discharge summary
|
report
|
Admission Date: [**2104-12-23**] Discharge Date: [**2104-12-28**]
Date of Birth: [**2038-6-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypotension, low Hct
Major Surgical or Invasive Procedure:
EGD
IR embolization
History of Present Illness:
This is a 66 yo male with h/o metastatic bladder ca to liver,
lung on chemo who originally presented on [**2104-12-23**] from clinic
with hypotension and Hct of 17. Pt was having episodes of
syncope at home and some abdominal pain, went to his outpt
oncologist's office for chemotherapy (C1D8
Gemcitabine/Cisplatin) where he was noted to have a BP of 75/56
and Hct was 17 and thus pt was sent to the ED. In the [**Name (NI) **], pt
was given IVF, started on blood transfusions. CT abd showed
pneumobilia [**12-17**] cholecystoenteric fistula. Pt was admitted to
SICU for further management. Though surgery was initially
considered, it was determined that pt is not a surgical
candidate. Pt has remained hemodynamically stable, not
requiring pressors. Pt has been continuously transfused with
goal Hct>30. GI has been following who performed an EGD which
showed ulcers in stomach and duodenal bulb as well as a larger
ulcerated region at the junction of duodenal bulb and second
part of duodenum on the posterior wall of the duodenum with
adherent clot, suggestive of possible tumor eroding the small
bowel wall. Per GI recs, pt was continued on PPI gtt and blood
transfusions. Since, pt continued to bleed, pt underwent an IR
procedure today, where no active bleeding was seen and the
gastroduodenal artery was embolized. Pt continues to get
supportive care with transfusions. Currently, Hct is 21.2 and
getting 2U pRBCs.
.
Upon arrival to the MICU, pt is comfortable in bed. Endorses
some mild pain in abdomen, but much better from admission.
Denies n/v. States he continues to have dark red stools.
Denies chest pain. Denies dysuria. Admits to occasional
shortness of breath but denies fevers or cough.
.
ROS: per HPI, endorses 20 lb weight loss in last 6 months.
endorses syncopal episodes at home prior to admission. [**Doctor First Name 1638**]
HAs.
Past Medical History:
ONCOLOGIC HISTORY:
- [**6-/2104**] pt referred to Dr [**First Name (STitle) **] for microscopic hematuria,
found
to have abnormal digital rectal exam with nodularity adjacent to
the right prostate and the right seminal vesicle
- [**2104-7-22**] cystoscopy showed normal bladder mucosa except for
>2 cm calculus protruding from a diverticulum between the right
urothelial orifice and bladder neck.
- [**2104-9-11**] prostate biopsy showed invasive high-grade
carcinoma
involving the prostatic stroma and extraprostatic adipose
tissue,
one core showed prostatic adenocarcinoma, [**Doctor Last Name **] score 3+3.
- [**2104-10-16**] cystoprostatectomy and ileal conduit.The final
pathology examination showed invasive urothelial (transitional
cell) carcinoma arising from the bladder diverticulum and
extending into the perivesicular adipose tissue, prostate gland
and right seminal vesicle. The tumor greatest dimension was 5.5
cm, high-grade, pT4a; two of the five regional lymph nodes were
positive for metastasis (pN2), the margins were uninvolved by
carcinoma, but there was extensive lymphovascular invasion and
perineural invasion. A [**Doctor Last Name **] 3+3 adenocarcinoma of the
prostate
was identified, as well.
Other Medical History:
1. Nephrolithiasis
2. Peripheral vascular disease
3. Depression/Anxiety
Social History:
Smoked 1/2-1 ppd for 50 years, quit recently. Denies EtOH (used
to drink 2 drinks per day prior to bladder ca diagnosis) or
drugs.
Family History:
father died of colon cancer at age 60. mother with breast
cancer at age [**Age over 90 **] s/p lumpectomy. one sister who died in her late
20s of ovarian cancer.
Physical Exam:
VS: Temp: 96.8 BP: 118/63 HR: 94 RR: 22 O2sat 99% on RA
GEN: pale, weak, NAD
HEENT: PERRL, EOMI, pale conjunctivae, OP clear
RESP: CTAB with good air movement throughout
CV: RRR, no m/r/g
ABD: soft, mild diffuse ttp in abdomen
EXT: no c/c/e
NEURO: AAOx3. CN II-XII intact. 5/5 strength throughout. No
sensory deficits.
Pertinent Results:
[**2104-12-27**] 05:47AM BLOOD Hct-22.5*
[**2104-12-27**] 02:00AM BLOOD WBC-4.3 RBC-2.85*# Hgb-8.9*# Hct-24.4*
MCV-86 MCH-31.1 MCHC-36.3* RDW-14.9 Plt Ct-96*
[**2104-12-26**] 10:14PM BLOOD Hct-26.7*#
[**2104-12-26**] 05:06PM BLOOD Hct-20.9*
[**2104-12-26**] 02:10PM BLOOD Hct-26.3*
[**2104-12-26**] 09:27AM BLOOD WBC-4.8 RBC-4.15*# Hgb-12.2*# Hct-34.0*#
MCV-82 MCH-29.3 MCHC-35.8* RDW-14.7 Plt Ct-109*
[**2104-12-26**] 03:41AM BLOOD WBC-5.1 RBC-2.61* Hgb-7.7*# Hct-21.3*
MCV-82 MCH-29.7 MCHC-36.3* RDW-14.0 Plt Ct-80*
[**2104-12-25**] 08:39PM BLOOD Hct-21.2*
[**2104-12-25**] 03:53PM BLOOD Hct-22.4* Plt Ct-145*#
[**2104-12-25**] 08:26AM BLOOD Hct-22.8* Plt Ct-70*
[**2104-12-25**] 01:45AM BLOOD WBC-10.0 RBC-3.38*# Hgb-10.3*# Hct-28.5*
MCV-84 MCH-30.6 MCHC-36.3* RDW-14.3 Plt Ct-63*
[**2104-12-24**] 11:01PM BLOOD Hct-29.6*#
[**2104-12-24**] 07:15PM BLOOD Hct-22.3*
[**2104-12-24**] 01:44PM BLOOD Hct-21.4*
[**2104-12-24**] 07:23AM BLOOD Hct-28.3*
[**2104-12-24**] 03:59AM BLOOD Hct-28.9*#
[**2104-12-23**] 10:45PM BLOOD WBC-11.5* RBC-2.65* Hgb-7.9* Hct-22.0*
MCV-83 MCH-29.9 MCHC-36.1* RDW-15.2 Plt Ct-108*
[**2104-12-23**] 06:15PM BLOOD WBC-8.8 RBC-2.68*# Hgb-8.0*# Hct-22.5*#
MCV-84 MCH-29.7 MCHC-35.5* RDW-14.7 Plt Ct-105*
[**2104-12-23**] 12:25PM BLOOD WBC-8.9 RBC-1.98* Hgb-5.9* Hct-17.1*
MCV-86 MCH-29.8 MCHC-34.5 RDW-14.4 Plt Ct-124*
[**2104-12-23**] 10:46AM BLOOD WBC-10.4# RBC-2.30*# Hgb-6.6*# Hct-20.6*#
MCV-90 MCH-28.7 MCHC-32.1 RDW-14.1 Plt Ct-154#
[**2104-12-26**] 09:27AM BLOOD PT-15.1* PTT-24.5 INR(PT)-1.3*
[**2104-12-26**] 03:41AM BLOOD PT-19.9* PTT-27.1 INR(PT)-1.8*
[**2104-12-25**] 01:45AM BLOOD PT-15.0* PTT-22.7 INR(PT)-1.3*
[**2104-12-24**] 03:59AM BLOOD PT-13.7* PTT-23.5 INR(PT)-1.2*
[**2104-12-23**] 12:25PM BLOOD PT-13.4 PTT-19.6* INR(PT)-1.1
[**2104-12-24**] 03:59AM BLOOD Fibrino-515*
[**2104-12-27**] 02:00AM BLOOD Glucose-623* UreaN-63* Creat-1.6* Na-134
K-3.9 Cl-110* HCO3-16* AnGap-12
[**2104-12-26**] 03:41AM BLOOD Glucose-212* UreaN-72* Creat-1.7* Na-148*
K-4.5 Cl-120* HCO3-19* AnGap-14
[**2104-12-25**] 01:45AM BLOOD Glucose-114* UreaN-66* Creat-1.3* Na-146*
K-4.2 Cl-116* HCO3-21* AnGap-13
[**2104-12-24**] 03:59AM BLOOD Glucose-112* UreaN-59* Creat-1.3* Na-140
K-3.3 Cl-108 HCO3-22 AnGap-13
[**2104-12-23**] 10:46AM BLOOD UreaN-65* Creat-1.6* Na-130* K-4.1 Cl-91*
HCO3-29 AnGap-14
[**2104-12-26**] 03:41AM BLOOD ALT-14 AST-18 LD(LDH)-153 AlkPhos-28*
TotBili-0.5
[**2104-12-23**] 10:46AM BLOOD ALT-30 AST-26 LD(LDH)-128 AlkPhos-79
TotBili-0.4 DirBili-0.2 IndBili-0.2
[**2104-12-27**] 02:00AM BLOOD Calcium-5.5* Phos-3.8 Mg-1.6
[**2104-12-26**] 03:41AM BLOOD Calcium-6.1* Phos-4.8* Mg-2.0
[**2104-12-25**] 01:45AM BLOOD Calcium-7.0* Phos-4.5 Mg-2.4
[**2104-12-24**] 03:59AM BLOOD Calcium-7.0* Phos-3.6 Mg-1.9
[**2104-12-23**] 10:46AM BLOOD Albumin-2.7* Mg-2.1
[**2104-12-23**] 10:46AM BLOOD Hapto-357*
[**2104-12-23**] 06:27PM BLOOD Lactate-1.0
[**2104-12-23**] 12:44PM BLOOD Lactate-2.4*
Micro:
[**2104-12-24**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2104-12-23**] BLOOD CULTURE Blood Culture,
Routine-PENDING
Imaging/Studies:
[**12-23**] CXR: IMPRESSION: Relatively stable examination. The patient
has diffuse nodules presumably from metastatic disease.
Conceivably, there could be early consolidation of the right
lower lung; however, the increased opacity is felt more likely
due to differences in technique, inspiratory effort, and
resultant ronchovascular crowding.
[**12-23**] CT Head: IMPRESSION: No acute intracranial process.
[**12-23**] CT abd/pelvis: IMPRESSION:
1. Likely fistulous communication between the first portion of
the duodenum and the gallbladder which may be from ulceration or
inflammation of previously seen duodenal diverticulum.
High-density material within the gallbladder lumen likely
represents clot/blood.
2. Bilateral moderate-to-severe hydronephrosis, left worse than
right. The right hydronephrosis is new since [**2104-12-8**],
although the cause of the new-onset hydronephrosis not
appreciated on this study.
3. Multiple pulmonary metastases as described on prior studies.
4. Multiple intramuscular metastases as described above.
5. Extensive diverticulosis.
[**12-25**] mesenteric angiogram with embolization of GDA
[**12-26**] GI bleed study: IMPRESSION: Bleeding in the region of
duodenum, presumably in the GDA territory.
[**12-26**] mesenteric angiogram
Brief Hospital Course:
This is a 66 yo male with h/o metastatic bladder ca to liver,
lung on chemo who originally presented on [**2104-12-23**] from clinic
with hypotension and Hct of 17, has been in SICU getting blood
transfusions, then transferred to MICU for further management as
pt is not a surgical candidate.
.
# Goals of care: On admission, pt was full code. Pt was deemed
not a surgical candidate by Surgery. Pt was DNR/DNI at time of
transfer to the MICU. IR performed IR embolizations with no
success in stabilizing the bleeding. As the pt continued to
bleed, it was then decided by him and his family that he would
be CMO. SW and Palliative care teans were involved. Pt was
started on a Morphine gtt for comfort and the pt passed in early
hours of [**2104-12-28**].
.
# Anemia: Pt not a surgical candidate. Continued to require
blood transfusions. Pt was s/p IR embolization of the
gastroduodenal artery on [**2104-12-25**]. However, continued to require
transfusions and shows active bleeding. Pt was continued on
PPI gtt. Per IR recs, pt underwent a tagged RBC scan which
showed active bleeding in GDA territory and pt underwent IR
embolization again on [**2104-12-26**]. However, as pt continud to
bleed, pt and his family decided to change his goals of care to
comfort measures only. NSAIDs and ASA were held.
.
# Metastatic bladder cancer/cholecystoenteric fistula: Pt was
maintained on Unasyn to cover any possible GI infections. Pain
was controlled with Dilaudid PRN. Pt's outpt oncologist Dr.
[**Last Name (STitle) **] was following closely. SW and palliative care were
consulted to help pt and his family with end of life issues.
.
# PVD: Home ASA and statin were held.
.
# Depression/Anxiety: Home Citalopram was held. Ativan PRN was
used for anxiety.
.
Pt was initially NPO at MN for possible interventions then
allowed to eat when became CMO. Pt was on pneumoboots for DVT
ppx.
Medications on Admission:
APREPITANT [EMEND] - 125 mg (1)-80 mg (1)-80 mg (1) Capsule,
Dose
Pack - 1 Capsule(s) by mouth daily the day of chemotherapy and
the following 2 days
CITALOPRAM - 10 mg Tablet - 1 Tablet(s) by mouth daily
DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth every twelve
(12) hours x 2 days after chemotherapy
LORAZEPAM - 0.5 mg Tablet - [**11-16**] Tablet(s) by mouth daily as
needed for anxiety or nausea
LOVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth
twice daily x2 days after chemo and as needed afterward
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every six (6) hours as needed for nausea
ASPIRIN - 81 mg Tablet - 1 Tablet(s) by mouth once a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day as needed for constipation take this while taking narcotic
pain medication, stop if you develop diarrhea
POLYETHYLENE GLYCOL 3350 [MIRALAX] - (Prescribed by Other
Provider) - Dosage uncertain
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic prostate ca
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2104-12-28**]
|
[
"584.9",
"591",
"197.7",
"575.5",
"458.9",
"532.40",
"285.1",
"531.40",
"300.4",
"197.0",
"V10.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.44",
"45.13",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
11645, 11654
|
8657, 10557
|
327, 348
|
11720, 11725
|
4284, 7714
|
11777, 11812
|
3758, 3923
|
11617, 11622
|
11675, 11699
|
10583, 11594
|
11749, 11754
|
3938, 4265
|
267, 289
|
376, 2248
|
7723, 8634
|
2270, 3593
|
3609, 3742
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,111
| 132,258
|
52232
|
Discharge summary
|
report
|
Admission Date: [**2160-2-15**] Discharge Date: [**2160-2-19**]
Date of Birth: [**2087-2-19**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / A.C.E Inhibitors / Cefazolin / Propoxyphene
/ Gabapentin / Oxycontin / Phenergan
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 72 y/o F with a PMH significant for CAD, diabetes,
hypertension, diastolic heart failure, and s/p stroke presenting
with a 1 week history of dyspnea, cough and productive sputum.
The pt states that symptoms began one week ago Sturday after
eating some soup. That evening she started to have arthralgias
and myalgias. no fevers [**Last Name (un) 9507**]. Pt woke up with a cough, which
has been progressive as well as SOB. Patient denies any recent
headaches, dizziness. No ear aches. No difficulty swallowing. No
ear aches. No rhinitis. No chest pain, no pedal edema, no weight
gain. She endorses fatigue without syncopal events. No nausea,
vomitting, diarrhea. No sick contacts.
.
On arrival to the ED, initial vitals: T 98.9, HR 80, BP 137/65,
RR 20, O2sat 99%2L. She received combivent neb, lasix 20mg IV
X1, levaquin 750mg IV X1. CXR demonstrated evidence of
multifocal infiltrates. ECG unchanged from prior. NSR with no
ST/T changes.
.
On arrival to the medical floor, the patient spiked temp 101 at
8pm. She triggered for tachypnea to 40s. ABG 7.44/37/153/26. She
was found to have diffuse wheezes, nebs given with some
improvement however she was transferred to ICU for persistent
tachypnea.
.
On arrival to the MICU, she continued to be tachypneic up to the
40s, was sweating and felt generally poor. She complained of
subjective SOB and continued to have productive cough.
Otherwise, she had no other complaints. She talked in short
sentences and using accessory muscles.
Past Medical History:
DM II (last Hgb A1C 7.9 [**2160-1-10**])
CAD s/p 3V bypass
s/p pacemaker for bradycardia
Chronic renal insufficiency (Baseline Cr 1.6 [**2160-1-10**])
Renal artery stenosis
HL
HTN
h.o. stroke w/ no residual
Social History:
She lives alone at home independently. No family locally, no
children. Family is in [**Country 26467**] and has a trip planned for this
[**Month (only) 958**]. Friend listed as health care proxy in [**Hospital1 18**] system. Is
originally from [**Location (un) 6847**], no exposure to TB per pt. No hx of
smoking, no etoh, no IVDU.
.
Family History:
Mother died at age 85 from diabetes and heart disease.
Father died in his 50s from complications related to diabetes.
Physical Exam:
PHYSICAL EXAM:
Vitals: Tm 101,
General: Awake, alert,in in moderate distress,rapidly breathing.
HEENT:PERRL, EOMI, no scleral icterus, MMM
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs bilaterally wheezes heard through out lungs, no
crackles or rhonchi, using accessory muscles to breath
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted
Extremities: No edema, 2+ radial, DP pulses b/l
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented x 3. Cranial nerves II-XII intact.
No abnormal movements noted.
Pertinent Results:
[**2160-2-15**] 01:50PM BLOOD WBC-8.9# RBC-3.28* Hgb-10.4* Hct-29.3*
MCV-89 MCH-31.6 MCHC-35.4* RDW-13.9 Plt Ct-234
[**2160-2-15**] 01:50PM BLOOD Neuts-77.4* Lymphs-13.7* Monos-6.9
Eos-1.7 Baso-0.3
[**2160-2-15**] 11:58PM BLOOD PT-13.7* PTT-37.0* INR(PT)-1.2*
[**2160-2-15**] 01:50PM BLOOD Glucose-86 UreaN-44* Creat-1.9* Na-129*
K-4.4 Cl-96 HCO3-23 AnGap-14
[**2160-2-15**] 01:50PM BLOOD ALT-49* AST-53* LD(LDH)-263* AlkPhos-58
TotBili-0.8
[**2160-2-15**] 01:50PM BLOOD proBNP-[**Numeric Identifier **]*
[**2160-2-18**] 08:00AM BLOOD calTIBC-203* VitB12-1131* Folate-18.7
Ferritn-505* TRF-156*
[**2160-2-15**] 11:58PM BLOOD TSH-0.50
[**2160-2-15**] 11:58PM BLOOD Cortsol-22.2*
.
[**2160-2-15**] Blood cultures (prelim): NGTD
[**2160-2-15**] Urine culture: no growth
[**2160-2-15**] Urine legionella: negative
[**2160-2-16**] Rapid Viral Antigen Nasal Aspirate: negative, including
influenza A and B
[**2160-2-17**] Sputum Sample: contaminate
.
[**2160-2-15**] Chest X-ray (prelim): multifocal pneumonia
.
[**2160-2-19**] Transthoracic Echo:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade II (moderate) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2157-8-24**],
evidence of Grade II diastolic dysfunction is now present.
Brief Hospital Course:
72 year old woman that has a history significant for CAD,
diabetes, hypertension, diastolic heart failure, and s/p stroke
admitted with dyspnea and multifocal PNA initially admitted to
the medical floor, then transferred to the MICU for respiratory
distress, then transferred back to the floor < 24 hours later.
.
In the MICU, the patient was treated with Levofloxacin 750mg PO
q48 hours for community-acquired pneumonia. She was given Lasix
20mg IV for possible pulmonary edema due to heart failure. She
improved and was transferred to the floor the following day.
.
Once on the medical floor, she continued to improve with IV
Lasix which she received 40mg IV BID X 2 days, ipratropium and
albuterol nebs, and Levofloxacin which she completed during her
admission. Her legionella and viral nasal swabs were negative.
Blood cultures are no growth to date and sputum cultures were
contaminated.
.
For her coronary artery disease, she was continued on aspirin
and plavix. Her BNP was elevated on admission and she likely
has some component of congestive heart failure. She was
diuresed and improved. Her wheezing may have been a cardiac
wheeze. She had an echo on [**2160-2-19**] which showed grade II
diastolic failure. She was continued on her home blood pressure
medications with the exception of Losartan which was initially
held due to elevated creatinine of 2.0 (baseline 1.4-1.7). Her
creatinine improved to 1.7 on discharge and she was restarted on
her Losartan. She will follow-up with her PCP regarding testing
her kidney function again.
.
She was also anemic while admitted with a hematocrit of 25-29.
She had no clear source of bleeding. Iron studies revealed iron
deficiency and she was started on iron 325mg PO qday. B12 and
folate were checked and were normal. She did not require any
blood transfusions and prior colonoscopy this year was normal.
She will follow-up with her PCP regarding her anemia. Her
chronic kidney disease is likely contributing.
.
Ms. [**Known lastname **] was hyponatremic on admission with a sodium of 129.
This improved to 137 and on discharge was 133. She likely had
an SIADH-related hyponatremia due to her pneumonia. TSH and
cortisol were checked and were normal.
.
Her diabetes was controlled on home doses of Lantus and Humalog
sliding scale. She was slightly hyperglycemic with blood sugars
in the 200s. Her oral hyperglycemic [**Doctor Last Name 360**] was held while
inpatient and resumed upon discharge. Her insulin sliding scale
was increased. She should follow-up with her PCP regarding
further glucose control.
.
Ms. [**Known lastname **] was put on SC heparin for DVT prophylaxis. She was
discharged with an appointment to follow-up in [**Hospital 191**] clinic.
.
PENDING STUDIES AT TIME OF DISCHARGE:
[**2160-2-15**] final blood cultures
[**2160-2-15**] final chest x-ray [**Location (un) 1131**]
Medications on Admission:
Alendronate 35 mg daily
Amlodipine 10 mg daily
ASA 162 mg [**Hospital1 **]
Atenolol 50 mg daily
BD ULTRA-FINE 3/10CC SYRINGE, [**1-4**]-IN 30-GAUGE NEEDLE - - use
four times a day and as needed
CLOBETASOL - 0.05 % Ointment - APPLY TO AFFECTED AREAS TWICE A
DAY AS NEEDED FOR ITCH, ONLY TO FACE FOR ONE WEEK
CLOPIDOGREL BISULFATE - 75 MG TABLET - TAKE ONE EVERY DAY
COZAAR - 50MG Tablet - ONE TABLET BY MOUTH TWICE A DAY
GLIPIZIDE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100
unit/mL Solution - 13 units at hs
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - 6 units in the
am, 7-8 units at lunch, 13-15 units at dinner once a day. Adjust
dose as directed.
ISOSORBIDE DINITRATE - 40 mg Tablet Sustained Release - 1
Tablet(s) by mouth three times a day
RANITIDINE HCL - 150MG Capsule - ONE BY MOUTH TWICE A DAY
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day (to
replace Lipitor)
Medications - OTC
ACCU-CHEK COMFORT CURVE TEST - Strip - use one strip 4 times
a day as needed for and as needed
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (OTC) - 400 unit
Tablet - 2 Tablet(s) by mouth once a day
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - 500
mcg-250 mcg Tablet, Chewable - 1 Tablet(s) by mouth once a day
.
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Isosorbide Dinitrate 40 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO TID (3 times a day).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Losartan 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Insulin Glargine 100 unit/mL Solution Sig: Thirteen (13)
units Subcutaneous at bedtime.
13. Insulin Lispro 100 unit/mL Solution Sig: 6-14 units
Subcutaneous three times a day: as per previously prescribed
dosage.
14. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. Alendronate 35 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Pneumonia
2. Acute on Chronic Renal Failure
3. Hyponatremia
Secondary Diagnoses:
4. Coronary Artery Disease
5. Diabetes Mellitus, Type II
6. Diastolic Congestive Heart Failure, Chronic
7. Chronic Renal Insufficiency
Discharge Condition:
afebrile, breathing well on room air, hemodynamically stable
Discharge Instructions:
You were admitted to the hospital with pneumonia. You were
treated with antibiotics and will lasix to remove some fluid.
You improved and on discharge you were feeling well. Your blood
sugars were elevated during your hospitalization. You should
follow-up with your PCP about this. You should be seen in the
next week by your PCP.
No changes were made to your medications. You should continue
to take them as prescribed.
You should return to the hospital or call your PCP with any
fevers > 101, chills, night sweats, chest pain, worsening
shortness of breath, worsening cough, nausea, vomiting,
diarrhea, leg swelling or any other symptoms that concern you.
Followup Instructions:
Primary Care Physician's Office Follow-up Visit:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2160-2-25**] 1:30
Other previously scheduled appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 60**]
Date/Time:[**2160-7-8**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2160-7-8**] 1:20
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
|
[
"403.90",
"276.1",
"272.4",
"V12.54",
"584.9",
"585.9",
"428.0",
"428.33",
"250.00",
"285.9",
"V45.81",
"V45.01",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10953, 10959
|
5502, 8377
|
366, 372
|
11242, 11305
|
3376, 5479
|
12018, 12643
|
2494, 2614
|
9733, 10930
|
10980, 10980
|
8403, 9710
|
11329, 11995
|
2644, 3357
|
11084, 11221
|
323, 328
|
400, 1895
|
10999, 11063
|
1917, 2126
|
2142, 2478
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
333
| 160,548
|
45196
|
Discharge summary
|
report
|
Admission Date: [**2137-9-29**] Discharge Date: [**2137-10-2**]
Date of Birth: [**2072-4-8**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization s/p bare metal stent in RCA
History of Present Illness:
65 yo F with tobacco history presented to OSH with sudden onset
chest pain. The patient reports that the pain began at 11:30PM
while at home. The pain was described as sudden, [**10-15**]
constant, substernal, unrelieved by rest or position. She also
reports radiation of the pain to the left arm, jaw, and neck.
She also experienced nausea and vomitting x 1, diaphoresis, mild
LH. She denied any SOB, syncope, palpitations.
.
In the ED at the OSH, the patient had an EKG which showed ST
elevations in II, III, aVF, as well as in V3-V6, with
depressions in V1-V2, I, aVL. CPK 54, MB 4.2, Trop I 0.16. She
was given nitro and morphine with mild relief of her chest pain.
She also received ASA, lopressor, integrillin bolus, and was
transferred to [**Hospital1 18**] for urgent cath.
.
On cath lab noted to have totally occluded RCA, otherwise
normal. Bare metal stent was placed. After reprofusion she had
bradycardia and required atropine. On right heart cath went
into Vfib and was shocked once returning to sinus rhythm.
Currently chest pain free.
.
ROS: Prior to event she was feeling well except for recent back
injury. However this had improved by yesterday. Denied any
recent fevers, chills, nausea, vomting. No SOB, orthopnea, PND,
LE edema. No diarrhea, constipation, melena, abd pain.
Past Medical History:
Uterine ca s/p XRT
Rt Fem- Lt [**Doctor Last Name **] bypass
Social History:
tobacco use 1ppd for 40 yrs. Occasional ETOH use. No illicit
drug use. Lives with mother, brother. Widowed, 2 children.
Family History:
Mother alive at 93, questionable history of CAD in 40-50's.
Father died at age 83 from complications of hip surgery.
Physical Exam:
Vital signs: T 97.1 BP 118/67 HR 87 RR 16 O2sats 100% 3LNC
General: Comfortable, lying flat in bed, NAD
HEENT: PERRL, EOMI, dry mm, anicteric
Neck: No JVD
Lung: CTAB anteriorly
Heart: Distant HS, RRR, no m/r/g
Abdomen: Soft, NT, ND, + BS
Ext: Right groin with sheath in place. 1+ DP bilaterally
Neuro: A&O times 3
Pertinent Results:
Cardiac Cath: FINAL DIAGNOSIS:
1. Inferior ST elevation MI due to mid RCA occlusion.
2. Cardiac arrest during right heart catheterization.
3. Successful PCI of a totally occluded RCA with a bare metal
stent.
.
EKG: NSR, STE in II,III,aVF,V3-V6, STD in V1-V2,I,aVL
.
Echo [**2137-9-30**]
LA is normal in size. IVC is dilated (>2.0 cm). LV wall
thicknesses and cavity size are normal. EF 35-40%, Moderate
regional LVsystolic dysfunction with focal severe hypokinesis of
the inferior septum, inferior, and inferolateral walls. The
remaining segments contract well. RV chamber size is normal. AV
leaflets (3) are mildly thickened but aortic stenosis is not
present. MV leaflets are structurally normal. There is no mitral
valve prolapse. Mild (1+) MR, mild 1+ TR. Mild PA systolic
hypertension. There is an anterior space which most
likely represents a fat pad.
.
[**2137-9-29**] 06:57PM TYPE-ART PO2-87 PCO2-31* PH-7.42 TOTAL CO2-21
BASE XS--2 INTUBATED-NOT INTUBA
[**2137-9-29**] 06:57PM GLUCOSE-106* LACTATE-1.4 NA+-133* K+-3.9
CL--105
[**2137-9-29**] 06:57PM HGB-10.2* calcHCT-31
[**2137-9-29**] 06:57PM freeCa-1.16
[**2137-9-29**] 04:12PM GLUCOSE-92 UREA N-10 CREAT-0.6 SODIUM-132*
POTASSIUM-8.1* CHLORIDE-104 TOTAL CO2-21* ANION GAP-15
[**2137-9-29**] 04:12PM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.2
[**2137-9-29**] 04:12PM PT-15.8* PTT-25.5 INR(PT)-1.4*
[**2137-9-29**] 02:31PM POTASSIUM-4.6
[**2137-9-29**] 02:31PM CK(CPK)-4297*
[**2137-9-29**] 02:31PM CK-MB->500
[**2137-9-29**] 02:31PM MAGNESIUM-2.0
[**2137-9-29**] 12:32PM POTASSIUM-6.4*
[**2137-9-29**] 12:32PM CK(CPK)-5090*
Brief Hospital Course:
Mrs.[**Doctor Last Name 14539**] is a 65 year old female presenting with acute
substernal chest pain, nausea, vomiting, and EKG with STE in II,
III, aVF admitted for STEMI, now s/p RCA bare metal stent.
.
Cardiac:
Ischemia: Ms. [**Name13 (STitle) **] presented with sudden onset chest pain
found to have inferior STEMI. Unfortunately the patient waited
several hours and developed Q-waves inferiorly. On admission to
[**Hospital1 18**] the patient underwent cardiac catheterization which showed
a total occluded RCA otherwise patent vessels. A bare metal
stent was placed in the RCA. After reperfusion she had
bradycardia and required atropine. On right heart
catheterization the patient went into VF and was shocked once
returning to sinus rhythm. A bare metal stent was used
secondary to the patient's need for chronic coumadin therapy, in
an attempt to avoid long term use of aspirin, plavix and
coumadin. The patient was started on plavix 600mg load,
followed by 75mg qday which she will continue for 1 month, ASA
325mg qday. She was originally started on a beta blocker and an
ACE inhibitor however as her blood pressure could not tolerate
both (SBPs in the 80s), metoprolol was d/c'd based on her heart
rate in the 60s. A trial of captopril 6.25mg tid alone was
attempted the evening prior to her discharge, however, again her
blood pressure remained in the 80s (low of SBP of 69) despite
fluids. Based on this inability to tolerate both the ACE
inhibitor and metoprolol, both medications were d/c'd. She was
also placed on lipitor 80mg qday for an elevated LDL and low
HDL. Her HgA1c was checked and was 5.4%. She was monitored on
telemetry. An Echo showed LVEF 35-40% with moderate regional
left ventricular systolic dysfunction with focal severe
hypokinesis of the inferior septum, inferior, and inferolateral
walls. In addition, smoking cessation was discussed with the
patient and she expressed understanding of the importance of
this. By report the patient had a questionable reaction to
heparin at the outside hospital.
.
Pump: The patient had no signs of failure on exam. Echo results
are as above.
.
Rhythm: The patient maintained sinus rhythm with PVC's after MI.
She was briefly put on metoprolol but this was d/c'd due to low
SBPs. She remained in sinus rhythm.
.
Valve: No known valve disease.
.
PVD: Ms. [**Name13 (STitle) **] is s/p bilateral fem-[**Doctor Last Name **] bypass which she
required as a result of raditation. After catheterization she
was restarted on coumadin. Her INR was followed and she will
continue to follow up with this as an outpatient.
.
Back pain: The patient reported lower back pain after an injury
sustained a week prior to admission. She says the pain had been
improving prior to admission, however she continued to report
LBP and paraspinal tenderness. She was given valium and heat
packs which reportedly relieved her pain.
FEN: She was maintained on a cardiac diet
.
Code: Full
Medications on Admission:
Warfarin 2/3mg qhs(alternate)
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
pci.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for pci.
Disp:*30 Tablet(s)* Refills:*0*
4. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: STEMI s/p stent of RCA
VF
Secondary: fem-[**Doctor Last Name **] bypass bilaterally
Discharge Condition:
Stable. The patient is ambulating around the unit.
Discharge Instructions:
You were admitted for a heart attack. You are now on
medications which help patients after a heart attack including
Plavix and aspirin. Please take all medications as prescribed.
If you begin to experience chest pain, shortness of breath,
lightheadedness, or any other concerning symptoms please call
Followup Instructions:
CARDIOLOGY
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2137-10-18**] 9:00
INTERNAL MEDICINE PCP
[**Name Initial (PRE) 2169**]: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2137-10-10**] 1:30
|
[
"458.29",
"427.1",
"E849.8",
"E879.0",
"414.01",
"410.41",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"88.56",
"99.20",
"37.23",
"00.66",
"00.45",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
7711, 7717
|
4019, 6976
|
285, 338
|
7855, 7909
|
2385, 2399
|
8261, 8621
|
1917, 2035
|
7056, 7688
|
7738, 7834
|
7002, 7033
|
2416, 3996
|
7933, 8238
|
2050, 2366
|
235, 247
|
366, 1676
|
1698, 1760
|
1776, 1901
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,905
| 135,265
|
8578
|
Discharge summary
|
report
|
Admission Date: [**2137-1-27**] Discharge Date: [**2137-1-30**]
Date of Birth: [**2082-6-12**] Sex: F
Service: C MED
CHIEF COMPLAINT: Chest and back pain and lethargy.
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
white female with a long history of labile hypertension,
multiple lacunar infarcts who presented to an outside
hospital, [**Hospital3 4527**] on [**2137-1-27**] with a complaint of
chest pain times one day and back pain times one week which
was worse today rated [**9-18**]. Her husband thought she was
more sleepy and fatigued than usual. Given her history of
stroke, they brought her to the Emergency Room. When she
arrived, her systolic blood pressure was in the 70s and she
was given multiple liters of normal saline and started on
Dopamine with some increase in her systolic blood pressures.
She described her pain as dull, occurring intermittently,
radiating to her jaw and left arm. She does have a DDD
pacemaker so her electrocardiogram was difficult to
interpret, however, there was one electrocardiogram done at
the outside hospital that had a possibility of anterior ST
elevations. There were concern that she was having cardiac
ischemia. After the dopamine and intravenous fluids, her
blood pressure ultimately rose and she was started on
intravenous nitroglycerin for question of cardiac ischemia.
She was transferred to [**Hospital6 256**]
for potential cardiac catheterization.
On arrival to [**Hospital6 256**], her chest
and back pain had resolved on the intravenous nitroglycerin.
She gave an additional history of nausea, vomiting and
diarrhea up to seven stools per day for one week with fevers
and chills to 101 and decreased po intake for one week,
however, she reports she continued to take all of her blood
pressure medication. An electrocardiogram was repeated in
our Emergency Room that did not show any significant changes
from one done on the previous admission in [**2136-10-10**].
There were no acute ST and T wave changes and she was chest
and back pain free. However, given her extreme hypotension
and description of severe back pain at the outside hospital,
a bedside transesophageal echocardiogram was performed to
rule out aortic dissection. She is unable to get MRI
secondary to having a pacer and she has a severe allergy to
intravenous dye. The transesophageal echocardiogram revealed
hyperdynamic left ventricle with normal left ventricular
function, no pleural effusion. No obvious wall motion
abnormalities and no evidence of aortic dissection. She was
therefore admitted to the [**Hospital6 13568**] for rule out
myocardial infarction and further evaluation and management
of her labile blood pressures and symptoms.
PAST MEDICAL HISTORY:
1. Hypertension since age 13. Has been very labile in the
past. She was admitted in [**2136-10-10**] for lacunar
infarcts and blood pressure control. She had a past
work-up for secondary causes of hypertension which have
all been negative. This includes pheochromocytoma,
[**Location (un) **] syndrome, hyperaldosteronism, carcinoid syndrome
and she has had multiple renal ultrasounds to evaluate
for bilateral renal artery stenosis which have been
negative per her primary care physician.
2. History of multiple lacunar infarcts since [**2118**]. She
usually presents with left-sided symptoms including left
facial, arm and leg weakness, dysarthria, dysphasia and
clumsiness. She still has several residual deficits from
prior infarcts. She has increased left-sided tone with
contractures from her previous infarcts.
3. DDD pacemaker implanted for possible complete heart
block, although the patient is unsure.
4. Mild asthma.
5. Gout.
6. Cataract in the left eye.
7. She does not have any urinary sensation and urinates on a
routine daily scheduled.
ALLERGIES: To Penicillin, aspirin, Tylenol, Beclovent,
Percocet and intravenous dye, which gives her hypotension
resulting in a stroke many years ago. Question of allergy to
Nitepride.
MEDICATIONS: Clonidine 0.7 mg po t.i.d., Labetalol 400 mg po
b.i.d., Carvedilol 18.75 mg po q.a.m. and 12.5 mg po q.p.m.,
Zestril 10 mg po q.d., Plavix 75 mg po q.d., Flexeril 10 mg
po t.i.d., Intal 2 puffs t.i.d., colchicine 0.6 mg prn gout,
Lasix 20 mg po q.d., Lomotil b.i.d. prn, Urecholine 25 mg po
q.i.d.
SOCIAL HISTORY: She lives with her husband and works as a
bookkeeper for his contracting company. No tobacco, no
alcohol.
FAMILY HISTORY: Multiple family members with hypertension,
strokes and renal failure. Her mother died of a brain
hemorrhage and had hypertension and renal disease. Her
father died of hypertensive stroke.
REVIEW OF SYSTEMS: She complains of shortness of breath and
dyspnea on exertion when walking 30 feet. For the past week
she has had fevers to 101 with nausea, vomiting and diarrhea,
up to seven stools per day. No bloody bowel movements or
melena. Occasional abdominal pain. She notes decreased
urine output times two months with hematuria for three days,
two weeks prior to this admission. No headaches, no visual
changes. She complains of fluid retention times two months
with edema of her lower extremity and hand. She complains of
worsening gout over the past three weeks.
PHYSICAL EXAMINATION: Temperature afebrile. Pulse 84.
Respirations 15. Blood pressure 122/70. O2 saturation 99%
on room air. In general, no apparent distress, alert and
oriented times three, but sleep, but easily arousable. Slow
speech. Head, eyes, ears, nose and throat, pupils equal,
round and reactive to light. Extraocular movements intact.
Sclerae are anicteric. Dry mucous membranes. Neck supple,
no carotid bruits. Cardiovascular, regular rate and rhythm,
normal S1, S2, 2/6 systolic murmur at the left lower sternal
border. Lungs are clear to auscultation bilaterally with the
exception of crackles at the left base. Abdomen is obese,
soft, nontender, positive bowel sounds, guaiac negative in
the Emergency Room. Extremities with 1+ pitting edema
bilaterally. Lower extremities with bilateral hand edema.
Back, left greater than right CVA tenderness. Neurologic
exam, cranial nerves intact. Left upper extremity with
contracture and left lower extremity and upper extremity with
weakness.
LABORATORY STUDIES AT THE OUTSIDE HOSPITAL: Reveals a sodium
of 137, potassium 3.6, chloride 99, bicarbonate 22.6, BUN of
43, creatinine of 4.0 and glucose of 121. White count of 5.1
with 63% neutrophils, hematocrit 34.0, platelet count
173,000. Normal coagulation studies. Initial CK is 105 with
an MB of 1.73 and an index of 1.6. First troponin less than
0.2.
Electrocardiogram on admission revealed normal sinus rhythm
with a rate of 80, first degree AV delay and a prolonged QTC
interval of 479. There was T wave flattening in III and aVF.
No significant change from [**10/2136**].
Chest x-ray at the outside hospital demonstrated low lung
volumes, but no infiltrates and no edema.
A bedside Emergency Room transesophageal echocardiogram
demonstrated normal left ventricular and right ventricular
function on limited views. There was mild to moderate aortic
regurgitation, trace mitral regurgitation. The visualized
portions of the ascending, descending and transverse aorta
were not dilated and no dissection was identified.
HOSPITAL COURSE: The patient was admitted to the [**Hospital6 21665**] for further work-up and evaluation of her chest and
back pain, as well as her labile blood pressures. She was
ruled out for myocardial infarction with three negative CKs
and two negative troponins. She was monitored on telemetry
with no significant events. A VQ scan was obtained on [**1-29**]
which was read as low probability for pulmonary embolus. A
chest x-ray was also obtained which revealed a small left
pleural effusion, otherwise, there was no change compared to
previous film in [**2136-2-8**]. Given that she had ruled out
for myocardial infarction, aortic dissection and pulmonary
embolus, it was felt that her profound hypotension on
presentation to the outside was most likely related to
hypovolemia given her nausea, vomiting and diarrhea for one
week with poor po intake and continuation of her outpatient
antihypertensive regimen. Her blood pressures were monitored
closed and adjustments were made in her outpatient regimen.
Her primary care physician was [**Name (NI) 653**] and by his report,
her systolic blood pressures typically run in the 160 to 220
range. Her blood pressure the first one to two days of
admission was in the 125 to 140 range and the patient felt
that this was too low, therefore, the dosages of several of
her antihypertensives were decreased and her systolics
increased to the 160 to 170 range.
On presentation to the outside hospital, initially her BUN
was 44 with a creatinine of 4.0. Her primary care physician
states that her creatinine has been as high as 2.2 in the
previous two months, however, it normally ranges lower than
that. As her creatinine steadily decreased to 2.6 and then
2.2 with rehydration and improved blood pressure control, it
was felt the most likely etiology for her acutely elevated
creatinine was hypovolemia with hypoperfusion secondary to
low systolic blood pressures.
The patient reported that over the past few weeks her gout
has been acting up. She normally takes colchicine prn to
help control it, however, as she has been having diarrhea,
she has had to cut back on the amount of colchicine she has
been taking. A uric acid level was checked which was
elevated at 10.9. The patient states that she had been tried
on Allopurinol in the past and this was unsuccessful. This
will be followed up on an outpatient basis by her primary
care physician. [**Name10 (NameIs) 4692**], her carvedilol was decreased
as there is a low risk of side effect of hyperuricemia with
this medication.
The Physical Therapy Service evaluated the patient and
recommended that she receive home Physical Therapy Services.
Upon discharge given her deconditioning associated with this
most recent hospitalization. On [**2137-1-30**], the patient was
stable for discharge to home in stable condition. She will
follow-up the following day, Thursday [**2137-1-31**] with her
primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) **].
DISCHARGE MEDICATIONS:
1. Plavix 75 mg po q.d.
2. Flexeril 10 mg po t.i.d.
3. Lasix 20 mg po q.d.
4. Intal 2 puffs t.i.d.
5. Urecholine 25 mg po q.i.d.
6. Labetalol 200 mg po b.i.d.
7. Clonidine 0.7 mg po b.i.d.
8. Carvedilol 12.5 mg po q.a.m. and 6.25 mg po q.p.m.
9. Zestril 10 mg po q.d.
10. Colchicine 0.6 mg po prn gout.
DISCHARGE DIAGNOSES:
1. Severe labile hypertension.
2. Dehydration secondary to nausea, vomiting, diarrhea and
decreased po intake with a resultant hypotension.
3. History of multiple lacunar infarcts.
4. Gout.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Last Name (NamePattern1) 24984**]
MEDQUIST36
D: [**2137-1-30**] 16:38
T: [**2137-1-30**] 16:38
JOB#: [**Job Number 30112**]
|
[
"426.0",
"401.9",
"V12.59",
"493.90",
"274.9",
"V45.01",
"786.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"42.23"
] |
icd9pcs
|
[
[
[]
]
] |
4510, 4701
|
10744, 11218
|
10410, 10723
|
7362, 10387
|
5309, 7344
|
4721, 5286
|
152, 187
|
216, 2718
|
2740, 4368
|
4385, 4493
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,615
| 104,209
|
45791+58852
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-1-30**] Discharge Date: [**2181-2-5**]
Service: MEDICINE
Allergies:
Penicillins / Epinephrine / Novocain / Codeine / Celebrex /
Naprosyn
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Patient is an 89F with hx of CAD s/p Cypher to 80% OM in [**Month (only) 547**]
[**2178**] who reports that she has't been feeling well all week. Had
some SOB during exertion that was not alleviated with rest. She
denies any chest pain, but describes tightness with breathing.
Also complained of nausea and headache in the back of her head.
She had a constant feeling of weakness all over that lasted for
a couple of hours. She felt fatigued for the remainder of the
weak. and was unable to complete a flight of stairs.
.
She denies CP, palpitations. Reports chronic orthopnea with 2
pillows, some lightheadeness with shortness of breath. Chronic
lower extremity edema. + Hemmorhoids with occasional blood on
TP.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
*** Cardiac review of systems is notable for absence of chest
pain, paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
HTN
hyperlipidemia
coronary artery disease s/p stent in [**2178**]
gout
osteoarthritis
hyperparathyroidism.
Social History:
Social history is significant for the absence of current tobacco
use. 42 pack/yr history, quit 35 yrs ago. There is no history of
alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 35.8, BP 132/77 , HR 73 , RR 21, O2 99% on 2L
Gen: WDWN elderly female in NAD, resp or otherwise. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. R lid ptosis
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi anteriorly
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: 2+ pitting edema to mid-calf bilaterally. No femoral
bruits.
Skin: +chronic venous stasis dermatitis
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Neuro: R lid ptosis; otherwise CX II-Xii intact; tongue midline;
decreased light touch over toes bilaterally; moves all 4- unable
to assess strength 2/2 femoral sheath
Pertinent Results:
[**2181-1-30**] 03:30PM PT-12.6 PTT-28.1 INR(PT)-1.1
[**2181-1-30**] 03:30PM PLT COUNT-207
[**2181-1-30**] 03:30PM NEUTS-62.5 LYMPHS-27.0 MONOS-9.3 EOS-1.1
BASOS-0.1
[**2181-1-30**] 03:30PM WBC-4.8 RBC-3.75* HGB-12.1 HCT-35.7* MCV-95
MCH-32.3* MCHC-33.9 RDW-14.3
[**2181-1-30**] 03:30PM cTropnT-0.82*
[**2181-1-30**] 03:30PM CK(CPK)-45
[**2181-1-30**] 03:30PM GLUCOSE-146* UREA N-40* CREAT-1.6* SODIUM-139
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2181-1-30**] 03:53PM HGB-12.2 calcHCT-37 O2 SAT-99
[**2181-1-30**] 03:53PM TYPE-ART PO2-123* PCO2-31* PH-7.44 TOTAL
CO2-22 BASE XS--1 INTUBATED-NOT INTUBA
[**2181-1-30**] 05:00PM URINE RBC-0-2 WBC->1000 BACTERIA-MANY
YEAST-NONE EPI-0
[**2181-1-30**] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2181-1-30**] 05:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.024
[**2181-1-30**] 11:15PM CK-MB-NotDone cTropnT-0.69*
[**2181-1-30**] 11:15PM CK(CPK)-33
.
ECHO:Mild symmetric left ventricular hypertrophy with regional
systolic dysfunction. Mild aortic regurgitation. Pulmonary
artery systolic hypertension. Dilated ascending aorta.
Compared with the report of the prior study (images unavailable
for review) of [**2178-3-24**], the regional left ventricular systolic
dysfunction is new and c/w multivessel CAD or Takotsumo
cardiomyopathy. The estimated pulmonary artery systolic pressure
is higher. The ascending aorta dilation is similar.
.
MRI/MRA head:
1. Infundibulum at the origin of the left posterior cerebral
artery P1 segment versus sub-3-mm aneurysm in this area. A CTA
of the head would be valuable in clarifying this issue.
2. Extensive bilateral white matter T2/FLAIR hyperintensity
consistent with small vessel ischemic disease.
3. Incompletely evaluated degenerative change of the upper
cervical spine.
.
Cardiac catheterization:
1. Non-obstructive CAD with 40% proximal LAD thrombus likely
representing resolved thrombus.
2. Elevated left sided filling pressures.
3. Mild pulmonary arterial hypertension.
Brief Hospital Course:
ASSESSMENT AND PLAN, TO BE REVIEWED AND DISCUSSED IN
MULTIDISCIPLINARY ROUNDS:
.
89F with PMH of CAD s/p DES to OM [**2178**], HTN, hyperlipidemia
presents with 1 week of shortness of breath.
.
# CAD/Ischemia: Patient presented with one week of shortness of
breath but denied chest pain. Noted to have diffuse, nonspecific
ST elevations on ECG. Underwent cardiac catheterization
significant for patent stent and 40% proximal LAD thrombus. Pt
had persistent ST elevations post cath. Unclear etiology. No
evidence of pericarditis clinically. ESR was slightly elevated
making myocarditis unlikely. No apical ballooning noted on ECHO
but patient did have diffuse hypokinesis making stress
cardiomyopathy a possible etiology of her ECG changes. No
evidence of aneurysm. Patient was continued on aspirin, statin,
started on ace inhibitor and bblocker was titrated. Her plavix
was discontinued as her stent was placed in [**2178**].
.
# Pump: Echo with EF of 25%. Patient required nasal cannula and
was decompensated heart failure with pulmonary edema. She was
treated with diuresis and discharged on double her home dose
lasix. An ace inhibitor was added for afterload reduction.
.
# Rhythm: Patient had one episode of afib with RVR complicated
by hypotension converted to sinus rhythm s/p amiodarone load.
Remained in sinus on telemetry for duration of stay. Discharged
on amiodaron 200mg daily. Toprol was titrated up as tolerated by
her blood pressure.
.
# HTN: Titrated her toprol and lisinopril as tolerated by blood
pressure.
.
# Pansensitive E.coli UTI: Treated with 5 days of bactrim. Foley
was removed. Symptoms improved.
.
# Chronic kidney disease: Presumed chronic kidney disease. Hx of
partial nephrectomy. Creatinine remained stable in setting of
diuresis.
.
# FEN: cardiac/heart healthy diet; replete lytes PRN
.
# Code: Full, discussed with patient and husband
.
# Communication: patient and husband ([**Telephone/Fax (1) 97554**] (home);
Office ([**Telephone/Fax (1) 97555**]
.
Medications on Admission:
Toprol XL 12.5 daily
Diovan 80mg daily
Lasix 40mg daily
Lipitor 10mg daily
Protonix 40mg daily
Plavix 75mg daily
Aspirin 325mg daily
SL nitro PRN
Allopurinol 100mg daily
Colchicine?
Triamcinolone creme
Silver sulfadiazine
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Congestive heart failure, atrial fibrillation
Secondary: Coronary artery disease
Discharge Condition:
Good, chest pain free, vital signs stable
Discharge Instructions:
You were admitted to the hospital with shortness of breath.
Adjustments were made to your medications. You were also noted
to develop an abnormal heart rhythm. This resolved with the
addition of a new medication.
Changes to your medication include:
Toprol XL 25mg daily
Amiodarone 200mg daily
Lasix 40mg twice daily
Lisinopril 5mg daily
Lipitor 40mg daily
Discontinue diovan
.
Please follow up with your cardiologist in 2 weeks.
Please follow up with your primary care doctor in 4 weeks.
.
Please contact your doctor or return to the emergency room i f
you develop any worrisome symptoms such as chest pain, worsening
shortness of breath, lightheadedness, fluttering in your chest,
passing out, etc.
Followup Instructions:
Please follow up with your cardiologist in 2 weeks.
Please follow up with your primary care doctor in 4 weeks.
Name: [**Known lastname 15555**],[**Known firstname 1194**] M Unit No: [**Numeric Identifier 15556**]
Admission Date: [**2181-1-30**] Discharge Date: [**2181-2-5**]
Date of Birth: [**2091-8-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Epinephrine / Novocain / Codeine / Celebrex /
Naprosyn
Attending:[**First Name3 (LF) 6568**]
Addendum:
Stage I pressure ulcer: Patient noted to have Stage I ulcer.
Treated with skin care creams and frequent rotation with
improvement of skin integrity.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3518**] MD [**MD Number(1) 3519**]
Completed by:[**2181-2-28**]
|
[
"414.01",
"041.4",
"428.0",
"274.9",
"252.00",
"427.31",
"V45.82",
"403.90",
"272.4",
"414.8",
"715.90",
"428.20",
"599.0",
"707.03",
"585.9",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9954, 10177
|
5126, 7119
|
294, 320
|
8468, 8512
|
3006, 5103
|
9261, 9931
|
1863, 1945
|
7392, 8245
|
8355, 8447
|
7145, 7369
|
8536, 9238
|
1960, 2987
|
235, 256
|
348, 1553
|
1575, 1685
|
1701, 1847
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,126
| 109,288
|
51403
|
Discharge summary
|
report
|
Admission Date: [**2140-5-5**] Discharge Date: [**2140-5-14**]
Date of Birth: [**2083-10-9**] Sex: F
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: This is a 56 year old African
American female with a history of sickle cell disease, gout,
hypertension, diastolic congestive heart failure and chronic
renal failure who was recently admitted [**2140-4-9**], to
[**2140-4-16**], with mental status changes and lethargy, which were
attributed to pain medicines with an element of uremia. She
also developed diarrhea with negative stool cultures and
negative Clostridium difficile toxin times three. She was
discharged home on [**2140-4-16**], and then had a follow-up
appointment in hematology clinic the day of admission with
Dr. [**Last Name (STitle) **]. She was noted to be febrile to 101 and reported
having fevers for the last few days. She also reported
urinary frequency but no dysuria. She complained of pain
over tophi of her bilateral elbows and redness. She was
originally admitted to the [**Company 191**] service on the floor but she
was noted to have a diffuse back and abdominal pain and chest
pain. She was given one liter of D5 normal saline, Ceptaz
and Magnesium, Tylenol and Morphine for pain.
REVIEW OF SYSTEMS: Positive for mild chronic shortness of
breath on home four liters oxygen, no cough, positive
diarrhea times two days, no nausea, vomiting, no bright red
blood per rectum, no melena, no dysuria, no frequency, no
sick contacts. She sleeps with four pillows at baseline and
has had no changes in her weight recently. There was concern
for acute chest given her sickle cell disease and then she
was transferred to the Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Sickle cell disease, recent pain crisis and admission.
2. Gout.
3. History of poor response to blood transfusions secondary
to immune mediated hemolysis.
4. Chronic renal insufficiency with focal glomerulosclerosis
with a normal baseline creatinine of 3.0 to 4.0.
5. History of increased ferritin with possible secondary to
hemochromatosis.
6. Congestive heart failure with an echocardiogram on [**3-27**],
with an ejection fraction of greater than 55% and diastolic
dysfunction.
7. Depression.
8. Home oxygen, two liters.
9. Hypertension.
10. Anemia.
11. Status post cholecystectomy.
12. Reactive airway disease.
13. Hepatomegaly on CT found on [**2140-4-1**], increased alkaline
phosphatase and GGT secondary to question of chronic
intrahepatic cholestasis.
MEDICATIONS ON ADMISSION:
1. Celexa 20 mg p.o. once daily.
2. Albuterol one to two puffs q6hours p.r.n.
3. Amlodipine 5 mg once daily.
4. Folate 5 mg once daily.
5. Silvamere 1600 three times a day.
6. Epogen 16,000, however, she has not been receiving this.
7. Sodium Bicarbonate 1300 three times a day.
8. Hydroxyurea [**2137**] once a day.
9. Hydralazine 50 mg q6hours.
10. Lasix 60 mg p.o. once daily.
11. Protonix 40 mg once daily.
12. Actigall 300 mg three times a day.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: She is retired and lives with her daughter.
[**Name (NI) **] tobacco and no alcohol and no intravenous drug abuse.
PHYSICAL EXAMINATION: On admission, temperature 101.6, pulse
113, blood pressure 158/80, respiratory rate 24, oxygen
saturation 100% on four liters. She appeared uncomfortable
and tired. Head is normocephalic and atraumatic. The pupils
are equal, round, and reactive to light and accommodation.
Extraocular movements are intact. Mucous membranes are
moist. No sinus tenderness. The neck was supple with full
range of motion. She was tachycardic with a normal S1 and S2.
Her lungs were clear to auscultation bilaterally with no
wheezes or crackles. Her abdomen was obese, positive bowel
sounds, diffusely tender, positive enlarged liver, 13
centimeter span, no spleen tip, no caput, no fluid ascites
appreciated. She had no costovertebral angle tenderness.
Extremities showed no cyanosis, clubbing or edema. She had
positive warm and swollen left elbow. Cranial nerves II
through XII are intact. Strength is [**5-30**] throughout in all
four extremities. No asterixis.
LABORATORY DATA: White blood cells was 0.8, hematocrit 11.0,
platelet count 81,000. Sodium 139, potassium 2.8, chloride
112, bicarbonate 15, blood urea nitrogen 69, creatinine 3.3,
glucose 121, ALT 22, AST 45, alkaline phosphatase 736, total
bilirubin 0.9, LDH 153, albumin 3.0, calcium 8.2, magnesium
1.3, phosphate 4.0, uric acid 7.9. Reticulocyte count was
pending. ANC was 130. Hepatoglobin 155. Fibrinogen 571.
Chest x-ray demonstrated improvement from prior chest x-ray
on [**2140-4-15**], with a decreased pleural effusion, no focal
infiltrative process, but positive cardiomegaly.
HOSPITAL COURSE: She was admitted to the unit with concern
for acute chest, however, given her febrile neutropenia, she
was placed on Ceftazidime which was renally dosed. She
remained febrile until [**2140-5-8**], three days into admission.
It was thought that there was a possibility of septic
arthritis. Her left elbow was tapped. The second tap
revealed 220,000 white blood cells, 792,500 red blood cells
of which the differential was 92% polys, 3% lymphocytes and
4% monocytes. They were unable to aspirate much from the
joint given the high prevalence of gout crystals. However,
her elbow decreased in size and clinically began to improve.
She did remain afebrile. Additionally, blood cultures also
came back positive for MSSA for which she was changed to
Oxacillin on [**2140-5-9**].
Pancytopenia - This was thought to be secondary to
Hydroxyurea, the dose of which had been escalated recently.
This medication was discontinued and her count began to
slowly improve.
Acute renal failure - She had chronic renal insufficiency.
On admission, her creatinine was 3.3, however, after
aggressive diuresis in the Intensive Care Unit, her
creatinine bumped to as high as 6.7. Renal consultation was
obtained and felt that this was secondary to hypoperfusion
from the diuresis and her creatinine slowly began to recover
and was 4.5 at discharge. The renal team following thought
that she would eventually need hemodialysis and was to set
her up for an outpatient port after discharge.
Pulmonary - The patient had chronic lung disease on home
oxygen, however, chest CT demonstrated multiple infarcts
thought to be secondary to sickle disease. She was also
found to have pulmonary hypertension on echocardiogram. The
etiology of this was also likely to sickle cell disease. She
was set up with an outpatient with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from
pulmonary to further evaluate this.
Cardiac - The patient has a tendency to easily go into
congestive heart failure. She is on Lasix at home. Because
of her mild chest pain shortness of breath on admission, she
was ruled out by enzymes on [**2140-5-6**]. The Lasix was
initially held secondary to renal failure. An echocardiogram
on [**2140-5-9**], demonstrated an ejection fraction of 70%,
moderate pulmonary hypertension, left atrial dilatation, left
ventricular hypertrophy, 1+ mitral regurgitation, 2+
tricuspid regurgitation, and her fluid status remained
stable.
Additionally, she had an episode of atrial fibrillation while
in the Intensive Care Unit with rapid ventricular response.
This was responsive to Diltiazem and she remained in normal
sinus rhythm at discharge.
Gastrointestinal - The patient complained of right upper
quadrant chronic abdominal pain. It was thought this was
secondary to iron overload and hemochromatosis. She had
previously been seen by Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] during a
previous hospitalization. Therefore, she was set up with an
outpatient appointment to evaluate this for possible biopsy
and kelation therapy.
Gout - It was thought that the left elbow swelling and pain
was secondary to gout, however, she was unable to be
medicated for this as the pancytopenia prohibited her from
Hydroxyurea and Colchicine. There was a question of septic
arthritis. Therefore, Prinivil was also not begun. However,
orthopedic consultation by Dr. [**Last Name (STitle) 284**] felt that there was
no evidence of infection and therefore no indication for
surgery. Therefore, she was started on Hydroxyurea upon
discharge as all her cell lines had normalized at that time.
She had follow-up with Dr. [**Last Name (STitle) **] in hematology clinic to
follow-up this closely.
The patient clinically did very well once transferred out of
the Intensive Care Unit. PICC line was placed and she was
discharged home on intravenous Oxacillin times fourteen days
with home VNA.
MEDICATIONS ON DISCHARGE:
1. Hydroxyurea 1000 mg one tablet p.o. once daily.
2. Oxacillin two grams q6hours for ten days.
3. Celexa 20 mg p.o. once daily.
4. Folic Acid 1 mg p.o. once daily.
5. Thiamine 100 mg p.o. once daily.
6. Pantoprazole 40 mg p.o. once daily.
7. Erythropoietin 10,000 three times a week.
8. Silvamere 800 mg three times a day.
9. Sodium bicarbonate 650 mg three times a day.
10. Diltiazem 60 mg p.o. four times a day.
11. Hydralazine 75 mg p.o. q6hours.
12. Albuterol one to two puffs inhaled q6hours p.r.n.
FOLLOW-UP: Hematology/oncology Clinic with Dr. [**Last Name (STitle) **],
Pulmonary Clinic with Dr. [**Last Name (STitle) **], [**Hospital **] Clinic
with Dr. [**Last Name (STitle) **], and an appointment with her primary care
physician one week following discharge.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern1) 20150**]
MEDQUIST36
D: [**2140-5-15**] 11:36
T: [**2140-5-17**] 20:20
JOB#: [**Job Number 106564**]
|
[
"584.9",
"790.7",
"428.0",
"416.0",
"427.31",
"274.0",
"585",
"726.33",
"284.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
8718, 9749
|
2523, 3037
|
4767, 8692
|
3193, 4749
|
1264, 1702
|
174, 1244
|
1724, 2497
|
3054, 3170
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,736
| 160,423
|
46495
|
Discharge summary
|
report
|
Admission Date: [**2168-12-20**] Discharge Date: [**2168-12-23**]
Date of Birth: [**2103-1-12**] Sex: F
Service: [**Company 191**]
HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname 3501**] is a 65-year-old
lady with a history of diabetes, three vessel coronary artery
disease, CHF, chronic renal insufficiency, hypertension,
anemia, who was admitted by Night Floor to the SICU for
episodes of bright red blood per rectum times three in the
morning of admission. She reports a history of melena a week
prior to admission likely secondary to Pepto Bismol use for
diarrhea. She denied any other symptoms including fevers,
chills, nausea, vomiting, abdominal pain, and diarrhea. She
did have baseline exertional chest discomfort and chronic
nausea.
She was seen in her PCPs office and was referred to the
Emergency Room for further evaluation. In the Emergency
Room, she complained of episodes of substernal chest pain
with shortness of breath which was consistent with her
baseline angina symptoms. The EKG was with lateral T wave
inversions and ST depressions in leads I, aVL, and V4 through
V5. She was admitted for rule out MI and lower GI bleeding.
Her hematocrit had remained stable in the hospital without
further episodes of bright red blood per rectum. She also
had serial cardiac enzymes which were negative. She had no
event on telemetry.
She was evaluated by the Cardiology Consult Service who
recommended continuing medical management and outpatient
follow-up. She was also seen by the GI Service for the need
of EGD and colonoscopy. Given her concurrent cardiac issues
and no suspicion for upper GI bleeding, the GI Service
recommended colonoscopy in the setting of a stable
hematocrit.
ADMISSION MEDICATIONS:
1. Protonix 40 mg b.i.d.
2. NPH 36 units q.a.m., 34 units q.p.m.
3. Regular insulin sliding scale.
4. Epogen 8,000 units q. week.
5. Metoprolol 100 mg b.i.d.
6. Lipitor 10 mg q.d.
7. Cozaar 100 mg q.d.
8. Imdur 60 mg q.d.
9. Neurontin 300 mg t.i.d.
10. Lasix 120 mg q.d.
11. Colace 100 mg b.i.d.
12. Dulcolax 10 mg q.d.
REVIEW OF SYSTEMS: Three pillow orthopnea, stable angina,
minimally active at baseline. Exercise tolerance, unable to
climb upstairs.
FAMILY HISTORY: Colon cancer.
SOCIAL HISTORY: No cigarettes or tobacco.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient was
a pleasant obese elderly woman sitting in a chair without
acute distress. Head and neck examination: The oropharynx
was clear. The sclerae were anicteric. The mucous membranes
were moist. Cardiovascular: Regular rate and rhythm, normal
S1, S2. Possible S3 versus S2 split at the right sternal
border. Lungs: Clear to auscultation bilaterally but with
decreased breath sounds throughout secondary to excessive
subcutaneous tissue. Abdomen: Obese, soft, nontender.
Extremities: No edema.
LABORATORY DATA: White count 12.3, 71% neutrophils, 22%
lymphocytes, 3% monocytes, hematocrit 29.6, platelets
276,000. Trending of hematocrit in the hospital 29.4 to 29.6
to 31.3 to 32.5 without transfusion. PT 13.3, PTT 26.8, INR
1.2. The U/A showed negative nitrates, trace leukocyte
esterase. There were 2 white blood cells, [**1-18**] red blood
cells, rare bacteria, [**4-25**] epithelials. Sodium 142,
potassium 3.8, chloride 105, bicarbonate 25, BUN 68,
creatinine 2.2, glucose 75, calcium 8.6, magnesium 1.8,
phosphorus 4.4, albumin 3.4, total bilirubin 0.2, AST 11,
alkaline phosphatase 114. CK 188-165, troponin less than 0.3
times three. Iron 43, TIBC 211, ferritin 468, consistent
with chronic disease anemia. Hemoglobin in [**2163-1-15**] was
13.7. Lipid panel in [**2168-8-16**] revealed LDL 77, HDL
37, total cholesterol 135.
Echocardiogram in [**2167-6-17**] showed an ejection fraction
of 45-50%, [**11-17**]+ MR, moderate pulmonary hypertension, mild LV
dilatation, mild regional LV systolic dysfunction with
akinesis of basal inferior posterior wall.
Catheterization in [**2167-1-15**] showed severe three vessel
disease.
HOSPITAL COURSE: The patient had remained stable in the
hospital without further episodes of chest pain or bright red
blood per rectum. After discussing with both GI and
Cardiology Consult Service, the decision was made to send the
patient home with outpatient cardiology follow-up and
outpatient virtual colonoscopy to evaluate the source of her
lower GI bleeding. It was thought that her bright red blood
per rectum was most likely secondary to diverticulosis.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Home with VNA.
DISCHARGE DIAGNOSIS:
1. Lower gastrointestinal bleeding.
2. Angina.
3. Rule out myocardial infarction.
4. Diabetes.
5. Hypertension.
6. Coronary artery disease.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. b.i.d.
2. NPH 36 units q.a.m. with breakfast, 36 units q.p.m. with
dinner.
3. Epogen 8,000 units q. Wednesday subcutaneously.
4. Metoprolol 100 mg p.o. b.i.d.
5. Lipitor 10 mg p.o. q.d.
6. Cozaar 100 mg p.o. q.d.
7. Imdur 60 mg p.o. q.d.
8. Colace 100 mg p.o. b.i.d.
9. Dulcolax 10 mg p.o. q.d.
10. Aspirin 81 mg p.o. q.d.
11. Norvasc 5 mg p.o. q.d.
12. Lasix 120 mg b.i.d.
DISCHARGE FOLLOW-UP: The patient will continue to follow-up
with her PCP and Cardiology as an outpatient. The patient
will also need a virtual colonoscopy to evaluate for the
source of her lower GI bleeding.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 225**]
MEDQUIST36
D: [**2169-1-2**] 10:09
T: [**2169-1-3**] 09:44
JOB#: [**Job Number 98772**]
|
[
"278.00",
"411.89",
"250.40",
"578.1",
"593.9",
"285.29",
"401.9",
"794.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4500, 4544
|
2239, 2254
|
4735, 5622
|
4565, 4712
|
4029, 4478
|
1755, 2085
|
2105, 2222
|
2334, 4011
|
2271, 2319
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,982
| 133,321
|
23606
|
Discharge summary
|
report
|
Admission Date: [**2126-6-19**] Discharge Date: [**2126-7-18**]
Service: SURGERY
Allergies:
Plavix / Lipitor / Iodine Containing Agents Classifier /
Macrobid / Ticlid / Ambien
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Left groin wound infection
Major Surgical or Invasive Procedure:
Incision and drainage of left groin wound.
History of Present Illness:
This 83-year-old lady has had an aortobifemoral
graft in the distant past. She clotted her left limb a few
weeks ago, developed left foot ischemia. On [**2126-6-1**], she
underwent a thrombectomy of the graft and revision with a
Dacron patch profundoplasty. She did well from this procedure
and was in rehab recovering. However, last night was taken to
a local emergency room with bleeding from the left groin. A
left groin cellulitis was seen and the patient was
transferred here urgently for further care. CT scan showed
some fluid around the graft, although was unclear as to
whether or not the infection involved the graft itself and
there was no pseudoaneurysm noted. Admitted for IV ABX and I&D
Past Medical History:
1. Coronary artery disease
a. CABG ([**2116**])
--> LIMA-LAD
--> SVG-OM1-OM2-D1 (known occluded)
b. PCI with stent to LMCA (outside institution)
c. NSTEMI ([**5-2**]) with PCI
--> LCX with 70% stenosis; stented with 3.0x28mm Cypher
[**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]. PCI ([**6-1**])
e. Current anatomy as follows:
- LMCA s/p stent
- LIMA-->LAD
- LCx s/p stent in [**5-2**]
- RCA totally occluded
- SVG-->OM1 (occluded)
- SVG-->OM2 (occluded)
- SVG-->D1 (occluded)
OTHER PAST HISTORY:
2. Peripheral vascular disease
a. aorto-bifemoral bypass
b. ? failed LLE bypass (per prior d/c summary left iliofem
bypass and anterior tib bypass noted in Dr. [**Last Name (STitle) **]??????s note)
3. Renal artery stenosis (right), severe
--> PCI ([**6-1**]) with 80% stenosis; stented with 5.0x18mm Ultra
RX
4. Carotid disease
- s/p Left CEA [**2116**]
5. s/p Stroke times two with residual right sided weakness
6. Hypertension
7. Hyperlipidemia
8. Chronic kidney disease: baseline SCr ~1.3-1.5
9. Anemia: baseline hct ~30
10. Hypothyroidism
11. s/p Left ORIF
12. s/p Ventral hernia repair x 4
13. s/p TAH
Social History:
Social history is significant for the absence of current tobacco
use (quit >30 years ago). There is no history of alcohol abuse
(drinks socially). She currently lives alone and is independent.
She is a widow and has two daughters.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: 98.1, 74, 120/75, 16 97% 3L
GEN: NAD
Neuro: A&OX3
CV: RRR
RESP: CTA
ABD: +BS
Pulses: B/L DP/PT dop
Lt groin- healing well, no evidence of infection
Pertinent Results:
[**2126-7-15**] 05:54AM BLOOD WBC-5.7 RBC-3.12* Hgb-10.0* Hct-29.0*
MCV-93 MCH-32.0 MCHC-34.4 RDW-16.6* Plt Ct-338
[**2126-7-15**] 05:54AM BLOOD Plt Ct-338
[**2126-7-15**] 05:54AM BLOOD PT-12.1 PTT-32.6 INR(PT)-1.0
[**2126-7-15**] 05:54AM BLOOD Glucose-92 UreaN-35* Creat-1.0 Na-137
K-4.2 Cl-97 HCO3-35* AnGap-9
[**2126-7-15**] 05:54AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.6
[**2126-7-7**] 05:40AM BLOOD Vanco-18.6
[**2126-6-29**] 11:41PM BLOOD Vanco-16.6
Brief Hospital Course:
Underwent I&D of superficial LT groin infection.
Started on Vanco/Levo/Flagyl. Wound care continued.
[**6-24**]: Became confused, contributed to Haldol and lack of sleep.
Sitter in place for safety. Vac applied to LT groin.
[**6-25**] SOB, 99% on 2L. WT stable. 38cm Vaxcel PICC inserted in RT
basilic. PICC tip in mid SVC. A+O X3. physical therapy/Rehab
screening.
[**6-26**]: SOB, wheezing , somnolent. ABG drawn with PCO2 of 62, ph
,7.30. Transfer to CSRU/ICU for hypoxia/close monitoring. Head
CT shows no bleed or shift.
[**Date range (1) 16006**] remained to ICU, transfused for HCT. On bi-pap, serial
ABGs. Neuro evaluated for somnolence - doubt CNS etiology,
likely hypercarbic related encephalopathy. Signed off. Continued
on Vanco/Levo/Flagyl.
[**6-30**]: Re-intubated for resp acidosis/distress. Pulmonary
evaluated, felt malnutrition contributing to resp issues Tube
feeds started via Dobbhoff. Nutrition consult obtained.
[**Date range (1) 60416**] Remained in ICU. ABX and wound care.
PICC exchanged single to double. Continued TF, physical therapy
working with pt. EKG stable, no changes. enzymes negative. All
sedation and narcotics held. Extubated on [**5-17**] VSS.
Continued diuresis with lasix, agressive chest PT.Continued ABX
(needs 6 weeks total of Vancomycin)
Bedisde swallowing exam performed. Patient with productive
cough. Had video swallow:
The study was done in conjunction with the speech and swallow
division. Multiple consistencies of barium were administered
under constant video fluoroscopic surveillance. The oral phase
was normal with normal bolus control and formation. Although
there is a mild delay in swallow initiation palatal elevation,
laryngeal elevation and laryngeal valve closure were within
normal limits. The patient had one episode of penetration with
thin liquid secondary to mild swallow delay. No aspiration was
seen.
IMPRESSION: One episode of penetration with thin liquid with no
evidence of aspiration.
Geriatrics consult obtained for confusion, delirium. Diagnosis:
Multifactorial delirium due to prolonged hospitalization, ICU.
Recommendation include sitter if needed, avoid restraints,
family visits, Tylenol only for pain.
[**Date range (1) 60417**]. VSS, Continued on Vanco IV, wound care. wound VAC
d'ced and started on saline dressings as wound is healing well
and shallow. No evidence of infection.
Patient progressing well. General surgery consult obtained for
PEG tube. Surgery scheduled for [**7-15**] but cancelled as patient
has had abdominal surgery with mesh. Will begin rehab screening
for facility that will take Dobbhoff. Receives cycled tube
feeds at night and regular diet as tolerated. Working with
physical therapy and nursing staff
[**7-18**]: Discharged to rehab with continued tube feeds via Dobbhoff
and regular diet. PICC n place for IV Vancomycin for additional
2 weeks. VSS. Continues on 2-3L NC. Patient to follow up with
Dr. [**Last Name (STitle) **] in 3 months or sooner with any issues, signs of
infection etc.
Medications on Admission:
Aspirin 325', Lopressor 25"', Zetia 10', Levothyroxine 88',
Regular insulin SS, Protonix 40', Estradiol 0.5', Colace 100",
Atacand 8', Vitamin D 400", Plavix 75', vit B12 1000'
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: [**1-29**] Injection
[**Hospital1 **] (2 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. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
11. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed.
12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
14. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day) as needed.
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
18. Other
Sodium Chloride 0.9% Flush 10 ml IV DAILY:PRN
For vaxcel PICC flush before and after use- Inspect site every
shift
19. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Hold SBP <100.
20. Vancomycin 1,000 mg Recon Soln Sig: 750mg Intravenous Q36
hours for 2 weeks: needs 2 weeks more
Check through around 3rd dose weekly.
21. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
22. PICC care per institution protocol
Sodium Chloride 0.9% Flush 10 ml IV DAILY:PRN
For Vaxcel PICC Flush. Use before and after each use. No heparin
required.
23. Outpatient Lab Work
Vanco through weekly and CBC/Cr weekly while on Vancomycin
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 17921**] Center - [**Location (un) 5450**], NH
Discharge Diagnosis:
Left groin wound infection status post thrombectomy of left
aortobifemoral graft limb.
Dyslipidemia, HTN CVA x2 with residual right sided weakness,
Anemia, Hypothyroidism, Chronic kidney disease: baseline SCr
~1.3-1.5
Discharge Condition:
Stable
Discharge Instructions:
When to Call the Doctor:
Watch for the following signs and symptoms and notify your
doctor if these occur:
Temperature over 101.5 F or chills
Foul-smelling drainage or fluid from the wound
Increased redness or swelling of the wound or skin around it
Increasing tenderness or pain in or around the wound
Followup Instructions:
Call Dr [**Name (NI) **]0seeli office and schedule an appointment for two
weeks. he can be reached at [**Telephone/Fax (1) 3121**]
Completed by:[**2126-7-18**]
|
[
"263.9",
"348.31",
"V45.81",
"412",
"593.9",
"780.79",
"518.81",
"428.0",
"438.89",
"401.9",
"285.29",
"V45.82",
"V09.80",
"440.1",
"998.59",
"428.20",
"443.9",
"244.9",
"V09.0",
"733.00",
"272.4",
"787.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"99.04",
"86.04",
"93.90",
"38.93",
"96.04",
"93.59",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8781, 8867
|
3328, 6338
|
317, 362
|
9130, 9139
|
2853, 3305
|
9496, 9658
|
2584, 2666
|
6566, 8758
|
8888, 9109
|
6364, 6543
|
9163, 9473
|
2681, 2834
|
251, 279
|
390, 1093
|
1115, 2319
|
2335, 2568
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,251
| 123,847
|
39087
|
Discharge summary
|
report
|
Admission Date: [**2197-3-10**] Discharge Date: [**2197-3-15**]
Service: MEDICINE
Allergies:
Aspirin / Nsaids / Trimethoprim
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
lower GI bleed
Major Surgical or Invasive Procedure:
status post flexible sigmoidoscopy and ethiodol injection with
hemostasis in the rectal varices
History of Present Illness:
89 y/o female with DM, CHF, cryptogenic cirrhosis noted by CT/US
(followed by hepatology), s/p splenectomy, undergoing
thrombocytopenia w/u with question of ITP (started with
prednisone 60 mg approx 2 weeks ago, now on 30 mg daily) who
presented to the ED from the [**Hospital **] clinic for GI bleed.
.
Pt was recently admitted from [**Date range (1) **] for GI bleed and
thrombocytopenia. EGD on this admission was unremarkable;
colonoscopy showed sigmoid diverticulosis, large rectal varices
without stigmata of recent bleeding, and grade 1 internal
hemorrhoids. On that admission, she also had work-up of
thrombocytopenia (nadir 18K, 60K on d/c) with the most likely
etiologies thought to be ITP and cirrhosis.
.
Pt was shortly readmitted on [**2-16**] to the Neurology service for
AMS in the setting of hypoglycemia. During that admission, Heme
was consulted for further work-up of her thrombocytopenia to
nadir 38K, and pt was started on prednisone 60mg for presumed
ITP with subsequent improvement in her platelet count to 74K on
discharge on [**2-19**]. Her thrombocytopenia continued to improve at
her Hematology f/u on [**2-26**], and her anemia (Hct 24-28) was
attributed mostly to CKD.
.
On morning of admission, while at her Hematology f/u, she had a
large loose BM with bright red blood admixed with dark colored
BM. The patient reports having loose stools once to twice daily
over the past several months; they are always dark due to her
iron supplement. She does occasionally have bright red blood on
toilet paper after a BM but never admixed with stool; this began
prior to her last colonoscopy. She has felt more drained in the
past week with increased fatigue and mild dyspnea on exertion
and occasional lightheadedness. She was referred to the ED for
further evaluation.
.
Rectal exam was notable for marroon stools (neither bright red
nor melanic per ED resident), guaiac positive. Labs WBC 20.2 (on
steroids), Hct 23.4, Plt 103. INR 0.9. BNP 3645. EKG baseline.
NG lavage was negative. Patient was given pantoprazole 40mg IV x
1 and started octreotide gtt given her history of rectal varices
per Liver recs.
.
In the ICU, Flex sig showed large rectal varices without
bleeding, ethiodol injection with hemostasis in the rectal
varices. Hct has been stable. Got 1 unit of pRBC.
Anti-hypertensives were held overnight; now back on amlodipine 5
[**Hospital1 **], lisinopril 40 qday, natolol; furosemide 40 mg being held
currently. Leukocytosis WBC 19; ?due to steroids.
.
On transfer, VS: 122/55, 78, 97%2L. put out 1 L of UOP today.
Net -1L today.
Past Medical History:
- Cryptogenic Cirrhosis - documented esophageal varices and
rectal varices
- S/p splenectomy in [**2190**] - unknown cause
- Thrombocytopenia - ?ITP
- Anemia - ?related to CRF
- Hypertension
- Type 2 Diabetes Mellitus
- CHF (EF nl in [**2-8**])
- Pulmonary Hypertension
- Mild AS, mild MS, mild MR on [**2-8**] echo
- CKD baseline Cr 1.4
- Paraproteinemia
- L rotator cuff injury s/p MVA
- S/p appendectomy
- Left macular degeneration
- H/o gait disturbance
- S/p TAH, unilateral oophorectomy
Social History:
Lives w/ daughter. Worked for [**Location (un) **] for 25 years as an office
assisstant.
- Tobacco: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
Family Hx:
[ + ] HTN
[ - ] CVA/TIA
[ + ] CAD/PVD
[ - ] Intracerebral aneurysms/AVM
[ - ] Connective tissue disorders ([**Last Name (un) 42664**] Dahnlos, Marfans,
PKD)
[ - ] Autoimmune d/o
Physical Exam:
Vitals: T:afebrile, BP:124/55, P:81, R:16, O2:97% 2L NC
General: Alert, oriented, no acute distress
HEENT: Ecchymoses over left orbit - mildly TTP, sclera
anicteric, MMM, +thrush, MMM
Neck: Supple, JVP elevated to angle of jaw, no LAD
Lungs: Minimal crackles at bases, no wheezes or rhonchi
CV: Irregular, normal S1 + S2, 3/6 systolic MM across precordium
and radiating to axilla, no rubs or gallops
Abdomen: Soft, non-tender, obese but non-distended, no fluid
wave, bowel sounds present, no rebound tenderness or guarding,
no organomegaly
GU: No foley
Ext: Warm, well perfused, 2+ pulses, ecchymoses over LLE, range
of motion intact, 1+ edema to knees b/l
Pertinent Results:
LABS ON ADMISSION:
[**2197-3-10**] 11:30AM BLOOD WBC-20.2* RBC-2.47* Hgb-7.2* Hct-23.4*
MCV-95 MCH-29.0 MCHC-30.6* RDW-15.4 Plt Ct-103*
[**2197-3-10**] 11:30AM BLOOD Neuts-86.9* Lymphs-8.7* Monos-4.1 Eos-0.2
Baso-0
[**2197-3-10**] 02:28PM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Schisto-1+
[**2197-3-10**] 11:30AM BLOOD Plt Ct-103*
[**2197-3-10**] 11:30AM BLOOD UreaN-66* Creat-1.5* Na-141 K-4.7 Cl-107
HCO3-24 AnGap-15
[**2197-3-10**] 02:28PM BLOOD ALT-36 AST-26 AlkPhos-63 TotBili-0.3
[**2197-3-10**] 02:28PM BLOOD Lipase-36
[**2197-3-10**] 02:28PM BLOOD CK-MB-3 cTropnT-0.02* proBNP-3645*
[**2197-3-10**] 11:30AM BLOOD TotProt-6.3*
.
LABS ON DISCHARGE:
[**2197-3-15**] 07:00AM BLOOD WBC-PND RBC-3.11* Hgb-8.8* Hct-27.7*
MCV-89 MCH-28.5 MCHC-32.0 RDW-16.2* Plt Ct-PND
[**2197-3-14**] 06:48AM BLOOD Plt Ct-105*
[**2197-3-15**] 07:00AM BLOOD Glucose-183* UreaN-60* Creat-1.3* Na-144
K-4.0 Cl-109* HCO3-24 AnGap-15
[**2197-3-15**] 07:00AM BLOOD Calcium-7.7* Phos-2.8 Mg-2.2
.
CXR PA and lateral [**2197-3-12**]:
.
FINDINGS: In comparison with the study of [**2-17**], there is
increasing
prominence of interstitial markings that are somewhat
ill-defined, consistent with developing pulmonary edema and
small pleural effusions. Fluid is seen tracking into the minor
fissure on the right.
.
Because of the vascular consolidation, an early consolidation is
secured.
.
CT head without contrast [**2197-3-10**]:
.
FINDINGS: A non-contrast CT of the head was obtained. The
previously
identified focal hyperdensity within the midline pons is
redemonstrated and unchanged in appearance compared to prior
study of [**2197-2-15**]. There is no associated edema or mass
effect. No additional focal hyperdensities are noted within the
brain parenchyma. The ventricles and cerebral sulci are stably
enlarged compatible with age-related involutional change. The
extra-axial spaces are unremarkable in appearance. The basilar
cisterns are patent. There is no evidence of midline shift. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. The calvarium is
intact. The visualized paranasal sinuses are clear.
.
IMPRESSION: Unchanged focal pontine hyperdensity. No new focal
abnormality is identified.
Brief Hospital Course:
89 y/o female with DM, CHF (LVEF > 60%), cryptogenic cirrhosis,
s/p splenectomy, undergoing thrombocytopenia w/u with question
of ITP (on steroids per oncology), recently admitted for BRBPR
who represents with GI bleed, flex sig showing large rectal
varices without bleeding, ethiodol injection with hemostasis in
the rectal varices.
.
# GI bleed: Given recent colonoscopy finding, most likely
etiologies are rectal varices, diverticuli, or hemorrhoids.
Hemodynamically stable, s/p 2 units pRBC and flex sig showing
large rectal varices without bleeding, ethiodol injection with
hemostasis in the rectal varices. Negative NG lavage, and recent
unremarkable upper EGD. Hct remained stable prior to discharge
(discharge Hct 27.7). Patient was maintained with active T&S,
PIV x 2 for access. Empiric octreotide gtt was discontinued as
etiology not felt to be UGIB. Empiric ciprofloxacin prophylaxis
discontinued, as etiology not felt to be UGIB and pt w/o
ascites. Patient was discharged on home PPI. She will have Hct
check on [**Last Name (LF) 2974**], [**3-17**], with results to be faxed to PCP.
.
# Thrombocytopenia: Etiology thought to be ITP; plts improving
on prednisone. With ITP, pts usually not at increased bleeding
risk even with markedly decreased plt counts. Prednisone was
decreased to 30 mg as recommended by oncology, and patient was
discharged on this dose. Given elevated BG likely in setting of
steroids, patient was also started on lantus 10 units qAM and
ISS with instructions to use sliding scale if BG > 250. Her BG
range was from 200-300 while on this insulin regimen.
.
# Leukocytosis: patient afebrile, without localizing
signs/symptoms. ?steroids as etiology. Urinalysis and culture
unremarkable. CXR was without infiltrate. Blood cultures were
NGTD on discharge. Cdiff negative x 1.
.
# Thrush: Likely secondary to prednisone. Patient continued on,
and discharged with, nystatin S&S qid.
.
# Cryptogenic cirrhosis: No signs of encephalopathy. Appears
compensated. Restarted nadalol when Hct was stable. Hepatology
f/u arranged for [**2197-3-21**].
.
# CRF: initially with slight increase from baseline, which
trended down to baseline Cr 1.4-1.6 on discharge (discharge Cr
1.3). FEUrea was consistent with intrinsic renal disease. Urine
output remainded good. Etiology unclear, but Cr did return to
baseline prior to discharge. ACEi was resumed on discharge.
.
# CHF: Nl EF on recent TTE. Pt with evidence of mild fluid
overload, but this resolved once resuming home lasix regimen.
She was oxygenating well on room air and had ambulatory O2
saturation > 94% prior to discharge.
.
# HTN: Pressures more elevated recently, perhaps in setting of
prednisone. Home medications were re-started once Hct was
stable, and SBP remainded in 140s-150s prior to discharge.
.
# DM Type II: [**Month (only) 116**] have elevated blood sugars in setting of
steroids. Infectious work-up negative. Patient was discharged
with lantus 10 units qAM and ISS for BG > 250, as steroids may
be long term management strategy for her ITP. Patient and
daughter were provided with diabetes/insulin teaching. Both were
informed that BG fingersticks can be checked prior to breakfast,
lunch, and prior to bedtime and to treat with ISS for BG > 250.
This is in addition to her standing 10 units of lantus qAM (to
be taken as long as she is on the 30 mg prednisone). On
discharge, glyburide was held until discussion with PCP at next
appointment.
.
# S/p fall: CT head w/o evidence of acute path. Pt
neurologically intact and reportedly with resolving ecchymoses.
PT saw patient and felt she was appropriate for home with PT
services.
.
# HCP is daughter [**Name (NI) **] [**Telephone/Fax (1) 86634**]
.
# Dispo: discharge to home, PCP [**Name9 (PRE) 702**], [**Name9 (PRE) 269**] and PT services
at home
Medications on Admission:
- Ferrous Sulfate 300mg (60mg) daily
- Prednisone 30mg (decreased today from prednisone 60mg)
- Nadolol 40mg [**Hospital1 **] or 80mg daily (doubled last week)
- Glyburide 1.25mg [**Hospital1 **]
- Furosemide 40mg daily (doubled last week)
- Lisinopril 40mg daily
- Pantoprazole 40mg daily
- Amlodipine 5mg [**Hospital1 **] (doubled last week)
- Colace 100mg prn constipation
- Calcium 500 + D (D3) 500-125 mg-unit [**Unit Number **] tab daily
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation.
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*600 ML(s)* Refills:*2*
9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
10. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
11. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous qAM.
Disp:*1 vial* Refills:*1*
12. Humalog 100 unit/mL Solution Sig: AS PER SLIDING SCALE units
Subcutaneous as per sliding scale.
Disp:*1 vial* Refills:*1*
13. Outpatient Lab Work
Please have blood work drawn for hematocrit on [**Last Name (LF) 2974**], [**3-17**],
and have results faxed to primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 86635**].
14. GLUCOMETER
Please provide glucometer to patient
Dispense: 1
Refills: 0
15. TEST STRIPS
Please provide test strips which are compatible with glucometer
Dispense: 1 month supply
Refills: 0
16. LANCETS
Please provide patient with lancets for blood glucose monitoring
Dispense: 1 box
Refills: 0
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
1. lower gastrointestinal bleeding
2. status post flexible sigmoidoscopy and ethiodol injection
with hemostasis in the rectal varices
3. thrombocytopenia, felt to be ITP
.
SECONDARY:
1. cryptogenic cirrhosis
2. diabetes
3. chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the intensive care unit for lower
gastrointestinal bleeding. You received 2 units of blood
products, and underwent flexible sigmoidoscopy which showed
large rectal varices, which were injected with ethiodol. Your
blood counts were stable prior to discharge. You met with the
physical therapy doctors and they suggested home services and
physical therapy on discharge.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- START prednisone 30 mg daily until changed by your oncology
doctors
- START nystatin 5 mL by mouth four times a day for thrush
- START glargine insulin 10 units every morning
- START humalog insulin as per sliding scale (no need to give
insulin if blood sugar < 250).
- STOP glyburide until discussed with your primary care doctor
on [**2197-3-23**]
.
Please seek medical attention for chest pain, shortness of
[**Date Range 1440**], fevers, blood in your bowel movements, lightheadedness,
dizziness, abdominal pain, or any other concerning symptoms.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
Followup Instructions:
An appointment has been made with your primary care doctor, Dr.
[**Last Name (STitle) **], on [**3-23**] at 3:15 pm. The number is [**Telephone/Fax (1) 28399**].
.
Please attend your other appointments listed below, including
your hepatology/liver appointment.
.
Please call [**Telephone/Fax (1) 86636**] to discuss your next
hematology/oncology appointment time. It will likely be on
[**2197-3-24**].
.
Provider [**Name9 (PRE) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2197-3-21**] 10:15 (Hepatology/Liver)
.
Provider RADIOLOGY MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2197-5-10**]
11:40
Completed by:[**2197-3-17**]
|
[
"428.42",
"403.90",
"287.31",
"456.1",
"250.00",
"288.60",
"584.9",
"428.0",
"V15.88",
"455.2",
"571.5",
"578.1",
"285.1",
"572.3",
"112.0",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"49.42"
] |
icd9pcs
|
[
[
[]
]
] |
12727, 12802
|
6794, 10592
|
253, 350
|
13101, 13101
|
4522, 4527
|
14352, 15032
|
3639, 3830
|
11087, 12704
|
12823, 13080
|
10618, 11064
|
13252, 13659
|
3845, 4503
|
13679, 14329
|
199, 215
|
5221, 6771
|
378, 2946
|
4541, 5202
|
13116, 13228
|
2968, 3462
|
3478, 3623
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,217
| 161,623
|
42023
|
Discharge summary
|
report
|
Admission Date: [**2129-9-3**] Discharge Date: [**2129-9-15**]
Date of Birth: [**2047-1-27**] Sex: F
Service: SURGERY
Allergies:
Tetanus&Diphtheria Toxoid / Pneumovax 23
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2129-9-6**]
Closure of abdominal wall, irrigation of the abdominal cavity
[**2129-9-6**]
Removal of lap pad from previous surgery and enterocolic
anastomosis
[**2129-9-4**]
1. Re-exploration with right colectomy and no anastomosis.
2. Placement of negative-pressure dressing
[**2129-9-3**]
Reopen of recent laparotomy with exploration of the abdomen and
packing of the pelvis.
History of Present Illness:
The patient is a 82F otherwise healthy who presented to
[**Hospital 8**] hospital on [**2129-9-2**] via EMS with abdominal pain,
hypotension, nausea, and emesis. Upon arrival to the ED she was
tachycardic and complaining of lower abdominal pain with
persistent loose stools, emesis, and dysuria. She denied any
chest pain, SOB, or other complaints. She remained hypotensive
despite fluid resuscitation and blood products in the ER. CT
scan
was performed that showed hemoperitoneum with extravasation of
contrast concerning for acute inta-abdominal bleed.
The patient was taken emergently to the operating room on
[**2129-9-2**] for exlap. She was noted to have several mesenteric
hematomas, but no obvious bleeding source. 3 liters of blood was
evacuated from the abdomen and it was packed with towels and
surgicel and the abdomen was left open. Postoperatively, the
patient required NEO gtt to maintain MAP > 60, but this was
discontinued in the am [**9-3**]. She was maintained intubated and
sedated with fentanyl/versed on CMV ventilator support. In total
the patient received 6 units PRBCs, 2 units FFP, 1 cryo. She
started to become coagulopathic with decrease in plts,
increasing
INR, and decreasing fibrinogen. She was transferred to [**Hospital1 18**] for
further management.
Past Medical History:
PMH: HLD, osteoporosis, compression L1 fx - received steroid
shots
PSH: none
Social History:
Denies smoking, ETOH, drug use
Family History:
non contributory
Physical Exam:
Temp 97.3 HR 124 BP 107/60 RR 21 O2 sat 100% CMV FIO2
100%, PEEP 8
GEN: Intubated/sedated
HEENT: anicteric
CV: RRR
Lungs: clear anteriorly, no distress
ABD: soft, Open abdomen covered with towels and ioban, JPx2
exiting from inferior portion of wound, with serosanguinous
drainage
EXT: warm well perfused, palpable DP/PT bilaterally
Pertinent Results:
[**2129-9-15**] 05:07AM BLOOD WBC-13.2* RBC-2.98* Hgb-8.8* Hct-27.5*
MCV-92 MCH-29.5 MCHC-31.9 RDW-16.6* Plt Ct-429
[**2129-9-14**] 05:03AM BLOOD WBC-18.0* RBC-3.00* Hgb-8.8* Hct-27.5*
MCV-92 MCH-29.4 MCHC-32.1 RDW-16.0* Plt Ct-359
[**2129-9-13**] 05:20AM BLOOD WBC-20.5* RBC-3.02* Hgb-9.3* Hct-26.8*
MCV-89 MCH-30.7 MCHC-34.6 RDW-16.2* Plt Ct-321
[**2129-9-3**] 01:26PM BLOOD WBC-3.1* RBC-2.62* Hgb-8.2* Hct-22.4*
MCV-86 MCH-31.3 MCHC-36.6* RDW-14.9 Plt Ct-90*
[**2129-9-10**] 01:45AM BLOOD Neuts-92.9* Lymphs-5.2* Monos-1.7*
Eos-0.1 Baso-0.1
[**2129-9-15**] 05:07AM BLOOD Plt Ct-429
[**2129-9-7**] 02:06AM BLOOD PT-15.4* PTT-23.3 INR(PT)-1.3*
[**2129-9-15**] 05:07AM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-139
K-4.0 Cl-112* HCO3-18* AnGap-13
[**2129-9-14**] 05:03AM BLOOD Glucose-130* UreaN-13 Creat-0.9 Na-136
K-3.4 Cl-107 HCO3-18* AnGap-14
[**2129-9-3**] 01:26PM BLOOD Glucose-95 UreaN-14 Creat-1.2* Na-141
K-3.9 Cl-116* HCO3-20* AnGap-9
[**2129-9-6**] 01:46AM BLOOD ALT-118* AST-113* AlkPhos-48 TotBili-0.8
[**2129-9-5**] 01:54AM BLOOD ALT-120* AST-140* AlkPhos-30* TotBili-1.2
[**2129-9-15**] 05:07AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.9
[**2129-9-14**] 05:03AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.8
[**2129-9-4**] 11:54AM BLOOD CEA-<1.0 AFP-2.2
[**2129-9-9**] 06:01AM BLOOD Vanco-11.8
[**2129-9-8**] 03:12AM BLOOD Lactate-1.2
[**2129-9-7**] 05:39PM BLOOD Lactate-1.1
[**2129-9-3**]: chest x-ray:
Heart size and mediastinum are grossly unchanged since the prior
study, but there is interval progression of pulmonary edema,
currently interstitial, associated with bibasilar atelectasis,
left more than right, and left pleural effusion. No pneumothorax
is seen.
[**2129-9-4**]: chest x-ray:
FINDINGS: Nasogastric tube has been advanced with side port now
terminating in the stomach. Others support devices are unchanged
in position. Heart size is normal. Bibasilar opacities have
nearly resolved. There is no evidence of pulmonary edema or new
areas of consolidation to suggest a developing
pneumonia. Small pleural effusions are again demonstrated, left
greater than right
[**2129-9-9**]: chest x-ray:
IMPRESSION: Mild to moderate left pleural effusion has minimally
increased, minimal right pleural effusion has decreased since
[**2129-9-8**].
[**2129-9-9**]: x-ray of the abdomen:
IMPRESSION: No retained surgical objects within the visualized
abdomen.
These findings were discussed between Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from
radiology and Dr. [**Last Name (STitle) **] from the surgical service by
telephone at 4:25 p.m. on [**2129-9-9**]
[**2129-9-8**]:
[**2129-9-8**] 2:02 pm CATHETER TIP-IV Source: cvl.
**FINAL REPORT [**2129-9-10**]**
WOUND CULTURE (Final [**2129-9-10**]): No significant growth.
[**2129-9-8**]: sputum:
[**2129-9-8**] 2:02 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2129-9-10**]**
GRAM STAIN (Final [**2129-9-8**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2129-9-10**]):
Commensal Respiratory Flora Absent.
YEAST. RARE GROWTH.
[**2129-9-9**] 8:24 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2129-9-10**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2129-9-10**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2129-9-12**] 11:01 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT [**2129-9-13**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2129-9-13**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Time Taken Not Noted Log-In Date/Time: [**2129-9-13**] 9:22 pm
STOOL CONSISTENCY: NOT APPLICABLE
**FINAL REPORT [**2129-9-14**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2129-9-14**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
Mrs [**Known lastname 2271**] was admitted on [**2129-9-3**] transferred from [**Hospital 8**]
hospital where she had undergone an exploratory laparotomy and
packing for spontaneous hemoperitoneum. Of note, she had
received L5/S1 epidural steroid injection two days prior to
admission.
The patient arrived to [**Hospital1 18**] intubated but off pressors. She had
been started on broad spectrum antibiotics empirically. She had
an open abdomen and was taken back to the operating room for
further exploration and re-packing.
On HD2 since her clinical status failed to improve and she had
worsening lactic acidosis she was taken to the operating room
once more. A patch of gangrene in hepatic flexure with a small
perforation was noted and an extended right hmeicolectomy was
performed. The abdomen was left open with the intention to
re-explore in 24-48 hours. Please refer to operative reports for
full detail.
On HD4 she was therefore taken back to the operating room for
re-exploration, removal of lap pad placed during previous
surgery and enterocolic anastomosis. Her abdomen was left open
with a [**State 19827**] patch. Postoperatively she was diuresed with
lasix in attempt to improve her respiratory status.
Her LFTs were noted to be mildly elevated, possibly because of
hypoperfusion injury, were trended and found to be normalizing.
On HD6 Tube feedings were started and tolerated except for some
loose stools. C difficile was negative.
On HD7 the patient was taken back to the operating room for
abdominal washout and closure of the abdominal wall. The patient
tolerated the procedure well. Her WBC increased to 27.5 on HD7.
Blood cultures are negative to date. The tip of her CVL was also
cultured after being taken out and results were negative. Sputum
and urine culture were also negative. Broad spectrum antibiotics
were continued.
On HD8 she was able to be extubated, NGT was removed and she was
started on a full liquid diet. Her diahhrea was decreasing and a
second stool for C difficile was negative. On HD9 she was doing
well and was stable to be transferred to the floor.
Following transfer to the Surgical floor she continued to make
good progress. Her WBC continued to decline and she remained
afebrile. Her Foley catheter was removed without difficulty.
Her antibiotics were also stopped on [**2129-9-12**]. Her diarrhea
continued and on [**9-13**] she was started on flagyl for c.diff
prophalaxsis. Her stools have been negative for c.diff. Her
appetite has diminshed and she has required encouragement to
eat.
The Physical Therapy service evaluated her in light of her
prolonged hospitalization and found her to be well below her
functional baseline. A short term rehab was recommended prior
to her returning home.
Medications on Admission:
MVI, calcium
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. acetaminophen 650 mg/20.3 mL Solution Sig: Thirty (30) mls PO
Q4H (every 4 hours).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day) as needed for HTN: Hold for SBP < 100, HR < 60.
6. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
7. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for constipation.
10. multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
12. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 5 days: started [**9-13**]...1 week course).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1820**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
1. Hemoperitoneum.
2. Retroperitoneal hematoma
3. Patchy gangrene, right colon hepatic flexure.
4. Perforated intestine
5. Acute blood loss anemia
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:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**3-29**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*Your staples will be removed on [**2129-9-20**].
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 2 eweeks.
Call your primary care doctor for a follow up appointment after
you are discharged from rehab.
Completed by:[**2129-9-15**]
|
[
"568.81",
"276.2",
"733.00",
"272.4",
"569.83",
"276.69",
"286.9",
"458.9",
"293.0",
"285.1",
"557.0",
"789.59",
"599.0",
"584.9",
"787.91",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.62",
"45.73",
"96.6",
"96.72",
"54.12",
"45.93"
] |
icd9pcs
|
[
[
[]
]
] |
10665, 10761
|
6739, 9494
|
314, 699
|
10952, 10952
|
2576, 6716
|
12791, 13017
|
2181, 2199
|
9558, 10642
|
10782, 10931
|
9520, 9535
|
11135, 12404
|
12420, 12768
|
2214, 2557
|
260, 276
|
727, 2014
|
10967, 11111
|
2036, 2116
|
2132, 2165
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,216
| 137,766
|
5627
|
Discharge summary
|
report
|
Admission Date: [**2182-6-5**] Discharge Date: [**2182-6-8**]
Date of Birth: [**2123-7-24**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
Symptomatic Anemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 58yo female with history of HIV (last CD4 246, VL 303 in
[**4-/2182**]), Hepatitis C Cirrhosis, ESRD secondary to HIV
nephropathy on HD, GI bleed with recent discharge on [**6-2**], who
presents with melena. Sent in today from [**Hospital **] clinic; the appt was
f/u from most recent discharge. Pt states that since her
discharge on Sunday, 4 days ago, she has continued to have
black-brown stools. During her last admission, she was having
black, tarry stools, but since discharge they have been more
formed and black-brown. She has not had any BRBPR since the
beginning of her initial last admission. She has felt weak for
the past few days since her discharge. She denies any SOB, chest
pain, chest pressure, or lightheadedness. She has been compliant
on taking her omeprazole. She denies any recent NSAID use.
.
Regarding history of GI bleed patient has been hospitalized
several times in the last year and has undergone extensive
work-up including colonoscopy, EGD, and capsule study which were
all unrevealing. During her last admission, she refused
additional diagnostic workup. GIB thought to be slow bleed from
AVM in setting of known portal hypertensive gastropathy. She was
transfused 6 units of PRBC's during her last admission. She was
discharge on omeprazole 40mg po bid, and given follow-up with GI
for further discussion of studies, etc.
.
In the ED, initial vs were: T 97.6 P 98 BP 90/57 R 18 O2 sat 97%
RA.
Labs were notable for Hct 18.3, prior Hct 29 on discharge [**6-2**].
Cr 7.4, baseline Cr [**7-17**], on HD. Exam notable to be benign,
though fatigued. SBP 84, guaiac positive brown stool, did not
look like melena. Pt has 2x18g IV's. Pt received 1 dose of
Protonix 80 IV, and started on gtt. Pt refused NGL. Vital signs
prior to transfer, HR 97 BP 88/49 RR 17 O2 sat 100%RA.
.
On the floor, she currently feels very weak, but has no other
complaints. She had a headache earlier, but that has since
improved.
.
She did go to HD yesterday. She felt slightly cold the last few
days but denied any fever. She says she has had a good appetite
and has been taking good po fluids.
.
Review of systems:
(+) Per HPI. Also with some mild nasal drainage.
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Past Medical History:
- ESRD due to HIV nephropathy on HD TuThSa
- HIV, diagnosed [**2165**]; last CD4 246, VL: [**2165**]
- Hepatitis C with cirrhosis and portal hypertension
- Zoster [**2177**]
- Bronchitis
- GIB - chronic, thought to be due to AVM
- Thrombocytopenia
Social History:
Patient is on disability. Lives with adult son; has 5 adult
children.
Tob: >25 pack-year tobacco history, currently smokes few
cigarrettes/day.
EtOH: Denies EtOH use. None for several years since diagnosis of
cirrhosis.
Drugs: History of crack cocaine use and IVDU (last use 10 yrs
ago); stopped since starting dialysis ~[**2171**]. Family aware of
HIV diagnosis.
Uses marijuana occasionally, last used yesterday.
Family History:
Mother with DM and HTN; died from brain aneurysm.
GM with DM, HTN; died from diabetic coma.
Older sister died of liver cancer.
[**Name (NI) **] sister w/ breast cancer; in remission
No history of colon cancer. No history of bleeding disorders or
GIB.
Physical Exam:
ADMISSION:
Vitals: T: 96.5 BP: 99/64 P: 101 R: 13 O2: 100% 2L
General: alert, oriented, appears fatigued, NAD
HEENT: Sclera icteric, + conjunctival pallor, dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: no use of accessory of muscles, scattered crackles
bilaterally at bases, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, 4/6 systolic murmur
heard best at LLSB without radiation, no rubs, gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CN II-XII grossly intact, moving all extremities,
no focal deficits
Pertinent Results:
ADMISSION LABS:
[**2182-6-5**] 08:05PM GLUCOSE-101* UREA N-40* CREAT-7.4* SODIUM-140
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-27 ANION GAP-17
[**2182-6-5**] 08:05PM ALT(SGPT)-7 AST(SGOT)-15 LD(LDH)-163 ALK
PHOS-60 TOT BILI-0.2
[**2182-6-5**] 08:05PM HAPTOGLOB-70
[**2182-6-5**] 08:05PM WBC-5.4 RBC-2.00*# HGB-5.9*# HCT-18.3*#
MCV-92 MCH-29.7 MCHC-32.4 RDW-17.8*
[**2182-6-5**] 08:05PM PT-15.0* PTT-24.1 INR(PT)-1.3*
RUQ US w Doppler:
FINDINGS: The liver is normal in echogenicity and no focal liver
lesion is
identified. No biliary dilatation is seen and the common duct
measures 0.3
cm. The gallbladder contains a tiny 4 mm stone. The pancreas is
unremarkable; however, the distal tail is obscured from view by
overlying
bowel. The spleen is unremarkable and measures 11.3 cm. A scant
trace of
ascites is seen posterior to the spleen.
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images
were
obtained. The main, right and left portal veins are patent with
hepatopetal
flow. Appropriate flow is seen in the splenic vein, SMV, hepatic
veins, and
hepatic arteries.
IMPRESSION:
1. Patent hepatic vasculature.
2. No focal liver lesion and no biliary dilatation.
3. Scant trace of ascites.
4. Cholelithiasis
DISCHARGE LABS:
[**2182-6-8**] 07:53AM BLOOD WBC-5.4 RBC-3.42* Hgb-10.2* Hct-31.1*
MCV-91 MCH-30.0 MCHC-32.9 RDW-18.0* Plt Ct-148*
[**2182-6-8**] 07:53AM BLOOD Glucose-133* UreaN-37* Creat-7.6*# Na-136
K-3.8 Cl-99 HCO3-24 AnGap-17
[**2182-6-8**] 07:53AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.9
Brief Hospital Course:
MICU COURSE:
Pt is a 58yo female with history of HIV, Hepatitis C Cirrhosis,
ESRD secondary to HIV nephropathy on HD, presenting with
possible melena and Hct drop.
.
# Acute on Chronic Anemia: Most likely [**3-13**] to acute on chronic
GIB. Possible melena reported, vs. brown stool that was guaiac
positive. Hct drop likely [**3-13**] bleed from AVM in setting of known
portal hypertensive gastropathy per prior diagnosis. Extensive
work-up to date (c-scope, EGD, tagged RBC) unable to localize
source of bleed. Baseline Hct 26, last discharged on [**6-2**] with
Hct 29. Now presents with admission HCT 18. Other possible ddx
for Hct drop would be hemolysis coagulopathy. However, coags
were at baseline (INR 1.2-1.3), and Hemolysis labs were
negative. She was transfused 5 units and her Hct bumped
appropriately. She was started on protonix gtt overnight in the
MICU. GI followed, and recommended a CTA abdomen if the pt's
hematocrit were to drop, which it did not.
# ESRD secondary to HIV nephropathy: On HD TuThSa. Last had HD
day prior to admission. HD team notified of her admission. She
was continued on Nephrocaps & Sevelamer. Continued on Epo &
Zemplar with HD
.
# HIV: Non-complaint with HAART per previous admission
information. Last CD4: 246 VL:303 copies/ml in 3/[**2182**].
Discharged on Tenofovir, etravirine, and Lamivudine. Pt has
missed at least one dose since recent discharge. Restarted on
HAART meds and Bactrim for PCP [**Name Initial (PRE) 5**]. ID team notified of
admission.
.
# Hepatitis C Cirrhosis: Last VL:201,000 IU/mL in 3/[**2181**].
Synthetic function stable. INR: 1.3 on admission. Last screening
abd US in [**7-/2181**] wnl. GI followed as above.
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
MEDICAL WARDS COURSE:
Pt was stabilized and resuscitated appropriately in the MICU
with 5U PRBC's, on ICU day one was found to be HD stable with no
evidence of declining HCT. She was then transferred to the
medical floor in stable condition.
ACTIVE ISSUES:
1) Melena
- GI believed the source was either a portal gastropathy or AVM
- These have been visualized on endoscopy and capsule study
but every time they perform EGD or colonoscopy with intent to
intervene there has been no actively bleeding lesion found
- Per GI notes the pt had also been refusing any further
endoscopy (push or spiral endoscopy) that could provide an
answer
- Pt experienced melena x3 overnight on wards day 0-1, but Hct
did not decrease and pt did not become more tachycardic,
hypotensive etc to suggest any active bleeding
- Her melena was therefore thought to be clearing of the old
blood in her GI tract from her prior bleed
- GI recommended a CTA abdomen if the pt were to develop a
decline in her Hct to suggest active bleeding, but the patient's
Hct remained stable
- Pt will require close follow up and Hct measurements at HD,
and then will need a way to be transfused on an as needed basis
if she continues to refuse any interventional procedure
- We have arranged for her to have her Hct checked at dialysis,
and then the pt will be sent to the Pheresis unit for
intermittant transfusions at the direction of the Renal team
2) HIV Nephropathy
- Pt receives HD TTS, last dialyzed successfully on Thurs [**6-6**]
for 2L UF
- Continued nephrocaps, sevelamer, Epo, Zemplar
3) HCV cirrhosis
- Leading theory as to etiology of the pt's bleed was portal
hypertension leading to gastropathy
- Underwent RUQ US that showed hepatopetal flow in the main and
R/L portal veins with no evidence of thrombosis or abnormality
of the liver architecture
- Pt currently without ascites or encephalopathy, recent EGD
showing no varices but portal gastropathy
- Admission labs showed INR 1.2, alb 3.0, Cr 8.0, Tbili 1.2
giving a MELD UNOS of 22
- Last VL:201,000 IU/mL in [**4-/2181**]
- Pt at this time appears to be well compensated and therefore
did not require any treatment for this problem while in house
4) HIV
- pt has not been compliant with her regimen per admission notes
- Last CD4: 246 VL:303 copies/ml in [**4-/2182**]
- Continued Lamivudine, Etravirine, Viread
- Continued Bactrim at HD for PCP [**Name9 (PRE) **]
[**Name Initial (PRE) **] Notified Dr. [**First Name (STitle) **] [**Name (STitle) **] of her medication noncompliance and
instructed the patient to take her medications more diligently.
TRANSITION OF CARE:
- pt will have her Hct checked by the Renal team at dialysis,
and then they will arrange for her to have blood tranfusions on
an as needed basis
- pt will have a follow up appointment with Dr. [**First Name (STitle) **] [**Name (STitle) **] to
discuss her compliance with her HAART regimen
- pt will have FU with the GI team to discuss any potential
management or intervention for her chronic, occult GI bleed
*****NOTE*****
The patient left the hospital on Saturday [**6-8**] without
staying long enough to be properly discharged and therefore did
not have her discharge paperwork. Her official post discharge
instructions were given to her verbally by the house staff
Medications on Admission:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB,
wheeze.
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO QFRI (every Friday).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (TU,TH,SA).
5. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. lamivudine 100 mg Tablet Sig: 0.5 Tablet PO once a day.
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
.
Pt has missed a dose of her HIV meds. Has not been taking
nephrocaps.
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO QFRI (every Friday).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO QHD (each hemodialysis).
5. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
6. sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. lamivudine 100 mg Tablet Sig: 0.5 Tablet PO once a day.
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal Bleeding of unknown origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
THIS IS THE DISCHARGE PAPERWORK THAT WOULD HAVE BEEN GIVEN TO
THE PATIENT. SHE LEFT BEFORE SHE COULD RECEIVE THIS. PATIENT
HAS BEEN CONTACT[**Name (NI) **] AND ASKED TO PICK UP THIS PAPERWORK.
Dear Ms. [**Known lastname 13551**],
You were admitted to the [**Hospital1 18**] for evaluation and treatment of
your gastrointestinal bleeding. When you were admitted your
blood counts were very low, and you were given blood
transfusions to which you responded quite well. You continued
to have dark bowel movements for awhile but this was thought to
be from the old bleeding as your blood counts did not decrease
after your transfusion.
While you were here, we discussed options that could help us
find a source for your bleeding, as we know that this has been
very difficult in your previous admissions. Since you have
requested to not undergo any more endoscopy procedures, our
options are somewhat limited. If you were to develop any more
rapid bleeding, we would perform an abdominal CT scan, but we
can't do this unless there is a fairly rapid bleed.
In the meantime, we have tried to arrange a system where you
will get your blood checked at dialysis, and then the kidney
doctors could get [**Name5 (PTitle) **] into a tranfusion unit where you could get
blood cells on an as needed basis. This will not stop your
bleeding but would rather give you enough blood cells to keep
you from becoming short of breath or tired.
Medications:
Added: None
Changed: None
Removed: None
Followup Instructions:
Your Renal doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 138**] the number below to arrange for a
blood transfusion if you need one:
Pheresis Unit [**Hospital1 18**]
[**Telephone/Fax (1) 14067**]
If they are having trouble, they can call the nurse manager for
the unit:
[**Doctor First Name **] (pheresis nurse manager)
[**Telephone/Fax (1) 22562**]
pager [**Numeric Identifier 22563**]
|
[
"276.52",
"V45.11",
"287.5",
"V08",
"585.6",
"537.89",
"537.83",
"070.54",
"572.3",
"571.5",
"285.1",
"V15.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12838, 12844
|
6118, 8155
|
289, 296
|
12932, 12932
|
4578, 4578
|
14593, 14988
|
3594, 3847
|
12055, 12815
|
12865, 12911
|
11225, 12032
|
13083, 14570
|
5822, 6095
|
3862, 4559
|
2454, 2872
|
231, 251
|
8171, 11199
|
324, 2435
|
4595, 5805
|
12947, 13059
|
2894, 3144
|
3160, 3578
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,829
| 168,706
|
32799
|
Discharge summary
|
report
|
Admission Date: [**2150-12-23**] Discharge Date: [**2150-12-27**]
Service: MEDICINE
Allergies:
Penicillins / Citrus Derived / Lactulose
Attending:[**Last Name (un) 32349**]
Chief Complaint:
mechanical fall with right hip fracture
Major Surgical or Invasive Procedure:
[**2150-12-24**] - Open reduction with internal fixation of right hip
fracture
History of Present Illness:
This is an 88 y.o man with history of coronary artery disease,
alzheimer's who lives at [**Hospital 100**] Rehab who presented to the
hospital [**12-24**] after an unwitnessed fall in the bathroom. The
patient recalls that he was finishing up in the bathroom when he
slipped and fell backwards towards the toilet, hitting his head.
He subsequently landed on his right side and had sudden onset of
sharp pain in the right hip. On evaluation here in our emergency
room, he was found to have a right femur fracture with extention
to the subtrochanter. He denies any prodrome, lightheadedness,
nausea, dizziness, chest pain, or shortness of breath
immediately prior to his fall. The patient at baseline is not
very active; he walks using a walker and has not used stairs for
some time.
Patient had trochanteric femoral nail for right hip placed by
ortho on [**12-25**]. In the PACU he was found to be hypotensive with
SBP 80s with oliguria. 1unit of PRBC was transfused with 500cc
NS bolus x2 with improved BP, so patient was transferred to
floor. He dropped his BP again, so was transferred back to PACU,
where he received another unit of PRBC and 500cc NS bolus. His
urine output was 30cc/hr but BP did not improve, so was
transferred to TICU for further management with trop enzymes
sent.
Past Medical History:
- Alzheimer's
- STEMI [**1-3**] s/p mid and distal LAD placement of 2 bare metal
stents
- Ulcerative colitis
- Recurrent UTI
- Dysphagia s/p esophageal dilatation
- Bilateral leg ulcers and skin grafts
- h/o C diff
- left hip fx s/p ORIF
Social History:
Lives at [**Hospital1 100**] Seniorlife. Social history is significant for
the absence of current tobacco use. There is no history of
alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
BP103/65 sats96%ra t98.7 hr83 reg
Mrs [**Known lastname 76375**] is lying comfortably in bed in no respiratory
distress. He has a marked deviation of his head to the right
shoulder which he reports is longstanding, gradual and painless
and his sister also has this trait. He has a pronounced resting
tremor but reports he does not have Parkinsons disease.
His speech is difficult to understand. He is hard of hearing and
complained of severe tinnitus overnight. He now has a right
hearing aid in .
Seborrheic keratoses on his central chest. V thin habitus-
sarcopenic.
Heart sounds normal. no added sounds or murmus. CHest is clear
to auscultation. Abdomen soft, nontender, bowel sounds, no
masses.
Foley in with some dried blood at meatus.
Some intertrigo central abdomen.
No peripheral edema.
Swelling at right thigh, inf dressing is blood soaked. Can
wiggle toe of both feet and plantarflex and dorsiflex bilat. Has
pneumaboots and splints on bilat ?for foot drop prevention. Does
not have foot drop clinically. Chronic venous stasis changes
distally bilat and also dystrophic onychogryphosis bilat.
.
DISCHARGE PHYSICAL EXAM:
T 98.0 BP 98/60 P 76 RR 18 SaO2 95% RA
right leg internally rotated.
Pertinent Results:
ADMISSION LABS:
WBC-6.6 RBC-4.55* Hgb-14.7 Hct-43.4 MCV-95 MCH-32.3* MCHC-33.8
RDW-12.6 Plt Ct-216
Neuts-74.9* Lymphs-13.4* Monos-10.0 Eos-1.3 Baso-0.4
PT-12.0 PTT-33.1 INR(PT)-1.1
Glucose-94 UreaN-24* Creat-0.8 Na-139 K-4.7 Cl-100 HCO3-29
AnGap-15
Digoxin-1.0
WBC-6.6 RBC-3.37* Hgb-10.1* Hct-29.6* MCV-88 MCH-30.0 MCHC-34.2
RDW-16.5* Plt Ct-165
.
DISCHARGE LABS:
Glucose-98 UreaN-15 Creat-0.4* Na-141 K-3.4 Cl-107 HCO3-29
AnGap-8
Calcium-7.9* Phos-1.4* Mg-2.0
WBC-6.6 RBC-3.37* Hgb-10.1* Hct-29.6* MCV-88 MCH-30.0 MCHC-34.2
RDW-16.5* Plt Ct-165
.
CT HEAD ([**12-24**]): Stable appearance of head CT without evidence
for acute
intracranial hemorrhage.
.
CT C-SPINE ([**12-24**]): No CT evidence for acute fracture or
malalignment. However, severe degenerative change places the
patient at risk for cord contusion even with minor trauma. If
clinically indicated, MR is more sensitive for evaluation of the
spinal cord.
.
CHEST X-RAY ([**12-24**]): Markedly rotated patient making examination
suboptimal, although grossly, there has been no significant
interval change since the prior study. Consider repeat with
better positioning as able.
.
HIP X-RAY ([**12-24**]):
1. Displaced right intertrochanteric fracture with extension
into the
proximal right femoral diaphysis, with varus angulation of the
right femoral head.
2. Large stool ball in the rectum.
3. Linear lucencies projecting over the bilateral superior pubic
rami more
likely relates to overlying bowel; however, non-displaced
fractures are not excluded.
.
Brief Hospital Course:
Mr. [**Name14 (STitle) 76379**] is an 8 yo M with h/o STEMI, CHF with EF 30%, and
Alzheimer's Disease presenting after mechanical fall, found to
have right hip fracture.
.
#.RIGHT HIP FRACTURE: patient was admitted to the Orthopedic
service on [**2150-12-23**] for a right hip fracture after being
evaluated and treated with closed reduction in the emergency
room. He underwent open reduction internal fixation of the
fracture without complication on [**2150-12-24**]. Please see operative
report for full details. He was extubated without difficulty and
transferred to the recovery room in stable condition. In the
early post-operative course Mr. [**Known lastname 76375**] was noted to be
hypotensive to the 70's and 80's with low urine output and he
remained in the post-anesthesia care unit. An EKG was ordered
and was unremarkable. Serial troponins were sent and negative
for any ischemic cardiac event. He was given three separate
500cc boluses of normal saline over the next several hours as
well as 2 units of packed red cells, with a goal hematocrit of
>30 given his cardiac history. He was transferred to the ICU for
continued care overnight, where he remained off pressors with
systolic blood pressure in the low 90's. His urine output
increased as well to 20-30cc per hour.
He remained awake and alert throughout this period with no
change in his mental status. On post-operative day 1, he was
transferred to the floor in stable condition, to the
Medicine/Geriatrics service for further management of his
hypotension. He required 4 units of PRBC after surgery due to
falling hematocrit and hypotension to 90s. A compression
dressing was placed on the right thigh to aid in tamponade. His
pressures responded well to blood transfusions and his Hct rose
appropriately. He was discharged in stable condition back to
his original rehab home. He is currently on bedrest, to continue
PT at rehab. Pain management with oxycodone 2.5mg PO q4 hrs PRN
and standing Tylenol 1gram PO TID.
.
# CONSTIPATION: Patient constipated [**1-28**] pain meds and
immobility, which responded to standing senna, docusate,
bisacodyl suppository, milk of magnesia, and miralax. Held
multivitamin, vit D, calcium while in hospital, to be restarted
in rehab.
.
# ALZHEIMER'S DISEASE: stable, not on any medications. Patient
AAOx3 during hospitalization.
.
# CAD/CHF: last EF 30% [**2146**]. on ASA and digoxin.
.
# ULCERATIVE COLITIS: on mesalamine
.
======================================
TRANSITION OF CARE:
- Please check Chem 10 on [**2150-1-3**]
Medications on Admission:
Tylenol 325 mg Tab Oral 2 Tablet(s) , as needed
Aspir-81 81 mg Tab Oral 1 Tablet, Delayed Release (E.C.)(s) Once
Daily
calcium carbonate 650 mg calcium (1,625 mg) Tab Oral 1 Tablet(s)
Once Daily
cholecalciferol (vitamin D3) 1,000 unit Tab Oral 1 Tablet(s)
Once
Daily
[**Doctor Last Name **] Milk of Magnesia 400 mg/5 mL Oral Susp Oral 15 ml
Suspension(s) as needed
Remeron 15 mg Tab Oral [**12-30**] Tablet(s) Once Daily
digoxin 125 mcg Tab Oral 1 Tablet(s) Once Daily
fluticasone 50 mcg/Actuation Nasal Spray, Susp Nasal 1 Spray,
Suspension(s) both nares, daily
mesalamine ER 250 mg Cap Oral 1 Capsule, Extended Release(s)
Three times daily
omeprazole 20 mg Tab, Delayed Release Oral 1 Tablet, Delayed
Release (E.C.)(s) Once Daily
sorbitol 70 % Soln Miscellaneous 15ml Solution(s), as needed
senna 8.6 mg Cap Oral 1 Capsule(s), as needed
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable [**Month/Day (4) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. calcium carbonate 650 mg calcium (1,625 mg) Tablet [**Month/Day (4) **]: One
(1) Tablet PO once a day.
3. cholecalciferol (vitamin D3) 1,000 unit Tablet [**Month/Day (4) **]: One (1)
Tablet PO once a day.
4. magnesium hydroxide 400 mg/5 mL Suspension [**Month/Day (4) **]: Fifteen (15)
ML PO Q6H (every 6 hours) as needed for constipation.
5. mirtazapine 15 mg Tablet [**Month/Day (4) **]: 0.25 Tablet PO DAILY (Daily).
6. digoxin 125 mcg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
7. fluticasone 50 mcg/Actuation Spray, Suspension [**Month/Day (4) **]: One (1)
Spray Nasal DAILY (Daily).
8. mesalamine 250 mg Capsule, Extended Release [**Month/Day (4) **]: One (1)
Capsule, Extended Release PO TID (3 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day (4) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. sorbitol 70 % Solution [**Month/Day (4) **]: Fifteen (15) mL Miscellaneous
once a day as needed for constipation.
11. senna 8.6 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2 times a
day).
12. acetaminophen 500 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO TID (3
times a day) as needed for pain.
13. enoxaparin 40 mg/0.4 mL Syringe [**Month/Day (4) **]: Forty (40) mg
Subcutaneous QHS (once a day (at bedtime)) for 4 weeks.
14. Outpatient Lab Work
Please check chem 10 (sodium, potassium, chloride, bicarbonate,
BUN, creatinine, magnesium, phosphorus, calcium) on [**2151-1-3**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Right intertrochanteric hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Orthopedic Wound Care:
- Keep Incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be weight bearing as tolerated on your right leg
- You should not lift anything greater than 5 pounds.
- Elevate your right leg to reduce swelling and pain.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so 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 (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up
appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks at [**Telephone/Fax (1) 1228**].
|
[
"285.1",
"564.09",
"458.29",
"V15.51",
"V45.82",
"412",
"E849.7",
"294.10",
"E885.9",
"820.21",
"556.9",
"414.01",
"331.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.15"
] |
icd9pcs
|
[
[
[]
]
] |
10039, 10104
|
5016, 7556
|
289, 370
|
10185, 10185
|
3475, 3475
|
12047, 12257
|
2134, 2216
|
8448, 10016
|
10125, 10164
|
7582, 8425
|
10320, 10331
|
3839, 4993
|
2256, 3361
|
210, 251
|
10343, 12024
|
398, 1688
|
3491, 3823
|
10200, 10296
|
1710, 1950
|
1966, 2117
|
3386, 3456
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,407
| 151,911
|
7605
|
Discharge summary
|
report
|
Admission Date: [**2170-3-5**] Discharge Date: [**2170-3-14**]
Date of Birth: [**2108-5-29**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2988**]
Chief Complaint:
T7-T8 osteomyelitis
Major Surgical or Invasive Procedure:
s/p Thoracotomy T6, anterior fusion T7-T9; partial vertebrectomy
T7-T8 [**2170-3-5**]
s/p T5-T11 post fusion [**2170-3-8**]
History of Present Illness:
Unfortunate 61 y.o. male with several month history of shoulder
pain who presented initially with fever, shoulder pain, shoulder
infection, and mass over the sternum. He had two I&D by Dr.
[**Last Name (STitle) 2719**] and because of the persistent pain, he had MRI of the
spine and it showed T7 and T8 increased T2 signal c/w
osteomyelitis. There is a small
bulging disk at the T78 level that is not causing any neural
impingement. He was treated with IV antibiotics and he has
improved significantly and is able to ambulate. He is scheduled
for ant/post fusion on [**3-5**] and [**2170-3-8**].
Past Medical History:
PMH:
htn
etoh abuse quit [**2169-12-19**]
hypercholesterolemia
pancreatitis [**2165**]
depression
epistaxis with recent cauterization [**2170-1-2**]
Social History:
sh: employed, no smoking, etoh abuse-quit one mo ago, no hx of
DTs, no IVDU, married 11 years, monogamous, denies hiv risk
factors, 28 yo son
Family History:
fH: mother died 92 from emphysema; father died of "old age" 82
Physical Exam:
97.8 114/64 75 10 96%
AO X 3
R/R/R
CTA anteriorly
Ext- mild edema b/l, N/V/I distally; He can flex forward and
back without significant pain. Mild discomfort with palpation.
Uses B LE well. His gait is wide. Joints at stable with good
ROM of B LE.
Pertinent Results:
[**2170-3-12**] 05:06AM BLOOD WBC-7.3 RBC-3.32* Hgb-9.2* Hct-28.1*
MCV-85 MCH-27.7 MCHC-32.8 RDW-15.4 Plt Ct-249
[**2170-3-11**] 03:36AM BLOOD WBC-7.4 RBC-3.17* Hgb-9.1* Hct-26.6*
MCV-84 MCH-28.6 MCHC-34.1 RDW-15.5 Plt Ct-230
[**2170-3-9**] 02:43AM BLOOD WBC-7.3 RBC-3.15* Hgb-8.8* Hct-26.4*
MCV-84 MCH-28.1 MCHC-33.5 RDW-15.6* Plt Ct-233
[**2170-3-12**] 05:06AM BLOOD Glucose-95 UreaN-9 Creat-0.6 Na-137 K-3.6
Cl-99 HCO3-30* AnGap-12
[**2170-3-10**] 03:44AM BLOOD Glucose-103 UreaN-12 Creat-0.7 Na-140
K-3.5 Cl-105 HCO3-27 AnGap-12
[**2170-3-6**] 03:59AM BLOOD Glucose-138* UreaN-14 Creat-0.7 Na-137
K-3.9 Cl-103 HCO3-26 AnGap-12
Brief Hospital Course:
Pt taken to OR on [**3-5**] for anterior fusion. Surgery went without
incident. Pt remained on vent secondary to several attempts to
extubate without success. Pt started on IV Vanco at that time.
Pneumoboots/IS for DVT prophylaxix. Please see Op note for
further details. Pt taken back to OR on [**2170-3-8**] for post T5-T11
fusion. Surgery went without incident. See Op note. Pt has been
followed by Medicine/ID while in house. Pt has remained
medically stable and was extubated [**2170-3-9**]. Transferred to floor
where he has progressed well. CTLSO placed on [**3-13**]. Pt will
require brace with ambulation. He may remove while in bed. He
will continue IV Vanco x 6 weeks for tx of osteo. Levofloxacin x
10 days for tx of UTI. He will continue PT/OT while at rehab.
F/u in 2 weeks with Dr [**First Name (STitle) 1022**].
Discharge Medications:
1. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
8. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
9. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 6 weeks.
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. Hydromorphone HCl 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H
(every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
T7-T8 osteomyelitis
Discharge Condition:
good
Discharge Instructions:
Activity as tolerated. OOB with assist. CTLSO when out of bed,
may remove while in bed. IV Vanco x 6 week course. Pt will need
Qweek trough, BUN/Creatine, CBC to monitor infection. Levo PO x
10 days for UTI. Please have results faxed to Dr[**Name (NI) 2989**] office.
[**Telephone/Fax (1) 27752**]
Followup Instructions:
f/u with Dr [**First Name (STitle) 1022**] in 2 weeks. Phone # [**Telephone/Fax (1) 7807**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 2991**]
Completed by:[**2170-3-14**]
|
[
"272.0",
"722.11",
"733.00",
"599.0",
"730.18",
"401.9",
"518.5",
"285.29",
"V11.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"38.93",
"84.52",
"81.62",
"77.89",
"81.63",
"96.6",
"81.05",
"81.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4452, 4525
|
2447, 3276
|
338, 464
|
4589, 4595
|
1792, 2424
|
4942, 5174
|
1439, 1503
|
3299, 4429
|
4546, 4568
|
4619, 4919
|
1518, 1773
|
279, 300
|
492, 1091
|
1113, 1264
|
1280, 1423
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,947
| 165,916
|
36194
|
Discharge summary
|
report
|
Admission Date: [**2113-11-6**] Discharge Date: [**2113-11-12**]
Date of Birth: [**2049-9-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Wheezing and Somnolence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64 yo M with complex medical history including history of COPD
and complex sleep disordered breathing. Presented to hospital on
[**2113-11-6**] from [**Hospital3 **] after three days of cough,
dyspnea, and loss of appetite. As outpatient he was thought to
have pneumonia and was started on levofloxacin with addition of
ceftriaxone earlier today when there was no improvement in
symptoms. Initial labwork at [**Hospital3 **] facility showed a
leukocytosis of 15.7 with 14% bands and a new elevation in Cr up
to 2.4. Additionally had hypoxemia with O2 sat down to 79%. At
that point NRB was applied and patient was transferred to [**Hospital1 18**]
ED.
.
On the medical floor, the primary team was treating primarily
for COPD exacerbation and HCAP. As patient's breathing was
appearing labored around 2200, an ABG was 7.34/67/63. Given that
patient appeared to have a baseline pCO2 around 80 in [**Month (only) 216**] of
this year, team opted for close monitoring through the night. At
approximately 0200 today, the patient was triggered for
increasing somnolence and tachypnea. The covering nightfloat
intern performed two separate ABGs which showed a trend toward
worsening acidosis with serial measures of 7.32/74/80 at 0054
today and 7.28/79/77 at 0147 today. Given this trend, decision
was made to tranfer to the MICU for non-invasive ventilation.
Patient was afebrile and normotensive on floor. Of note, patient
has a diagnosis of complex sleep disordered breathing with
recent BiPAP titration in sleep lab on [**2113-9-18**]. Was initially
diagnosed with sleep disordered breathing during inpatient
admission in 12/[**2112**].
.
While in the MICU, the patient was started on a 10-day course of
vancomycin/cefepime and 5-day course of azithromycin. He was
also re-started on his home BiPAP. His hypoxemia improved, and
he was transferred back to the medical floor.
.
The patient remained stable on the medical floor and reported
subjective improvement in his breathing. His O2sat's remained
stable on supplemental oxygen, and he remained afebrile without
leukocytosis. When he returned to the medical floor, a
hyperkeratotic, hyperpigmented, raised, demarcated patch was
noted on his left lower extremity. We will recommend that the
patient be followed on an out-patient basis by dermatology.
.
REVIEW OF SYSTEMS:
Patient minimally interactive and unable to provide full ROS
Past Medical History:
1) Diabetes mellitus, type II
2) CAD s/p CABG
3) COPD on 2L home O2
4) Complex sleep-disordered breathing (On [**2113-10-28**] was
prescribed Ipap 13, Epap 10, non-vented full face mask, and EERS
100mL)
5) Hx of PE in [**2110**] on coumadin
6) Hypertension
7) Peripheral vascular disease
8) Chronic renal insufficiency (baseline Cr 1.8 - 2.0)
9) ? decreased systolic function on last TTE (poor image
quality)
10) Rheumatoid arthritis
11) Depression
12) Bipolar Disorder
13) Schizophrenia
14) Recurrent hyperkalemia
15) Glaucoma
16) MRSA carrier (swab +ve on [**2113-8-22**])
Social History:
Lives at [**Hospital3 2558**] in [**Location (un) **] currently. Not currently
working. He ambulates with difficulty using a walker and prefers
to be in a wheelchair. He is divorced and has no children.
Tobacco: He smoked one pack per day for 35 years, but quit about
a year ago. Question of recently starting again.
EtOH: He quit drinking about five years ago, but only drank
socially before then.
Illicits: Denies
Family History:
Mother: [**Name (NI) 3730**]
Father: [**Name (NI) 3495**] disease
Physical Exam:
VS: T 96.6, HR 94, BP 120/88, RR 20, O2Sat 97% 2L NC
GEN: Awake, sitting up right in chair
HEENT: PERRL, moist mucous membranes
NECK: Supple, no JVP elevation
PULM: Decreased air movement bilaterally; no wheezes, rhonchi,
or rales.
CARD: RRR, nl S1, nl S2, no M/R/G
ABD: Obese, BS+, soft, NT, ND
EXT: BLE with chronic venous stasis changes, no edema.
Hyperkeratotic, hyperpigmented, raised, well-demarcated patch
noted on left lower extremity.
NEURO: AOx3
Pertinent Results:
On admission:
[**2113-11-6**] 04:20PM BLOOD WBC-14.9*# RBC-3.56* Hgb-10.2* Hct-32.3*
MCV-91# MCH-28.6 MCHC-31.5 RDW-15.0 Plt Ct-190
[**2113-11-6**] 04:20PM BLOOD Neuts-84* Bands-0 Lymphs-6* Monos-10
Eos-0 Baso-0
[**2113-11-6**] 04:20PM BLOOD Plt Ct-190
[**2113-11-6**] 09:00PM BLOOD PT-14.1* INR(PT)-1.2*
[**2113-11-6**] 04:20PM BLOOD Glucose-110* UreaN-61* Creat-3.1*# Na-140
K-5.4* Cl-94* HCO3-34* AnGap-17
[**2113-11-6**] 10:11PM BLOOD Type-ART pO2-63* pCO2-67* pH-7.34*
calTCO2-38* Base XS-6 Comment-O2 DELIVER
[**2113-11-6**] 10:11PM BLOOD Lactate-0.7
[**2113-11-6**] 10:32PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2113-11-6**] 10:32PM URINE Blood-TR Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2113-11-6**] 10:32PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
[**2113-11-6**] 10:32PM URINE Hours-RANDOM UreaN-511 Creat-71 Na-37
K-29 Cl-11
[**2113-11-6**] 10:32PM URINE Osmolal-310
Discharge labs:
[**2113-11-11**] 05:50AM BLOOD WBC-10.5 RBC-2.96* Hgb-8.3* Hct-27.9*
MCV-94 MCH-28.2 MCHC-29.9* RDW-15.5 Plt Ct-251
[**2113-11-11**] 05:50AM BLOOD Plt Ct-251
[**2113-11-11**] 05:50AM BLOOD PT-31.1* PTT-32.9 INR(PT)-3.1*
[**2113-11-11**] 05:50AM BLOOD Glucose-139* UreaN-73* Creat-1.7* Na-140
K-5.6* Cl-104 HCO3-30 AnGap-12
[**2113-11-11**] 05:50AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.4
Legionella Urinary Antigen (Final [**2113-11-7**]): NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
URINE CULTURE (Final [**2113-11-8**]): <10,000 organisms/ml.
Blood Culture, Routine (Pending):
.
ECG [**2113-11-6**]:
Sinus tachycardia. QRS width at 160 milliseconds. Right
bundle-branch block. Axis indeterminate. Since the previous
tracing of [**2113-8-22**] the rate is faster.
.
CXR (AP) [**2113-11-6**]:
ONE VIEW OF THE CHEST: The lungs are low in volume and show a
right upper lobe consolidation. Elevation of the left
hemidiaphragm is unchanged compared to prior exam. The cardiac
silhouette is mildly enlarged. No definite pleural effusions are
noted.
IMPRESSION: Right upper lobe pneumonia. Limited exam.
.
ECG [**2113-11-7**]:
Sinus rhythm. Since the previous tracing the rate is slower. Now
apparent are ST segment elevations in the early precordial
leads V2-V6 are more prominent, although were present to a
lesser degree on [**2113-8-22**]. Clinical correlation is suggested.
.
CXR (AP) [**2113-11-8**]:
IMPRESSION: Elevation of the left hemidiaphragm and associated
left lower lobe atelectasis are longstanding. Large area of
consolidation in the right upper lobe, new since [**8-24**], is
more extensive today than on [**11-6**]. Heart is mildly
enlarged. Right lower lung grossly clear. No appreciable pleural
effusion.
.
CXR(AP) [**2113-11-9**]:
IMPRESSION: Stable right upper lobe consolidation with small
right pleural
effusion.
Brief Hospital Course:
64 yo M with complex medical history including history of COPD
and complex sleep disordered breathing. Presented to hospital
with clinical history of pneumonia and then developed somnolence
on medical floor in setting of suspected COPD exacerbation.
Transferred to the MICU due to increasing somnolence and
respiratory acidosis, started on BiPAP and
vancomycin/cefepime/azithromycin antibiotic regimen, then
returned to the medical floor with stable O2sats on supplemental
oxygen.
.
#. Acute on chronic hypercapneic respiratory failure:
Patient with history of COPD and complex sleep disordered
breathing as well as obesity which all are likely contributing
to acute presentation of respiratory failure. Patient was not
ordered for home BiPAP while on medical floor and this likely
contributed to his inability to maintain adequate ventilation.
Upon night of admission the patient was triggered for increasing
somnolence and tachypnea. Two separate ABGs showed a trend
toward worsening acidosis with serial measures of 7.32/74/80 and
7.28/79/77. Given this trend, decision was made to tranfer to
the MICU for non-invasive ventilation. His worsening resp
status was attributed to lack of BiPAP and he was placed back on
BiPAP. He also did have evidence of a RUL pneumonia on CXR.
Given bandemia prior to presentation and tachypnea as well as
somnolence, we broadened to pseudomonal coverage. He was
treated with cefepime, vancomycin, and azithromycin. For his
COPD, he was given a steroid burst prednisone 40mg x 6 days and
continued on nebs. Resp status improved and he was neither
tachypneic nor somnolent and had oxygen saturations in the 90s
by time of discharge.
.
#. Acute on chronic renal failure:
Cr on admission was 3.1, up from his baseline of 1.8. Pt
appeared clinically hypovolemic but his FeBUN of 36% argued
against prerenal etiology. His home lasix was held. Cr
improved to 1.7 by time of discharge with minimal IV fluids.
.
#. PE history:
Pt was not tachycardic and EKG did not show changes
corresponding to acute PE. He did, however, have a history of
PE and was on coumadin. INR was subtherapeutic at 1.2 on
admission. He was started on a heparin drip to bridge to
coumadin. His coumadin was initially started at 7.5mg and
increased to 10mg. His dose was reduced again to 5.0mg and his
INR=3.1 on discharge.
.
#. Diabetes:
No acute issues. He was maintained on HISS.
.
#. Coronary artery disease:
No acute issues. He was continued on his aspirin and beta
blocker. He was not on a statin for unclear reasons.
.
#. Bipolar / Schizophrenia:
No acute issues. He was continued on his home risperidone,
oxcarbazepine, and divalproex
.
#Left leg lesion and leg ulcerations: No interventions made
while in house, but would consider outpatient dermatology follow
up for raised lesion on L leg and vascular surgery follow up for
leg ulcers.
Medications on Admission:
1) Warfarin (illegible dose in record)
2) DuoNebs TID
3) Alendronate 70mg PO QSunday
4) Furosemide 60mg Daily
5) Aspirin 81mg Daily
6) Spiriva 1 cap daily
7) Amlodipine 10mg Daily
8) Calcitriol 0.25mg daily
9) Emulose 10g/15mL daily
10) Ventolin HFA 90mcg 2 puffs [**Hospital1 **]
11) Divalproex 500mg [**Hospital1 **]
12) Docusate 100mg [**Hospital1 **]
13) Ferrous Sulfate 325mg [**Hospital1 **]
14) Flovent HFA 110mcg 1 puff [**Hospital1 **]
15) Hydroxychloroquine 400mg [**Hospital1 **]
16) Metoprolol 25mg [**Hospital1 **]
17) Oxcarbazepine 300mg [**Hospital1 **]
18) Ranitidine 150mg [**Hospital1 **]
19) Risperidone 3mg QHS
20) Tamsulosin 0.4mg QHS
21) HISS
Discharge Medications:
1. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
1tab every Sunday.
3. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Tablet(s)
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
5. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: Thirty (30) Inhalation once a day.
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily). Capsule(s)
8. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) Inhalation twice a day.
9. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
12. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day.
13. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
16. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
18. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
19. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours).
20. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours).
21. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
22. lactulose 10 gram/15 mL Solution Sig: One (1) PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary: pneumonia, acute renal failure, COPD
Secondary: Hypertension, type II diabetes, coronary artery
disease, rheumatoid arthritis, depression, bipolar disorder,
schizoaffective disorder, peripheral vascular disease, glaucoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 4587**] -- You were recently hospitalized at the [**Hospital 61**] [**Hospital 1225**] Medical Center for fever, shortness of breath,
and low oxygen saturation. It was likely due to a pneumonia and
exacerbation of your COPD. You arrived on the medical [**Hospital1 **] on
[**11-6**] and in your first night here you had difficulty
breathing and staying awake. Your kidney function was also
reduced because you were dehydrated. You were transferred to
the Intensive Care Unit (ICU) in order to improve your
oxygenation and then returned to the medical [**Hospital1 **] on [**11-10**]
for further management. While you were in the ICU, you were
started on antibiotics and given fluids to increase circulation
to your kidneys. You were also given your BiPAP to help you
breath while you were sleeping and a PICC line to administer the
antibiotics. When you returned to the medical [**Hospital1 **], your fever
had subsided and your breathing returned to baseline. You were
continued on your antibiotics and will complete the full course
in the coming days.
Followup Instructions:
Please follow-up with your PCP when you return to the [**Hospital 7137**]. You also have the following upcoming appointments in
[**2114**]:
Physician: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 1803**]
Date/Time: [**2114-2-20**] @ 10:00AM
Physician: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD
Phone:[**Telephone/Fax (1) 612**]
Date/Time: [**2114-4-25**] @ 10:00AM
Completed by:[**2113-11-13**]
|
[
"428.22",
"584.9",
"491.21",
"585.9",
"518.0",
"285.9",
"790.92",
"428.0",
"365.9",
"440.20",
"V58.61",
"295.90",
"714.0",
"416.2",
"518.84",
"276.52",
"296.80",
"V45.81",
"403.90",
"V02.54",
"414.00",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12679, 12749
|
7214, 10080
|
339, 345
|
13023, 13023
|
4367, 4367
|
14316, 14798
|
3808, 3876
|
10796, 12656
|
12770, 13002
|
10106, 10773
|
13203, 14293
|
5352, 5898
|
3891, 4348
|
5933, 7191
|
2697, 2760
|
276, 301
|
373, 2678
|
4382, 5335
|
13038, 13179
|
2782, 3358
|
3374, 3792
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,724
| 185,998
|
53339
|
Discharge summary
|
report
|
Admission Date: [**2144-2-29**] Discharge Date: [**2144-3-6**]
Date of Birth: [**2087-12-10**] Sex: M
Service: NEUROSURGERY
Allergies:
Tramadol / Hydrocodone Bitartrate/Apap
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
New left motor deficit
Major Surgical or Invasive Procedure:
Right Frontal craniotomy for resection of mass
placement PEG
History of Present Illness:
Patient is a 56 yo man with PMH of Non small cell lung
CA,dementia, brain injury, DM, DVT who was brought in by EMS
after family noted decline in his cognition and strength over
the last week. His wife reports that his Lung Cancer was
diagnosed in [**2143-7-3**], and that he had a right lung lobectomy,
chemo,radiation all in [**2143-7-3**]. Outside notes however report
that Lung Bx was in [**2143-1-3**] and portacath for chemo was removed
in [**2143-4-3**]. Wife says that he had 1 week of chemo, and then
had to be discontinued because portacath infection. Lung
surgery was complicated by vocal cord paralysis. He has
continued to lose weight, becoming weaker. Apparently over the
last week had more difficulty with cognition and generally
became weaker. They note that left arm seems weaker than right.
He can still speak, but speaks less reliably and seems confused
from time to time.Fluctuates. He has been unable to walk for
the last several days. EMS found him on floor with pressure
ulcers over left ear and left side.
Past Medical History:
NSCLCA s/p radiation and chemo
Right upper lobectomy
vocal cord paralysis
Diabetes Mellitus
Dementia
Brain injury s/p drug overdose [**2118**]
NPH
RUE DVT [**2143**]
Social History:
active smoker trying to quit, - ETOH
Family History:
DM, Heart Disease
Physical Exam:
On Admission:
O: T: 96.9 BP: 103/58 HR: 78 R 18 O2Sats 96
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-3**] bilat EOMs intact
Neck: Supple.
Lungs: Decreased sounds right lung field, poor effort.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, flat
affect. Has a left hand grasp reflex.
Orientation: Oriented to person, month and says "01" for year
and
"[**Hospital3 **]" for place.
Recall: could not recall. Inattentive and cannot do DOWB.
Language: Says only [**2-5**] words at a time. Has good comprehension
and repeats 3 word sentence.
Naming intact only 2 of 3. No dysarthria or paraphasic errors.
Can only whisper because of vocal cord paralysis.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields difficult to assess duw to
inattention.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Slight left facial weakness, lower. Upper face intact.
Sensory intact.
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: D T B FE IP TE Q
R 4+ 5 5 5 4 5 poor effort
L 4- 4+ 5 3+ 2+ 2 poor effort
Sensation: Intact to light touch.
Reflexes: B T Br Pa Ac
Right trace throughout
Left trace throughout
Toes downgoing bilaterally
Coordination: Patient could not cooperate.
On Discharge:
Speech improved, awake, alert oriented x2, usually off on date
but close. motor full on right, 4+ to [**5-6**] UE and LE
Pertinent Results:
CT Head [**2-28**]
Right frontal lobe mass as described above. Differential
diagnosis includes necrotic metastasis, primary cystic neoplasm,
or abscess. MRI is recommended for further evaluation.
MRI Head with and without [**2-29**]
Large right frontal lobe mass with extensive surrounding
vasogenic edema which most likely represents a metastatic lesion
in this patient with lung cancer. Differential include primary
glial neoplasm.
CT Head [**3-1**]
Interval right frontal craniotomy and resection of the right
frontal lobe mass with hyperdense material in the resection bed
concerning for acute hemorrhage. Significant interval decrease
in leftward shift of the normally midline structures compared to
[**2144-2-28**].
Brief Hospital Course:
Patient presented to [**Hospital1 18**] from OSH with complaints of recent
weight loss, left sided weakness, cognition difficulties,
inability to ambulate , and difficulty speaking. CT Scan in the
ED showed a new large right frontal mass. He was admitted to
the neurosurgery service and on the morning of [**2-29**] it was
decided that he would undergo resection of the mass with Dr.
[**Last Name (STitle) 548**] on the morning of [**3-1**]. Given his history of nonsmall
cell lung cnacer a CT Chest was obtained to evaluate for any
lesions. The CT was negative for lesions but an AV fistula was
found between the Right subclavian artery and vein. No emergent
treatment was needed for this and per radiology this should be
followed up with a potential IR guided procdure in the near
future. Also on the 27th an MRI with gadolinium showed a cystic
enhancing, 4.3cm by 5.5cm mass in the right frontal area with
1cm of midline shift. In preparation for the OR a WAND study was
obtained early in the morning of [**3-1**]. In order to do this
study, in the setting of a low GFR, consent was required to
administer the gadalinium which was obtained by one of the
neuroradiology residents.
On [**3-1**] he underwent a right frontal craniotomy for mass
resection with Dr. [**Last Name (STitle) 548**]. Post-operativly he was transferred to
the surgical ICU intubated for further care.
He remained stable overnight and on [**2144-3-2**] he was extubated in
the morning without difficulty and transferred to the floor
later that day. His steroids were tapered as his exam continued
to improve. He was evaluated by vascular surgery for his h/o
coumadin use for arm DVT and findings on CT but their
recommendation was that anticoagulation was not needed and
patient should follow up with vascular surgeon in 3 months. He
was evaluated by PT and OT and felt suitable for rehab. He was
also evaluated by Speech and swallow and failed twice on
consecutive days and ended up having a PEG placed [**2144-3-4**]. 24
hours later it was ready for use for meds and tube feed was
started and goal was reached. His glucose was elevated due to
steroids but this improved with tapering of steroids and
addition of tube feed and usual insulin doses. He was seen by
neuro-oncology and radiation oncology and has plans for follow
up [**2144-3-30**] at which point some type of radiation therapy will be
initiated 3- 6 weeks after surgery. He had staples in his wound
which was well healing and should be removed [**2144-3-11**]. His left
motor function continued to improve and was essentially full at
time of discharge with the exception of [**4-6**] left IP.
Medications on Admission:
ATivan 0.5 Q8 prn anxiety
Ambien 12.5 mg daily
Oxycodone CR 30 mg Q3 hrs
Metoprolol 12.5 TID
Coumadin 5mg daily
Meclizine
Aldactone 25 once daily
Lantus 30 daily
Arricept 10
MVi, Spiriva
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
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).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain,fever.
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for [**Female First Name (un) **].
12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
13. Levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID
(2 times a day).
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
16. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
17. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for no bm.
18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
19. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at lunchtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right Frontal brain mass
UTI
heel pressure ulcers
dysphagia
protein/calorie malnutrition
Discharge Condition:
Mental Status: Confused - sometimes
Activity Status: Out of Bed with assistance to chair or
wheelchair
Level of Consciousness: Alert and interactive
Discharge Instructions:
General Instructions
?????? Have your incision checked daily for signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair beginning [**2144-3-5**] then recommend daily
showers.
?????? 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.
?????? Do not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, and Ibuprofen etc for 2 weeks.
?????? You were on a medication Coumadin (Warfarin) for history of
blood clot in arm [**4-/2143**] but vascular surgery saw you and felt
coumadin no longer needed for this.
?????? You have been prescribed Keppra (Levetiracetam), for
anti-seizure medicine, take it as prescribed, you will not
require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please have your staples removed at rehab [**2144-3-11**] or if needed
in the neurosurgery office. This appointment can be made with
the Physician [**Name Initial (PRE) 19158**]. Please make this appointment by
calling [**Telephone/Fax (1) 2992**]. If you live quite a distance from our
office, please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 2726**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**], to be seen in 6 weeks.You will also need a CT scan of the
brain without contrast prior to this appt.
??????You will not need an MRI of the brain with/ or without
gadolinium contrast.
You have an appt with: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital 341**] Clinic.
Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2144-3-30**] 2:00. Future radiation
treatment and lung cancer treatment will be planned at this
appt.
Please follow up with Dr. [**Last Name (STitle) **] in Vascular Surgery in 3 months
for arm. Call [**Telephone/Fax (1) 1241**] for appt.
Completed by:[**2144-3-6**]
|
[
"294.8",
"272.0",
"530.81",
"348.5",
"496",
"331.5",
"478.30",
"414.01",
"V10.11",
"V12.51",
"787.20",
"250.00",
"707.20",
"599.0",
"707.07",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.6",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
8879, 8949
|
4269, 6916
|
326, 389
|
9082, 9082
|
3519, 4246
|
10932, 12123
|
1717, 1736
|
7153, 8856
|
8970, 9061
|
6942, 7130
|
9257, 10909
|
1751, 1751
|
3378, 3500
|
264, 288
|
417, 1458
|
2541, 3364
|
1765, 2057
|
9097, 9233
|
1480, 1647
|
1663, 1701
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,510
| 160,965
|
39131
|
Discharge summary
|
report
|
Admission Date: [**2169-7-6**] Discharge Date: [**2169-7-21**]
Date of Birth: [**2109-11-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
nasogastric tube placement
diagnostic and therapeutic paracentesis
colonoscopy
Diagnostic and therapeutic paracentesis
Colonoscopy
PICC line placement
[**Last Name (un) 1372**]-intestinal tube placement
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 8271**] is a 59 year old male with alcoholic
cirrhosis, HTN, and PUD who was recently discharged from the
hepatology service on [**7-2**] where he was treated for hepatic
encephalopathy and SBP with ciprofloxacin. After leaving the
hospital he developed nausea, vomiting, and then abdominal pain.
He has mostly stayed in bed and has had difficulty tolerating
POs. Vomiting has been bilious, non-bloody. He vomited once
yesterday. He denies fevers or lightheadedness. He had one
headache that resolved. No photophobia or neck stiffness. He has
a chronic cough that has become slightly more productive of
yellow sputum. He has some shortness of breath with exertion and
ocassional lower chest discomfort.
.
Upon arrival to the ED intial vitals were pain 8, T 98.5, HR
112, BP 139/85, RR 16, O2 sat 100% RA. Exam notable for a
protuberant and diffusely tender abdomen. Labs notable for WBC
count 18.1 with 6 bands on the diff, lactate 2.8. CT abdomen and
pelvis was concerning for SBO with dilated loops of bowel.
Transplant surgery was consulted and recommended serial
abdominal exams, NGT, foley, NPO, foley, paracentesis, pan
culture, and CXR. NGT had 1.5L of output. The patient underwent
diagnostic paracentesis with 20cc of fluid removed. Fluid was
unremarkable, but patient received zosyn for concern for SBP. He
also received 25g of albumnin per recommendation from the
hepatology fellow. Vitals prior to transfer to the floor HR 104,
BP 120/73, RR 13, O2 sat 96% RA.
.
Upon arrival to the floor the patient was comfortable and felt
much better since insertion of the NGT.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies rhinorrhea or
congestion. Denies palpitations. Denies diarrhea , constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rashes or
skin breakdown. No numbness/tingling in extremities. No feelings
of depression or anxiety. All other review of systems negative.
.
Past Medical History:
-ETOH cirrhosis
-HTN
-PUD
-GERD
Social History:
Lives at home with his wife and son in [**Name (NI) 189**]. Last drink about
3 months ago per family. Pt. denies tobacco use.
Family History:
non-contributory
Physical Exam:
.
On Discharge:
.
T - 98.6, HR - 106 (86 - 106), BP - 109/63,
Gen: Comfortable, NAD, NG tube in place, temporal wasting
CV: RRR, S1, S2, no murmurs/rubs/gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: distended, soft, non-tender, tympanitic to percussion, +
bowel sounds
Ext: 2+ LE edema to knees
Neuro: A&Ox3
Pertinent Results:
On AdmissionL
[**2169-7-5**] 08:35PM PLT COUNT-171#
[**2169-7-5**] 08:35PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
BURR-OCCASIONAL BITE-OCCASIONAL
[**2169-7-5**] 08:35PM NEUTS-85* BANDS-6* LYMPHS-5* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2169-7-5**] 08:35PM WBC-18.1*# RBC-3.37* HGB-11.5* HCT-35.3*
MCV-105* MCH-34.2* MCHC-32.7 RDW-15.8*
[**2169-7-5**] 08:35PM ALBUMIN-3.0*
[**2169-7-5**] 08:35PM LIPASE-78*
[**2169-7-5**] 08:35PM ALT(SGPT)-16 AST(SGOT)-35 ALK PHOS-103 TOT
BILI-3.6*
[**2169-7-5**] 08:35PM GLUCOSE-97 UREA N-47* CREAT-1.4* SODIUM-127*
POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-24 ANION GAP-14
[**2169-7-5**] 10:15PM PT-12.8 PTT-26.2 INR(PT)-1.1
[**2169-7-6**] 01:00AM ASCITES WBC-260* RBC-3260* POLYS-26* LYMPHS-7*
MONOS-0 MESOTHELI-11* MACROPHAG-54* OTHER-2*
[**2169-7-6**] 02:16AM LACTATE-2.8*
[**2169-7-6**] 02:16AM COMMENTS-GREEN TOP
[**2169-7-6**] 06:30AM PT-20.5* PTT-41.6* INR(PT)-1.9*
[**2169-7-6**] 06:30AM PLT COUNT-159
[**2169-7-6**] 06:30AM WBC-14.4* RBC-3.21* HGB-11.0* HCT-32.5*
MCV-101* MCH-34.1* MCHC-33.7 RDW-15.2
[**2169-7-6**] 06:30AM OSMOLAL-289
[**2169-7-6**] 06:30AM CALCIUM-9.1 PHOSPHATE-3.2 MAGNESIUM-2.2
[**2169-7-6**] 06:30AM LIPASE-87*
[**2169-7-6**] 06:30AM ALT(SGPT)-17 AST(SGOT)-31 ALK PHOS-91 TOT
BILI-3.3*
[**2169-7-6**] 06:30AM GLUCOSE-67* UREA N-42* CREAT-1.2 SODIUM-129*
POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-28 ANION GAP-10
[**2169-7-6**] 06:38AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2169-7-6**] 06:38AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.046*
[**2169-7-6**] 07:17AM LACTATE-2.4*
[**2169-7-6**] 07:17AM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2169-7-6**] 10:57AM URINE OSMOLAL-637
[**2169-7-6**] 10:57AM URINE HOURS-RANDOM UREA N-976 CREAT-59
SODIUM-25 POTASSIUM-45 CHLORIDE-27
At Discharge:
[**2169-7-21**] - Chemistry: Na-132, K-4.6, Cl-103, HCO3-23, BUN-42,
Cr-0.8, Ca-7.9, Mg-2.1, Phos-4.3
[**2169-7-21**] - CBC: WBC-6.6, HCT-24.8, Plts 101,
[**2169-7-21**] - Coag: 20.1, INR - 1.9
[**2169-7-21**] - LFT: ALT - 21, AST - 46, AP - 122, LDH - 150, TBili -
2.5, Alb - 2.3
Studies:
[**7-6**] CT Abdomen Pelvis:
IMPRESSION:
1. Massive ascites.
2. Small-bowel is distened and large bowel is distended to the
distal
transverse colon where there is a relative transition point
without obvious
mass consistent with a large bowel obstruction. A barium enema
is recommended
for further investigation.
3. Nodule at the liver dome is concerning for a hepatama.
Nodular densities
along the left flank may be omental implants. Recommend MR [**First Name (Titles) 151**] [**Last Name (Titles) 86688**]m
for further evaluation of the liver lesion
3. Dilated and fluid-filled esophagus and stomach.
4. Small left pleural effusion.
5. Portal vein patent.
6. Subacute left rib fracture.
8. Perisistent bilateral subcentimeter hypodensities, too small
to
characterize, statistically likely to be benign cysts.
.
[**7-7**] MRI Abdomen/Pelvis:
IMPRESSION:
1. Cirrhotic liver with enhancing lesion with washout
characteristics in the dome of the liver in segment VIII,
concerning for hepatocellular carcinoma.
2. Massive ascites.
3. Small left pleural effusion with adjacent atelectasis.
4. Incompletely visualized gastrointestinal tract which
demonstrates
distention of the small bowel and large bowel as seen on recent
CT.
.
COLONOSCOPY:
[**7-11**]
No mass or obstructing lesion was noted. Preparation was noted
to be poor. Therefore, any smaller underlying lesions could not
be completely excluded. Retroflexion was not performed due to
large amount of stool in rectal vault.
.
[**7-13**] - decompression in ICU
Colonic dilatation without overt mass lesion or external
compression. Stool throughout colon. Decompression using
colonoscope. Please insert rectal tube. Maintain in ICU.
.
[**7-17**]-ABDOMINAL XRAY: Dilated loops of both small and
large bowel are noted, with air also seen within the ascending
and transverse colons. The overall degree of distention and
appearance are not significantly changed from prior study, and
may reflect an ileus. There is no free air or pneumatosis.
.
IMPRESSION: No interval change in persistent small bowel
dilatation, as well as dilated ascending and transverse colon.
[**7-20**]- ABDOMINAL XRAY: Dobhoff tube in standard location, appears
post-pylroic.
Brief Hospital Course:
Mr. [**Known lastname 8271**] is a 59 y/o M w/ ESLD [**2-21**] ETOH cirrhosis c/b
ascites, SBP and PSE who was admitted for nausea, vomiting and
abdominal pain due to bowel obstruction.
1. Bowel obstruction: Mr. [**Known lastname 8271**] was discharged from the
hospital on [**7-2**] on ciprofloxacin to treat SBP with last dose
scheduled to be [**7-6**]. On admission, his repeat diagnostic
paracentesis was negative SBP. The patient was found to have a
large bowel obstruction with dilated large and small bowel
loops. He had a colonoscopy, which showed no intraluminal mass,
but it was a poor prep. The patient was given an NG tube to
suction and was kept NPO. His symptoms did not improve and he
was unable to tolerate PO. On hospital day 7, the patient
started to complain of increased abdominal pain. There was
concern for perforation versus obstruction. KUB showed no signs
of free air and repeat paracentesis was negative for SBP. In
the afternoon, the patient became more sleepy (arousable to
voice), with asterixis and was noted to have [**4-24**] small bright
red blood clots in his NG tube fluid drainage. He was
transfered to the ICU for closer monitoring and possible
colonoscopy for decompression of ileus.
.
Pt was admitted to MICU for colonoscopy and possible
decompression of his bowel. He underwent colonoscopy with
decompression using colonoscope. Following colonoscopy, the
patient passed flatus and had a bowel movement. His condition
improved and he was transferred out of the MICU back to the
floor.
.
Mr. [**Known lastname 8271**] continued to have bowel movements and pass gas. His
diet was gradually advanced to full diet, which he tolerated.
His lactulose dose was decreased as he had discomfort from gas
pains. His NG tube to suction was removed and he denied nausea
and vomiting.
.
2. ESLD [**2-21**] Alcoholic Cirrhosis: Initially the patient's lasix
and spironolactone were held and the patient was intravascularly
dry. They were re-started after he was volume repleted.
Lactulose and rifaximin were continued. The patient had two
paracentesis, both were negative for SBP. In the second
paracentesis on [**7-13**], 2L of fluid were removed. After
re-starting diuretics, the patient had persistent peripheral
edema as well as ascites. The patient's Lasix dose was
increased from 40 to 80 mg daily, and his spironolactone dose
was increased from 100 to 200 daily.
.
The patient's MRI showed concern for hepatocellular carcinoma.
However, his AFP was normal. No work-up was initiated in the
hospital because of the patient's acute issues.
.
3. Acute renal failure: The patient had acute renal failure at
time of admission with creatinine up to 1.4, from his baseline
of 0.7. It was thought to be pre-renal in etiology from
vomiting and poor PO intake. It resolved to .6 during
hospitalization with IV fluids and increased PO intake.
.
4. Malnutrition: Mr. [**Known lastname 8271**] is very malnourished. He presented
with an albumin of 2.5. He was unable to tolerate PO [**2-21**] to his
ileus. He started on TPN on [**7-14**] and it was continued
throughout the hospitalization. He was discharged on both a
full diet and TPN. He also had a post-pyloric [**Last Name (un) **]-intestinal
tube placed to start enteric feeds as wll.
.
5. Anemia/thrombocytopenia: During the hospitalization the
patient's hematocrit trended down to the mid-20s, from the low
30s on admission. Iron studies on [**6-30**] consistent with anemia of
chronic disease. He had both normal folate and B12 levels. EGD
in [**4-29**] consistent with portal hypertensive gastropathy and
ulceration. Platelets are low likely due to splenomegaly.
Throughout the hospitalization, the hematocrit remained stable
in the mid-20s. The patient had small amount of blood from NG
on [**7-13**] (which resolved), but no other bleeding during
admission. He was given a PPI twice a day.
.
Medications on Admission:
Home Medications: (per [**7-2**] discharge summary)
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
7. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a
day: titrate to [**2-22**] bowel movements per day.
Disp:*1800 ML(s)* Refills:*2*
9. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*1*
10. Phytonadione 5 mg Tablet Sig: One (1) Tablet PO once a day
Discharge Medications:
1. Rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily).
5. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Spironolactone 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary:
Large bowel obstruction
abdominal ascites
malnutrition
acute renal failure
alcoholic cirrhosis
Secondary:
hypertension
peptic ulcer disease
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with abdominal pain and
vomiting. You were found to have a blockage in your large
intestine. You had a colonscopy that showed no large mass in
your colon. You also had a nodule on your liver that was
concerning for cancer. You had an IV placed to receive nutrition
through your vein. You also had fluid removed from your
abdomen, which did not show any infection or cancer cells. You
had an tube placed through your nose into your intestine so that
you could get adequate nutrition.
Please see below for your follow up appointments.
The following changes have been made to your medications:
1. Added Ciprofloxacin 250 mg daily. This medication will
prevent infection recurrence. Please take it every day.
2. Changed dose of Lasix to 80 mg PO daily
3. Changed dose of Spironolactone to 200 mg PO daily
4. Changed dose of Lactulose to 15ML PO, once per day
Followup Instructions:
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2169-7-27**] 1:00 (If he
is unable to get appointment with his own GI - I called Dr. [**Name (NI) 86689**] office to get an appointment, they will get back to
both me and patient).
Please call your PCP ([**Telephone/Fax (1) 86690**] to make an appointment
Please call your GI Doctor at ([**Telephone/Fax (1) 86690**] to make an
appointment
|
[
"303.91",
"560.1",
"578.9",
"276.51",
"560.39",
"572.3",
"511.9",
"571.2",
"287.5",
"533.90",
"235.3",
"572.2",
"537.89",
"273.8",
"285.29",
"518.0",
"E879.8",
"584.9",
"996.79",
"560.89",
"260",
"401.9",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"45.23",
"54.91",
"46.85",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13548, 13623
|
7738, 11647
|
348, 553
|
13816, 13824
|
3241, 5201
|
14768, 15214
|
2836, 2854
|
12831, 13525
|
13644, 13795
|
11673, 11673
|
13848, 14745
|
2869, 2871
|
11691, 12808
|
5215, 7715
|
2885, 3222
|
2225, 2621
|
276, 310
|
581, 2206
|
2643, 2676
|
2692, 2820
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,491
| 175,920
|
52049
|
Discharge summary
|
report
|
Admission Date: [**2162-10-23**] Discharge Date: [**2162-10-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1845**]
Chief Complaint:
G tube placement, subdural hematoma in ED
Major Surgical or Invasive Procedure:
IR guided G tube replacement
History of Present Illness:
85 yo M with history of AF on coumadin, CAD, stroke who
presented from the rehab on [**10-23**] for replacement of his G tube.
While in the ER, a small catheter was placed through the ostium.
While the patient was in the ER however, he fell from his bed
and hit his head. An emergent CT was done that showed a small
ICH (9mm right parietal). Thus the patient was admitted to the
ICU for further monitoring and serial neuro checks.
Of note the patient was recently admitted to [**Hospital1 18**] on [**8-26**] for Right Superior MCA embolus CVA and resultant mild L
hemiparesis and bladder CA (high-grade papillary urothelial ca),
underwent transurethral resection, was admitted to [**Hospital Unit Name 153**] with
intubation and CVL placement, G-tube placement by IR [**9-7**],
discharged to rehab. He was discharged on [**9-7**] on a heparin
gtt with plans to transition back to coumadin. The coumadin (for
AF) was stopped prior to the CVA in anticipation of a surgical
procedure.
Past Medical History:
-Hematuria
-Paroxysmal atrial fibrillation, off coumadin ~ 3 weeks prior to
[**2162-8-26**] surgery
-h/o Cerebellar hemorrhage ([**2136**]), s/p craniotomy (staples
present in cranium)
-Vascular disease: Severe stenosis of the left vertebral artery,
approximately 2-3 cm proximal to the vertebrobasilar junction.
40% right ICA stenosis ([**2162-8-27**])
-Alzheimer's dementia, disinhibition and frontal dysfunction per
OMR ([**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, Neurology, [**2162-8-12**])
-Hypertension
-CAD: angina since [**3-/2151**], fixed perfusion defects in the apical
and apical portion of the anterior wall per Thallium ETT
([**2151-4-7**]) mild regional LV systolic dysfunction with
infero-lateral akinesis per TEE ([**2162-8-27**])
-Secundum Atrial Septal Defect w/ left to right shunt
-Valvular disease: Moderate (2+) MR, mild to moderate [[**12-16**]+] TR
-LVH by EKG & echo
-h/o Anemia, baseline Hct mid-30s
-h/o Pulmonary TB:~[**2110**] in USSR, multiple calcified granulomas
bilat lungs, R>L per CXR, h/o cavitary lung lesion, neg for AFB
by bronchoalveolar lavage ([**2154-9-6**])
-h/o Pulmonary nodule, RLL (superior segment) per CXR & CT scan
-Stage III colon cancer (T3N1):s/p resection, adjuvent
5-FU/leucovorin rx ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD, Oncology)
-h/o Alcohol abuse (quit in [**2160**])
-h/o falls, L Ankle fx ([**6-/2152**]), R ankle injury ([**6-/2153**])
-Back Paincervical radiculopathy & myelopathy, T12 compression
fracture, hemangioma at L2, bulging disk @ L2/3, multilevel
degenerative disk disease
-Cataracts, s/p excision & lens implant o.s.
-Glaucoma
-Wet macular degeneration w/ neovascularization
-GERD
-Giant hemangioma of the liver
-CRF, baseline creatinine 1.1 - 1.3
-h/o Right Renal cyst, CT Scan ([**2162-8-3**])
-h/o ARF ([**8-/2154**])
-h/o bowel obstruction
PSHx:
s/p Transurethral resection of the bladder, c/b CVA ([**2162-8-26**])
s/p Complex cataract surgery with intraocular lens implantation,
o.s. ([**2159-8-27**])
s/p Cystoscopy & random biopsies of the bladder ([**2157-2-11**])
s/p Colonoscopy ([**2156-1-15**])
s/p Cystoscopy and fulguration of bladder tumor ([**2155-9-26**])
s/p RIH repair with mesh plug & patch ([**2155-4-16**])
s/p Colonoscopy ([**2155-1-2**])
s/p Anterior resection of the colon ([**2152-9-5**])
s/p TURP, ? Prostate Ca ([**2147-6-9**])
s/p TURP for BPH, [**2138**]
s/p Posterior fossa craniectomy for a cerebellar hemorrhage
([**2136**])
Social History:
Relationships: [**Name (NI) **] (brother)- Cell: [**Telephone/Fax (1) 107744**], Home:
[**Telephone/Fax (1) 107745**]; [**Doctor First Name **] (neice, [**Name (NI) 2979**] daughter) - Cell:
[**Telephone/Fax (1) 107746**]; [**First Name5 (NamePattern1) 440**] [**Last Name (NamePattern1) 107747**] (neice, and [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) **]), Cell:
([**Telephone/Fax (1) 107748**]; Friend [**Name (NI) 751**]
Social:
Immigrated from [**Country 532**] in [**2134**], at baseline speaks & understands
limited English - translator needed. Positive h/o alcohol abuse,
but per PCP note stopped drinking ~1 year ago. He does not
smoke. Previously employed as a photographer. Brother states
patient is a Holocaust survivor.
Assistive Devices:
Glasses at baseline, upper & lower dentures; no hearing aides,
did not use walker or cane prior to admission.
Functional Status:
Was living independantly in senior housing: elevator & no steps
into building. Had HHA/HM (?) for personal care & cleaning,
three meals delivered to him every day. Supportive brother lives
nearby & does shopping. Out-patient Neurological evaluation (OMR
[**2162-8-12**]) notes abnormal mental status screen, h/o disinhibition
and frontal dysfunction, positive visuospatial signs that may
suggest Alzheimer's Disease. PCP had recently filled out forms
for adult daycare.
Values/Belief: [**Hospital1 **]
Family History:
Both parents died in [**2095**] in the [**Location (un) 25508**] ghetto.
Physical Exam:
VS: t 97.7 BP 158/62 HR 65 rr 18 96% RA
Gen: NAD, sleeping comfortably, awakens to alert, converses with
translator by phone who reports that the patient is alert and
oriented x 3.
HEENT: OP clear, EOMI
Neck: No JVD, no thyromegaly, no LAD
Cor: RRR no m/r/g
Pulm: CTAB, rare wheeze, laying flat, normal respirations
Abd: +BS, NTND, No HSM. G tube replaced by small gauge cathether
Extrem: no c/c/e
Skin: no rashes
Neuro: Left sided facial droop, mild decrease in strength in
left arm, but able to do hand grip bilaterally. Moves all
extremities and withdraws to pain. Preferentially grabs objects
with right hand. No tremor appreciated.
Pertinent Results:
[**2162-10-23**] 09:00PM BLOOD WBC-7.3 RBC-4.80 Hgb-12.8* Hct-38.6*
MCV-80* MCH-26.7* MCHC-33.3 RDW-18.3* Plt Ct-245
[**2162-10-25**] 05:55AM BLOOD WBC-5.3 RBC-4.39* Hgb-11.5* Hct-35.3*
MCV-80* MCH-26.2* MCHC-32.7 RDW-17.4* Plt Ct-215
[**2162-10-23**] 09:00PM BLOOD PT-28.5* PTT-35.9* INR(PT)-2.9*
[**2162-10-25**] 05:55AM BLOOD PT-14.9* PTT-32.7 INR(PT)-1.3*
[**2162-10-23**] 09:00PM BLOOD Glucose-95 UreaN-22* Creat-1.1 Na-141
K-3.6 Cl-101 HCO3-33* AnGap-11
[**2162-10-25**] 05:55AM BLOOD Glucose-87 UreaN-16 Creat-1.1 Na-141
K-3.4 Cl-105 HCO3-27 AnGap-12
[**2162-10-24**] 05:12AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.8
CT head w/o contrast ([**2162-10-23**]): 1. Small superficial right
parietal hemorrhage. 2. More hypodense appearance of right MCA
territory infarction. 3. Post-surgical changes in the occipital
region, with prior left cerebellar
resection. 4. Age-related parenchymal atrophy.
CT spine w/o contrast ([**2162-10-23**]): 1. No evidence of fracture or
malalignment. 2. Multilevel degenerative change, most pronounced
at C5-C6.
3. Prior right MCA infarction and occipital post-surgical
changes as well as new right parietal hemorrhage are better
evaluated on concurrent head CT.
Abd XR ([**2162-10-23**]): Contrast injected through the gastric tube
opacifies the stomach without evidence of contrast
extravasation.
CT head w/o contrast ([**2162-10-24**]): No significant change over the
four-hour interval, with no new hemorrhage seen.
CXR ([**2162-10-24**]): Findings most consistent with old granulomatous
disease and
scarring. No acute change.
CT head w/o contrast ([**2162-10-25**]): No significant change over the
preceding interval.
CT head w/o contrast ([**2162-10-25**]): No significant change over the
preceding 18 hours.
Brief Hospital Course:
Intracranial Hemorrhage: While in the ICU, the patient had
serial neuro checks which were normal and reversal of his INR
(2.9-->1.4). En total, he received 3 U FFP, 2 vials of factor
IX, 10 mg Vit K PO and 5 mg vit K IV (ED). In the ICU and on
the floor, the patient continued to have serial neuro checks and
head CTs per neurosurgery team, all of which were normal. At
baseline he has a left facial droop and mildly decreased
strength in his left arm. Given history of previous strokes and
former recommendations not to use coumadin, the patient is being
discharged on no anticoagulation, with recommendation to restart
ASA on [**2162-11-3**] and to defer to PCP and neurosurgery about
restarting coumadin at any point in the future.
G-Tube Placement: In the ED, a small catheter was placed for
patency. Tube feeds were started in the ICU at 15 cc with
concern for abdominal pain. On [**2162-10-25**] he had g-tube
replacement, without complication, and subsequently TF were
restarted. consider giving bolus tube feeds and covering the PEG
with a binder or ACE wrap when not in use to deecrease the risk
of dislodging.
Deconditioning: Unsteady gait and decreased strength, in the
context of period of immobility s/p fall. Patient would venfit
from continued phyical and occupational therapy. Recommend
frequent ambulation with assist and fall precautions, including
low bed and floor padding.
Hypertension: BP control was difficult while in the ED and the
patient was briefly on labetolol gtt. Following restarting his
home hypertensive doses per G-tube, he was hypertensive to 180
requiring 20 mg labetolol IV, metoprolol 25 mg PO and 20 mg
hydral IV. He continued to have systolic blood pressure ranging
160-170s, and his dose of metoprolol was increased from 50mg [**Hospital1 **]
to 50mg TID.
History of embolic stroke [**8-/2162**]: DC summary and notes from
prior admission suggest patient was not to be restarted on
coumadin, but rather asa and heparin gtt. However, restarted on
coumadin at rehab. He is now discharged on no anticoagulation.
He should be restarted on ASA on [**2162-11-3**], with plan to discuss
coumadin recs with PCP and neurosurgery in follow up.
Anemia: normocytic anemia with baseline low 30s, currently
stable.
Insulin: pt on insulin sliding scale, though no history of
diabetes. Insulin was discontinued and his glucose remained
within normal.
Glaucoma: continued drops
Medications on Admission:
1. docusate liquid [**Hospital1 **]
2. brimonidine 0.15 % 1 drop q8
3. latanoprost 0.005 % 1 drop qhs
4. insulin Lispro sliding scale
5. simvastatin 20mg qd
6. ferrous Sulfate 325 qd
7. ipratropium Bromide 0.02 % q6hrs prn
8. albuterol q6 prn
9. metoprolol tartrate 50 [**Hospital1 **]
10. lansoprazole 30 mg qd
11. senna 8.6mg qhs:prn
12. bisacodyl 10mg prn
13. lisinopril 40mg qd
14. acetaminophen 325 q6hrs prn
15. PER NURSING - COUMADIN ?DOSE
16. PER NURSING - LACTULOSE 10MG [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
2. Brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic Q8H
(every 8 hours).
3. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
4. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
8. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
11. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Intracranial hemorrhage
G tube replacement
Discharge Condition:
Neurologically stable and feeding well through g-tube
replacement
Discharge Instructions:
You were admitted to the hospital on [**2162-10-24**] when you presented
to the ED for replacement of your g-tube. In the ED, you had a
fall, and head CT showed a small intracranial bleed. You were
monitored in the intensive care unit for two days, during which
time the Neurosurgery team followed you. Serial neurologic
exams and head CTs were stable. On [**2162-10-25**] your g-tube was
replaced, without complication.
.
Please continue to take all your medications through the g-tube.
Coumadin and aspirin have been stopped. You should not restart
the coumadin until further discussion with your primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) 39992**]. Please restart the aspirin on [**2162-11-3**].
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 39992**] as
instructed below.
.
Seek medical attention if you have any further falls,
lightheadedness, syncope, weakness, changes in vision, or
difficulties with your feeding tube.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2162-10-27**] 9:45
Provider: [**Name10 (NameIs) 1239**] BRAIN, N.P. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2162-11-23**]
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2162-12-7**] 1:00
11:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2162-12-7**] 1:30
|
[
"853.01",
"228.04",
"403.90",
"585.9",
"E884.4",
"285.9",
"E849.7",
"438.83",
"536.42",
"331.0",
"294.11",
"E879.8",
"427.31",
"V10.51",
"745.5",
"424.0",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"97.02"
] |
icd9pcs
|
[
[
[]
]
] |
11912, 11997
|
7843, 10259
|
306, 337
|
12084, 12152
|
6066, 7820
|
13197, 13746
|
5318, 5392
|
10806, 11889
|
12018, 12063
|
10285, 10783
|
12176, 13174
|
5407, 6047
|
225, 268
|
365, 1350
|
1372, 3870
|
3886, 5302
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,443
| 169,093
|
21875
|
Discharge summary
|
report
|
Admission Date: [**2105-10-16**] Discharge Date: [**2105-10-21**]
Date of Birth: [**2055-6-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Anterior mediastinal mass- admitted for resection.
Major Surgical or Invasive Procedure:
mediastinal mass excision via sternotomy, total thymectomy,
right coronary artery stent x 2
History of Present Illness:
50 yr male with hodgkin's lymphoma ([**2097**])- rec'd chemo and XRT.
Doing well until [**2102**] when found to have an anterior mediastinal
mass. The mass was PET postive. FNA of mass non-diagnostic. Pt
was admitted for mediastinoscopy and mass resecetion.
Past Medical History:
Hodgkin's lymphoma post Chemo, XRT.
HTN, Hyperchol
Social History:
drinks 3-6 beers/day
smoked [**12-20**] 1/2 packs for 35 yrs
? chemical exposure at Lucent tech where he worked for 20 yrs.
Family History:
mother died of pancreatic cancer, afther of emphysema, prostate
cancer
Physical Exam:
General; 50 yr old male who appears older than stated age but
in NAD
HEENT: unremarkable.
COR; RRR S1, S2
Chest: Lungs CTA bilat
ABD; soft, NT, Nd, +BS
Extrem: No C/C/E
Neuro: A+OX3
Pertinent Results:
[**2105-10-16**] 09:51PM TYPE-ART PO2-191* PCO2-24* PH-7.46* TOTAL
CO2-18* BASE XS--4
[**2105-10-16**] 05:48PM GLUCOSE-185* UREA N-23* CREAT-1.1 SODIUM-140
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-18* ANION GAP-18
[**2105-10-16**] 05:48PM WBC-14.8* RBC-3.54* HGB-11.4* HCT-32.5*
MCV-92 MCH-32.2* MCHC-35.2* RDW-14.3
[**2105-10-16**] 02:43PM CK(CPK)-94
[**2105-10-16**] 02:43PM CK-MB-2 cTropnT-0.02*
Cardiac Catheterization:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
single vessel coronary artery disease. The LMCA had no
angiographically
apparent flow limiting stenosis. The LAD had no angiographically
apparent flow limiting stenosis. The LCX had no angiographically
apparent flow limiting stenosis and gave rise to large OM
branches. Teh
RCA was a dominant vessel and was totally occluded prximally
with fresh
thrombus.
2. Resting hemodynamics revealed elevated mildly elevated right
and left
sided pressures. The cardiac output was 5.1 l/min and the
cardiac index
was 3.1 l/min/m2.
3. Left ventriculography was deferred.
4. Successful placement of a 3.0 x 28 mm Cypher drug-eluting
stent in
the proximal RCA with a more distal and overlapping 3.0 x 33 mm
Cypher
drug-eluting stent. Postdilation was with a 3.5 mm balloon.
Final
angiography demonstrated no residual stenosis, no
angiographically
apparent dissection, and normal flow (See PTCA Comments).
5. Brief episode of ventricular tachycardia which terminated
without
chest compressions or cardioversion occurring during
postdilation of the
stents.
FINAL DIAGNOSIS:
1. Angiographic evidence of single vessel coronary artery
disease.
2. Mildly elevated left and right sided pressures.
3. Acute inferior myocardial infarction, managed by primary PCI
with drug-eluting stenting of the RCA.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**First Name3 (LF) **]
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) 2389**] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) 3904**],[**First Name3 (LF) 2482**] P.
[**Last Name (LF) **],[**First Name3 (LF) **] T.
ATTENDING STAFF: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J.
[**2105-10-16**] Pathology Tissue: PERICARDIUM DEEP MARGIN,ANT [**2105-10-16**]
[**Last Name (LF) 1533**],[**First Name3 (LF) 1532**] P. Not Finalized
Brief Hospital Course:
Pt was admitted on [**2105-10-16**] for excision of mediastinal mass via
mediansternotomy pathology small cell.
Post op course was compliacted by acute IMI in PACU. Pt was
emergently intubated and taken to cath lab. His RCA was 100%
occluded proximally. RCA was stented x2. Pt was started on beta
blockers, ASA , Plavix and transferred to the cardiac surgery
ICU and remained intubated over noc. He was hemodynamically
stable, was weaned and extubated in POD#1.
Mediastinal chest tube was d/c'd on POD#4. Pleural tubes were
d/c'd on POD#5.
Pt was d/c'd to home with cardiac f/u at [**Hospital1 18**] and initial
heme-onc follow up here with transition to a hospital close to
home.
Medications on Admission:
Lisinopril 20', omeprazole 20', Aleve and Tylenol p.r.n
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
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*
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
home health and hospice care
Discharge Diagnosis:
mediastinal mass excision via partial sternotomy, total
thymectomy complicated by acute Mi and stent x 2 to the right
coronary artery.
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you experience
chest pain, shortness of breath, fever, chills, or redness or
drainage from your incision.
No tub bathing or swimming for 3 weeks.
you may shower- after showering, place a clean bandaid daily.
Followup Instructions:
You have a follow up with Dr. [**Last Name (STitle) **] for [**10-29**] at
10:30am in the [**Hospital Ward Name 23**] clinical center [**Location (un) **].
You have an appointment with your cardiologist Dr. [**Last Name (STitle) **] on
[**11-23**] at 4pm in the [**Hospital Ward Name 23**] clinical center [**Location (un) 436**].
Completed by:[**2105-11-3**]
|
[
"410.41",
"V15.3",
"164.8",
"518.81",
"272.4",
"414.01",
"V10.72",
"401.9",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.46",
"96.71",
"89.64",
"99.04",
"88.56",
"37.31",
"32.29",
"36.07",
"96.04",
"00.40",
"34.3",
"00.66",
"00.17",
"37.23",
"07.82"
] |
icd9pcs
|
[
[
[]
]
] |
5186, 5245
|
3580, 4262
|
330, 424
|
5424, 5431
|
1233, 2790
|
5754, 6116
|
942, 1014
|
4368, 5163
|
5266, 5403
|
4288, 4345
|
2807, 3557
|
5455, 5731
|
1029, 1214
|
240, 292
|
452, 711
|
733, 785
|
801, 926
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,047
| 158,491
|
11239+11272
|
Discharge summary
|
report+report
|
Admission Date: [**2194-9-3**] Discharge Date: [**2194-9-9**]
Date of Birth: [**2117-10-3**] Sex: M
Service: PLASTIC SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old
man, a patient of Dr. [**Last Name (STitle) 5385**], who for many years has been
treated with recurrent resections for squamous cell cancer
involving the dome of his scalp. After initial excision and
recurrence, he was treated with radiation therapy. The
entire dome of his calvarium was either ulcerated or
surrounded by very thin atrophic skin. He presented a number
of months ago with a chronic indurated ulcer which had not
healed in several years so he was brought to the Operating
Room for a definitive excision of the ulcer including
recurrence in the margins. Resurfacing of the entire dome of
the scalp was done and it was planned to be done with a
latissimus dorsi flap and covered with split-thickness skin
graft.
The patient had been previously taking Coumadin at home which
was discontinued prior to the operation and his original
wound site was from squamous cell carcinoma and the planned
treatment was excision with radiation. Already, this had
been attempted in the past with radiation and two failed
grafts had already been attempted.
PAST SURGICAL HISTORY:
1. Cholecystectomy.
2. Left inguinal hernia.
PAST MEDICAL HISTORY:
1. TIAs.
2. Hypertension.
3. Squamous cell carcinoma, as mentioned above, with two
failed grafts and radiation treatment.
4. Diabetes mellitus which was controlled by diet on a daily
basis.
ADMISSION MEDICATIONS:
1. Zestril.
2. Atenolol.
3. Hydrochlorothiazide.
4. Coumadin, discontinued on [**2194-8-26**], prior to his
admission.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97.3, 138/70, heart rate 56, 98% on room air. General: He
was alert and oriented, in no acute distress. Lungs: Clear
to auscultation bilaterally. Heart: S1 and S2 was
appreciated. A III/VI systolic ejection murmur was heard at
the apex. Of note, cardiology clearance was performed by Dr.
[**Last Name (STitle) 1391**] for his mitral regurgitation and paroxysmal atrial
fibrillation. It was viewed that he was an acceptable
surgical risk to proceed with the planned surgery. An
echocardiogram showed no significant change from a previously
scheduled echocardiogram. Recommendations from Cardiology
were to resume his regular Coumadin dose once adequate
hemostasis and the patient had emerged from the immediate
postoperative course. Abdomen: Soft, nontender,
nondistended. Extremities: No clubbing, cyanosis or edema.
LABORATORY/RADIOLOGIC DATA: Preoperatively, a chest x-ray
was ordered. An EKG was ordered. Preoperative laboratories,
CBC, Chem-10, PT/PTT.
HOSPITAL COURSE: Consent was done. The patient was n.p.o.,
given LR, and Anesthesia saw the patient. The patient was
taken to the Operating Room on [**2194-9-4**]. The preoperative
diagnosis was osteo radial necrosis of scalp and skull. He
underwent excision of recurrent squamous cell carcinoma of
the scalp, subtotal removal of the scalp and chronic ulcer, a
latissimus dorsi flap to scalp using left superficial
temporal vessels was performed. Split-thickness skin graft to
scalp 25 by 30 cm was performed and plastics closure of the
back donor site.
The patient tolerated the procedure well. See operative note
dictation for further information. Postoperatively, the
patient was comfortable, in no acute distress. His lungs
were clear to auscultation. The flap was noted to be well
perfused with excellent Doppler signal. The skin paddle
showed some sites of ecchymosis; however, it was extremely
viable and it had an excellent Doppler signal. JP drains
were in place and they were functioning well and holding
suction.
On postoperative day number two, the patient was continued to
be monitored. His hematocrit had trended down to 21.7 from
38.3 preoperatively. Immediately postoperatively it was
26.1. On postoperative day number one, it was 27.9 and on
postoperative day number two, it trended down at 21.7. It
was decided at that juncture to undertake transfusion with 2
units of packed red blood cells and recheck the hematocrit
which later stabilized to 28 and then hovered around 30.
On postoperative day number three and four, the patient had
low potassium, low hypokalemia, and hypomagnesemia,
hypocalcemia. These electrolytes were replaced as needed.
The patient continued to improve. Wound care was continually
performed with dressing changes, Xeroform followed by Kerlix
wrap around the scalp. Care was taken not to have the
patient rest on his left side. Care was also taken to have
the patient keep his head elevated. JP drains were monitored
for outputs and JP drains were stripped continuously.
The patient continued to improve, was gotten up and out of
bed to chair. His Foley was discontinued. On postoperative
day number four, the patient was begun for rehabilitation
screen. Physical Therapy evaluated the patient for safety
and rehabilitation potential. Once again, electrolytes were
repleted as needed. The patient's vital signs remained
stable. His hemoglobin or hematocrit remained stable. The
patient was begun postoperatively on his return to his normal
Coumadin regimen. The flap was viable throughout this time
and continued to be monitored with all appropriate monitoring
and continued to show an excellent Doppler signal.
It was decided that after evaluation with Physical Therapy,
the patient would need an acute rehabilitation setting so,
therefore, it was decided to undertake after rehabilitation
screening and acceptance that the patient had met criteria
for discharge. Therefore, discharge was planned with case
management.
FINAL DIAGNOSIS: Osteo radial necrosis of scalp and skull,
status post excision of recurrent squamous cell carcinoma of
scalp.
PROCEDURES PERFORMED: Subtotal removal of scalp and chronic
ulcer, latissimus dorsi muscle flap to scalp using left
superficial temporal vessels, split-thickness skin graft to
scalp measuring 25 by 30 cm and a plastics closure of the
back donor site.
DISCHARGE MEDICATIONS: The patient will return to his home
medication regimen. In addition, he was given seven days of
antibiotics being Kefzol and pain medication, Percocet used
for pain.
1. Famotidine.
2. Oxycodone, as mentioned.
3. Aspirin.
4. Hydrochlorothiazide.
5. Atenolol.
6. Lisinopril.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7738**]
Dictated By:[**Last Name (STitle) 36112**]
MEDQUIST36
D: [**2194-9-9**] 06:30
T: [**2194-9-9**] 18:40
JOB#: [**Job Number 36113**]
Admission Date: [**2194-9-3**] Discharge Date: [**2194-9-12**]
Date of Birth: [**2117-10-3**] Sex: M
Service:
ADDENDUM: The patient continued to do well, was awaiting bed
placement for rehabilitation. At points during the hospital
course his magnesium was low and repleted appropriately as
was his potassium. The patient continued to receive
Coumadin. His INR was checked until it became therapeutic.
The patient was stable. The flap was healthy, had good skin
color and good viability, and excellent Doppler signal
throughout. The patient was discharged to rehabilitation in
stable condition, and will follow up in the office with Dr.
[**Last Name (STitle) 5385**] next week. The patient has had his drains removed as
appropriate when they were putting out less than 20 cc per
shift, and the patient had no difficulties and continued to
improve postoperatively. After physical therapy evaluation,
it was deemed that the patient would be appropriate for
rehabilitation and bed placement was accrued and the patient
was sent to rehabilitation in stable condition.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7738**]
Dictated By:[**Last Name (STitle) 36112**]
MEDQUIST36
D: [**2194-9-12**] 05:50
T: [**2194-9-12**] 07:14
JOB#: [**Job Number 36184**]
|
[
"250.00",
"401.9",
"287.5",
"733.40",
"427.31",
"424.0",
"707.8",
"275.41",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.4",
"86.69",
"83.82"
] |
icd9pcs
|
[
[
[]
]
] |
6198, 8106
|
2813, 5793
|
5811, 6175
|
1578, 1777
|
1290, 1338
|
1792, 2795
|
1360, 1555
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,632
| 179,716
|
52260
|
Discharge summary
|
report
|
Admission Date: [**2123-2-23**] Discharge Date: [**2123-3-3**]
Date of Birth: [**2063-2-19**] Sex: F
Service: SURGERY
Allergies:
Morphine / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Known infra renal AAA
Major Surgical or Invasive Procedure:
[**2123-2-23**] AAA repair
History of Present Illness:
55 yo F w/COPD who was admitted [**2123-2-23**] for scheduled repair of
4.5cm infrarenal AAA.
Past Medical History:
CAD s/p MI [**09**]
HTN
DM2
COPD
smoker ([**2-16**] ppd)
^chol
anxiety
PSH: neck fusion, throat polyps ('[**21**]), bladder suspension ('[**14**]),
D&C
Social History:
current smoker
Family History:
n/c
Physical Exam:
VS: 98.6 P 74 BP 122/71 RR 18 O2 sat 92-96 RA
Gen: AAOx3, NAD
Card: RRR, no M/R/G
Lungs: CTAB
Abd: +BS, NT, ND, soft, L flank incision w/ staples intact, no
drainage open to air
Ext: well perfused
Pertinent Results:
[**2123-3-3**] 05:00AM BLOOD WBC-9.2 RBC-3.56* Hgb-11.6* Hct-33.3*
MCV-94 MCH-32.6* MCHC-34.9 RDW-14.1 Plt Ct-251
[**2123-3-3**] 05:00AM BLOOD Plt Ct-251
[**2123-3-3**] 05:00AM BLOOD PT-12.6 PTT-26.1 INR(PT)-1.1
[**2123-3-3**] 05:00AM BLOOD Glucose-109* UreaN-11 Creat-0.4 Na-138
K-4.2 Cl-103 HCO3-30 AnGap-9
[**2123-3-2**] 04:45AM BLOOD Glucose-117* UreaN-14 Creat-0.5 Na-138
K-3.6 Cl-102 HCO3-33* AnGap-7*
CHEST PORT. LINE PLACEMENT Study Date of [**2123-2-23**] 12:20 PM
The ET tube tip is 5 cm above the carina. The right internal
jugular line tip is most likely at the junction of the right
internal jugular vein and
subclavian vein. The cardiomediastinal silhouette is stable.
Interval
development of mild vascular engorgement as well as new right
lower lobe
consolidation accompanied by right pleural effusion are noted
that might
represent aspiration or atelectasis and pleural effusion.
Infectious process cannot be excluded. The NG tube tip is in the
stomach. The orthopedic hardware in cervical spine is unchanged.
CHEST (PORTABLE AP) Study Date of [**2123-2-24**] 6:30 PM
FINDINGS: As compared to the previous radiograph, the monitoring
and support devices are in unchanged positions. The
intrathoracic volumes have slightly decreased, as a consequence
the size of the cardiac silhouette has increased. The extent of
the right-sided pleural effusion is unchanged. There is
unchanged hypoventilation at the right lung base. The lung
parenchyma shows no evidence of newly appeared focal parenchymal
opacity suggestive of pneumonia.
The study and the report were reviewed by the staff radiologist.
CHEST PORT. LINE PLACEMENT Study Date of [**2123-3-2**] 9:31 AM
New right PICC terminates in the lower SVC in good
position. No pneumothorax. Left subclavian central venous
catheter is
unchanged with tip in the SVC. There has been improvement in
airspace opacity of the right lung base seen on [**2123-2-26**]. No appreciable pleural fluid.
[**2123-2-25**] 3:53 pm BLOOD CULTURE Source: Line-aline.
**FINAL REPORT [**2123-3-3**]**
Blood Culture, Routine (Final [**2123-3-3**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
Please contact the Microbiology Laboratory ([**7-/2420**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
Brief Hospital Course:
[**2123-2-23**] Patient admitted via holding room and taken to OR for
scheduled surgical AAA repair. Routine monitoring line placed
pre-op. Post-operatively re-intubated in the PACU for laryngeal
edema, epidural catheter placed for pain control. Had some
problems w/ hypotension, responded well to volume, given FFP.
Transfered to CVICU. Heparin subcu for DVT prophylaxis.
[**2123-2-24**] POD1/CVICU #1. T maxed 101.5, CXR-showed pneumonia.
Sputum sent for cultures (bronchial washing). Remains intubated
and sedated. RISS for glycemic control. Remains on epidural
Hydromorphone/Bupivicaine for pain control.
[**2123-2-25**] POD2/CVICU#2 Tmax 101.8, blood cultures sent. Remains
intubated and sedated. Exercising on the vent and attempted CPAP
wean. Increasing sputum- sent for culture. RISS. DVT
prophylaxix. Had some problems w/ tachycardia- managed w/
Metoprolol IV. Anxiety managed w/ Lorazepam IV. Epidural
catheter removed due to fever, started on Fentany drip for pain
control.
[**2123-2-26**] POD3/CVICU#3. Continued to be febrile. Remains intubated
and sedate. Good pain control on Fentany drip. Started on
Vanco/Zosyn for presumptive pneumonia. DVT prophylaxis. Vent
exercises. RISS for glycemic control. Started on Tube feeds via
NGT.
[**2123-2-27**] POD4/CVICU#4. Remains febrile. Continues on antibiotics
(Vanco/Zosyn) per ID consult for bacteremia-[**2-25**] blood cultures
w/ GPCs, repeat blood cultures sent. Remains intubated and
sedate, Fentany drip for pain control-started Toradol to wean
Fentany. Weaning sedation, and exercising on the vent. Tube
feeds at goal. DVT prophylaxis. Diuresed w/ Lasix IV.
[**2123-2-28**] POD5/CVICU#5 Remains w/ low grade fever. Remains
intubated-weaning and able to extubate. Remains sedate on
Fentanyl and Versed drips-weaned prior to extubation. Continues
tube feeds. Continues on Vanco/Zosyn.
[**2123-3-1**] POD6 Stable, [**Hospital 108079**] transferred to [**Hospital Ward Name 121**] 5
VICU/telemetry. Now afebrile. Continues on Vanco/Zosyn.
Oral/home meds resumed. Tube feeds d/c'd, started POs. A-line
and CVL d/c'd. ID following.
[**2123-3-2**] POD7 No acute events. Continue with Vanco, d'c'd Zosyn,
started Ceftriaxone for Moraxella pneumonia- to d/c on PO
Cefpodoxime for total 14 days. PICC line placed for home
antibiotics, placement confirmed w/ X-ray. Foley d/c'd and
voiding.
[**2123-3-3**] POD8 No acute events. Discharged to home w/ IV Vanco via
PICC and PO Cefpodoxime. Blood cultures and catheter tip on
[**12-25**]-came back no growth.
Medications on Admission:
Norvasc 10 mg qd
Lipitor 40 mg qd
Celexa 20 mg qd
Zetia 10 mg qd
Lasix 20 mg qd
Lisinopril 20 mg qd
Toprol XL 100 mg qd
Omeprazole 20 mg qd
ASA 81 mg qd
potassium 10 meQ qd
Advair [**Hospital1 **]
albuterol prn
spriva
proventil prn
Discharge Medications:
1. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 8 days.
Disp:*32 Tablet(s)* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) transdermal
Transdermal DAILY (Daily) for 6 weeks: please FU w/ PCP for
tapering.
Disp:*45 transdermal* Refills:*0*
15. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
19. Vancomycin 500 mg Recon Soln Sig: 1250 mg Recon Solns
Intravenous Q 12H (Every 12 Hours) for 7 days: [**3-11**].
Disp:*14 Recon Soln(s)* Refills:*0*
20. Normal Saline Flush 0.9 % Syringe Sig: One (1) syringe
Injection before and after use and prn for 7 days.
Disp:*100 syringes* Refills:*0*
21. Heparin Flush 10 unit/mL Kit Sig: Five (5) ml Intravenous
per protocol for 7 days.
Disp:*50 syringe* Refills:*0*
22. Outpatient Lab Work
Vanco trough [**2123-3-5**]
Fax report to Dr. [**Last Name (STitle) **] Fax # [**Telephone/Fax (1) 17352**]
23. PICC line care
Weekly dressing changes and PRN
Monitor site every before and after use
Flushes per protocol
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
AAA
History of CAD s/p MI [**09**]
History of HTN
history of DM2
history of COPD
history of smoker ([**2-16**] ppd)- wants to quit given Rx of Nicotine
patch
history of hypercholesterolemia
history of anxiety
post-operative pneumonia- currently treating
post-op bacteremia-currently treating per ID recs
Discharge Condition:
Good
discharging on antibiotics
started on Nicotine patch- will be FU by PCP
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-21**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-16**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2123-3-8**] 2:10
Dr. [**Last Name (STitle) 25693**], [**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 25694**] make an appointment
to be seen in [**2-16**] weeks, you were started on Nicotine patch
Completed by:[**2123-3-3**]
|
[
"441.4",
"790.7",
"041.10",
"996.62",
"482.9",
"327.23",
"414.00",
"278.00",
"412",
"E878.2",
"530.81",
"440.0",
"305.1",
"998.9",
"997.39",
"571.8",
"250.00",
"272.4",
"478.6",
"493.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.14",
"96.72",
"38.44",
"96.04",
"33.24",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
8885, 8937
|
3721, 6232
|
317, 346
|
9285, 9366
|
930, 3698
|
12106, 12476
|
693, 698
|
6514, 8862
|
8958, 9264
|
6258, 6491
|
9390, 11653
|
11679, 12083
|
713, 911
|
256, 279
|
374, 469
|
491, 645
|
661, 677
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,364
| 150,732
|
6110
|
Discharge summary
|
report
|
Admission Date: [**2139-8-7**] Discharge Date: [**2139-8-22**]
Date of Birth: [**2085-11-10**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing / Sorafenib
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
HCV/ETOH Cirrhosis with HCC and diuretic-resistant ascites,
admitted for liver transplant
Major Surgical or Invasive Procedure:
[**2139-8-7**]: Orthotopic Liver transplant
History of Present Illness:
year-old male with HCV/ETOH cirrhosis, HCC with diuretic
resistance ascites, portal hypertension, and approximately
weekly
paracentesis. Usually goes 10-12 days between U/S guided
paracentesis, most recently on [**2139-8-4**] with removal of 8 L of
clear yellow fluid. He has reported a slight re-accumulation of
fluid since his last paracentesis. Attempt was made at
radiofrequency ablation and CyberKnife therapy, which was
unsuccessful. He was given sorafenib in [**2139-2-3**], but
could not tolerate this. He underwent chemoembolization of the
right lobe of the liver on [**2139-5-13**]. Last afp=17.7.
Currently, he reports ascites has progressively worsened over
the
past 7days, resulting in shortness of breath on exertion and
mild
low back pain.
Past Medical History:
Cirrhosis: HCV complicated by diabetes and obesity.
- HAV and HCV reactive, HBV negative, Sm muscle ab +
Large volume ascites with multiple paracenteses
Liver bx [**11-9**] with portal mononuclear inflammation,
micro/macro vesicular steatosis, focal sinusidal fibrosis
Hepatocellular Carcinoma: 2cm lesion in dome of liver s/p bx on
[**2138-12-18**]
Coronary Artery Disease
- CABG in 6/98 with LIMA to LAD, SVG to PDA and radial graft to
OM and diagonal. Asymptomatic since CABG, but in w/u for liver
transplant pt was intubated for liver bx - trops elevated and
taken to cath. s/p stent - cath [**1-9**] prox LAD with ostial 90%
disease, 50% post LIMA touchdown, 90% ostial LCx, TO'ed RCA,
grafts with patent LIMA to LAD and patent SVG to PDA and fadial
to diag but radial to OM was TO'ed. PCI wo LCx
Type II DM - off meds, currently diet controlled
Asthma
Obesity
Thrombocytopenia
Chronic renal failure - recently improved & able to come off HD
Social History:
# Tobacco: 10 cig/day/25 years, quit [**2137**]
# Alcohol: Social drinker, quit [**2137**]
# Recreational drugs: No IVDU in past or presently
# Personal: Lives at home alone with VNA (per pt: to check BP,
ask how pt is doing) and food delivery services provided. 4
adult children, oldest >35yo.
# Employment: Former cook, on disability. Previously a police
officer. Pt thinks he got HepC from aiding a bleeding drug
addict while on job.
Family History:
Mother died of breast CA, Father died of MI at 61, HTN.
Physical Exam:
98.2 80 reg 100/64 20 99% RA /5'8", wt 136.6kg (141.5kg
[**8-4**])
Gen: alert / oriented x3, NAD
HEENT: PERRL, mild icterus, MMM, pharynx wnl
Neck: no LAD, 2+carotids, no bruits
Pulm: CTA, bilaterally
CV: RRR, nL S1 and S2, + sys murmur
Abd: well healed umbilical incision (hernia repair), +ventral
hernia, old scars on abd, obese/ascites, non-tender
Ext: pitting edema bilaterally to upper tibias, 2+ DPs
skin-scattered sm brown macules on upper back, no [**Location (un) **]
erythema, axillary papillomas
Neuro: no asterixis
Pertinent Results:
On Admission: [**2139-8-7**]
WBC-3.0* RBC-3.51* Hgb-10.9* Hct-32.9* MCV-94 MCH-30.9 MCHC-33.0
RDW-15.6* Plt Ct-60*
PT-15.0* PTT-30.4 INR(PT)-1.3* Fibrinogen-246
Glucose-102 UreaN-24* Creat-1.3* Na-134 K-4.2 Cl-105 HCO3-22
AnGap-11
ALT-58* AST-112* AlkPhos-93 Amylase-70 TotBili-0.9 Lipase-70*
Albumin-3.6 Calcium-8.6 Phos-3.8 Mg-2.0
Brief Hospital Course:
53 y/o male with ESLD due to Hep C/ETOH cirrhosis and HCC now
with diuretic resistant ascites who presents for liver
transplant. Of note he was called in several times previously
over the last few weeks. He was taken to the OR on [**8-7**] by Drs
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who performed an orthotopic liver
transplant with duct-to-duct anastomosis. The patient tolerated
the procedure well and was transferred to the SICU, stable,
intubated. He received protocol induction immunosuppression
which included Solumedrol, and Cellcept, and started Prograf on
pos op day 1.
He was extubated on POD 1. In the post op period he required
transfusion of 5 units RBCs and 3 units platelets. Over the
course of the hospitalization the platelet count increased and
the HCT remained stable.
He was transferred out of the SICU on POD 3. [**Last Name (NamePattern1) **]
evaluation of the liver revealed normal vasculature except the
right hepatic artery. This was possibly a technical difficulty
due to large abdominal size. A repeat U/S done on [**8-14**] showed
all patent vasculature including the RHA. There was some concern
due to velocities in the main portal vein ranging from 109 to
149 cm/sec, which was similar to the previous study. An MR was
initially suggestive of a Portal Vein stenosis and the patient
was initiated on a heparin drip. Portal venography was performed
on [**8-15**] showing discrepancy in size between the native and donor
portal veins with relative stenosis, but no significant pressure
gradient across the anastomosis. No interventions were performed
after discussion with Dr. [**Last Name (STitle) 816**].
Drain Bili measured on [**8-16**] was 8.1. The patient had one
remaining JP at the time of this test which was putting out
about 1-1.2 liters of ascitic fluid tinged with bile daily.
Liver enzymes (AST and ALT) which had briefly elevated at the
time of the portal venography trended back to normal. Alk phos
remained slightly elevated in addition to serum bilirubin of
5.9.
On [**8-19**], an ERCP was performed for concern for bile leak as the
JP bili was 25.7. This revealed biliary narrowing at the site of
duct to duct anastomosis. No extravasation of contrast was noted
- high pressure cholangiogram was not obtained given recent
transplant. A biliary sphincterotomy was performed and a biliary
stent was inserted. Recommendations included repeating an ERCP
in 2 months. LFTs trended down and the JP drainage decreased. A
CT without iv contrast was performed on [**8-20**] to assess for a
perihepatic collection. A collection was noted and this was
drained in CT for 260cc of serosanguinous fluid. A pigtail drain
was left in place. Culture of this fluid was negative. The
perihepatic drain and JP were left in place at time of discharge
from the hospital. VNA services were arranged to assist with
this at home. The JP drainage was ~700-1400cc/day.
On [**8-17**] (pod 9), the apex area of the incision was opened due to
inadequete approximation of the incision and fluid noted at the
site. A gram stain and culture were submitted and he was started
on Ancef. Gram stain had 1+pmns without growth on the culture.
Two 2x2 gauzes were placed at the apex.
Immunosuppression consited of cellcept, prednisone and prograf
titrated to 2mg [**Hospital1 **].
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult was obtain for assist with insulin management
of hyperglycemia. Initially, he was on an insulin drip in the
SICU, but this was switched to humalog sliding scale and
glargine insulin. He did well with insulin teaching and
experienced no low blood sugars.
He was ambulatory, vital signs were stable and he was tolerating
a regular diet when discharged home.
Medications on Admission:
asa 81', lactulose 30ml [**Hospital1 **]-tid, lasix 80mg', morphine sr 15mg
prn [**Hospital1 **], nexium 1 tab qd, aldactone 100mg tabs, 2 tabs qd,
rifaximin 600mg [**Hospital1 **], ambien 2.5 qhs
Discharge Medications:
1. Outpatient Lab Work
Patient needs to get Blood drawn on Monday: tacrolimus level,
CBC, Chem 10 and LFTs.
2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
3. Prednisone 5 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
9. Glucometer Elite Classic Kit Sig: One (1) kit
Miscellaneous once.
Disp:*1 glucometer* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day
for 2 weeks.
Disp:*56 Capsule(s)* Refills:*1*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Insulin Syringes (Disposable) 1 mL Syringe Sig: One (1)
syringe Miscellaneous four times a day.
Disp:*60 syringes* Refills:*2*
15. Humalog 100 unit/mL Solution Sig: 0-16 units Subcutaneous
four times a day: Per sliding scale.
Disp:*1 bottle* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
HCV/ETOH cirrhossis with HCC now s/p orthotopic liver transplant
DM
Bile leak
bile duct narrowing
perihepatic fluid collection
Discharge Condition:
Stable
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, diarrhea, inability to take or
keep down medications.
Monitor the incision daily for increased redness, drainage
bleeding. Dressing change twice daily to upper portion of the
incision.
Drain and record the JP drain output twice daily and as needed.
Call the office if you note that the drainage increases in
output volume, if it turns dark/brown/green or cloudy or
develops a foul odor.
Dressing change daily to the drain site. Place a drain sponge to
site daily.
You may shower, pat abdomen dry, do not rub. No tub baths or
swimming until directed otherwise.
No driving if taking narcotic pain medication
Drink enough fluids to keep urine light yellow in color
Please get labs drawn at the [**Hospital3 **] lab on Monday.
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2139-8-27**] 8:30
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2139-9-3**] 9:00
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2139-9-3**] 10:00
Please follow up with [**Last Name (un) **] about your blood glucose
management. Call ([**Telephone/Fax (1) 3537**] to make an appointment.
Completed by:[**2139-8-24**]
|
[
"997.4",
"412",
"276.7",
"576.2",
"789.59",
"278.00",
"070.54",
"572.8",
"338.18",
"303.93",
"997.5",
"459.2",
"V45.81",
"998.32",
"571.2",
"493.90",
"572.3",
"155.2",
"E878.0",
"250.00",
"576.8",
"E879.8",
"286.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"50.59",
"88.64",
"51.87",
"54.91",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
9491, 9548
|
3647, 7476
|
387, 433
|
9719, 9728
|
3290, 3290
|
10607, 11167
|
2666, 2723
|
7723, 9468
|
9569, 9698
|
7502, 7700
|
9752, 10584
|
2738, 3271
|
258, 349
|
462, 1220
|
3304, 3624
|
1242, 2194
|
2210, 2650
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.